Cardiovascular Evaluation For Noncardiac Surgery Research Articles

SC08.01 Impact and Management of Co-Morbidities

SC08.01 Impact and Management of Co-Morbidities

Use of Myocardial Perfusion SPECT for Preoperative Risk Stratification of Non-Cardiac Surgery

It is difficult to assess the likelihood of perioperative cardiac events mainly because of complicated interrelationships between clinical risk and type of surgery. To overcome this problem, The American College of Cardiology/American Heart Association（ACC/AHA）Task Force published guidelines for perioperative cardiovascular evaluation for non-cardiac surgery. The guidelines offer the strategy of preoperative cardiac therapy, operative performance and perioperative management depending on the urgency of surgery, the patient$ s risk factors, findings of cardiac testing and specific surgical considerations. Non-invasive cardiac testing including myocardial perfusion single-photon emission computed tomography（SPECT）is recommended to be used mainly in patients with poor functional capacity, when the results will affect patient treatment and outcomes. In the current review, we summarized the use of stress myocardial perfusion SPECT referring to previous reports and our data, and provided the tips for indication of SPECT in preoperative risk stratification in non-cardiac surgery.

Study of the corelation between level of preoperative high-sensitivity C-reactive protein and incidence of postoperative adverse cardiac events in elderly patients underwent noncardiac surgery

Objective To investigate the relevance between level of preoperative high-sensitivity C-reactive protein(hsCRP) and the occurrence of postoperative adverse cardiac events in elderly patients underwent noncardiac surgery. Methods 49 patients of more than 65 years that had undergone elective noncardiac surgery were enrolled in the study. And all patients were conformed to the standards of classification of risk factors for clinical history, content of Guidelines on Preoperative Cardiovascular Evaluation for Noncardiac Surgery established by the ACC/AHA .The patients were divided into two groups based on the preoperative hsCRP level:A group:hsCRP ≤ 3mg/L group (n=21) and B group: hsCRP>3mg/L group (n=28). General clinical characteristics of patients were recorded before operation, and 24 hours dynamic ECG was monitored a week prior to and after the operation. All patients taken measures of analgesia after surgery. The incidence of postoperative adverse cardiac events and the hospitalized days was recorded. The distinctions between two groups were analyzed regarding the occurrence of adverse cardiac events and hospitalized days after operation. Results 19 patients had postoperative myocardial ischemia; 4 cases in A group and 15 cases in B group. 7 patients suffered other postoperative adverse cardiac events, including 1 case in A group and the others in B group. There was statistically significant difference considering morbidity of myocardial ischemia in postoperation between the two groups, but there was no statistically significant difference about incidence of other adverse cardiac events and the length of stay in postoperation. Indexes about serious degree of myocardial ischemia:total depression time is(43.5±5.82 )min in A group, is( 135.0±81.2)min in B group. The depression times is(5.2±2.5 )in A group, is( 8.8±3.0)in B group.The longest depression time is( 23.7±9.2)min in A group, is( 84.3±54.1 )min in B group.Total ischemia burden is( 170.1 ±88.8 )mm· min-1 ·24h-1 in A group, is (311.3± 118.8 )mm· min-1 ·24h-1 in B group.There was statistically significant difference between the two groups. Conclusion Level of preoperative hsCRP>3 mg/L was relevant to the incidence of the most common postoperative adverse cardiac events--myocardial ischemia in elderly patients and level of preoperative hsCRP >3 mg/L was one of the risk factors of postoperative myocardial ischemia;Determination of preoperative hsCRP level may improve cardiovascular risk scoring system. Key words: High-sensitivity C-reactive protein; Adverse cardiac events; Noncardiac surgery; The elderly

Possible indications of beta-blockers in the perioperative period other than prevention of cardiac ischemia

According to the guidelines of the American College of Cardiology/American Heart Association 2006 for perioperative cardiovascular evaluation for non-cardiac surgery, beta-blocker therapy should be considered for high-risk individuals undergoing vascular surgery or high- and intermediate-risk patients undergoing non-cardiac surgery. This guideline might induce physicians to increasingly use beta-blockers in the hope of preventing perioperative cardiac complications. However, beta-blockers have potential beneficial effects outside the prevention of cardiac events. In addition to reducing anesthetic and analgesic requirements during the perioperative period, beta-blockers have neuroprotective effects in patients with brain trauma and possible effectiveness in the management of intraoperative awareness-induced post-traumatic stress disorder. Moreover, intrathecal administration of beta-blockers may have antinociceptive effects. Physicians need to bear in mind the benefits of beta-blockers for purposes other than preventing cardiac events when applied in the perioperative period, and they should be familiar with the pharmacodynamics and risk-benefit ratio with their use. This review focuses on possible extracardiac indications of beta-blockers.

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary

TABLE OF CONTENTSPreamble 686Definition of the Problem 688Purpose of These Guidelines 688Methodology and Evidence 689General Approach to the Patient 692History 693Physical Examination and Routine Laboratory Tests 693Multivariable Indices to Predict Preoperative Cardiac Morbidity 694Clinical Assessme

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery WRITING COMMITTEE MEMBERS Lee A. Fleisher, MD, FACC, FAHA, Chair; Joshua A. Beckman, MD, FACC; Kenneth A. Brown, MD, FACC, FAHA; Hugh Calkins, MD, FACC, FAHA; Elliott Chaikof, MD; Kirsten E. Fleischmann, MD, MPH, FACC; William K. Freeman, MD, FACC; James B. Froehlich, MD, MPH, FACC; Edward K. Kasper, MD, FACC; Judy R. Kersten, MD, FACC§; Barbara Riegel, DNSc, RN, FAHA; John F. Robb, MD, FACC ACC/AHA TASK FORCE MEMBERS Sidney C. Smith, Jr, MD, FACC, FAHA, Chair; Alice K. Jacobs, MD, FACC, FAHA, Vice Chair; Cynthia D. Adams, MSN, PhD, FAHA; Jeffrey L. Anderson, MD, FACC, FAHA; Elliott M. Antman, MD, FACC, FAHA; Christopher E. Buller, MD, FACC; Mark A. Creager, MD, FACC, FAHA; Steven M. Ettinger, MD, FACC; David P. Faxon, MD, FACC, FAHA; Valentin Fuster, MD, PhD, FACC, FAHA; Jonathan L. Halperin, MD, FACC, FAHA; Loren F. Hiratzka, MD, FACC, FAHA; Sharon A. Hunt, MD, FACC, FAHA; Bruce W. Lytle, MD, FACC, FAHA; Rick Nishimura, MD, FACC, FAHA; Joseph P. Ornato, MD, FACC; Richard L. Page, MD, FACC, FAHA; Barbara Riegel, DNSc, RN, FAHA; Lynn G. Tarkington, RN; Clyde W. Yancy, MD, FACC

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery

2007;50;e159-e242; originally published online Sep 27, 2007; J. Am. Coll. Cardiol. Tarkington, and Clyde W. Yancy Lytle, Rick Nishimura, Joseph P. Ornato, Richard L. Page, Barbara Riegel, Lynn G. W. Valentin Fuster, Jonathan L. Halperin, Loren F. Hiratzka, Sharon A. Hunt, Bruce Christopher E. Buller, Mark A. Creager, Steven M. Ettinger, David P. Faxon, Alice K. Jacobs, Cynthia D. Adams, Jeffrey L. Anderson, Elliott M. Antman, K. Kasper, Judy R. Kersten, Barbara Riegel, John F. Robb, Sidney C. Smith, Jr, Chaikof, Kirsten E. Fleischmann, William K. Freeman, James B. Froehlich, Edward Lee A. Fleisher, Joshua A. Beckman, Kenneth A. Brown, Hugh Calkins, Elliott L. Vascular Surgery Interventions, Society for Vascular Medicine and Biology, and Society for and Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography Society of Nuclear Cardiology, Heart Rhythm Society, Society of Collaboration With the American Society of Echocardiography, American Developed in Cardiovascular Evaluation for Noncardiac Surgery) (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiology/American Heart Association Task Force on Practice Guidelines Care for Noncardiac Surgery: A Report of the American College of ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and This information is current as of March 25, 2009 http://content.onlinejacc.org/cgi/content/full/50/17/e159 located on the World Wide Web at: The online version of this article, along with updated information and services, is

Guidelines for Cardiac Management in Noncardiac Surgery Are Poorly Implemented in Clinical Practice

The American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery recommend an algorithm for a stepwise approach to preoperative cardiac assessment in vascular surgery patients. The authors' main objective was to determine adherence to the ACC/AHA guidelines on perioperative care in daily clinical practice. Between May and December 2004, data on 711 consecutive peripheral vascular surgery patients were collected from 11 hospitals in The Netherlands. This survey was conducted within the infrastructure of the Euro Heart Survey Programme. The authors retrospectively applied the ACC/AHA guideline algorithm to each patient in their data set and subsequently compared observed clinical practice data with these recommendations. Although 185 of the total 711 patients (26%) fulfilled the ACC/AHA guideline criteria to recommend preoperative noninvasive cardiac testing, clinicians had performed testing in only 38 of those cases (21%). Conversely, of the 526 patients for whom noninvasive testing was not recommended, guidelines were followed in 467 patients (89%). Overall, patients who had not been tested, irrespective of guideline recommendation, received less cardioprotective medications, whereas patients who underwent noninvasive testing were significantly more often treated with cardiovascular drugs (beta-blockers 43% vs. 77%, statins 52% vs. 83%, platelet inhibitors 80% vs. 85%, respectively; all P < 0.05). Moreover, the authors did not observe significant differences in cardiovascular medical therapy between patients with a normal test result and patients with an abnormal test result. This survey showed poor agreement between ACC/AHA guideline recommendations and daily clinical practice. Only one of each five patients underwent noninvasive testing when recommended. Furthermore, patients who had not undergone testing despite recommendations received as little cardiac management as the low-risk population.

Comment on the guidelines for perioperative cardiovascular evaluation for noncardiac surgery of the ACC/AHA

Comment on the guidelines for perioperative cardiovascular evaluation for noncardiac surgery of the ACC/AHA

ACC/AHA 2006 Guideline Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery: Focused Update on Perioperative Beta-Blocker Therapy ??? A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)

The American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines makes every effort to avoid any actual, potential, or perceived conflict of interest that might arise as a result of an industry relationship or personal interest of the writing committee. Specifically, all members of the writing committee, as well as peer reviewers of the document, were asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest. These statements are reviewed by the parent task force, reported orally to all members of the writing committee at each meeting, and updated and reviewed by the writing committee as changes occur. Please see Appendix 1 for author relationships with industry and Appendix 2 for peer reviewer relationships with industry. These guidelines attempt to define practices that meet the needs of most patients in most circumstances. These guideline recommendations reflect a consensus of expert opinion after a thorough review of the available, current scientific evidence and are intended to improve patient care. If these guidelines are used as the basis for regulatory/payer decisions, the ultimate goal is quality of care and serving the patient's best interests. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and patient in light of all the circumstances presented by that patient.

Low negative predictive value of dobutamine stress echocardiography before abdominal aortic surgery

According to previous studies, a negative dobutamine stress echocardiography (DSE) test before major vascular surgery indicates that postoperative myocardial necrosis is very unlikely. We believe that the use of new cardiac troponin assays which can detect small amounts of myocardial necrosis results in a lower DSE negative predictive value for myocardial necrosis. A total of 418 consecutive patients were screened using the ACC/AHA Guideline for Perioperative Cardiovascular Evaluation for Noncardiac Surgery before scheduled abdominal aortic surgery. Of these 143 met ACC/AHA criteria for non-invasive testing and underwent DSE. Patients with a negative DSE were deemed to be fit for surgery. A positive DSE led to a coronary angiogram. DSE was negative in 110 (77%) and positive in 33 (23%) patients. Myocardial necrosis was monitored up to the third postoperative day by daily cardiac troponin I (cTnI) measurement and a daily 12-lead ECG. Coronary angiography showed artery stenosis in 27 (84%) of 32 patients with a positive DSE. The negative predictive value of DSE for cTnI elevation was 92.7% (95% CI 86.2-96.8%). This was significantly lower than the lowest value of negative predictive value for myocardial necrosis assessed in previous studies. A negative DSE prescribed before scheduled aortic surgery according to ACC/AHA guidelines does not rule out postoperative myocardial necrosis.

Indications of prophylactic coronary revascularization in patients undergoing major vascular surgery: the saga continues

When considering a patient for major vascular surgery, a careful pre-operative clinical risk evaluation and subsequent risk-reduction strategies are essential to improve post-operative outcome. The ACC/AHA TaskForce published therefore Practice Guidelines for Perioperative Cardiovascular Evaluation for Non-cardiac Surgery in 1996 and an update in 2002.1 Furthermore, due to increasing evidence of the beneficial effect of beta-blocker use in the perioperative period, the guidelines section on perioperative beta-blocker therapy is recently updated.2 The core of the ACC/AHA guidelines is an algorithm, which summarizes the stepwise evaluation of clinical parameters used to assess the need for further cardiac testing. According to the algorithm, after assessing the urgency of the surgery and the cardiac status of patients having previous coronary revascularization within 5 years or previous cardiac evaluation within 2 years, the patients are classified as major, intermediate, or minor clinical predictors of increased perioperative cardiovascular risk. The need for cardiac testing is then determined by an assessment of the functional status of the patient and the surgery-specific risk. Patients scheduled for major vascular surgery with only minor clinical predictors and adequate functional capacity represent a low-risk population and further evaluation is unnecessary. However, in patients with intermediate clinical predictors or patients with minor clinical predictors and reduced functional capacity, additional non-invasive evaluation should be considered before undergoing major vascular surgery. The main purpose of performing pre-operative cardiac risk assessment is … *Corresponding author: Tel: +31 10 4634613; fax: +31 10 4634957. E-mail address : d.poldermans{at}erasmusmc.nl

Left ventricular noncompaction and mid-caviter narrowing associated with Ebstein's anomaly: Three-dimensional transthoracic echocardiographic image

An 50 year-old asymptomatic female was admitted to preoperative cardiovascular evaluation for noncardiac surgery. Two-dimensional transthoracic echocardiography demonstrated that left ventricular dimensions and ejection fraction were normal. The mitral valve was normal both in morphology and function. The attached margin of septal and anterior leaflet of the tricuspid valve was apically displaced. But right ventricle and right atrium dimensions were normal, and Doppler interrogation showed a slight tricuspid regurgitation. Two and three-dimensional transthoracic echocardiography showed prominent numerous trabeculations in the left ventricular apex. Colour flow Doppler studies confirmed the presence of blood flow within the trabeculations. Multi-plane three-dimensional transthoracic echocardiography showed a muscular band leading to left ventricular mid-caviter narrowing. Pulse wave Doppler echocardiography demonstrated that no intraventricular gradient existed. Ventricular noncompaction associated with Ebstein's malformation has been reported. But left ventricular noncompaction and mid-caviter narrowing associated with Ebstein's anomaly have not been reported so far.

Asymptomatic cardiac lipoma originating from the interventricular septum diagnosed by multi-slice computed tomography

A 45 year-old asymptomatic man was admitted to preoperative cardiovascular evaluation for noncardiac surgery. Physical examination and ECG were normal. Transthoracic echocardiography showed a 17 x 35 mm suspicious hyperechoic mass in the interventricular septum. Multi-slice computed tomography (MSCT) was used. Volume rendered image and an axial maximal intensity projection image demonstrated a mass with a density consistent with fat tissue ( - 78 HU). The MSCT findings were diagnostic of a benign lipoma. Thus, this mass was noninvasively diagnosed as cardiac lipoma. Neither life-threatening arrhythmia on Holter monitoring nor myocardial ischemia on exercise scintigraphy was observed.Transthoracic echocardiography is usually the initial diagnostic test in patients with a suspected cardiac mass. However, its sensitivity for differentiating tissue characteristics is limited. MSCT allow for detailed delineation of intra and pericardiac masses. In conclusion, we demonstrated the value of cardiac MSCT to diagnose an interventricular lipoma.

ACC/AHA guidelines for preoperative cardiovascular evaluation for noncardiac surgery: a critical point of view.

This review examines the issue of preoperative cardiac evaluation from a critical point of view, based on recent medical literature. We reviewed the history of that field and focused on the American College of Cardiology and American Heart Association guidelines, which are a cornerstone in the field of cardiac patients undergoing noncardiac surgery. These guidelines synthesized the data into a comprehensive format and established the concept of integrating the patient's risk with the surgical risk. Nevertheless, there are some weaknesses in the guidelines. We believe that a better understanding of the guideline limitations will allow an improved and more educated practice of its recommendations.

Preoperative Cardiac Evaluation: When Should the Surgeon Consult the Cardiologist?

We compiled a manual aimed at reducing preoperative cardiac assessment costs and defining the roles of surgeons and cardiologists. We tested prospectively and retrospectively if this manual achieved these goals. Using the Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery of the American College of Cardiology (ACC) / American Heart Association (AHA), and other articles as a reference, we compiled the Jichi Medical School Hospital (JMSH) Manual in September 2002. This manual contains a novel checklist and flowcharts and includes all past and present cardiac disorders, complications, abnormalities in electrocardiograms (ECGs) and chest X-rays, and evaluation of daily activity. Using this manual, we prospectively studied 1087 surgical candidates from September 2002 to August 2003, and retrospectively analyzed 927 surgical candidates from September 2001 to August 2002. In the prospective study, 39 (3.6%) patients were deemed to require further cardiac assessment and 4 (0.37%) suffered postoperative complications. In the retrospective study, 108 (11.7%) were deemed to require further cardiac assessment and 20 (2.2%) suffered postoperative complications. Using this manual reduced preoperative cardiac examination costs by 1323,600 Japanese yen, representing a 70.5% reduction. The JMSH Manual defines the roles of surgeons and cardiologists and is useful for assessing preoperative cardiac function and surgical risks. This manual dramatically reduced the costs associated with preoperative cardiac examinations.

Are the Incidences of Cardiac Events During Noncardiac Surgery in Japan the Same as in the United States and Europe?

In Japan, an ever-present problem in the preoperative evaluation of patients with ischemic heart disease is that although such evaluations are based on Western data, these data serve as the basis for determining perioperative risk in Japanese patients. To remedy this problem, the Cardiac Ischemia and Anesthesia Research Committee was formed in 1997 and has conducted studies of perioperative complications in noncardiac surgery in Japan. In two retrospective studies in 1997, the proportions of patients with ischemic heart disease were 3.9% and 3.1%, approximately one tenth the rates reported in Europe and the United States. The incidences of perioperative cardiac complications in patients with ischemic heart disease were 16.4% and 13.2%, not widely divergent from rates reported in Europe and the United States. To investigate the baseline characteristics involved in perioperative complications, we conducted a prospective study of 237 patients classified as having intermediate risk for perioperative cardiac complications according to the American College of Cardiology/American Heart Association Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery. We found that the prominent factor in intraoperative cardiac complications was the presence of hypertension (odds ratio = 2.911). Factors contributing to postoperative cardiac complications included those reflecting coronary lesion severity and cardiac dysfunction (history of heart failure; odds ratio = 6.884, coronary risk index grade; odds ratio = 2.884, and a history of intervention; odds ratio = 4.774).

Sympatho-modulatory therapies in perioperative medicine

With increasing life expectancy and improved surgical technology an ever-larger number of elderly patients with cardiovascular disease, or significant cardiovascular risk factors will undergo major surgery. More than 5% of an unselected surgical population undergoing non-cardiac surgery will suffer from perioperative cardiovascular complications including myocardial infarction and cardiac death. The incidence of adverse cardiac events may even reach 30% in high-risk patients undergoing vascular surgery causing a substantial financial burden of perioperative health care costs. 59 Thus, all therapeutic measures should be undertaken to reach the challenging goal of a lower incidence of perioperative cardiovascular complications. Gaining control over sympathetic nervous system activity, that is blunting the adrenergic response to the surgical trauma, traditionally represents an important aspect of anaesthetic practice. 21 Anaesthesiology has been regarded as the ‘practice of autonomic nervous system medicine’. While variable and moderate changes in sympathetic nervous system activity function as a servo-control mechanism and are even required to maintain and optimize cardiac performance, undue liberation of excitotoxic substances such as catecholamines and inflammatory cytokines, particularly during emergence from anaesthesia and the painful postoperative period, facilitates the occurrence of cardiovascular complications. 83 84 At this point, the life-supporting adrenergic drive (‘fight-or-flight-response’) turns into a potentially hazardous life-threatening maladaptation. In support of this concept, the beneficial effects of antiadrenergic treatment regimens in perioperative medicine have been confirmed, in observational studies, metaanalyses 55 1 66 and randomized controlled clinical trials. 43 54 59 63 80 84 However, the seemingly established concept of ‘sympatholysis’ as an effective cardioprotective treatment modality needs considerable refinement in the light of the many new experimental and clinical findings. The parlance of ‘sympatholytic’ protection erroneously equates annihilation of any type of adrenergic stimulation with cardioprotection and should be replaced by ‘sympathomodulatory’protection. The present review summarizes findings from large-scale heart failure trials and discusses basic and clinical aspects of individual sympatho-modulatory therapies, as currently used in perioperative medicine, including b-adrenergic antagonism, a2-agonism, and regional anaesthetic techniques. For limitation of space, reviews will often be cited where further references to the primary literature may be found.

ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography: Summary Article: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to update the 1997 guidelines for the clinical application of echocardiography)

ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography: Summary Article: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to update the 1997 guidelines for the clinical application of echocardiography)

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