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.     

Surgery for esophageal cancer complicate with cardiovascular disease

A risk of cardiac complications is one of the most significant risks to patient undergoing major surgery. Especially, for the patients with cancer, the preoperative management can be complex. The direct effect of cancer and side effect of prior chemotherapy or radiation therapy should be considered. The 2007 American College of Cardiology/American Heart Association( ACC/AHA) guidelines on perioperative cardiovascular evaluation for noncardiac surgery concluded that 3 elements must be assessed to determine the risk of cardiac event. The preoperative risk in a patient is initially assessed by the presence or absence of clinical predictors of increased perioperative cardiovascular risk, the patient's level of cardiac function, and the underlying risk of the surgical procedure. Here we will provide an overview of issue that are relevant to patients with esophageal cancer.     

Should my outpatient center have a beta-blocker protocol?

PURPOSE OF REVIEW: Perioperative beta-blockade has been advocated by multiple authors and recent guidelines as a strategy to reduce cardiac risk in noncardiac surgery. Knowledge about application of this treatment modality to the ambulatory surgery population is poor. RECENT FINDINGS: Although the initial trial in patients with a positive stress test undergoing major vascular surgery demonstrated significantly fewer perioperative cardiac events among those randomized to perioperative beta-blocker therapy, more recent studies in patients without documented coronary artery disease undergoing major noncardiac surgical procedures were unable to demonstrate efficacy. Guidelines from the American Heart Association/American College of Cardiology have been reported and advocated class I recommendations for perioperative beta-blockade only for patients previously taking beta-blockers and those patients with a positive stress test undergoing vascular surgery. There was insufficient evidence to make a recommendation in low-risk surgery. SUMMARY: Based upon the available evidence and guidelines, patients currently taking beta-blockers and undergoing ambulatory surgery should continue these agents and protocols employing this strategy should be beneficial. In patients who are not currently taking beta-blockers and in whom long-term therapy is not warranted, current evidence does not support instituting prophylactic therapy in the ambulatory surgery population.     

Low utility of dobutamine stress echocardiograms in the preoperative evaluation of patients scheduled for noncardiac surgery

In this study, we examined the utility of preoperative dobutamine stress echocardiograms (DSE) obtained for 85 patients in accordance with guidelines published by the American College of Cardiology (ACC) and the American Heart Association (AHA). The medical record of each patient was reviewed to identify the clinical criteria that indicated the need for a DSE, the DSE results, therapeutic interventions rendered as a result of the DSE, and any perioperative cardiac morbidity. The DSE was positive for inducible ischemia in 4 patients (4.7%), negative in 74 (87.1%), and nondiagnostic in 7 (8.2%). DSEs that were obtained for 48 patients because of a history of diabetes mellitus, mild angina, or "minor clinical predictors" produced only negative results. Of the four patients with positive DSE results, three underwent coronary angiography, and one of those three underwent bypass grafting before surgery. An additional 29 patients received a preoperative DSE but were excluded from the study because the criteria for ordering the DSE did not meet the ACC/AHA guidelines. No patient had any perioperative morbidity related to myocardial ischemia. The total patient charge for the 85 DSEs obtained at our institution was US$104,635. Use of the ACC/AHA guidelines for preoperative DSEs does not appear to be cost-effective. However, the current algorithm could be significantly improved by altering the criteria for obtaining preoperative DSEs. IMPLICATIONS: This study was a retrospective review of 85 patient charts that found a low cost-effectiveness of using American College of Cardiology/American Heart Association guidelines for obtaining preoperative dobutamine stress echocardiograms. Suggested modifications of these guidelines should improve their specificity with no loss in sensitivity.     

Guidelines for Cardiac Management in Noncardiac Surgery Are Poorly Implemented in Clinical Practice: Results from a Peripheral Vascular Survey in The Netherlands

Background: 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.

Methods: 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.

Results: 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.     

Guidelines for cardiac management in noncardiac surgery are poorly implemented in clinical practice: results from a peripheral vascular survey in the Netherlands

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.     

Perioperatives kardiales Vorgehen bei nichtkardiochirurgischen Eingriffen

Since November 2009, the first European guidelines on perioperative cardiac care for non-cardiac surgery have been published by the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). The following article will describe the most important recommendations of these guidelines and discuss the clinically relevant differences to the corresponding recommendations of the current guidelines of the American College of Cardiology (ACC) and the American Heart Association (AHA).     

围腹部手术期患者伴有心脏支架的处理策略

美国心脏病学会联合美国心脏协会(ACC/AHA)和欧洲的心脏协会(ESC)相继发布了非心脏手术围手术期心血管评估与治疗指南推荐,对心脏支架患者非心脏手术围手术期的治疗提出指导意见,但是对非心脏手术的时机选择、围手术期抗凝治疗等问题仍有争议。掌握心脏支架患者腹部围手术期的处理相关策略,对减少围手术期心脏相关并发症至关重要。     

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.     

Perioperative Medikation bei arteriellen Operationen

Preoperative evaluation and perioperative management of ischemic cardiac disease are a great challenge in patients undergoing major vascular surgery. They have an important impact on perioperative morbidity and mortality in patients with atherosclerotic disease needing surgery. Perioperative medication is most important in reducing these risks. This review summarizes the current literature and European and American guidelines on the perioperative use of beta-blockers, statins and platelet aggregation inhibitors and their impact on reducing perioperative morbidity.     

Perioperative beta-blocker and statin therapy

PURPOSE OF REVIEW: Perioperative beta-blockade and statin therapy have been advocated to reduce cardiac risk of noncardiac surgery. This review evaluates recent articles published on the cardioprotective effects of perioperative therapy with these medications. RECENT FINDINGS: Initial studies evaluating beta-blocker therapy during the perioperative period suggested that beta-blockers may be beneficial in reducing cardiac deaths and myocardial infarctions. Later studies and recent meta-analyses, however, are less favorable and suggest that beta-blockers may be associated with increased incidence of bradycardia and hypotension. One randomized trial and several cohort studies have found a significant reduction in cardiovascular complications with perioperative statin therapy. Additionally, statin withdrawal is associated with increased postoperative cardiac risk. SUMMARY: Based upon the available evidence and guidelines, patients currently taking beta-blockers should continue these agents. Patients undergoing vascular surgery who are at high cardiac risk should also take beta-blockers. The question remains regarding the best protocol to initiate perioperative beta-blockade. Statins should be continued in patients already taking these agents prior to surgery. The optimal duration and time of initiation of statin therapy remains unclear.     

Critical appraisal of cardiac risk stratification before elective vascular surgery

This study was undertaken to evaluate the efficacy of the cardiac risk stratification protocol proposed by the American College of Cardiology/American Heart Association (ACC/AHA) in predicting cardiac morbidity and mortality associated with elective, major arterial surgery. Cardiac risk stratification using ACC/AHA guidelines was done on 425 consecutive patients before 481 elective cerebrovascular (n = 146), aortic/inflow (n = 166), or infrainguinal (n = 169) procedures at an academic Veterans Affairs Medical Center. Cardiac risk was stratified as low, intermediate, or high based on clinical risk factors, such as, Eagle criteria, history of cardiac intervention, patient functional status, results of noninvasive cardiac stress testing, and coronary angiography with coronary revascularization performed when appropriate. Outcomes (myocardial infarction, unstable angina, congestive heart failure, ventricular arrhythmia, cardiac death, and mortality) within 30 days of surgery were compared between the various risk stratification groups. Univariate and multivariate analyses were used to identify clinically useful prognostic variables from the preoperative cardiac evaluation algorithm. Overall mortality (1.7%), cardiac death (0.4%), and adverse cardiac event (4.8%) rates were low, but cardiac death and morbidity were increased (p < 0.05) in high-risk stratified patients (3.4%, 11.9%) compared to intermediate (0%, 2.8%) and low (0%, 4.0%) cardiac risk groups. The presence of 3-vessel angiographic coronary artery occlusive disease was an independent predictor of cardiac morbidity, while inducible ischemia by cardiac stress imaging was not. Previous coronary revascularization was associated with increased mortality as was the development of a non-cardiac complication. Cardiac risk assessment identified 78 (18%) patients with indications for coronary angiography. Angiographic findings resulted in coronary artery intervention (9-angioplasty; 4-bypass grafting) in 13 (3%) patients who experienced no adverse cardiac events after the planned vascular surgery (15 procedures). Cardiac risk stratification using ACC/AHA guidelines can predict adverse cardiac events associated with elective vascular surgery; however, protocol modification by increased reliance on Eagle criteria and less use of cardiac stress testing can improve identification of the "highest risk" patients who may benefit from prophylactic coronary intervention.     

Prämedikationsvisite

The older the patient, the higher the risk of perioperative cardiac complications. Therefore, patients at risk have to be identified and the appropriate diagnostic or therapeutic measures initiated. The most important factor in this context is whether a planned surgery can be postponed. Several strategies have been developed (e.g. Goldman index, Eagle criteria) and the American Heart Association (AHA/ACC) has produced guidelines concerning perioperative diagnosis and therapy of cardiac risk patients. The common goal of these strategies is always the risk classification of the patient by combining the operative risk and the risk factors of the patient. The further procedure (diagnostic or therapeutic measures) is based on the risk classification. If further invasive therapy proves to be necessary, the determining factor is the period of time for which the operation can be delayed. This appears to be about 3 months but if this is not possible the outcome could be improved with a beta-blocker therapy in advance. A working group from the university hospital in Marburg has developed a strategy for risk classification and further diagnostic and therapeutic measures as outlined in this article.     

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

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

How to avoid cardiac ischemic events associated with aortic surgery.

Whereas there is some degree of coronary artery disease (CAD) in most patients undergoing vascular surgery, there is no consensus regarding how to avoid perioperative cardiac ischemic events. Although this edition of Seminars in Vascular Surgery is devoted to aortic surgery, it must be remembered that the incidence of adverse cardiac outcomes after infrainguinal operations is at least as great as after aortic procedures. Thus, much of the information discussed herein will be applicable to patients undergoing all varieties of vascular surgery. Numerous strategies exist for preoperative cardiac testing before vascular operations. These strategies range from routine evaluation before surgery to a "minimalist" approach, treating all patients as though CAD was present. Although advocates of various algorithms often are unwavering in their convictions, there are no randomized, prospective studies comparing different strategies for evaluation and management of patients with CAD undergoing vascular surgery. Potential adverse effects of evaluation and cardiac intervention should be considered before undertaking screening studies. The authors analyzed the adverse outcomes of preoperative cardiac evaluation and intervention before vascular operations in patients treated at the Denver Department of Veterans Affairs Medical Center. Of 153 patients undergoing vascular procedures, 42 had extended cardiac evaluations. Sixteen (38%) patients had untoward events related to this evaluation. Extensive cardiac evaluation before vascular operations can result in morbidity, delays, and refusal to undergo vascular surgery. The underlying indication for vascular operations and the local iatrogenic cardiac complication rates should be considered before ordering special studies. Several recent randomized, prospective studies have established that perioperative beta-adrenergic blockade is beneficial in vascular patients with CAD. Beta-Blocker therapy can reduce the risk of perioperative adverse cardiac outcomes by 55%. The Coronary Artery Revascularization Prophylaxis (CARP) trial currently underway is a multicenter, prospective comparison of invasive intervention for CAD versus best medical care in patients undergoing aortic and lower extremity vascular surgery funded by the Department of Veterans Affairs Cooperative Studies Program.     

麻醉科住院医师通常不能恰当使用2007美国心脏病学会／美国心脏协会（ACC／AHA）指南评估模拟患者

背景2007美国心脏病学会／美国心脏协会（American College of Cardiology/American Heart Association, ACC/AHA）有关围术期心脏评估与非心脏手术医疗保障的指南是围术期心脏评估的公认标准。麻醉培训计划要求教授这些评估方法。我们评估了美国全国范围内麻醉科住院医师在评估临床常见场景下模拟患者时能够正确使用ACC／AHA指南所建议的测试评估方法的百分比人数。方法24所培训机构中的麻醉科住院医师志愿者参加,设置以外科手术、患者危险因素和患者功能能力为特征的6种场景。均随机分配所有场景和针对每种场景的5种推荐建议。分配之前,美国24所不同培训机构的高级麻醉医师与2007年ACC／AHA指南的第一作者一同确认该网络调查的推荐建议恰当。结果参加的548名住院医师占美国麻醉科培训医师的12％,包括48名PGY-1S（麻醉专科培训前第一年）、166名临床麻醉工作一年的住院医师（CA-1）、161名CA-2s和173名CA-3s。评估活动性心脏病的患者时,建议的评估与指南一致的住院医师为78％（95％可信上限）。然后,在剩余的5种场景中,给出恰当建议的住院医师为46％（95％可信上限）。结论结果显示,美国全国范围内不足一半的麻醉科住院医师能够正确地应用术前心脏评估标准的方法。必须进一步研究来阐明正确的干预措施,如决策支持工具的应用、增加常规使用指南的清晰度、调整教育计划和（或）负责教员更熟悉该教材。     

Preoperative coronary revascularization in high-risk patients undergoing vascular surgery: a core review

Patients undergoing vascular surgery are at increased risk for cardiac complications related to the presence of underlying coronary artery disease. Preoperative cardiac evaluation may help to identify high-risk patients in whom coronary angiography may be planned with subsequent coronary revascularization for the purpose of improving perioperative and long-term cardiac outcomes. However, the indications and efficacy for type of revascularization for the reduction of cardiac complications compared to medical therapy has been controversial. My aim in this review is to summarize the role of preoperative revascularization compared to conservative medical therapy before elective vascular surgery using current evidence from published studies.     

Evaluation,severity and prognostic significance of silent myocardial ischaemia in vascular patients

This paper intends to make an update of recent publications and guidelines for evaluation in coronary symptom-free patients undergoing vascular surgery. It emphasizes the role of preoperative clinical evaluation that should identify the most appropriate testing, and treatment strategies to optimize care of the patient and avoid unnecessary testing in this era of cost containment. Selective preoperative coronary artery disease screening and revascularization achieve excellent perioperative and late results after high-risk vascular surgery. Supplemental preoperative evaluation is discussed (exercise ECG, stress echocardiography and stress tomoscintigraphy). Asymptomatic patients with good functional capacity can undergo intermediate-risk surgery without further non-invasive testing. Conversely, further noninvasive testing is often considered for patients with poor functional capacity or moderate functional capacity but higher-risk surgery especially for patients with 2 or more intermediate risk predictors. Additional testing may be considered on an individual basis for patients without clinical markers but with poor functional capacity prior to vascular surgery, particularly those with several minor clinical risk predictors. Because of a higher prevalence of silent myocardial ischaemia in diabetes mellitus, these patients require specific care. Until further data are available, indications for myocardial revascularization in the perioperative setting are similar to those in the ACC/AHA guidelines for use of myocardial revascularization in general. General practitioners, cardiologists, angiologists, vascular surgeons and anaesthesiologists should collaborate and aim to slow down the progression of atherosclerosis by giving their patients an optimum secondary cardiovascular prevention.     

Evaluation,Severity and Prognostic Significance of Silent Myocardial Ischaemia in Vascular Patients

This paper intends to make an update of recent publications and guidelines for evaluation in coronary symptom-free patients undergoing vascular surgery. It emphasizes the role of preoperative clinical evaluation that should identify the most appropriate testing, and treatment strategies to optimize care of the patient and avoid unnecessary testing in this era of cost containment. Selective preoperative coronary artery disease screening and revascularization achieve excellent perioperative and late results after high-risk vascular surgery. Supplemental preoperative evaluation is discussed (exercise ECG, stress echocardiography and stress tomoscintigraphy). Asymptomatic patients with good functional capacity can undergo intermediate-risk surgery without further non-invasive testing. Conversely, further noninvasive testing is often considered for patients with poor functional capacity or moderate functional capacity but higher-risk surgery especially for patients with 2 or more intermediate risk predictors. Additional testing may be considered on an individual basis for patients without clinical markers but with poor functional capacity prior to vascular surgery, particularly those with several minor clinical risk predictors. Because of a higher prevalence of silent myocardial ischaemia in diabetes mellitus, these patients require specific care. Until further data are available, indications for myocardial revascularization in the perioperative setting are similar to those in the ACC/AHA guidelines for use of myocardial revascularization in general. General practioners, cardiologists, angiologists, vascular surgeons and anaes-thesiologists should collaborate and aim to slow down the progression of atherosclerosis by giving their patients an optimum secondary cardiovascular prevention.     

Implementing ACC/AHA guidelines for the preoperative management of patients with coronary artery disease scheduled for noncardiac surgery: effect on perioperative outcome

STUDY OBJECTIVE: To review the new consensus guidelines for cardiac testing for the patient with cardiac disease scheduled for elective, noncardiac surgery, and their impact on cardiac functional testing. DESIGN: Retrospective chart review study. SETTING: Tertiary care medical center. PATIENTS: 181 patients scheduled for elective, major surgery who met American College of Cardiology/American Heart Association (ACC/AHA) criteria for a preoperative stress test. INTERVENTIONS: A variety of tests were ordered, including treadmill stress testing, persantine-thallium imaging, dobutamine echocardiography, and exercise stress echocardiography. MEASUREMENTS: The numbers of and outcome of the stress tests and the cardiac outcome of the patients who underwent cardiac testing and surgery were recorded. MAIN RESULTS: Abnormal tests occurred in 27 patients. Two patients declined treatment, eight patients had primary medical management, and the remainder (17) had cardiac catheterization. Results included no lesion (2 patients), angioplasty (4 patients), angioplasty plus stenting (1 patient), coronary artery bypass grafting (CABG) (4 patients), and delineated lesions treated with medical optimization (6 patients). One patient had CABG and declined further surgery. One patient had myocardial infarction 6 months after surgery that was treated by medical management after cardiac catheterization. The other 23 patients had surgery without cardiac complication within 1 year of surgery. Only 15% (27/180) of the patients with indications for a stress test had a positive result. Even fewer patients had any alteration of the perioperative period. Despite this finding, cardiac morbidity was very low. CONCLUSIONS: The guidelines for stress test may be over-sensitive, and further prospective clinical studies are indicated.