Perioperative Cardiovascular Research Articles

Präoperative Vorbereitung von Patienten mit Herz- und Gefäßkrankheiten für nicht-herzchirurgische Eingriffe

Preoperative preparation of patients with cardiovascular disease is best initiated by the general practitioner. Updated Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery have been published by the American Heart Association und American College of Cardiology (2007). Individual cardiac evaluation must take into account active cardiac conditions, functional capacity, additional clinical risk factors and surgical risk. Stable, asymptomatic patients with normal functional capacity can proceed to elective anesthesia and surgery without further cardiac evaluation. Active cardiac conditions require evaluation and treatment by a cardiology service prior to elective surgery. In stable patients with poor (<4 metabolic equivalents, MET) or unknown functional capacity and clinical risk factors, who are scheduled for intermediate- or high-risk surgery, further cardiac evaluation and preparation is to be considered. Established indicated beta blocker and statin medication is to be continued; timely institution of beta blocker medication (target heart rate, <65 bpm) may be required depending on the risk of surgery, the presence of coronary heart disease, and the number of clinical risk factors present. Following percutaneous coronary intervention, specific waiting periods are required prior to elective surgery. In patients on antiplatelet therapy, the risk of stopping it should be weighed against the benefit of reduction in bleeding complications from the planned surgery.

Prevention of acute coronary events in noncardiac surgery: β-blocker therapy and coronary revascularization

During major vascular surgery, patients are at high risk for developing myocardial infarction and myocardial ischemia, and two risk-reduction strategies can be considered prior to surgery: pharmacological treatment and prophylactic coronary revascularization. β-blockers are established therapeutic agents for patients with hypertension, heart failure and coronary artery disease. There is still considerable debate concerning the protective effect of β-blocker therapy towards perioperative coronary events, which will be outlined in this article. Two randomized, controlled trials suggest that coronary revascularization of cardiac-stable patients provides no benefits in the postoperative outcomes. In the current American College of Cardiology/American Heart Association guidelines for ‘Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery’, routine prophylactic coronary revascularization is not recommended in patients with stable coronary artery disease. However, a recent retrospective, observational study suggests that intermediate-risk patients may benefit from preoperative coronary revascularization. The present article provides an extended overview of leading observational studies, randomized, controlled trials, meta-analyses and guidelines assessing perioperative β-blocker therapy and prophylactic coronary revascularization.

Abnormal aortic-to-radial arterial pressure gradients resulting in misdiagnosis of hemodynamic instability

This Perioperative Cardiovascular Rounds article features a common cause of perceived hemodynamic instability resulting from abnormal aortic-to-radial arterial pressure gradients. The possible mechanisms and the diagnostic criteria are considered. Permission was obtained from the Research Ethics Board of the Montreal Heart Institute to archive this article into a databank for educational purposes and to reproduce the anonymized echocardiographic images for publication. A 69-year-old patient with no clinical evidence of subclavian steal underwent uneventful open replacement of the mitral and aortic valves. Following the bivalvular replacement, it was difficult to wean the patient from cardiopulmonary bypass (CPB). Despite normal filling pressures and an infusion of noradrenaline 30 lg min, the mean arterial pressure at the end of CPB was only 75 mmHg. A transesophageal echocardiographic examination was performed to establish the cause of the perceived hemodynamic instability. The examination revealed preserved left and right ventricular systolic function, no valvular abnormalities, and no reason for the apparent hypotension. With assistance from the surgeon, a new cannula was transduced into the aortic root, and a large aortic-to-radial arterial pressure gradient was identified. The radial artery pressure was 86/77/69 mmHg (systolic, mean, diastolic) while the aortic root pressure was 132/107/92 mmHg (Fig. 1). In light of the 46 mmHg systolic pressure gradient, the patient was rapidly weaned from vasoactive support using the aortic root pressure as a guide, followed by easy separation from CPB. This scenario can be commonly observed in the cardiac operating room (Fig. 1) and in the intensive care unit (Fig. 2, Supplementary Video #1) in patients who are thought to be hemodynamically unstable. Despite previous descriptions of these observations, the mechanisms responsible for this abnormal pressure gradient remain poorly understood and its occurrence is not routinely recognized. The pressure gradient between the aortic root and the radial artery is normally\20 mmHg, being higher in the distal arteries. In our clinical experience, an aortic root-to-radial artery systolic pressure gradient [25 mmHg occurs in approximately 30–50% of cardiac procedures. Such pressure gradients typically manifest during the

Adjusting clinical prediction rules: an academic exercise or the potential for real world clinical applications in perioperative medicine?

To some, the subject of clinical prediction rules would seem an arcane exercise of limited utility to the everyday clinical anesthesiologist. Nothing could be further from the truth. Clinical prediction rules are plentiful and are in wideranging use in everyday practice. The American Society of Anesthesiologists’ physical status classification is one of the most widely used indices of preoperative physical status, and is easy to commit to memory. Thus, it has stood the test of time. Remarkably, it was introduced into everyday practice with little in the way of derivation, validation, or testing, yet it has been proven to perform as well as the Original (Goldman) Cardiac Risk Index, the Detsky Index, or the Revised Cardiac Risk Index. The Revised Cardiac Risk Index (RCRI) was derived from a cohort of 4,315 patients to predict the incidence of major cardiac morbidity in patients over the age of 50. In the validation set of 1,422 patients, the all-cause mortality doubled, due mostly to increased morbidity in the higher risk population, and the calibration of the index improved significantly. In addition, in the revised index, the coefficients of two risk factors identified from the validation set, diabetes and renal dysfunction, were subsequently found to no longer be significant. These observations highlight just a few of the issues involved with the application of clinical prediction rules. Despite the fact that the RCRI has been utilized in many cohort studies to risk-adjust patients, this index has yet to be externally validated. The performance of the RCRI was reported in a recent meta-analysis of 16 trials reporting on a total of 791,282 patients. This report found that the RCRI performs poorly (receiver operator characteristic [ROC] values of 0.630 compared to the original validation set value of 0.8). There are a number of reasons why the RCRI does not perform as well in ‘‘real life’’, including differences in the frequency of outcomes. In the derivation paper, the mortality was 1%, approximately half of that observed in the largest cohort study utilizing the RCRI, where the mortality rate was found to be 2%. Furthermore, there may have been different factors being applied. One factor in the derivation cohort was insulin-treated diabetes, which is now largely regarded as diabetes with or without insulin therapy. The original definition was renal dysfunction, defined as a serum creatinine concentration [176 mmol L. However, this definition has not been universally applied. Despite these important shortcomings, i.e., changes in the ROC between derivation and validation, the lack of external validation, or the findings that the RCRI loses accuracy when performed outside the original institution, the RCRI has been incorporated into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Non-cardiac Surgery. Thus, the RCRI has become an integral part of what now constitutes the ‘‘standard of care’’ for patients having non-cardiac surgery. Therefore, by default, any clinician involved in the evaluation of patients prior to non-cardiac surgery should have an understanding of the workings and limitations of this clinical prediction tool. Given the limitations of clinical prediction rules, the statement would also imply that the clinician should know the incidence of important outcomes and have the tools necessary to calibrate the instrument. P. M. A. Brasher, PhD (&) Centre for Clinical Epidemiology and Evaluation, VCH Research Institute, University of British Columbia, 828 West 10th Avenue, Vancouver, BC V5Z 1L8, Canada e-mail: brasher@interchange.ubc.ca

Statins to Prevent Perioperative Cardiovascular Events

Rupture of coronary plaque probably accounts for half of perioperative myocardial infarctions. Because statins have plaque-stabilizing effects, they are plausible candidates for preventing perioperative MIs. In the industry-supported DECREASE-III trial, Dutch researchers randomized 497 statin-naive patients scheduled for elective vascular surgery (carotid, aortic, or lower extremity) to receive daily extended-release …

Anemia as an Independent Predictor of Perioperative and Long-term Cardiovascular Outcome in Patients Scheduled for Elective Vascular Surgery

Anemia as an Independent Predictor of Perioperative and Long-term Cardiovascular Outcome in Patients Scheduled for Elective Vascular Surgery

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

Anemia as an Independent Predictor of Perioperative and Long-Term Cardiovascular Outcome in Patients Scheduled for Elective Vascular Surgery

Anemia is common in patients scheduled for vascular surgery and is a risk factor for adverse cardiac outcome. However, it is unclear whether this is an independent risk factor or an expression of underlying co-morbidities. In total, 1,211 patients (77% men, 68 +/- 11 years of age) were enrolled. Anemia was defined as serum hemoglobin levels <13 g/dl for men and <12 g/dl for women and was divided into tertiles to compare mild (men 12.2 to 13.0, women 11.2 to 12.0), moderate (men 11.0 to 12.1, women 10.2 to 11.1), and severe (men 7.2 to 11.0, women 7.5 to 10.1) anemia with nonanemia. Outcome measurements were 30-day and 5-year major adverse cardiac events (MACEs; cardiac death or myocardial infarction). All risk factors were noted. Multivariable logistic and Cox regression analyses were used, adjusting for all cardiac risk factors, including heart failure and renal disease. Data are presented as hazard ratios with 95% confidence intervals. In total, 74 patients (6%) had 30-day MACEs and 199 (17%) had 5-year MACEs. Anemia was present in 399 patients (33%), 133 of whom had mild anemia, 133 had moderate anemia, and 133 had severe anemia. Presence of anemia was associated with renal dysfunction, diabetes, and heart failure. After adjustment for all clinical risk factors, 30-day hazard ratios for a MACE per anemia group were 1.8 for mild (0.8 to 4.1), 2.3 for moderate (1.1 to 5.4), and 4.7 for severe (2.6 to 10.9) anemia, and 5-year hazard ratios for MACE per anemia group were 2.4 for mild (1.5 to 4.2), 3.6 for moderate (2.4 to 5.6), and 6.1 for severe (4.1 to 9.1) anemia. In conclusion, the presence and severity of preoperative anemia in vascular patients are significant predictors of 30-day and 5-year cardiac events, regardless of underlying heart failure or renal disease.

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

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

Abstract 3702: Anemia as an Independent Predictor of Perioperative and Long Term Cardiovascular Outcome in Patients Scheduled for Elective Vascular Surgery

BACKGROUND: Anemia has been shown to be an independent risk factor for adverse cardiac outcome in various populations. This study evaluated the predictive value of anemia in patients scheduled for elective vascular surgery. METHODS: In total, 1211 patients (76% male, age 68 ± 11 yrs) were enrolled. Anemia was defined as serum hemoglobin &lt; 13 g/dL for men and &lt; 12 g/dL for women, as defined by WHO. Anemia was divided into tertiles to compare mild, moderate and severe anemia with non-anemic patients. Outcome measures were 30-day and 5-year cardiac events (CE) (cardiac death or myocardial infarction). Mean follow up was 3.4 ± 3.2 years. Multivariable linear and Cox regression analysis was used, adjusting for age, sex, type of surgery and baseline characteristics, including angina, myocardial infarction, heart failure, diabetes and renal failure. Data are presented as HRs, with 95% confidence intervals. RESULTS: In total, 74 (6%) patients experienced a 30-day CE and 199 (16%) a 5-year CE. Anemia was present in 399 (33%) patients, of which 133 were mild, 133 moderate, and 133 severe anemia. The presence of anemia was associated with renal failure, diabetes and heart failure. CE free survival at 30 days and 5 years was worse for patients with anemia (Figure ). After adjustment for all clinical risk factors, the 30-day HRs for a CE per anemia group were; mild 1.8, 1.0 – 4.1, moderate 2.9, 1.4 – 6.2, and severe 7.6, 4.1–13.1, and 5-year HRs for CE per anemia group were; mild 2.2, 1.3–3.8, moderate 3.6, 2.4 –5.6, and severe 6.6, 4.6 –9.6. CONCLUSION: The presence and severity of preoperative anemia are significant predictors of 30-day and 5-year cardiac events in patients undergoing elective vascular surgery.

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.

Adrenergic Receptor Genotype but Not Perioperative Bisoprolol Therapy May Determine Cardiovascular Outcome in At-risk Patients Undergoing Surgery with Spinal Block

Neuraxial blockade is used as primary anesthetic technique in one third of surgical procedures. The authors tested whether bisoprolol would protect patients at risk for cardiovascular complications undergoing surgery with spinal block. The authors performed a double-blinded, placebo-controlled, multicenter trial to compare the effect of bisoprolol with that of placebo on 1-yr composite outcome including cardiovascular mortality, nonfatal myocardial infarction, unstable angina, congestive heart failure, and cerebrovascular insult. Bisoprolol was given orally before and after surgery for a maximum of 10 days. Adrenergic receptor polymorphisms and safety outcome measures of bisoprolol therapy were also determined. A total of 224 patients were enrolled. Spinal block could not be established in 5 patients. One hundred ten patients were assigned to the bisoprolol group, and 109 patients were assigned to the placebo group. The mean duration of treatment was 4.9 days in the bisoprolol group and 5.1 days in the placebo group. Bisoprolol therapy reduced mean heart rate by 10 beats/min. The primary outcome was identical between treatment groups and occurred in 25 patients (22.7%) in the bisoprolol group and 24 patients (22.0%) in the placebo group during the 1-yr follow-up (hazard ratio, 0.97; 95% confidence interval, 0.55-1.69; P = 0.90). However, carriers of at least one Gly allele of the beta1-adrenergic receptor polymorphism Arg389Gly showed a higher number of adverse events than Arg homozygous (32.4% vs. 18.7%; hazard ratio, 1.87; 95% confidence interval, 1.04-3.35; P = 0.04). Perioperative bisoprolol therapy did not affect cardiovascular outcome in these elderly at-risk patients undergoing surgery with spinal block.

Perioperative Glucose Control and Cardiovascular Complications of the Cardiac Patient

Unless a cure is found, the number of patients suffering from diabetes mellitus (OM) and its co-morbidities will continue to rise. According to the World Health Organization, a diabetes epidemic is already underway. In 1985, an estimated 30 million people worldwide suffered from diabetes. By 2000 that number reached 177 million. By 2025, researchers project that DM will affect roughly 300 million people and result in approximately 4 million deaths per year, many from cardiovascular complications.1 According to Boyle et al., the number of Americans who are diagnosed with DM is projected to increase 165%, from 11 million in 2000 to 29 million in 2050.2 An increasing number of diabetic patients are presenting for anesthesia and surgery, which may translate to greater numbers of surgical patients at risk for ischemic heart disease. While OM has long been considered to be a significant predictor of perioperative cardiovascular morbidity and mortality, recent studies indicate that hyperglycemia, rather than diabetes, is responsible for adverse clinical outcomes. These studies imply that hyperglycemia is an independent predictor of perioperative cardiovascular risk, and that aggressive treatment of hyperglycemia may significantly decrease complications of myocardial ischemia and infarction.

Perioperative and Long-Term Cardiovascular Outcomes in Patients Undergoing Endovascular Treatment Compared With Open Vascular Surgery for Abdominal Aortic Aneurysm or Iliaco-Femoro-Popliteal Bypass

Perioperative and Long-Term Cardiovascular Outcomes in Patients Undergoing Endovascular Treatment Compared With Open Vascular Surgery for Abdominal Aortic Aneurysm or Iliaco-Femoro-Popliteal Bypass

The Impact of Non-Cardiovascular Surgery on Arterial Endothelial Function: Implication in Perioperative Cardiovascular Complications

The Impact of Non-Cardiovascular Surgery on Arterial Endothelial Function: Implication in Perioperative Cardiovascular Complications

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

Preoperative Exercise Echocardiography and Perioperative Cardiovascular Outcomes in Elderly Patients Undergoing Cancer Surgery

Limited information is available on the value of exercise echocardiography (EE) for identifying operative risk in elderly patients undergoing noncardiac surgery. The authors investigated the outcome in 221 consecutive patients 75 years and older who had EE before intermediate- or high-risk cancer surgery. Baseline clinical data, postoperative adverse cardiovascular events (PACE), and 30-day mortality were collected from the medical records and the Social Security Death Index. The mean age +/- SD of the group was 78.9+/-3.5 years; 57% were men. Significant cardiovascular abnormalities (by echocardiography) were present in 71.5%. Mean metabolic equivalents +/- SD achieved during exercise was 4.9+/-1.9. EE identified 50 (22.6%) patients with ischemia and/or infarction. Perioperative beta-blockers were used in 80% of patients with coronary artery disease vs 48.5% without coronary artery disease (P<.0001). There were 31 PACE in 26 (11.8%) patients. Atrial fibrillation was the most common PACE, seen in 18 (8.1%) patients, followed by congestive heart failure in 8 (3.6%), acute coronary syndrome in 2 (0.9%), and cardiac arrest in 1 (0.5%). Thirty-day mortality was only 0.9%. Hospital lengths of stay for patients with and without PACE were 16.8+/-14.9 and 8.5+/-4.8 days (P< or =.0001), respectively. An abnormal EE predicted PACE (22% vs 8.8%; P< .025). Perioperative beta-blockers reduced the incidence of postoperative atrial fibrillation (4.9% vs 12.2%; P=.052). In conclusion, EE is feasible in very elderly patients. There is a high prevalence of cardiac abnormalities in the elderly. An abnormal EE predicts PACE, which, in turn, is associated with increased length of stay.