Cardiac Risk Of Noncardiac Surgery Research Articles

Preoperative cardiac risk stratification 2007: Evolving evidence, evolving strategies

Various guidelines and risk indices have optimized cardiac risk stratification, and the emphasis has shifted to reducing perioperative risk. This review is an update on invasive (CABG/PCI) and noninvasive (medical therapy with beta-blockers, alpha-agonists, and statins) strategies to reduce cardiac risk for noncardiac surgery and the controversies surrounding their use.

Cardiovascular Evaluation and Care for Noncardiac Surgery: Revised Guidelines

Sponsoring Organizations: American College of Cardiology, American Heart Association Background and Purpose: These guidelines represent an update to those published in 2002 and provide a framework for considering the cardiac risk of noncardiac surgery. New tables and algorithms provide quick references for decision making regarding treatment and testing. A principal message of the revised document is that the need for intervention is indicated by cardiovascular findings and rarely just to lower the surgical risk. Key …

Influence of ageing on perioperative cardiac risk in non-cardiac surgery}{Ageing and perioperative cardiac risk

ageing is known to augment perioperative cardiac risk in non-cardiac surgery. However, it remains unclear whether the increased risk is attributable to ageing itself or to the associated cardiac risk factors and coronary artery disease. this retrospective study enrolled 1,351 patients who underwent non-cardiac surgery after dipyridamole stress myocardial perfusion scintigraphy. These patients were divided into the following four groups: Group 1-E (aged 75 or more, normal single photon emission computed tomography (SPECT)), Group 1-Y (aged less than 75, normal SPECT), Group 2-E (aged 75 or more, abnormal SPECT) and Group 2-Y (aged less than 75, abnormal SPECT). Clinical risk factors, scintigraphic findings and occurrence of perioperative cardiac events were analysed. the older cohorts had a significantly higher number of risk factors than their younger counterparts. No significant difference was observed in the degree of perfusion abnormality between Groups 2-E and 2-Y. Although the event rates were comparable in Groups 1-E and 1-Y, Group 2-E yielded a significantly higher rate than Group 2-Y. Ageing was an independent predictor of cardiac events in Group 2 in multivariate analysis. ageing has no influence on perioperative cardiac risk in patients without overt myocardial infarction or ischaemia. The likelihood of cardiac events is increased by ageing, independently of other variables, in patients with perfusion abnormality.

Assessing and Reducing the Cardiac Risk of Noncardiac Surgery

Accurate estimation of a patient’s risk for postoperative cardiac events (eg, myocardial infarction, unstable angina, ventricular tachycardia, pulmonary edema, and death) after noncardiac surgery can guide allocation of clinical resources, use of preventive therapies, and priorities for future research. This review addresses selected issues in clinical risk assessment, approaches to using diagnostic tests, choices among preventive interventions, and postoperative monitoring. Although we have not used a formal systematic review protocol, we emphasize evidence published after the American College of Cardiology/American Heart Association (ACC/AHA) 1 and American College of Physicians (ACP) 2 guidelines, outline the limitations of the evidence, and suggest clinical approaches. A summary of our review of the evidence is presented in Table 1, and suggested approaches using these data are presented in Table 2 and Figures 1 and 2.

Predicting Perioperative Cardiac Risk

Cardiovascular complications are the major cause of perioperative morbidity and mortality of patients undergoing major vascular surgery. This is related to the frequent presence of an underlying coronary artery disease. This paper reviews the pathology of perioperative cardiac complications and cardiac risk assessment and risk reduction strategies. Guidelines of the American College of Cardiology and American Heart Association for the evaluation of cardiac risk for noncardiac surgery may provide the necessary framework for the assessment and management of patients undergoing major vascular surgery. Based on the American College of Cardiology and American Heart Association guidelines and data from contemporary studies, patients without risk factors are considered to be at low risk and do not require additional evaluations for coronary artery disease. Patients with 1 or 2 cardiac risk factors represent an intermediate-risk group for perioperative cardiac complications. If beta-blockers are prescribed, the probability of cardiac complications is low and there is no need for further noninvasive testing. Patients with 3 or more risk factors are at high risk for cardiac complications and the use of noninvasive testing may help further refine cardiac risk based on the presence and absence of test-induced myocardial ischemia. beta-Blockers should be prescribed to all patients, and coronary revascularization should be reserved for high-risk patients who have a clearly defined need for revascularization independent of the need for major vascular surgery.

Noncardiac Surgery: Evaluating and Minimizing Cardiac Risk

Perioperative cardiac complications remain a great concern during noncardiac surgeries since a large majority of patients undergoing such procedures are elderly, who have a greater prevalence of coronary artery disease. Thus, it is imperative to assess risk of perioperative cardiac complications in all patients scheduled for noncardiac surgery. The current review attempts to outline a systematic approach to assess cardiac risk for noncardiac surgery and suggest strategies to minimize these risks. This approach uses a combination of the urgency of noncardiac surgery, interval since prior revascularization to noncardiac surgery, the interval between prior evaluation of coronary artery disease, patients clinical risks for cardiac complications, and patients functional status to decide their perioperative cardiac risks. If surgery is urgent or the estimated risk for perioperative event is low, then irrespective of the risk, patients should proceed with noncardiac surgery under the influence of appropriate medical strategy to minimize risk. If patients risk of perioperative events is high, then postponing or canceling surgery and referral for invasive approach to identify and when appropriate revascularize coronary artery disease may help reduce the perioperative cardiac risk. In contrast, patients at intermediate risk for perioperative events may benefit from noninvasive assessment for coronary artery disease and referral for appropriate patients for coronary revascularization based on the results of such noninvasive testing. Medical perioperative strategy that should be part of all patients undergoing noncardiac surgery who have or are at risk for coronary artery disease, should include betablockers, adequate analgesia, monitoring fluid status, and maintaining hematocrit > 30 gm /dl. Finally, the physician-patient interaction during the hospitalization during noncardiac surgery should be recognized as an important opportunity to institute secondary prevention strategies for coronary artery disease in patients at risk for coronary atherosclerosis. Keywords: coronary artery disease, non-cardiac surgery, myocardial infarction, revascularization, electrocardiogram, functional capacity

Perioperative myocardial injury: individual and population implications

It is generally understood that patients who have cardiovascular disease are at risk of cardiac complications after surgery. In patients undergoing major or vascular surgery, the risk of such complications can be signi®cant. Eagle and colleagues studied patients enrolled on the CASS (Coronary Artery Surgery Study) registry who subsequently underwent non-cardiac surgery. They reported a perioperative myocardial infarction rate of 8.5% in patients with medically managed coronary artery disease who underwent vascular surgery. The authors de®ned high-risk surgery as surgery associated with a risk of perioperative death or myocardial infarction of greater than 4%. Abdominal surgery, thoracic surgery, and head and neck surgery fell into this category. For patients undergoing these types of surgery who had medically treated coronary artery disease, the overall perioperative myocardial infarction rate was 2.7% and the overall death rate 3.3%. This compared with rates of 0.8 and 1% respectively in patients undergoing similar surgery who did not have coronary artery disease. Data such as these are often considered with information on the prevalence of coronary artery disease to obtain some indication of the population burden of disease. For example, in 1990 Mangano stated that 25 million patients undergo major surgery in the USA each year and suggested that perhaps 6±7 million of these people are at risk of perioperative cardiac complications. Such estimates suggest that perioperative cardiac complications are both a major issue in the care of individual surgical patients and a major public health issue. This review will examine in more detail the population impact of perioperative cardiac morbidity and the implications of this for the individual patient.

ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery—executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)

These guidelines represent an update of those published in 1996 and are intended for physicians who are involved in the preoperative, operative, and postoperative care of patients undergoing noncardiac surgery. They provide a framework for considering cardiac risk of noncardiac surgery in a variety of patient and surgical situations. The overriding theme of these guidelines is that preoperative intervention is rarely necessary simply to lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context. The purpose of preoperative evaluation is not simply to give medical clearance but rather to perform an evaluation of the patient’s current medical status; make recommendations concerning the evaluation, management, and risk of cardiac problems over the entire perioperative period; and provide a clinical risk profile that the patient, primary physician, anesthesiologist, and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes. The goal of the consultation is to identify the most appropriate testing and treatment strategies to optimize care of the patient, provide assessment of both short- and long-term cardiac risk, and avoid unnecessary testing in this era of cost containment. ### A. Development of Guidelines These guidelines are based on an update of a Medline, EMBASE, Cochrane library, and Best Evidence search of the English literature from 1995 through 2000, a review of selected journals, and the expert opinions of 12 committee members representing various disciplines of cardiovascular care, including general cardiology, interventional cardiology, noninvasive testing, vascular medicine, vascular surgery, anesthesiology, and arrhythmia management. As a result of these searches, more than 400 relevant new articles were identified. In addition, draft guidelines were submitted for critical review and amendment to the executive officers representing the American College of Cardiology (ACC) and the American Heart Association (AHA). A large proportion of the data used to develop these guidelines are …

Preoperative cardiac risk assessment: an updated approach.

We provide an updated algorithm for approaching preoperative cardiac risk assessment in patients undergoing noncardiac surgery. A National Library of Medicine PubMed literature search was performed dating back to 1985 using the keywords "preoperative cardiac risk for noncardiac surgery." This search was restricted to English language articles involving human subjects. Patient-specific and operation-specific cardiac risk can be determined clinically. Patients with major cardiac risk factors have a high incidence of perioperative cardiac complications, whereas the risk is less than 3% for low-risk patients. For intermediate-risk patients, no prospective randomized studies demonstrate the efficacy of noninvasive stress testing (dipyridamole thallium or dobutamine echocardiography) or of subsequent coronary revascularization for preventing perioperative cardiac complications. Recent studies demonstrate that perioperative beta-blockade significantly reduces the adverse cardiac event rate in intermediate-risk patients. Most patients with high cardiac risk should proceed with coronary angiography. Patients with low cardiac risk can proceed to surgery without noninvasive testing. For intermediate-risk patients, consideration may be given to further stress testing prior to surgery; however, in most patients, proceeding to surgery with perioperative beta-blockade is an acceptable alternative.

Preoperative cardiac risk stratification: Ritual or requirement?

IS THERE ANY real benefit to doing preoperative cardiac evaluation and risk stratification tests in a stable patient? Most physicians would intuitively maintain that there is benefit in identifying the subset of patients at high risk of perioperative myocardial ischemia before surgery. 1 Eagle KA Brundage BH Chaitman BR et al. ACC/AHA Task Force Report: Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Circulation. 1996; 93: 1278-1317 PubMed Google Scholar Notably, patients with evidence of ongoing plaque rupture and thrombosis causing an acute unstable coronary syndrome should have cardiac intervention before noncardiac surgery. However, in all patients without evidence of an acute unstable coronary syndrome, several peer-reviewed publications advocate proceeding directly to surgery. 2 Bodenheimer MM Noncardiac surgery in the cardiac patient: What is the question?. Ann Intern Med. 1996; 124: 763-766 Crossref PubMed Scopus (43) Google Scholar , 3 D'Angelo AJ Puppala D Farber A et al. Is preoperative cardiac evaluation for abdominal aortic aneurysm repair necessary?. J Vasc Surg. 1997; 25: 152-156 Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar , 4 Lee TH Reducing cardiac risk in noncardiac surgery. N Engl J Med. 1999; 341: 1838-1840 Crossref PubMed Scopus (75) Google Scholar , 5 Rosenfeld BA Breslow MJ Dorman T Postoperative management strategies may obviate the need for most preoperative cardiac testing. Anesthesiology. 1996; 84 (letter): 1267-1268 Crossref Scopus (6) Google Scholar Other authors state the decision to pursue perioperative cardiac risk stratification tests and possible coronary revascularization should be the same as in the nonoperative setting. 6 Palda VA Detsky AS Guidelines for assessing and managing the perioperative risk from coronary artery disease associated with major noncardiac surgery. Ann Intern Med. 1997; 127: 309-312 Crossref PubMed Google Scholar , 7 Palda VA Detsky AS Perioperative assessment and management of risk from coronary artery disease. Ann Intern Med. 1997; 127: 313-328 Crossref PubMed Scopus (193) Google Scholar

Cardiac risk of noncardiac surgery: influence of coronary disease and type of surgery in 3368 operations. CASS Investigators and University of Michigan Heart Care Program. Coronary Artery Surgery Study.

The influence of prior coronary artery bypass surgery (CABG) versus medical therapy for reducing the risk of postoperative cardiac complications after noncardiac surgery continues to be debated. To further clarify this controversy we studied 24,959 participants in the Coronary Artery Surgery Study (CASS) database with suspected coronary disease by identifying those who required noncardiac surgery during more than 10 years of follow-up. CASS registry enrollees were either treated with CABG or medical therapy after initial entry. During follow-up, patients who required noncardiac operations were evaluated for hospital death or out-of-hospital death within 30 days of noncardiac surgery and nonfatal postoperative myocardial infarction (MI). At a mean follow-up of 4.1 years, 3368 patients underwent noncardiac surgery, with abdominal (36%), urologic (21%), orthopedic (15%), and vascular being most common. Abdominal, vascular, thoracic, and head and neck surgery each had a combined MI/death rate among patients with nonrevascularized coronary disease >4%. Among 1961 patients undergoing higher-risk surgery, prior CABG was associated with fewer postoperative deaths (1.7% versus 3.3%, P=.03) and MIs (0.8% versus 2.7%, P=.002) compared with medically managed coronary disease. Contrariwise, 1297 patients undergoing urologic, orthopedic, breast, and skin operations had mortality of <1% regardless of prior coronary treatment. Prior CABG was most protective in patients with advanced angina and/or multivessel coronary artery disease. In patients with known coronary artery disease, noncardiac surgeries involving the thorax, abdomen, vasculature, and head and neck are associated with the highest cardiac risk, which is reduced among patients with prior CABG.

Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery: An Abridged Version of the Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery: An Abridged Version of the Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

Cardiac risk of noncardiac surgery in patients with asymmetric septal hypertrophy: J.M. Haering, M.E. Comunale, R.A. Parker, E. Lowenstein, P.S. Douglas, H.M. Krumholz, W.J. Manning. Dept. of Anesthesia/Critical Care, Beth Israel Hospital, Boston, MA. Anesthesiology 1996;85:254–9

Cardiac risk of noncardiac surgery in patients with asymmetric septal hypertrophy: J.M. Haering, M.E. Comunale, R.A. Parker, E. Lowenstein, P.S. Douglas, H.M. Krumholz, W.J. Manning. Dept. of Anesthesia/Critical Care, Beth Israel Hospital, Boston, MA. Anesthesiology 1996;85:254–9

Cardiac risk of noncardiac surgery in patients with asymmetric septal hypertrophy.

Many data are available regarding cardiac risk in patients with coronary artery disease undergoing noncardiac surgery, but few data are available regarding risk for patients with hypertrophic cardiomyopathy and asymmetric septal hypertrophy. Seventy-seven patients with asymmetric septal hypertrophy were identified in whom an echocardiogram had been performed within 24 months of noncardiac surgery. Patients' charts were reviewed for data regarding surgical operations, including length of surgery, type of anesthesia, and intravascular monitoring used. Data regarding adverse perioperative cardiac events also were gathered. Forty percent (n = 31) of patients had one or more adverse perioperative cardiac events, including one patient who had a myocardial infarction and ventricular tachycardia that required emergent cardioversion. There were no perioperative deaths. All 31 patients had minor outcomes. Of the 77 patients, perioperative congestive heart failure developed in 12 (16%). Factors associated with adverse cardiac events were increasing length of surgical time (P < 0.01) major surgery (P < 0.05), and intensity of monitoring (P < 0.05). Age, gender, resting outflow tract gradient, systolic anterior motion of the anterior mitral leaflet, prior myocardial infarction, severity of mitral regurgitation, type of anesthetic, septal thickness, and the interval between echocardiogram and surgery were not associated with the occurrence of adverse cardiac events. Patients with asymmetric septal hypertrophy undergoing noncardiac surgery have a high incidence of adverse cardiac events, frequently manifested as congestive heart failure. However, irreversible cardiac morbidity and mortality was extremely low. Important independent risk factors for adverse outcome in all patients include major surgery and increasing duration of surgery.

Assessment of cardiac risk in noncardiac surgery.

Surgical techniques have been refined so that complications directly resulting from surgical procedures are relatively small. However, with the high prevalence of coronary artery disease in the United States, many surgical patients have concomitant coronary artery disease. Anesthesia as well as the surgical procedure induce stresses on the heart and circulatory system which could result in perioperative cardiac morbidity and mortality. Assessing patients prior to surgical procedures by history, physical examination, laboratory data, and newer cardiovascular diagnostic procedures can stratify the cardiac risk and help to predict the incidence of perioperative cardiac morbidity and mortality. If great risk exists, an alternative therapy or cancellation of the surgical procedure may be considered. In certain subgroups of patients, coronary artery revascularization, valvular heart surgery, or beginning medical therapy of the underlying cardiac pathology could be performed prior to the surgical procedure. If this cannot be arranged for high-risk patients, more intensive and invasive hemodynamic monitoring and optimal medical management perioperatively might reduce cardiac complications.

Cardiac Risk of Noncardiac Surgery in Patients with Asymmetric Septal Hypertrophy

Cardiac Risk of Noncardiac Surgery in Patients with Asymmetric Septal Hypertrophy

The cardiac risks of noncardiac surgery

The cardiac risks of noncardiac surgery

The cardiac risks of noncardiac surgery

The cardiac risks of noncardiac surgery

Prediction of cardiac risk in non-cardiac surgery.

This prospective study was carried out to develop a model for the prediction of cardiac risk in non-cardiac surgery. Detailed data were collected concerning the preoperative status of 2609 consecutive patients, who were followed closely during the postoperative course. Fatal or life-threatening cardiac complications occurred in 68 patients (2.6%). By utilizing logistic regression, a model for prediction of cardiac risk was developed. The model contained six significant preoperative predictor variables: Congestive heart failure (with 3 degrees of severity); ischaemic heart disease (with 2 degrees of severity); diabetes mellitus; serum creatinine above 0.13 mmol l-1; emergency operation; and the type of operation (two categories). With this model it seems possible to discriminate between patients with very different levels of cardiac risk.

Cardiac Risk Factors in Patients Undergoing Noncardiac Surgery

Cardiac risks of noncardiac surgery are associated with some noncardiac risk factors but are primarily a function of the patient's underlying cardiac disease. Elective surgery should only be performed when the patient is in optimal condition--i.e., with no evidence of heart failure, at least 6 months after a previous myocardial infarction, and so forth. Careful monitoring of fluid status should lead to reduced cardiac morbidity and mortality after surgery in these patients.