Calcium channel blockade does not offer adequate protection from perioperative myocardial ischemia

This study aimed to detect the difference in hemodynamic and electrocardiographic responses during the prebypass period in patients undergoing coronary bypass grafting who were receiving beta-adrenergic blocking drugs, calcium entry blocking drugs, or both beta-adrenergic and calcium entry blocking drugs. Electrocardiographic evidence of myocardial ischemia was noted significantly more frequently in patients receiving calcium entry blocking drugs alone at induction of anesthesia (P less than 0.03), skin incision (P less than 0.05), and sternotomy (P less than 0.002). Heart rate at sternotomy was significantly higher in patients receiving calcium entry blocking drugs (P less than 0.02) as compared to patients receiving beta-adrenergic blocking drugs or the combination of both drugs. In conclusion, patients treated with calcium entry blocking drugs alone had significantly higher incidence of perioperative ischemic ECG changes compared with patients receiving beta-adrenergic blocking drugs alone or in combination with calcium channel blocking drugs.     

Myocardial ischemia in untreated hypertensive patients: effect of a single small oral dose of a beta-adrenergic blocking agent

In a non-double-blind, prospective, randomized study, the intra-operative electrocardiograms of 128 mildly hypertensive surgical patients were examined in order to determine the incidence of myocardial ischemia during anesthesia. No patient had been receiving chronic antihypertensive therapy prior to the study, but a single small oral dose of a beta-adrenergic blocking agent (labetalol, atenolol, or oxprenolol) was given to 89 of them along with premedication. Forty-four per cent of the untreated control patients and 61% of the patients pretreated with a beta-adrenergic blocking agent had normal preoperative electrocardiograms and no risk factors for coronary artery disease other than hypertension (this difference between groups was not statistically significant). During tracheal intubation and/or emergence from anesthesia, a brief, self-limited episode of myocardial ischemia was detected in 11 of 39 untreated control patients, and in two of 89 patients pretreated with a beta-adrenergic blocking agent (P less than 0.001). Tachycardia always accompanied the ischemic events, but a conspicuous increase in blood pressure did not. The authors conclude that mild hypertension, when untreated prior to the induction of anesthesia, is associated with a high incidence of myocardial ischemia; and that a single small oral dose of a beta-adrenergic blocking agent, given with pre-medication, can significantly reduce that risk.     

Aktuelle Evidenz einer Statintherapie in der Herzchirurgie

Statins have gained a pivotal role in the primary and secondary prevention of coronary artery disease. Postoperative statin therapy effectively reduce the rate of bypass graft failure and cardiovascular complications in patients who undergo coronary artery bypass grafting. However, the benefits of a perioperative statin therapy for cardiac surgery patients are currently under extensive investigation. Accumulating evidence from clinical trials suggests that patients scheduled for coronary artery bypass surgery profit from perioperative statin therapy and that discontinuation of statins during the perioperative period may increase adverse events. Whether an additional high-dose statin treatment shortly before myocardial revascularization reduces major adverse cardiocerebral events is currently being determined in a large clinical trial. In contrast to patients undergoing coronary artery bypass grafting, current evidence from clinical trials does not support the routine use of statins for the prevention of biological valve degeneration in patients having undergone valve replacement.     

Prävention perioperativer Myokardischämien – ein Update

Perioperative cardiac morbidity and mortality are a major health care challenge with important individual as well as economic aspects. Up to 30% of all perioperative complications and up to 50% of all postoperative deaths are related to cardiac causes. Perioperative myocardial ischemia, which occurs in more than 40% of patients with or at risk for coronary artery disease and undergoing noncardiac surgery, represents a dynamic predictor of postoperative cardiac complications. Long-duration myocardial ischemia and ischemic episodes associated with myocardial cell damage are particularly of prognostic relevance. In patients suffering from this type of ischemia, the incidence of adverse cardiac outcome is increased up to 20-fold. Reducing the incidence of perioperative myocardial ischemia is associated with a decrease in adverse cardiac outcome. Important issues related to perioperative myocardial ischemia are hematocrit level, body temperature, and hemodynamic variables. In contrast, the choice of anesthetic agents and techniques appears to be less important. Perioperative administration of anti-ischemic drugs in patients at risk, however, leads to a further decrease in the incidence of myocardial ischemia and to an improvement in patient outcome. Recent studies suggest that alpha 2-agonists and particularly beta-adrenoreceptor blocking agents are effective anti-ischemic drugs in the perioperative setting. Perioperative administration of beta-adrenoreceptor blocking agents in coronary risk patients undergoing noncardiac surgery is associated with a reduced rate of postoperative cardiac complications and an improvement in long-term outcome. This is particularly relevant in high risk patients with preoperative stress-induced ischemic episodes. In clinical practice, therefore, chronically administered anti-ischemic drugs should also be administered on the day of surgery and during the postoperative period. In untreated patients with or at risk for coronary artery disease and who have to undergo urgent surgical procedures without the opportunity of preoperative anti-ischemic intervention, perioperative administration of beta-adrenoreceptor blocking agents is mandatory.     

Novel stent/CEA strategy for patients with bilateral carotid artery stenosis and coronary artery disease: report of 2 cases

Recently, there are increasing numbers of patients with occlusive carotid artery disease and coronary artery disease. Simultaneous or two-staged surgery for both lesions has been recommended for these patients to reduce the incidence of perioperative complications. However, therapeutic options for the patients with bilateral carotid artery stenosis and coronary artery disease have not been established. In this report, we describe two patients who successfully underwent carotid endarterectomy (CEA) and carotid artery stenting (CAS) on each carotid artery in parallel with coronary artery bypass grafts (CABG). A 49-year-old male with severe stenosis of the bilateral internal carotid artery (ICA) and heart failure underwent CAS on the right side. Next day, he successfully underwent CABG and CEA on the left side at the same time. A 62-year-old male with severe stenosis of the bilateral ICA and coronary artery disease underwent CAS on the right side and CEA on the left side with an interval of 7 days. Subsequently, CABG was performed uneventfully. No perioperative complication occurred in either patient. The results suggest that combination therapy of CAS and CEA would be a valuable option for patients with complex carotid/coronary artery diseases.     

Knowledge and practice regarding prophylactic perioperative beta blockade in patients undergoing noncardiac surgery: a survey of Canadian anesthesiologists

A lack of awareness of the "best" current practice is frequently cited as a major barrier to the practice of evidence-based medicine. The purpose of this study was to survey Canadian anesthesiologists to determine their knowledge and practices associated with prophylactic perioperative beta blockade, a therapy that has been widely discussed in the literature and has the potential for a significant positive impact on patient outcomes. We sent questionnaires to 1234 members of the Canadian Anesthesiologists' Society. The overall response rate was 54%. Ninety-five percent of respondents were aware of the perioperative beta blocker literature, and of these, 93% agreed that beta blockers were beneficial in patients with known coronary artery disease (CAD). Fifty-seven percent reported always or usually administering prophylactic beta blockers in patients with known CAD, and 34% of these regular users continued therapy beyond the early postoperative period. Only 9% of respondents reported that a formal protocol existed at their facility. This study suggests that barriers to the translation of research to practice were not related to a lack of awareness of the current best evidence. With respect to perioperative beta blockers, controversies within the literature as well as practical considerations may be greater barriers to implementation of best evidence. IMPLICATIONS: This survey found that anesthesiologists were aware of and supported the use of prophylactic perioperative beta blockers in patients with risk factors or known coronary artery disease; however, only 57% frequently prescribed perioperative beta blockers. A lack of awareness of the current "best" evidence was not a barrier to use.     

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.     

Weak beta-adrenoceptor-mediated relaxation in the human internal mammary artery

The function of beta-adrenoceptors in the human internal mammary artery was studied in vitro to predict the way in which the internal mammary artery graft would respond to beta-adrenergic agonists and antagonists given in the perioperative period. Ring segments of the distal internal mammary artery obtained from patients not receiving beta-blocker therapy were mounted in organ baths and isometric wall force was measured. For comparison, similar experiments were conducted on segments of canine coronary artery, a vessel known to have powerful beta-adrenoceptor function. All arteries were precontracted with potassium or the thromboxane mimetic agent, U46619, before isoproterenol cumulative concentration-relaxation curves were constructed. In the human internal mammary artery, the maximum relaxation induced by isoproterenol was only 14% of the potassium-induced contraction and 24% of the U46619-induced contraction. These responses were weak compared with 54% and 86% for beta-adrenoceptor relaxation measured in corresponding experiments in the canine coronary artery. In all experiments, propranolol antagonized the relaxation induced by isoproterenol. These studies suggested that the human internal mammary artery has only a small number of beta-adrenoceptors. We conclude that beta-adrenoceptors would contribute little to the reactivity of the human internal mammary artery graft to sympathomimetic drugs.     

高危患者在血管外科手术前行冠状动脉重建术之利弊综述

血管外科手术患者如合并有冠状动脉疾病,发生心血管并发症的风险将增加。手术前心血管功能评估有助于发现需要进行冠状动脉造影的高危患者,并随后进行冠状动脉重建术,以达到改善围手术期甚至长期心血管转归的目的。但与药物治疗相比,冠状动脉重建手术的适应证和减少心血管并发症的有效性仍存在争议。本文通过分析已发表的文献,探讨与保守的药物治疗相比,手术前行血管重建术在择期血管手术中的作用。     

Operative treatment of coronary atherosclerosis

The evolution of percutaneous intervention has reduced the prevalence of coronary bypass surgery in a patient population that is older, with more comorbidity and advanced coronary disease. Despite this less favorable group, perioperative mortality has continued to decline as the operation improves. The latter includes off-pump coronary grafting, smaller incisions, better intraoperative myocardial preservation, improving management of cardiopulmonary bypass, perioperative glucose control, and increasing use of arterial conduits as the radial artery comes of age and the gastroepiploic artery is reborn as a free graft. This brief review of the basics of coronary artery bypass is part experience with an effort to be fair-minded and balanced and to include that which is new and promising. It is imperative that we continue to innovate and distill the best from the old so that we can provide the optimal intervention for coronary artery disease.     

Effects of short-term infusion of nifedipine or verapamil on systemic hemodynamics and left ventricular myocardial contractility in patients prior to coronary artery bypass surgery

The effects of short-term infusion (10 min) of nifedipine (7.5 micrograms . kg-1) or verapamil (0.15 mg . kg-1) on left ventricular (LV) contractility and on systemic hemodynamics in patients with coronary artery disease, chronically treated with low-dose beta-adrenergic blocking drugs, exhibiting a normal LV function at rest, are presented. In order to analyze the interaction between calcium entry blocking drugs and halothane, the results are discussed in light of data, obtained in similar patients during halothane anesthesia, using identical experimental conditions, which have already been reported. LV dP/dtmax and LV end-diastolic pressure (LVEDP) remained unaffected when nifedipine was infused in the awake patients. Verapamil significantly decreased LV dP/dtmax in patients while awake, but LVEDP did not change. Both calcium entry blocking drugs caused decreases in blood pressure and systemic vascular resistance, accompanied by increases in heart rate. The only significant differences between the awake and the anesthetized patients were the absence of changes in heart rate and the greater reduction in LV dP/dtmax following administration of the calcium entry blocking drugs during anesthesia. Possible explanations for this may include the drugs' combined interference with calcium ion fluxes within the myocardial and smooth muscle fibers, the ability of halothane to modify the response of the autonomic nervous system to the calcium entry blocking drugs and altered kinetics of the calcium entry blocking drugs induced by the volatile anesthetic. It is impossible to determine from the present investigation which of these mechanisms is predominant.     

Preoperative management of the patient with coronary artery disease before abdominal aortic surgery

Coronary artery disease accounts for more than half of the morbidity and mortality associated with abdominal aortic surgery. To improve the results of vascular surgery, the risk of perioperative cardiac ischemia should be evaluated in each patient. Routine coronary angiography demonstrated severe correctable coronary artery disease in 14% of patients who had no history or electrocardiographic evidence of coronary artery disease. Exercise testing before abdominal aortic aneurysm repair will identify patients at high risk of cardiac ischemia. Dipyridamole-thallium imaging will identify high-risk patients before surgery for aortoiliac occlusive disease. Some patients with symptomatic coronary disease who are at extremely high risk should undergo preoperative coronary revascularization. Others should have their vascular surgery deferred, because their cardiac risk may exceed the anticipated benefit of the vascular surgery. Patients at moderate risk may need more intensive intraoperative monitoring. Patients without evidence of cardiac ischemia with stress may undergo vascular surgery with a low risk of perioperative cardiac ischemia. Finally, patients who have evidence of ischemic heart disease should be considered for coronary revascularization following successful vascular repair in order to prolong their survival.     

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.     

Nitrous oxide does not induce myocardial ischemia in patients with ischemic heart disease and poor ventricular function

Despite evidence from animal experiments to the contrary, nitrous oxide (N2O) reportedly does not induce myocardial ischemia when used as an adjunct to fentanyl anesthesia in patients with coronary artery disease who have well-preserved left ventricular (LV) function. However, the incidence of ischemia with N2O administration in similar patients with poor LV function may be different. The effects of N2O on segmental LV function, as determined by two-dimensional transesophageal echocardiography, changes in the ST-segment of the electrocardiogram were compared with the effects of an equal concentration of nitrogen (N2) (crossover design) in 70 patients who required elective coronary artery bypass grafting. Of these patients, 24% had left ventricular ejection fraction (LVEF) less than or equal to 40%. Myocardial ischemia was diagnosed in 14 patients during the study: four while awake, seven during induction of anesthesia and tracheal intubation, and four during the remainder of the study (one during N2O and three during 100% oxygen; one patient had two distinct periods of ischemia). No value for LVEF could be found that would distinguish between patients who did or did not have ischemia during the study. Patients treated with beta-adrenergic blocking drugs preoperatively were less likely to develop ischemia (P less than 0.05). Preoperative calcium channel blockers made no such differences. Onset of ischemia was not closely associated with hemodynamic changes. Thus, N2O does not induce clinically detectable myocardial ischemia in patients who have coronary artery disease, and poor LV function in situations in which the effects of deepening anesthetic depth and mild depression of global myocardial function are deemed desirable or harmless.     

Coronary artery bypass grafting for left main disease and the risk of stroke: Incidence,aetiology and prevention

This review explores the association between left main disease and the increased risk of perioperative stroke following coronary artery bypass grafting, specifically addressing the potential underlying mechanisms and its potential prevention. In particular, this correlation appears stronger for patients with left main disease when compared to patients with isolated triple vessel disease. Even though evidence on this topic is limited and of modest quality, there appears to be a significant association between ascending aorta atherosclerosis and coronary artery disease. Furthermore, there seems to be a relationship between the severity and extent of carotid artery stenosis and coronary artery disease. Carotid artery disease is itself associated with atherosclerosis of the ascending aorta, a well-recognised risk factor for postoperative atheroembolic stroke. The association between left main disease, ascending aorta atherosclerosis and carotid artery stenosis may reflect an increased systemic atherosclerotic burden and hence explain, at least partially, the higher risk of perioperative cerebrovascular events. Potential pre-, intra- and post-operative strategies for stroke prevention are discussed.     

Coronary and major vascular disease: aggressive screening and priority-based therapy

It is well know that atherosclerosis can simultaneously affect different vascular subsystems, and patients with diffuse atherosclerosis can be a major management problem both for preoperative evaluation and for intraoperative management. The authors have conducted a prospective study to evaluate the prevalence of coronary artery disease in arteriopathic patients, and vice versa, to assess the effectiveness of aggressive screening together with a priority-based approach. Study 1 consisted of 1,000 consecutive non-emergent patients who were affected by abdominal aortic or carotid disease and were screened for the presence of coronary artery disease before surgery with a newly developed clinical risk assessment. They were stratified into three risk categories with different preoperative evaluation strategies. When coronary artery disease was concomitantly demonstrated in these patients, the choice of surgical method was based on priorities, and the use of combined surgical procedures as required. In study 2, 1,000 consecutive patients that required coronary angiography for suspected coronary artery disease were screened for the presence of carotid or abdominal aortic pathology, directly in the cardiac catheter laboratory during coronary angiography, by obtaining views of the aortic arch and abdominal aorta. Surgical approaches paralleled those of study 1. The results for study 1 showed that 720 patients (72%) were affected by abdominal aortic disease, 238 (24%) by carotid disease and 42 (4%) by both pathologies. Significant coronary artery disease was found in 152 patients (15%), of these 123 (81.5%) were affected by abdominal aortic disease and 29 (18.5%) by carotid artery disease. Abdominal aortic surgery was performed directly or after myocardial revascularization, with an overall mortality rate of 4/718 (0.6%), and a perioperative myocardial infarction rate of 10/718 (1.4%). For patients with carotid artery disease, the completed screening and possible therapy for coronary artery disease resulted in an in-hospital mortality rate of 2/238 (0.8%), and a perioperative myocardial infarction rate of 2/238 (0.8%). There were no significant differences in these rates between patients with or without coronary artery disease. Results for study 2 showed that of the 1000 consecutive patients enrolled for suspicion of coronary artery disease, 767 (77%) were affected by significant coronary artery disease. Among these, 38 (4.9%) had a surgically correctable aortic disease and 31 (4%) a surgically correctable carotid disease, which was monolateral and bilateral in 22 (74%) and nine (26%) patients, respectively, and four (0.5%) were diagnosed with both pathologies. These arteriopathic patients were treated for their coronary and vascular disease with no in-hospital mortality nor perioperative myocardial infarction. In patients with multiple vascular involvement, both coronary and vascular surgery can be performed with low risk when aggressive screening and priority-based therapy are adopted.     

Neuroprotection is associated with beta-adrenergic receptor antagonists during cardiac surgery: evidence from 2,575 patients

OBJECTIVE: To determine the impact of perioperative beta-adrenergic receptor (betaAR) antagonist administration on neurologic complications. DESIGN: Observational database analysis. SETTING: A clinical investigation at a single tertiary academic medical center. PARTICIPANTS: Elective coronary artery bypass graft surgical patients operated on in the period 1994-1996. INTERVENTIONS: Patients were divided into 2 groups: (1) patients given betaAR antagonist-blocking drugs in the perioperative period, including during operation, and (2) patients not given betaAR antagonists. MEASUREMENTS AND MAIN RESULTS: betaAR antagonist use in 2,575 consecutive patients undergoing coronary artery bypass graft surgery (1994-1996) was determined using the Cardiovascular Database and Anesthesia Information System Database. Outcome variables were postoperative stroke, coma, and transient ischemic attack. Of patients, 113 (4.4%) had postoperative neurologic complications, including stroke (n = 44), coma (n = 12), and transient ischemic attack (n = 3). Of patients, 2,296 (89%) received perioperative betaAR antagonist therapy, and 279 (11%) did not. Adverse neurologic events occurred in 3.9% (n = 90) of patients who received perioperative betaAR antagonists and 8.2% (n = 23) of patients who did not receive betaAR antagonists (odds ratio, 0.45; 95% confidence interval, 0.28 to 0.73; p = 0.003, unadjusted.) Severe neurologic outcomes (stroke and coma) occurred in 1.9% (n = 44) of patients who received betaAR antagonists and 4.3% (n = 12) of patients who did not receive betaAR antagonists (odds ratio, 0.43; 95% confidence interval, 0.23 to 0.83; p = 0.016). CONCLUSION: Use of beta-adrenergic antagonists was associated with a substantial reduction in the incidence of postoperative neurologic complications. A prospective randomized trial is needed to verify this potentially important neuroprotective strategy in cardiac surgery.     

The year in Cardiothoracic and Vascular Anesthesia: selected highlights from 2011

There have been rapid advances in oral anticoagulation. The oral factor Xa inhibitors rivaroxaban and apixaban and the oral direct thrombin inhibitor dabigatran recently have been rigorously evaluated. These novel anticoagulants will usher in a new paradigm for perioperative anticoagulation. Perioperative blood conservation in cardiac surgery recently has been highlighted in the updated guidelines by the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons. These recommendations reflect a comprehensive evaluation of the recent evidence to optimize transfusion practice. Transcatheter mitral valve repair continues to mature. Transcatheter aortic valve implantation for aortic stenosis has entered the clinical mainstream, with randomized trials showing its superiority over medical management and its equivalency to surgical valve replacement in high-risk patients. This transformational technology represents a major leadership opportunity for the cardiac anesthesiologist. Minimally invasive valve surgery has shown effectiveness in high-risk patients. Radial access is equivalent to femoral access for percutaneous coronary intervention in acute coronary syndromes but significantly reduces the risk of local vascular complications. Recent trials have further clarified the roles of medical therapy, percutaneous coronary intervention, and coronary artery bypass surgery in patients with significant coronary artery disease and left ventricular dysfunction. The past year has witnessed major advances in cardiovascular practice with new drugs, new devices, and new guidelines. The coming year most likely will advance these achievements to enhance the care of patients.     

Does chronic treatment with calcium entry blocking drugs reduce perioperative myocardial ischemia?

To examine the role of chronic calcium entry blocking drug administration on perioperative myocardial ischemia and, specifically, the frequency of hemodynamically unrelated ischemia, the authors studied 444 patients undergoing coronary artery bypass operations. Before induction of anesthesia, 119 patients who chronically took calcium entry blocking drugs received nifedipine 20 mg or diltiazem 60 mg orally, 74 received calcium entry and beta adrenergic blocking drugs, 71 received beta blocking drugs only, and 180 received neither. New ischemia occurred in 208 (46.8%) patients; 55 at arrival to the operating room, 86 only after induction, and 67 separately during both periods. Two-thirds of all ischemia was not related to extremes of heart rate or blood pressure; this type was not less frequent in patients receiving calcium entry blocking drugs. Ischemia did occur less frequently in the two patient groups receiving beta adrenergic blocking drugs (34% vs. 53%), a result of less tachycardia both on arrival (3.4% vs. 15.4%) and during anesthesia, when peak heart rate exceeded 109 bpm in only one of 145 beta-blocked patients compared to 29 of 299 not receiving beta blocking drugs. While ischemia appeared during anesthesia in 34.5% of all patients, its incidence was doubled (63%) when heart rate was greater than or equal to 110 bpm. At lower heart rates, the incidence of ischemia did not differ among groups. With respect to all types of ischemia, patients receiving calcium entry blocking drugs only were indistinguishable from those receiving no antianginal therapy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Myocardial ischaemia,infarction and cardiac-related death following carotid endarterectomy: risk assessment by thallium myocardial perfusion scan compared with clinical examination

Risk factors in 402 patients undergoing 447 carotid endarterectomies were reviewed to see whether the presence of coronary artery disease before operation influenced the likelihood of perioperative cardiac complications. A second aim of the study was to assess whether myocardial thallium scintigraphy was valuable for preoperative assessment. Fourteen patients developed postoperative cardiac complications, six (1.3%) of which were fatal. Four of these deaths occurred in 60 patients undergoing combined carotid-coronary revascularization (6.6%). In 387 carotid endarterectomies without simultaneous coronary revascularization, there were two deaths from myocardial infarcts (0.5%). These fatalities and other cardiac complications occurred in 204 patients with preoperative clinical or ECG evidence of coronary artery disease. In 198 patients with no preoperative evidence of coronary disease there were no fatalities and only one patient with reversible postoperative myocardial ischaemia (0.4%). It is concluded that carotid endarterectomy under general anaesthesia is unlikely to be followed by cardiac complications when there is no preoperative evidence of coronary artery disease. When coronary disease is detected before operation, postoperative cardiac complications occur after 5.6% of operations, including 0.9% fatalities. When coronary artery disease is severe enough to warrant combined carotid-coronary reconstruction, the perioperative mortality rate was 6.6%, all the deaths being cardiac-related. When myocardial thallium scintigraphy was normal, postoperative cardiac complications did not occur.