Évaluation du risque cardiovasculaire périopératoire en chirurgie non cardiaque

Patients with cardiovascular disease undergoing non cardiac surgery are exposed to three cardiac risks: myocardial infarction, heart failure and death. To estimate cardiac risk, clinical predictors of perioperative cardiovascular risk are classified as major, intermediate and minor and non cardiac surgery is stratified in high risk (greater than 5%), intermediate (from 1 to 5%), minor (lower than 1%) procedures. Efficient perioperative assessment of cardiac patients is obtained by teamwork and usually, indications for further cardiac investigations are the same as those in the nonoperative setting. An simplified algorithm, easier to use than original algorithm given in the guidelines of the American college of cardiology and the American heart association, may be helpful for the indication of further investigations. Five questions must be answered before using algorithm: is it an emergency surgical procedure?, was a coronary revascularization required in the past five years? has the patient had a coronary evaluation in the past two years?, are there identified clinical predictors of cardiac risk?, is it major or minor surgery? Three tests evaluate the preoperative cardiac risk: exercise testing, dipyridamole thallium scintigraphy, dobutamine stress echocardiography. Their accuracy is similar, their negative predictive value is high, their positive predictive value is low. These guidelines may be helpful to indicate further cardiac investigations which will have an impact on patient's treatment, monitoring during or after surgery and outcome.     

Surgical results and perioperative complications in patients presenting lung cancer and cardiovascular diseases

Among 525 patients with lung cancer who underwent an operation between 1985 and 1998, 24 patients who also had a cardiovascular disease, most commonly ischemic heart disease. We gave all of these patients a preoperative assessment for ischemic heart disease, done according to a diagnostic flow chart. Eighteen patients (3.4%) were found to have IHD. We performed myocardial revascularization before or simultaneously with an operation for lung cancer in patients who also have known IHD. None of these patients had major perioperative cardiac trouble. Inspite of our efforts, perioperative myocardial ischemic events occurred in 6 patients (1.2% of all patients) who were not detected by our preoperative IHD assessment. We conclude that this IHD assessment flow chart may be useful for proper perioperative management of patients undergoing lung surgery. However, more precise methods to detect patients with IHD will be necessary to improve their perioperative cardiac risk.     

Preoperative risk assessment in vascular surgery patients

The patient scheduled for peripheral vascular surgery is an increased anaesthetic challenge, mainly because of coexisting generalized cardiovascular atherosclerotic involvement leading to a high risk of perioperative cardiac complications. In clinical practice it is of importance preoperatively to predict, as accurately as possible, the potential risk of complications so that proper risk-reducing measures can be taken. Relevant clinical data, which have been included by Goldman and Detsky in multifactorial cardiac risk indices, are of potential value for differentiating between patients at low, intermediate, or high risk of perioperative cardiac morbidity and mortality. Patients with low risk scores can be accepted for surgery without further testing, thereby allowing more extensive cardiac testing, such as ambulatory ECG monitoring, exercise stress testing, echocardiography, dipyridamole thallium imaging, or coronary angiography, to be reserved for patients with higher risk scores or overt cardiac problems. The risk stratification is of importance not only for decisions on preoperative prophylactic therapeutic measures (e.g. optimization of medical therapies, coronary artery revascularization), but also for decisions on intraoperative anaesthetic management and postoperative care.     

Anaesthesia for patients with cardiac disease undergoing non-cardiac surgery

One of the biggest challenges for anaesthetists today is the safe conduct of anaesthesia for patients who might be elderly, have pre-existing cardiac disease and are scheduled to undergo non-cardiac surgery. Within the financial constraints of today's health services, the appropriate investigations need to be decided and performed for these patients in order to inform the anaesthetist, surgeon and the patient of the risk of surgery. These should be undertaken only if they will influence management of the patient. The preoperative assessment will help with the formation of a perioperative management plan, including preoperative optimization and postoperative care, in order to minimize the risk of an adverse outcome. The most recent guidelines for preoperative cardiovascular evaluation for non-cardiac surgery are discussed in detail, including assessment of risk factors and cardiac investigations. Current thinking in preoperative therapy, intraoperative management and postoperative management is discussed. Although most patients with cardiac disease have ischaemic heart disease, other specific cardiac conditions and the principles of their management are discussed briefly.     

Anaesthesia for patients with cardiac disease undergoing non-cardiac surgery

One of the biggest challenges for anaesthetists today is the safe conduct of anaesthesia for patients who might be elderly, have pre-existing cardiac disease and are scheduled to undergo non-cardiac surgery. Within the financial constraints of today's health services, the appropriate investigations need to be decided and performed for these patients in order to inform the anaesthetist, surgeon and the patient of the risk of surgery. These should be undertaken only if they will influence management of the patient. The preoperative assessment will help with the formation of a perioperative management plan, including preoperative optimization and postoperative care, in order to minimize the risk of an adverse outcome. The most recent guidelines for preoperative cardiovascular evaluation for non-cardiac surgery are discussed in detail, including assessment of risk factors and cardiac investigations. Current thinking in preoperative therapy, intraoperative management and postoperative management is discussed. Although most patients with cardiac disease have ischaemic heart disease, other specific cardiac conditions and the principles of their management are discussed briefly.     

Beneficial effect of acute normovolemic hemodilution in cardiovascular surgery

OBJECTIVE: The efficacy of acute normovolemic hemodilution (ANH) in avoiding homologous blood transfusion (HBT) during cardiovascular surgery remains controversial. Our objective was to evaluate the impact of ANH on blood transfusion requirements during open cardiovascular surgery using cardiopulmonary bypass (CPB). METHODS: We retrospectively reviewed 243 patients who had undergone open cardiac or thoracic aortic surgery using CPB between September 2001 and July 2003 in our department. ANH was performed when the hematocrit was over 35% and the patient was hemodynamically stable. Risk factors were selected in accordance with the Japanese Adult Cardiovascular Surgery Database and analyzed to determine their effect on perioperative HBT requirement. RESULTS: Of the 243 patients, 64 (26%) underwent preoperative autologous blood donation and 62 (26%) ANH. HBT was required in 62% of patients (150/243) overall, in 32% (20/62) of ANH patients, and in 76% (130/171) of non-ANH patients. Multivariate stepwise logistic regression analysis revealed that preoperative or pre-donation hemoglobin value (p < 0.001), duration of surgery (p = 0.001), intraoperative minimum rectal temperature (p = 0.001), age (p = 0.002), need for emergency surgery (p = 0.003), amount of ANH (p = 0.018), blood loss (p = 0.033) and amount of preoperative autologous blood donation (p = 0.042) were independent predictors of the need for perioperative HBT. CONCLUSIONS: Our data showed that open cardiovascular surgery using CPB continues to pose a high risk of HBT, but that ANH is an effective means of reducing this risk in those patients undergoing these operations.     

Guidelines for perioperative cardiac evaluation from the American College of Cardiology/American Heart Association task force are effective for stratifying cardiac risk before aortic surgery

PURPOSE: We assessed whether the American College of Cardiology/American Heart Association (ACC/AHA) task force guidelines for perioperative cardiac evaluation could reliably stratify cardiac risk before aortic surgery. METHODS: We retrospectively applied the guidelines to a closed database, set up prospectively. The setting was a referral center in an institutional practice with hospitalized patients. The closed database included 133 patients who had a routine cardiac examination, which comprised an estimation of functional capacity and noninvasive testing, before aortic surgery. This cardiac evaluation led to the proposal of coronarography in 23 patients and to treating an underlying coronary artery disease in 21 patients (including three myocardial revascularizations). One patient died after myocardial revascularization, and two patients died of cardiac causes after aortic surgery. The algorithm of the ACC/AHA guidelines was applied independently by two investigators to each patient's file that was included in the existing database. The main outcome measure was a comparison between cardiac risk stratification with the ACC/AHA guidelines and the results of the routine cardiac evaluation. RESULTS: The ACC/AHA guidelines were successfully applied to all 133 files by the two investigators. After applying the algorithm, 73 patients were stratified as low cardiac risk, and 60 patients were stratified as high risk. The 21 patients who had undergone a preoperative coronary artery disease optimization were stratified as high risk by means of the ACC/AHA guidelines. The patients who died from cardiac causes were stratified as high risk by means of the ACC/AHA guidelines, whereas none of the patients stratified as low risk died during hospitalization. CONCLUSION: The ACC/AHA guidelines were effective in stratifying cardiac risk by using clinical predictors and an estimate of the physical capacity of the patient. Their use may allow a reduction in unnecessary noninvasive testing in patients stratified as being at low risk, while permitting the selection of all patients likely to benefit from preoperative coronary artery disease optimization.     

Preoperative cardiac risk assessment prior to noncardiac surgery

Summary. Cardiac complications remain an important cause of perioperative morbidity and mortality with noncardiac surgery, despite improvement in surgical techniques and anaesthetic management. Therefore preoperative cardiovascular risk assessment plays a pivotal role in management of patients prior to noncardiac surgery. Thorough history-taking and careful examination are essential to consider further diagnostic steps in order to predict the patient's individual perioperative cardiac risk as accurately as possible. Besides elaboration of medical therapy, cardiac catherization and even balloon angioplasty or bypass surgery must be considered if indicated by preoperative cardiac testing.      

Anaesthesia for patients with cardiac disease undergoing non-cardiac surgery

One of the biggest challenges for anaesthetists today is the safe conduct of anaesthesia for patients who might be elderly, have pre-existing cardiac disease and are scheduled to undergo non-cardiac surgery. Within the financial constraints of today’s health services, the appropriate investigations need to be decided and performed for these patients in order to inform the anaesthetist, surgeon and the patient of the risk of surgery. These should be undertaken only if they will influence management of the patient. The preoperative assessment will help with the formation of a perioperative management plan, including preoperative optimization and postoperative care, in order to minimize the risk of an adverse outcome. The most recent guidelines for preoperative cardiovascular evaluation for non-cardiac surgery are discussed in detail, including assessment of risk factors and cardiac investigations. Current thinking in preoperative therapy, intraoperative management and postoperative management is discussed. Although most patients with cardiac disease have ischaemic heart disease, other specific cardiac conditions and the principles of their management are discussed briefly.     

Cardiovascular complications of obesity surgery in patients with increased preoperative cardiac risk

BackgroundObesity surgery reduces the incidence of long-term cardiovascular events by modifying the associated risk factors. The derived benefits of weight loss surgery might be counterbalanced by the increased cardiovascular risks in some patients. The primary objective of the present study was to determine the rate of cardiovascular events after obesity surgery in patients considered to have an increased cardiac risk profile at a tertiary referral hospital.MethodsA retrospective analysis of the data from consecutive patients who underwent obesity surgery at the Cleveland Clinic Florida was performed. The use of β-blockers, noninvasive stress testing, and perioperative events were assessed.ResultsThe data from 154 patients who had undergone a preoperative cardiac consultation at the Cleveland Clinic Florida before obesity surgery from 2003 to 2006 were analyzed. Most patients were women (n = 108, 69%), and 25 (16%) were >65 years old. The number of patients who received perioperative β-blockers was 72 (47%). Noninvasive stress testing was performed in 78 patients (50%). Of the 78 patients who underwent noninvasive stress testing, 25 (32%) had a positive finding. Only 1 patient with positive stress test results had an obstructive coronary artery lesion found on cardiac catheterization. A total of 5 nonfatal cardiac-related events (3.2%) occurred. The in-hospital mortality rate was 0%.ConclusionObesity surgery in patients with established coronary heart disease or risk factors is a safe and well-tolerated procedure, with an overall low rate of cardiac events. Noninvasive stress testing in this population resulted in a high rate of false-positive results and uncommonly led to intervention.     

Preoperative cardiac risk assessment: an updated approach.

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

Preoperative cardiac evaluation of the vascular surgery patient--an anesthesia perspective

The morbidity and mortality associated with vascular surgery procedures are largely the results of cardiac events. National guidelines have been regularly proposed and updated by the American College of Cardiology (ACC)/American Heart Association (AHA) to ensure optimal perioperative management and risk stratification. Controversy remains between experts and other cardiology societies regarding several patient care issues including revascularization before surgery, timing of β-blocker therapy, and the administration of antiplatelet therapy. Several landmark articles recently published have helped to modify the guidelines in the hope of improving vascular patient outcomes. In this review, we searched all recent available literature pertaining to perioperative cardiac evaluation before major vascular surgery. We propose an algorithm for preoperative cardiac evaluation, which is a modification to the AHA recommendations. Incorporated in this algorithm are recent published pivotal articles that can help in guiding physicians caring for the vascular patient requiring major operative or endovascular interventions.     

Diagnostic investigations of adult cardiac disease

Preoperative investigations in cardiac surgery can be divided into two stages: diagnostic studies and assessment of fitness for surgery. Diagnostic investigations are used by cardiologists to detect and evaluate coronary, valvular, myocardial and thoracic aortic disease and, in conjunction with symptoms, are used to determine the appropriate management of cardiovascular disease. Patients presenting for cardiac surgery frequently have significant co-morbidities. Knowledge of these co-morbidities helps to plan the perioperative care of the patient with the aim of reducing postoperative morbidity and mortality thereby maximizing the chances of an uneventful recovery, and allows for more accurate informed consent. The preoperative assessment may also determine a patient to be very high risk for conventional treatment and may steer clinicians to offer patients alternative treatments such as transcatheter aortic valve implantation (TAVI) for severe aortic stenosis. This article highlights the tests for preoperative diagnosis and assessment of fitness for surgery in adult cardiac patients. In combination they guide clinicians in making appropriate management decisions, particularly with regard to elderly, frail or complex cardiac cases discussed in the setting of joint cardiology and cardiothoracic meetings.     

Perioperative- and long-term mortality rates after major vascular surgery: the relationship to preoperative testing in the medicare population.

Debate continues regarding the value of cardiovascular testing and coronary revascularization before major vascular surgery. Whereas recent guidelines have advocated selective preoperative testing, several authors have suggested that it is no longer necessary in an era of low perioperative cardiac morbidity and mortality. We used data from a random sample of Medicare beneficiaries to determine the mortality rate after vascular surgery, based on the use of preoperative cardiac testing. A 5% nationally random sample of the aged Medicare population for the final 6 mo of 1991 and first 11 mo of 1992 was used to identify a cohort of patients who underwent elective infrainguinal or abdominal aortic reconstructive surgery. Use within the first 6 mo of 1991 was reviewed to determine if preoperative noninvasive cardiovascular imaging or coronary revascularization was performed. Thirty-day (perioperative) and 1-yr mortalities were assessed. Perioperative mortality was significantly increased for aortic surgery (209 of 2865 or 7.3%), compared with infrainguinal surgery (232 of 4030 or 5.8%); however, 1-yr mortality was significantly increased for infrainguinal surgery (16.3% vs 11.3%, P < 0.05). Stress testing, with or without coronary revascularization, was associated with improved short-and long-term survival in aortic surgery. The use of stress testing with coronary revascularization was not associated with reduced perioperative mortality after infrainguinal surgery. Stress testing alone was associated with reduced long-term mortality in patients undergoing infrainguinal revascularization. IMPLICATIONS: Analysis of the Medicare Claims database suggests that vascular surgery is associated with substantial perioperative and long-term mortality. The reduced long-term mortality in patients who had previously undergone preoperative testing and coronary revascularization reinforces the need for a prospective evaluation of these practices.     

The impact of a cardioprotective protocol on the incidence of cardiac complications after aortic abdominal surgery

We analyzed a local database including 468 consecutive patients who underwent elective aortic abdominal surgery over an 8-yr period in a single institution. A new cardioprotective perioperative protocol was introduced in January 1997, and we questioned whether perioperative cardiac outcome could be favorably influenced by the application of a stepwise cardiovascular evaluation based on the American College of Cardiology/American Heart Association guidelines and by the use of antiadrenergic drugs. Clonidine was administered during surgery, and beta-blockers were titrated after surgery to achieve heart rates less than 80 bpm. We compared data of two consecutive 4-yr periods (1993-1996 [control period] versus 1997-2000 [intervention period]). Implementation of American College of Cardiology/American Heart Association guidelines was associated with increased preoperative myocardial scanning (44.3% vs 20.6%; P < 0.05) and coronary revascularization (7.7% vs 0.8%; P < 0.05). During the intervention period, there was a significant decrease in the incidence of cardiac complications (from 11.3% to 4.5%) and an increase in event-free survival at 1 yr after surgery (from 91.3% to 98.2%). Multivariate regression analysis showed that the combined administration of clonidine and beta-blockers was associated with a decreased risk of cardiovascular events (odds ratio, 0.3; 95% confidence interval, 0.1-0.8), whereas major bleeding, renal insufficiency, and chronic obstructive pulmonary disease were predictive of cardiac complications. In conclusion, cardiac testing was helpful to identify a small subset of high-risk patients who might benefit from coronary revascularization. Sequential and selective antiadrenergic treatments were associated with improved postoperative cardiac outcome. IMPLICATIONS: Implementation of American College of Cardiology/American Heart Association guidelines and use of antiadrenergic drugs were associated with better cardiac outcomes after major vascular surgery.     

Two cases of preceded aortic valve replacement for severe aortic stenosis before the cancer operations

We report two cases of aortic valve replacement (AVR) for severe aortic stenosis (AS) before the cancer operations. Severe AS poses a great risk for noncardiac surgery. In the ACC/AHA 2007 Guideline on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery, if the AS is symptomatic, elective noncardiac surgery should generally be postponed or canceled. Such patients require AVR before elective noncardiac surgery. On the other hand, in patients with severe AS who refuse cardiac surgery, noncardiac surgery can be performed with a mortality risk of approximately 10%. In our cases, severe AS was found in the preoperative examination. We informed them about necessary AVR before noncardiac surgery, and patients consented to our suggestion. AVR was performed around 7 days after this consent, and cancer operation was performed around 30 days after the AVR. However, there are no clear guidelines for this interval between AVR and cancer operation. In our cases the patients underwent the cardiac surgery and noncardiac surgery in a short period without serious complication in the perioperative management. It is very important to discuss among surgeon, cardiovascular surgeon, cardiologist and anesthesiologist. Especially anesthesiologist should take an important role in organizing these departments for such patients.     

Cardiac anesthesia and surgery in geriatric patients

The average age of US population is steadily increasing, with more than 15 million people aged 80 and older. Coronary artery disease and degenerative cardiovascular diseases are particularly prevalent in this population. Consequently, an increasing number of elderly patients are referred for surgical intervention. Advanced age is associated with decreased physiologic reserve and significant comorbidity. Thorough preoperative assessment, identification of the risk factors for perioperative morbidity and mortality, and optimal preparation are critical in these patients. Age-related changes in comorbidities and altered pharmacokinetics and pharmacodynamics impacts anesthetic management, perioperative monitoring, postoperative care, and outcome. This article updates the age-related changes in organ subsystems relevant to cardiac anesthesia, perioperative issues, and intraoperative management. Early and late operative outcome in octogenarians undergoing cardiac surgery are reviewed. The data clearly indicate that no patient group is "too old" for cardiac surgery and that excellent outcomes can be achieved in selected group of elderly patients.     

First Time Myocardial Infarction in a Rheumatic Patient After Elective Arthroplasty

The management of perioperative cardiovascular risk in patients with rheumatoid arthritis (RA) is challenging due to the independent contribution to risk by high grade inflammatory mechanisms and the underestimation of risk by traditional cardiac risk factors alone. RA is associated with accelerated rates of subclinical atherosclerosis and markedly higher rates of both myocardial infarction and sudden cardiac death over non-RA controls. There is an absence of prospectively validated perioperative coronary heart disease (CHD) risk assessment tools for this unique patient population and available guidelines may fail to identify those patients most at risk. We examine a singular case of first time myocardial infarction after uncomplicated elective surgery in an adult RA patient with an unrevealing preoperative cardiac assessment. We also review the current literature for shared pathogenic mechanisms between systemic inflammation and atherosclerosis, discuss clinical and biologic markers such as C-reactive protein (CRP) in RA patients associated with heightened cardiac risk and discuss recommendations based on available evidence for cardiovascular risk management in this at risk cohort.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-012-9309-5) contains supplementary material, which is available to authorized users.     

Hipertensión arterial en el paciente quirúrgico. Adecuación de la medicación y criterios de suspensión

Arterial hypertension (AHT) is a modifiable risk factor for cardiovascular diseases, which may have an impact on perioperative complications, depending on the organ damage suffered by the patient. The perioperative management of treatment of arterial hypertension, is a mainstay in the preoperative assesment prior to any intervention. It doesn’t seem reasonable to delay surgery solely due to blood pressure values, although for patients with BP > 180/110 mmHg, the decision to perform scheduled surgeries should be carefully assessed.     

Predictive factors for perioperative blood transfusions in rectal resection for cancer: A multivariate analysis of a group of 212 patients

BACKGROUND. In colorectal cancer surgery, allogeneic blood transfusions have reportedly been associated with higher rates of postoperative complications and tumor recurrence. However, because of the increased cost of alternative types of blood transfusions (eg, the use of autologous blood or erythropoietin administration), their routine use cannot be recommended. This study evaluated the risk factors for perioperative blood transfusions in resection for rectal cancer in order to identify patients who could benefit from these methods. METHODS. From 1990 to 1997, 212 consecutive patients who underwent elective rectal resection for cancer were reviewed. The associations between perioperative heterologous blood transfusion and 18 patient-, tumor-, surgical-, and treatment-related variables were assessed by univariate and multivariate analysis. RESULTS. Of the 212 patients, 72 (34%) received transfusions. Multivariate analysis revealed that 5 preoperative variables were significant risk factors for perioperative blood transfusion: age > 65 years (P =.03), body mass index > 27 kg/m(2) (P =.04), preoperative hemoglobin < or = 12.5 g/dL (P <.0001), American Society of Anesthesiologists status > 2 (P =.024), and additional surgical procedures (P =.018). In patients with anemia, the risk of transfusion was at least 47% in patients with 1 other risk factor or more. In nonanemic patients, the risk of transfusion was under 11% in patients with 1 risk factor or none, but increased to 47% in those with 2 or more risk factors. CONCLUSIONS. Our analysis of risk factors for perioperative blood transfusion in rectal resection for cancer must be considered to constitute guidelines for a more responsible use of the expensive alternatives to allogeneic blood transfusion.