High Risk Of Cardiac Complications Research Articles

Atrial Flutter Associated with Carboplatin Administration

To report a novel case of atrial flutter associated with carboplatin administration and review chemotherapy-related cardiac toxicities, focusing on platinum-containing compounds. A 69-year-old man with extensive small cell lung cancer and asymptomatic cardiovascular and cerebrovascular disease was inconsistently adherent to his medication regimen. While undergoing carboplatin infusion, he developed atrial flutter. He had no other immediate arrhythmogenic causes of atrial flutter and the arrhythmia spontaneously reverted to sinus rhythm after 24 hours. His condition remained stable until he died 8 days later. The cause of death was unknown and the family declined postmortem examination. Although this patient's cardiac history and nonadherence to his medications may have increased his susceptibility to develop atrial arrhythmias, the Naranjo probability scale reveals a possible relationship between atrial flutter and infusion of carboplatin. A literature search revealed other adverse cardiac events due to platinum compounds; however, to our knowledge, this case is the first to describe an association with atrial flutter. A definitive causal link cannot be determined, but this may have been the result of a direct arrhythmogenic effect of treatment or to a novel hypersensitivity reaction. Given the potential deleterious impact of drug-induced arrhythmias, we have reported this case to the Food and Drug Administration as a new adverse effect of carboplatin. Providers should consider cardiac monitoring during carboplatin infusion in patients with known cardiac disease or at high risk of cardiac complications.

Perioperative cardiac evaluation, monitoring, and risk reduction strategies in noncardiac surgery patients

Cardiac complications after noncardiac surgery cause significant morbidity and mortality. This review will discuss recent developments in risk stratification, monitoring, and risk reduction strategies. The addition of biomarkers for ischemia, left ventricular function, and atherosclerosis to classic cardiac risk factors improves the prediction of both short-term and long-term outcome after noncardiac surgery. Intraoperative monitoring, using continuous 12-lead ECG assessment and transesophageal echocardiography, may timely identify treatable myocardial ischemia and arrhythmias. A prudent perioperative beta-blocker and statin regimen can reduce cardiac complications and mortality without increasing the risk of stroke in intermediate to high-risk patients. The use of circulatory assist devices might improve outcomes after major surgery in patients with severely reduced left ventricular function. Systematic preoperative assessment can identify patients at high risk of cardiac complications and guide the application of appropriate risk reduction strategies.

Mise au point sur les ß-bloquants en 2009 dans la prévention des infarctus du myocarde péri-opératoire

The peri-operative management of patients at high risk of cardiac complications consists in preoperative cardiac risk evaluation (stratification), in adequate peri-operative monitoring and in the management of cardioprotective treatments. Betablockers reduce cardiac oxygen consumption and the impact of rapidly changing physiologic responses during the stressful peri-operative period through their negative inotropic and chronotropic effects. On the contrary, the adverse effects of ß-blocker therapy such as bradycardia or hypotension may increase the risk of stroke and impair the long-term outcome. The results of some recent studies incite us to be careful in the peri-operative use of betablockers. The efficacy of peri-operative ß-blocker therapy appears to be related to the cardiac risk (Lee score ≥ 2), to a tight heart rate control achieved with titration of doses and to the correction of episodes of hypotension. The 2006 and 2007 ACC/AHA guidelines on perioperative ß-blocker therapy and management of patients with coronary artery disease are still valid. However, we have to wait to the results of recent large trials on betablockers to update the current recommendations.

Myelodysplastic Syndrome (MDS)-Specific Comorbidity Index for Predicting the Impact of Extra-Hematological Comorbidities on Survival of Patients with MDS

Myelodysplastic syndromes (MDS) occur mainly in older persons, who are likely to be affected with extra-hematological comorbidities. Recent findings suggest that proper assessment of comorbidities is useful to predict the outcome of MDS patients receiving allogeneic transplantation. However, the results obtained in this highly selected subset of patients cannot be applied to the whole MDS population. In this study, we evaluated the impact of extra-hematological comorbidities on the natural history of MDS with the aim of developing a specific prognostic index. The patients comprised a “learning cohort”, in which we defined the set of variables to be included in the prognostic model and their weighted scores, and a “validation cohort”, in which we confirmed the prognostic value of the scoring system. The learning cohort included 840 MDS patients diagnosed at the Fondazione IRCCS Policlinico San Matteo, Pavia, Italy, between 1992 and 2006, while the validation cohort consisted of 504 patients seen at the Heinrich-Heine-University Hospital, Duesseldorf, Germany, between 1982 and 2006. All cases were classified according to the WHO criteria. Patients who underwent allogeneic transplantation or intensive chemotherapy were censored at the time of the procedure. One or more comorbidities were present in 455 (54%) patients in the learning cohort at the time of diagnosis: the older the age, the higher the prevalence. Cardiac disease was the most frequent extra-hematological morbidity (25% of patients) and the main cause (63%) of non-leukemic death (NLD). In a Cox multivariable analysis with time-dependent covariates, the onset of a comorbidity significantly affected the risk of NLD (HR=2.29, P<.001) and worsened overall survival (OS, HR=1.51, P=.01). Patients who developed RBC transfusion-dependency had a significantly higher risk of NLD (HR=4.31 P=<.001), cardiac disease and death (HR 4.16 and HR 4.88, respectively; P=<.001). In this group, serum ferritin levels were significantly associated with the risk of cardiac disease and death (P=.001). The onset of cardiac, liver, renal, pulmonary disease and solid tumor were found to independently affect the risk of NLD in a multivariable Cox regression (HR from 3.57 to 1.97; P values from <0.001 to 0.04). Based on these results, we developed a dynamic prognostic model (MDS-specific comorbidity index, MDS-CI) for predicting the effect on NLD and OS of comorbidities either present at the time of diagnosis or occurring during the follow-up. Risk scores for each comorbidity were estimated from the regression coefficients (Table 1).Table 1. MDS-specific comorbidity index (MDS-CI)ComorbidityScoreCardiac disease2Moderate-to-severe hepatic disease1Severe pulmonary disease1Renal disease1Solid tumor1Risk groups: Low (score 0), Intermediate (score 1–2), High (score >2).MDS-CI allowed us to identify 3 groups of patients with different probability of NLD and OS (P<.001). The prognostic value of the MDS-CI was then evaluated in the validation cohort of patients, where the 3 MDS-CI risk groups showed significantly different probabilities of NLD (P<.001) and OS (P=.005), with a 2-year risk of NLD since diagnosis of 24%, 42% and 61% in the low, intermediate and high risk group, respectively. In summary, extra-hematological comorbidities significantly worsen the natural history of MDS patients, specifically increasing the risk of NLD. In particular, transfusion-dependency and secondary iron overload are associated with a higher risk of cardiac complications. The MDS-CI improves our ability to stratify the outcome of MDS patients and may be a useful tool for clinical decision-making. An accurate evaluation of extra-hematological comorbidity should be part of the prognostic assessment of patients with MDS.

Risk factors for cardiovascular complications following total joint replacement surgery

To determine risk factors for cardiac complications following total joint replacement (TJR) surgery. We performed a case-control study of patients who had undergone a primary or revision total knee or total hip replacement surgery. Cases consisted of those who received a TJR and experienced a cardiac complication during the surgical admission period (myocardial infarction [MI], congestive heart failure [CHF], unstable angina, arrhythmia, symptomatic hypotension, or pulmonary embolus). Controls consisted of those who received a TJR and did not experience a cardiac complication during the surgical admission period. Controls were matched to the cases for age at surgery, year of surgery, and surgeon. Case and control status and identification of potential risk factors were ascertained by review of medical records. Conditional logistic regression analysis was used to identify independent predictors of cardiac complications. The sample included 209 cases and 209 controls. Factors associated with a higher risk of cardiac complications included a history of arrhythmia (adjusted odds ratio [OR] 2.6 [95% confidence interval (95% CI) 1.5-4.3]), a history of coronary artery disease, MI, CHF, or valvular heart disease (OR 1.6 [95% CI 0.9-2.6]), revision surgery (OR 2.2 [95% CI 1.2-3.9]), and bilateral surgery (adjusted OR 3.5 [95% CI 1.6-8.0]). Even though controls were matched for age (within age brackets), age was still associated with a higher risk of cardiac complications (OR 1.7 [95% CI 0.9-3.4]). This case-control study identified 2 new risk factors for cardiac complications following TJR: bilateral and revision surgery. The study also confirmed previously documented risk factors, including older age at surgery and a history of arrhythmia and of other cardiac problems. These findings should help clinicians anticipate and prevent cardiac complications following TJR surgery.

The Impact of Left Ventricular Systolic Dysfunction on Survival After Renal Transplantation

Gated single photon emission computed tomography (SPECT) provides information on myocardial perfusion and left ventricular ejection fraction (LVEF), which correlates with risk of cardiac events in patients with known or suspected coronary artery disease (CAD). We hypothesize that decreased LVEF at time of renal transplant evaluation is an independent risk factor for cardiac death and nonfatal events after transplant. A total of 653 recipients of renal allografts between 1998 and 2005 had stress SPECT imaging before transplantation. One hundred and nineteen (18%) patients had left ventricular (LV) systolic dysfunction (LVEF </=45%). The patients with LV dysfunction differed from the patients with normal LVEF having a higher proportion of males, smokers, left ventricular hypertrophy, previous left heart catheterization, and higher exposure to dialysis. During a mean follow-up of 3.01+/-1.86 years postrenal transplant, 66 patients died and 67 additional patients experienced at least one nonfatal cardiac-related complication. Patients with LV systolic dysfunction were at considerably higher risk for cardiac complications (hazard ratio [HR] 1.8, P=0.01) and all-cause mortality (HR 2.0, P=0.01) after transplantation. By multivariate analysis, LV systolic dysfunction was associated with a 5-fold increase in the cardiac mortality risk, a 2-fold increase in all-cause mortality risk, and a 70% increase in posttransplant cardiac complications. Systolic dysfunction is associated with increased risk for overall and cardiac-related death and nonfatal events after renal transplantation, an association independent of ischemic disease.

Impact of &amp;#946;-blocker treatment and nutritional status on glycemic response during exercise in patients with type 2 diabetes

Most individuals with type 2 diabetes are affected by hypertension and thus have higher risk of cardiac complications. In addition to behavioural modifications, such as healthy food choices and regular physical activity, beta-blocker treatment may be considered to reduce morbidity and mortality, especially after a cardiovascular event. However, this medication is generally associated with a deleterious impact on glucose metabolism. The objective of the study was to assess the impact of beta-blocker treatment on glucose response during exercise in patients with type 2 diabetes, free of cardiovascular complications. Ten sedentary men, treated with diet and/or hypoglycemic agents have performed four exercise sessions at 60% of their V O2peak, in the fasted state or 2 hours following a standardized breakfast, with and without beta-blockers (atenolol 100 mg id for five consecutive days). Blood samples were drawn during the resting period, at 15-min intervals during the exercise session and during the recovery period. A reduction of blood glucose levels was observed following the exercise session in the postprandial state (48% and 44% reduction with and without beta-blockers respectively; P < 0.001). One hour of exercise performed in the fasted state had a minimal impact on glucose and insulin levels, whether with or without beta-blockers. beta-blocker treatment was not associated with increased baseline blood glucose or insulin levels in the fasted or the postprandial situation. Dietary status has a more important impact on plasma glucose and insulin modulation than short-term use of beta-blockers.

Impact of Beta-Blocker Treatment and the Nutritional Status on Glycemic Response During Exercise in Type 2 Diabetic Patients

Background/Objective: More than 60% of type 2 diabetic individuals present with hypertension and have higher risk of cardiac complications. In addition to behavioural modifications, such as healthy food choices and regular physical activity, beta-blocker (BB) treatment may be considered in order to reduce morbidity and mortality especially following a cardiovascular event. However, this medication is generally associated with a deleterious impact on glucose metabolism. To assess the impact of a BB treatment on glucose response in type 2 diabetic patients exempt of cardiovascular complications. &#x0D; &#x0D; Methods: Six sedentary men, treated with diet and/or a hypoglycemic agent performed four exercise sessions at 60% of their VO2 peak, in the fasted state or 2 hours after a standardized breakfast, with and without BB (Atenolol 100 mg id for five consecutive days). Blood samples were assayed during the resting period, at 15-minutes intervals during the exercise session and the recovery period. &#x0D; &#x0D; Results: A reduction of blood glucose levels was observed following the exercise session performed in the postabsorptive state (41% and 37% reduction with and without BB treatment respectively; P &lt; 0.01). One hour of exercise performed in the fasted state had minimal impact on glucose and insulin levels, with or without BB. BB treatment was not associated with increased baseline blood glucose or insulin levels in the fasted or the postabsorptive situation. &#x0D; &#x0D; Conclusion: These results suggest that the nutritional status has a more important impact on plasma glucose and insulin modulation than short-term use of BB per se.

Kasuistik interaktiv - Kreislaufdepression bei Narkoseeinleitung

Patients with coronary artery disease (CAD) undergoing noncardiac surgery (NCS) pose a special challenge for the anaesthesiologist, as the risk of serious perioperative cardiac complications, which represent a significant cause of morbidity and mortality, is increased in this population. Here we report about a patient with a solitary liver metastasis, who was admitted for hemihepatectomy. The patient with a known single vessel CAD, reporting no current cardiac problems, was cleared for the surgical procedure which carries a high risk of cardiac complications. Cardiology reports were present for evaluation. After an unremarkable placement of the peridural catheter and endotracheal intubation the patient presented with bradycardia and hypotension. Pharmacological resuscitation was initiated. After the patient was stabilized and the differential diagnosis suggested a cardiac problem, surgery was postponed. Following the end of anaesthesia, the patient remained in stable condition without catecholamine support. Coronary angiography on the next day revealed a progression of the CAD. The peridural catheter was removed before the intervention, Aspirin and clopidogrel were given on the same day. The patient was operated successfully without complications six weeks after the coronary intervention.

Lessons learned from a randomised controlled study of perioperative beta blockade in high risk patients undergoing emergency surgery

Perioperative beta blockade has been shown to reduce mortality after major elective surgery. The aim of this study was to determine whether it could reduce the rate of death and morbidity from cardiac complications in high risk patients undergoing emergency surgery. Over a one-year interval all patients undergoing major non-elective orthopaedic or general surgery were screened to identify those at high risk of cardiac complications. Consenting, high risk patients were randomly allocated atenolol or placebo for seven days, commencing at anaesthetic induction. Deaths and cardiac complications within 30 days were recorded. Some 2351 patients had an emergency operation; 145 were at high risk and eligible for the study. Of 89 patients approached, 57 initially consented. Only 38 patients, however, completed the study protocol, 19 were withdrawn. Of those who completed the study, 5/20 patients in the placebo group and 3/18 in the treatment group died before hospital discharge (p=0.520). Four others in the placebo group and two in the atenolol group had post-operative non-fatal cardiac events (positive troponin T), p=0.311. This study of emergency surgery proved more difficult than similar trials in elective surgery. The final study groups were small and there were no significant differences in outcomes. A much larger study is required for a definitive answer.

Perioperative cardiac risk reduction: doing it right.

arious interventions to reduce the risk of cardiac complications during surgery have been proposed. This article evaluates the evidence for these preventive approaches, examines methods of incorporating new and conflicting evidence into a coherent clinical approach, and reviews systems for successfully implementing evidence-based interventions in the hospital. ■ APPROACHES FOR PREVENTING CARDIAC COMPLICATIONS With revascularization reserved as a preventive measure for those patients at extremely high risk of cardiac complications, other less invasive preventive approaches should be considered. Maintenance of normothermia One preventive approach is maintenance of normal body temperature. In a randomized, controlled clinical study of 300 patients with or at high risk for coronary disease who underwent major abdominal or vascular surgery, supplemental warming care was associated with a significant (P = .02) reduction in perioperative morbid cardiac events compared with routine thermal care. 1 The risk of supplemental warming is low and the potential reward is high; in addition to the reduction in cardiac complications, patients randomized to normothermia in this study had a lower rate of surgicalsite infections, less nausea, and better pain control. Calcium channel blocker therapy A recent meta-analysis 2 demonstrated a significant reduction in adverse coronary endpoints with the use of calcium channel blockers, compared with placebo, as preventive therapy in patients undergoing various types of surgery. This reduction in the risk of events, however, was driven entirely by a significant reduction in the incidences of ischemia and supraventricular tachycardia, with no effect of calcium channel blockers on perioperative myocardial infarction (MI) or death. The largest reductions in risk with calcium channel blockers occurred in patients undergoing thoracic surgery. In most of the studies in which a favorable effect of calcium channel blockers was observed, patients were on concomitant beta-blockade that was not adequately controlled for, which obscures interpretation of the meta-analysis. For these reasons, calcium channel blockers should not be considered firstline therapy as a preventive strategy.

QTc Variability in Schizophrenia Patients Treated With Antipsychotics and Healthy Controls

QTc prolongation is associated with the administration of some antipsychotics but the QTc interval is also known to vary physiologically. There is little published evidence about changes in QTc variability during treatment with antipsychotics. In this prospective investigation, we analyzed ECGs in 61 patients suffering from a schizophrenic disorder who were treated with different antipsychotics and 31 sex- and age-matched healthy controls. We found no differences in QTc intervals nor in QTc variability between patients and controls. Our results raise the question of the clinical relevance of a single ECG for diagnostics of cardiac complications in schizophrenia patients and suggest the need to conduct ECG monitoring in patients at high risk for cardiac complications during antipsychotic treatment.

Impact of prolonged elevated heart rate on incidence of major cardiac events in critically ill patients with a high risk of cardiac complications*

To assess the incidence of major cardiac events in critically ill patients with a high risk of cardiac complications presenting with an elevated heart rate. Observational, retrospective study in a 15-bed medical/surgical Intensive Care Unit (ICU) at a university hospital for a period of 12 months. We studied patients with a high risk of cardiac complications, according to the revised Goldman index, who were treated for at least 36 hrs in the ICU. Patients presenting with prolonged elevated heart rate, defined as a heart rate >95 beats/min for >12 hrs in at least one 24-hr period of their ICU stay, were investigated. Cardiac high-risk patients not developing this criterion served as controls. Major cardiac events, defined as nonfatal myocardial infarction, nonfatal cardiac arrest, and cardiac related death, were the primary outcome measures. From a total of 791 patients, 69 patients were assessed as cardiac high-risk patients. Of 39 patients with prolonged elevated heart rates, 19 (49%) sustained major cardiac events, whereas in the control group of 30 patients, only four patients (13%) had a major cardiac event (p = .002; odds ratio, 6.2). Patients with elevated heart rate had to be treated 4.5 days longer in the ICU (p = .01), whereas the ICU and 30-day post-ICU discharge survival rates did not differ significantly. In this study, we provide evidence for an increased incidence of major cardiac events in critically ill, cardiac high-risk patients with a prolonged elevated heart rate during their ICU stay. In addition, elevated heart rate was associated with a significantly longer ICU stay.

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.

A Large Trial Is Vital to Prove Perioperative β-blockade Effectiveness and Safety before Widespread Use

A Large Trial Is Vital to Prove Perioperative β-blockade Effectiveness and Safety before Widespread Use

Prediction of cardiac risk prior to elective abdominal aortic surgery: role of multiple gated acquisition scan.

Debate continues regarding the value of cardiac testing before major vascular surgery. Studies looking at whether a low radioisotope left ventricular ejection fraction (LVEF) could reliably predict postoperative cardiac events have produced conflicting results. Technetium-99m multiple gated acquisition (MUGA) scanning was employed in 122 patients undergoing elective abdominal aortic aneurysm surgery to estimate the resting LVEF and to detect regional or global myocardial wall motion abnormalities (WMAs). Adverse cardiac outcomes were predicted using logistic regression analysis. Among this group of patients, 20 did not proceed to surgery for a variety of reasons, and 102 underwent surgical repair. More than half of the patients (55%) had a history of cardiac disease. The mean +/- SD LVEF was 55.5% +/- 11.1%. Altogether, 31 patients had WMAs, and 21 had both WMAs and an abnormal LVEF (< or = 50%). Altogether, 20 cardiac complications were encountered in 17 patients (17%). Logistic regression analysis identified four significant predictors of cardiac complications: history of cardiac disease [odds ratio (OR) 10.43; 95% confidence interval (CI) 1.3 and 80.5], the presence of WMAs (OR 10.1, CI 1.4 and 74.6), additional procedures (OR 12.1, CI 1.4 and 103.0), and reoperation during the postoperative period (OR 6.4, CI 1.4 and 30.4). This is the largest reported British series of cardiac testing using MUGA scans prior to abdominal aortic reconstruction. Only the presence of WMAs (not the resting LVEF) was useful for predicting postoperative cardiac events. A history of cardiac disease, additional procedures, and reoperation during the postoperative period also place a patient at high risk for cardiac complications. A normal LVEF is by no means reassuring that a patient is at low risk of suffering an adverse cardiac outcome.

Prediction of cardiac risk before abdominal aortic reconstruction: Comparison of a revised Goldman Cardiac Risk Index and radioisotope ejection fraction

Background: A revised Goldman Cardiac Risk Index has been suggested to identify patients at higher risk for cardiac complications in patients who undergo major noncardiac surgery. The aim of this study was to test the usefulness of this model in an independent series of patients who underwent abdominal aortic surgery and to compare the index with the multiple gated acquisition (MUGA) scan in the prediction of cardiac complications. Methods: We studied 77 patients who underwent MUGA scan before elective abdominal aortic reconstruction. The revised index was calculated for each patient after recording the following five risk factors: history of ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin-dependent diabetes, and creatinine level more than 2 mg/dL. Technetium-99m MUGA scan provided information about the resting left ventricular ejection fraction (LVEF) and the presence of regional wall motion abnormalities. Results: Fourteen patients (18%) had cardiac complications develop. The index proved to be a satisfactory predictor of postoperative cardiac events (P =.008), and an abnormal LVEF failed to do so (P =.1). The presence of wall abnormalities, with or without an abnormal LVEF, predicted cardiac complications (P =.004 and P =.006). Patients with a higher index score showed a tendency to have a lower LVEF (Spearman rank correlation, r = −0.43; P <.001). Wall abnormalities, with or without an abnormal LVEF, were more frequent in patients with higher scores (P =.03 and P =.009). Combining the index with the LVEF or the wall abnormalities or both could further stratify the cardiac risk (P =.004, P =.0003 and P =.0006, with χ2 test for trend). Conclusion: For those patients who undergo elective abdominal aortic surgery, the revised Goldman Cardiac Risk Index is a simple method of evaluating cardiac risk with minimum resource implications. MUGA scan can offer additional stratification in patients judged with the index to be at high risk. (J Vasc Surg 2002;35:943-9.)

Adverse cardiac events after surgery: assessing risk in a veteran population.

To establish rates of and risk factors for cardiac complications after noncardiac surgery in veterans. Prospective cohort study. A large urban veterans affairs hospital. One thousand patients with known or suspected cardiac problems undergoing 1,121 noncardiac procedures. Patients were assessed preoperatively for important clinical variables. Postoperative evaluation was done by an assessor blinded to preoperative status with a daily physical examination, electrocardiogram, and creatine kinase with MB fraction until postoperative day 6, day of discharge, death, or reoperation (whichever occurred earliest). Serial electrocardiograms, enzymes, and chest radiographs were obtained as indicated. Severe cardiac complications included cardiac death, cardiac arrest, myocardial infarction, ventricular tachycardia, and fibrillation and pulmonary edema. Serious cardiac complications included the above, heart failure, and unstable angina. Severe and serious complications were seen in 24% and 32% of aortic, 8.3% and 10% of carotid, 11.8% and 14.7% of peripheral vascular, 9.0% and 13.1% of intraabdominal/intrathoracic, 2.9% and 3.3% of intermediate-risk (head and neck and major orthopedic procedures), and 0.27% and 1.1% of low-risk procedures respectively. The five associated patient-specific risk factors identified by logistic regression are: myocardial infarction < 6 months (odds ratio [OR], 4.5; 95% confidence interval [CI], 1.9 to 12.9), emergency surgery (OR, 2.6; 95% CI, 1.2 to 5.6), myocardial infarction > 6 months (OR, 2.2; 95% CI, 1.4 to 3.5), heart failure ever (OR, 1.9; 95% CI, 1.2 to 3.0), and rhythm other than sinus (OR, 1.7; 95% CI, 0.9 to 3.2). Inclusion of the planned operative procedure significantly improves the predictive ability of our risk model. Five patient-specific risk factors are associated with high risk for cardiac complications in the perioperative period of noncardiac surgery in veterans. Inclusion of the operative procedure significantly improves the predictive ability of the risk model. Overall cardiac complication rates (pretest probabilities) are established for these patients. A simple nomogram is presented for calculation of post-test probabilities by incorporating the operative procedure.

Setting a New Gold Standard

Setting a New Gold Standard

The high-risk surgical patient and the role of preoperative management

Reducing the risk in high-risk surgical patients is a common effort of surgeons, anesthesiologists and internists. Several definitions of high-risk surgery exist and one should differentiate the risk for the development of shock and multiple organ dysfunction syndrome from explicitly cardiac risk. Insufficient tissue, especially splanchnic, perfusion can lead to a cascade with the liberation of cytokines and adhesion molecules. Ensuring adequate tissue perfusion is therefore of utmost importance. Assessing tissue perfusion and recognizing hypovolemia is, however, a difficult task using only standard clinical signs as blood pressure and heart rate. Several studies where high-risk surgical patients were treated preoperatively with fluid infusions and/or vasoactive drugs, mainly as determined by invasive monitoring, have shown a positive effect on outcome. On the other hand the value of β-blockade, started preoperatively, in selected patients at high risk for cardiac complications is accumulating and convincing. The author therefore suggests to aim for targets of therapy based on multiple baseline values for each individual patient. The author also calls for stopping the practice, as is still the case in many hospitals, to leave the patients the night before surgery with an overnight fast, without an intravenous infusion with the appropriate amounts of fluids. However, it is concluded that the definition of ‘appropriate’ is currently still a matter of opinion and not facts.