Expired CME Article

Perioperative Cardiac Evaluation: Novel Interventions and Clinical Challenges

Authors: Donna L. Mercado, MD, David Y. Ling, MD, Gerald W. Smetana, MD

Abstract

Cardiac complications are one of the most important sources of morbidity and mortality after noncardiac surgery. In this review, we discuss the pathophysiology of postoperative cardiac complications and published risk indices and guidelines that allow an estimation of preoperative risk. Recent evidence has challenged the primary role of perioperative beta blockers as a risk reduction strategy. The highest level of evidence for their use is for patients with coronary artery disease or multiple risk factors undergoing vascular surgery. Beta blockers may provide no benefit or may be potentially harmful for low- and intermediate-risk patients and surgeries. For patients with contraindications to beta blockers, diltiazem and clonidine are alternative agents that reduce cardiac risk. Statins are emerging as another potential strategy to reduce cardiac risk, although the evidence is based primarily on retrospective analyses. Coronary artery revascularization does not reduce cardiac complications after noncardiac surgery among patients with stable coronary artery disease.


Key Points


* Postoperative cardiac complications are common and are a major cause of perioperative morbidity and mortality.


* The Revised Cardiac Risk Index and the American Heart Association/American College of Cardiology guidelines on preoperative cardiovascular evaluation each provide tools to estimate cardiac risk before surgery.


* Recent evidence has questioned the value of perioperative beta blockers; benefit remains likely for intermediate- and high-risk patients.


* Diltiazem, clonidine, and statins each may reduce risk in selected patients.


* Coronary revascularization does not reduce perioperative cardiac risk for patients with stable coronary artery disease.

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References

1. Poldermans D, Boersma E. Beta-blocker therapy in noncardiac surgery. N Engl J Med 2005;353:412–414.
 
2. Fleisher LA. Strategies to reduce cardiac risk in noncardiac surgery: where are we in 2005? Anesthesiology 2005;102:881–882.
 
3. Fleisher LA. Preoperative cardiac evaluation. Anesthesiol Clin North America 2004;22:59–75.
 
4. Ellis SG, Hertzer NR, Young JR, et al. Angiographic correlates of cardiac death and myocardial infarction complicating major nonthoracic vascular surgery. Am J Cardiol 1996;77:1126–1128.
 
5. Dawood MM, Gutpa DK, Southern J, et al. Pathology of fatal perioperative myocardial infarction: implications regarding pathophysiology and prevention. Int J Cardiol 1996;57:37–44.
 
6. Priebe HJ. Triggers of perioperative myocardial ischaemia and infarction. Br J Anaesth 2004;93:9–20.
 
7. Maddox TM. Preoperative cardiovascular evaluation for noncardiac surgery. Mt Sinai J Med 2005;72:185–192.
 
8. Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 1977;297:845–850.
 
9. Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery update: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). American College of Cardiology Web site. Available at: http://www.acc.org/qualityandscience/clinical/guidelines/perio/perioupdate_index.htm.
 
10. Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999;100:1043–1049.
 
11. Eagle KA, Rihal CS, Mickel MC, et al. Cardiac risk of noncardiac surgery: influence of coronary disease and type of surgery in 3368 operations. CASS Investigators and University of Michigan Heart Care Program. Coronary Artery Surgery Study. Circulation. 1997;96:1882–1887.
 
12. Reilly DF, McNeely MJ, Doerner D, et al. Self-reported exercise tolerance and the risk of serious perioperative complications. Arch Intern Med 1999:159:2185–2192.
 
13. Hlatky MA, Boineau RE, Higginbotham MB, et al. A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J Cardiol 1989;64:651–654.
 
14. Myers J, Do D, Herbert W, et al. A nomogram to predict exercise capacity from a specific activity questionnaire and clinical data. Am J Cardiol 1994;73:591–596.
 
15. Mangano DT, Layug EL, Wallace A, et al. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group. N Engl J Med 1996;335:1713–1720.
 
16. Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. N Engl J Med 1999;341:1789–1794.
 
17. Brady AR, Gibbs JS, Greenhalgh RM, et al. Perioperative beta-blockade (POBBLE) for patients undergoing infrarenal vascular surgery: results of a randomized double-blind controlled trial. J Vasc Surg 2005;41: 602–609.
 
18. Yang H, Raymer K, Butler R, et al. The effects of perioperative beta-blockade: results of the Metoprolol after Vascular Surgery (MaVS) study, a randomized controlled trial. Am Heart J 2006;152:815–818.
 
19. Juul AB, Wetterslev J, Gluud C, et al. Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial. BMJ 2006;24:1482–1485.
 
20. Lindenauer PK, Pekow P, Wang K, et al. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med 2005;353:349–361.
 
21. Devereaux PJ, Beattie WS, Choi PT, et al. How strong is the evidence for the use of perioperative beta blockers in non-cardiac surgery? Systematic review and meta-analysis of randomised controlled trials. BMJ 2005;331:313–321.
 
22. Boersma E, Poldermans D, Bax JJ, et al. Predictors of cardiac events after major vascular surgery: Role of clinical characteristics, dobutamine echocardiography, and beta-blocker therapy. JAMA 2001;285:1865–1873.
 
23. Redelmeier D, Scales D, Kopp A. Beta blockers for elective surgery in elderly patients: population based, retrospective cohort study. BMJ 2005;331:932.
 
24. Fleisher LA, Beckman JA, Freeman WK, et al. 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) 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, and Society for Vascular Medicine and Biology. J Am Coll Cardiol 2006;47:2345–2355.
 
25. Wallace AW, Galindez D, Salahieh A, et al. Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery. Anesthesiology 2004;101:284–293.
 
26. Durazzo AE, Machado FS, Ikeoka DT, et al. Reduction in cardiovascular events after vascular surgery with atorvastatin: a randomized trial. J Vasc Surg 2004;39:967–976.
 
27. Biccard BM, Sear JW, Foex P. Statin therapy: a potentially useful peri-operative intervention in patients with cardiovascular disease. Anaesthesia 2005;60:1106–1114.
 
28. Poldermans D, Bax JJ, Kertai MD, et al. Statins are associated with a reduced incidence of perioperative mortality in patients undergoing major noncardiac vascular surgery. Circulation 2003;107:1848–1851.
 
29. Lindenauer PK, Pekow P, Wang K, et al. Lipid-lowering therapy and in-hospital mortality following major noncardiac surgery. JAMA 2004;291:2092–2099.
 
30. Wijeysundera DN, Beattie WS. Calcium channel blockers for reducing cardiac morbidity after noncardiac surgery: a meta-analysis. Anesth Analg 2003;97:634–641.
 
31. McFalls EO, Ward HB, Moritz TE, Goldman S, et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med 2004;351:2795–2804.
 
32. Godet G, Riou B, Bertrand M, et al. Does preoperative coronary angioplasty improve perioperative cardiac outcome? Anesthesiology 2005;102:739–746.
 
33. Kertai MD, Bax JJ, Heijenbrok-Kal MH, et al. A meta-analysis comparing the prognostic accuracy of six diagnostic tests for predicting perioperative cardiac risk in patients undergoing major vascular surgery. Heart 2003;89:1327–1334.
 
34. Boersma E, Kertai MD, Schouten O, et al. Perioperative cardiovascular mortality in noncardiac surgery: validation of the Lee cardiac risk index. Am J Med 2005;118:1134–1141.
 
35. Bradbury A, Adam D, Garrioch M, et al. Changes in platelet count, coagulation and fibrinogen associated with elective repair of asymptomatic abdominal aortic aneurysm and aortic reconstruction for occlusive disease. Eur J Vasc Endovasc Surg 1997;13:375–380.
 
36. Kaluza G, Joseph J, Lee JR, et al. Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol 2000;35:1288–1294.
 
37. Wilson SH, Fasseas P, Orford JL, et al. Clinical outcome of patients undergoing non-cardiac surgery in the two months following coronary stenting. J Am Coll Cardiol 2003;42:234–240.
 
38. Weitz HH. How soon can a patient undergo noncardiac surgery after receiving a drug-eluting stent? Cleve Clin J Med 2005;72:818–820.
 
39. Ferarri E, Benhamou M, Cerboni P, et al. Coronary syndromes following aspirin withdrawal: a special risk for late stent thrombosis. J Am Coll Cardiol 2005;45:456–459.
 
40. Burger W, Chemnitius JM, Kneissl GD, et al. Low-dose aspirin for secondary cardiovascular prevention - cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation - review and meta-analysis. J Intern Med 2005;257:399–414.
 
41. Beving H, Zhao C, Albage A, et al. Abnormally high platelet activity after discontinuation of acetylsalicylic acid treatment. Blood Coagul Fibrinolysis 1996;7:80–84.