Systemic Complications: Cardiac: Giora Landesberg and Chen Rubinstein

SECTION 7 COMPLICATIONS
CHAPTER 42
Systemic Complications:
Cardiac
GIORA LANDESBERG and CHEN RUBINSTEIN
EPIDEMIOLOGY 531 Cardiac Troponin 536

Prevalence of Coronary Disease 531 C-Reactive Protein 537
Definition of Adverse Postoperative Cardiac Events 531 Rest Electrocardiogram 537
Myocardial Infarction 531 Chest X-Ray 537
Type-1 Myocardial Infarction 531 Echocardiography 537
Type-2 Myocardial Infarction 531 Ambulatory ST Segment Monitoring 537
Unstable Angina Pectoris 532 Preoperative Investigation for Coronary Artery
Congestive Heart Failure 532 Disease 537
Life-Threatening Arrhythmia 532 Noninvasive (Stress) Testing 538
Cardiac Death 533 Exercise Stress Testing 538
THE PATHOPHYSIOLOGY OF PERIOPERATIVE Myocardial Perfusion Imaging 538
MYOCARDIAL INFARCTION 533 Dobutamine Stress Echocardiography 538
Perioperative Myocardial Injury and Mortality 533 Positron Emission Tomography 538
Incidence of Cardiac Complications Following Major Cardiac Magnetic Resonance Imaging 539
Vascular Surgery 534 Computed Tomography Coronary Angiography 539
Abdominal Aortic Surgery 534 Preoperative Coronary Angiography and
Lower-Extremity Bypass 535 Revascularization 539
Carotid Endarterectomy 535 CLASS I 540
PREOPERATIVE CARDIAC EVALUATION 535 CLASS III: NO BENEFIT 540
Clinical Risk Assessment 535 MEDICAL PROPHYLAXIS 540
Cardiac Risk Indices 535 Beta Blockade 540
Preoperative Laboratory Testing 536 Statins 540
Complete Blood Count 536 Aspirin 541
Creatinine 536 Dual Antiplatelet Therapy After Coronary Stenting 541
Blood Sugar 536 TREATMENT 542
Natriuretic Peptides 536
530
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CHAPTER 42 Systemic Complications: Cardiac 530.e1
Abstract Keywords
Vascular surgery patients as a groups are the patients with Myocardial infarction
the largest prevalence of cardiac disease among all non-cardiac Type-1
surgery patients. As such, they are also at high risk of developing Type-2
perioperative cardiac morbidity and mortality. This chapter will Myocardial injury and troponin elevation
focus on understanding the pathophysiology of perioperative Cardiac risk indices
cardiac events in vascular surgery patients, on the methods to
accurately define and diagnose preoperative cardiac pathologies
and cardiac risks and on the possible measures that can be taken
to improve perioperative cardiac risk.
CHAPTER 42 Systemic Complications: Cardiac 531
branch block; (3) development of new pathologic Q waves; (4)

EPIDEMIOLOGY imaging showing loss of viable myocardium or a new abnormal
left ventricular (LV) wall motion. The universal definition of
Prevalence of Coronary Disease MI identifies two main types of MI.4
Coronary artery disease (CAD) is highly prevalent in vascular
surgical patients. Hertzer and colleagues drew attention to this Type-1 Myocardial Infarction
by showing the small percentage of vascular surgery patients This is a sudden, spontaneous coronary event typically occur-
(8%) who were free of CAD.1 In a study from the Cleveland ring in an unstable or “vulnerable” coronary plaque that has a
Clinic from more than 30 years ago, 5% of patients had left large and highly inflammatory lipid core with a thin, weakened
main CAD and 11% had significant three-vessel disease. In fibrous cap that suddenly undergoes acute disruption, leading to
fact, 15% of these patients had severe, yet unsuspected CAD. acute coronary thrombosis. Acute plaque rupture and coronary
Since then, significant changes in both the primary and secondary thrombosis that occur in a major coronary artery, supplying
prevention of coronary disease have occurred, including smoking an area that was not significantly stenosed prior to the acute
cessation and the adoption of aggressive lipid lowering therapies. occlusion and lacks sufficient collaterals, typically results in
Subsequently, the incidence of myocardial infarction (MI) and ST-elevation-type MI (STEMI). STEMI, as a rule, is a medical
cardiac death in nonsurgical populations decreased by 30%.2 emergency. It typically causes severe chest pain, dyspnea, and
Conversely, patients presenting for vascular surgery in 2013 sweating, and requires an emergency intervention to reopen the
are on average a decade older, with more comorbidities, and occluded coronary artery, preferably by percutaneous coronary
the incidence of major coronary pathology in vascular patients intervention (PCI). Even with the urgent coronary intervention,
may be even higher. Thus, despite clear advances in the treatment STEMI is associated with up to 10% early mortality. Other
of CAD, it is conceivable that many patients presenting for patients may have similar symptoms but no ST-segment eleva-
vascular surgery have silent yet significant CAD. In the interventions or, rather, ST-depression on electrocardiogram (ECG/EKG).
ing years, our ability to identify patients with significant coronary These infarctions are defined as non-ST-elevation infarctions
disease has apparently been imperfect. This was demonstrated or NSTEMI. Pathologically, these are plaque ruptures and
by Monaco and colleagues, where screening patients using the coronary thromboses in coronary arteries supplying smaller
American Heart Association/American College of Cardiology myocardial territories or territories supplied also by collaterals,
(AHA/ACC) guidelines identified fewer patients with three-vessel or thromboses causing partial coronary occlusions. Patients
or left main coronary disease than a randomized cohort having with NSTEMI usually do not benefit from urgent coronary
routine preoperative coronary angiograms.3 In this chapter we interventions, unless hemodynamic instability or progression
will outline and define the pathology and document the of symptoms occurs. In the past, the proportions of STEMI
incidence, the diagnostic criteria, risk stratification, and treatment and NSTEMI, in the general nonsurgical Western populations
options designed to limit the effect of postoperative cardiac were approximately 50% each. Currently, with the older age
adverse events. of the population, with primary and secondary prevention
strategies available, and with the better detection of MI by
Definition of Adverse Postoperative the high-sensitivity troponin assays, the absolute incidence of
STEMI in the Western world is declining while the incidence
Cardiac Events of NSTEMI is increasing. Hence the current proportion of
These can be classified using the following terms: STEMIs of all infarctions is 30% or less.
• Acute coronary syndromes (i.e., unstable angina pectoris
[UAP], acute MI, or sudden cardiac death) Type-2 Myocardial Infarction
• Congestive heart failure (CHF) In contrast, type-2 MI often occurs in patients with severe yet
• Myocardial injury stable CAD, usually due to extracardiac causes leading to a
• Life-threatening arrhythmias prolonged imbalance between myocardial oxygen supply and
demand. The most common triggers for type-2 MI are prolonged
Myocardial Infarction tachycardia, hypotension or hypertension, anemia, and emotional
MI is one of the leading causes of death after surgical procedures. or physical stress causing coronary vasospasm.5 Type-2 MI is
Since the introduction of cardiac troponin assays in the 1990s almost uniformly associated with ST-depression or non-ST-
and the recognition of their high sensitivity, specificity, and elevation type ischemia and is therefore indistinguishable from
prognostic value, the diagnosis of MI is based mainly on serum type-1 NSTEMI. The clinical circumstances (i.e., spontaneous,
troponin elevations. The most recent universal definition of primary event in type-1 versus stress-induced, secondary event
MI4 endorsed by all major cardiology organizations defines MI in type-2) can help distinguish between the two types of MI
as a rise and fall in cardiac troponin above the 99th percentile (Fig. 42.1).
of the upper reference limit (for the specific troponin assay), Postoperative MI occurs in up to 24% of vascular surgery
in association with signs or symptoms of myocardial ischemia— patients if MI is defined only based on troponin elevation and
that is, at least one of the following: (1) symptoms of myocardial the low cutoff level of troponin elevations is used to define
ischemia (i.e., typical chest pain); (2) electrocardiographic MI.6 Postoperative ST elevation MI (STEMI) is usually less
evidence of acute ischemia, ST-T wave changes, or left bundle than 1% of all postoperative MIs.7 Many more patients sustain
532 SECTION 7 Complications
Unstable coronary plaques Severe, yet stable CAD
Hemodynamic ↑ Myocardial O2 ↓ Subendocardial

Sympathetic instability ↑ Sympathetic
demand O2 supply
hyperactivity (tachycardia hyperactivity
(increased hypertension) ↑ Heart rate Postoperative pain ↑ Heart rate
plasma
Coronary / arrhythmia / arrhythmia
catecholamines) Withdrawal of
vasoconstriction blockers
Hypovolemia
Cardiac
decompensation Hypotension
or Systemic
vasodilation
Plaque rupture Plaque erosion
↑ Blood pressure
↑ Myocardial
wall stress Hypervolemia/ ↑ Myocardial
wall stress
↑ Coagulability ↑ LVEDP
↓ Fibrinolysis Acute Coronary vasoconstriction

coronary
thrombosis Anemia
Recent PCI with stent Pulmonary congestion Hypoxemia
/ premature cessation / Atelectasis
of dual antiplatelet
ACS—type-1 MI Prolonged ST-depression ischemia >> type-2 MI
Figure 42.1 The two distinct mechanisms of PMI. CAD, Coronary artery disease; MI, myocardial infarction; PCI,
percutaneous coronary intervention.
a biomarker rise with ST-segment depression or without any is most commonly either secondary to LV failure, such as in
transient ST-T changes, which is analogous to a non-ST elevation the presence of severe mitral valve disease, or secondary to
myocardial infarction (NSTEMI) or myocardial injury. severe lung disease (i.e., cor pulmonale). In the perioperative
setting, congestive failure is often ill defined and is frequently the
Unstable Angina Pectoris result of fluid overload or transfusion-associated cardiac overload
UAP occurs when a patient has recurrent or new onset typical (TACO). The inability to handle excess fluids is a sign of a failing
chest pain, especially during rest, yet with no evidence of serum left ventricle. Postoperative CHF should be more thoroughly
troponin elevations, since the presence of serum troponins investigated with biomarkers (B-type naturetic peptide [BNP],
elevation already makes the diagnosis of MI. N-terminal pro-B-type naturetic peptide [NT-proBNP]), chest
x-ray, cardiac imaging, and particularly with echocardiography.
Congestive Heart Failure
Heart failure is the inability of the heart to provide adequate Life-Threatening Arrhythmia
cardiac output to meet the normal metabolic requirements of Most life-threatening arrhythmias (ventricular tachycardia,
all peripheral organs. Acute heart failure often leads to a drop ventricular fibrillation, high-degree A-V block) occur in the
in blood pressure and shock. Chronic, compensated heart setting of acute myocardial ischemia and infarction, or in the
failure is a situation in which the periphery adapts itself to the presence of structural myocardial disease such as severely dilated
lower capacity of the heart to supply adequate cardiac output. cardiomyopathy. Fortunately, these LTAs are rare in the periopera-
Currently heart failure is divided into two main subtypes: (1) tive period, and if they do occur, it is mostly in patients with
heart failure with reduced ejection fraction (HFrEF) or systolic known predisposing factors such as severe CAD or cardiomy-
heart failure (these are usually patients with dilated hearts due opathy. The more common arrhythmia in the perioperative
either to MIs or dilated cardiomyopathy and reduced systolic setting is new onset or recurrent atrial fibrillation, and the most
function), or (2) heart failure with normal or preserved ejection common causes of postoperative AF in patients with no known
fraction (HFnEF) or diastolic heart failure (these are often myocardial or valvular disease are severe diastolic dysfunction
patients with prolonged severe hypertension, left ventricular and chronic lung disease or pulmonary hypertension. Patients
hypertrophy [LVH] and are more likely in female than males). with new onset postoperative atrial fibrillation obviously have
Another type of heart failure is right ventricular failure, which the worse prognosis.
Cardiac Death TABLE 42.1 Universal Classification of

Cardiac death has also been defined in the universal definition Myocardial Infarction
statement. Type-3 MI is death or cardiac arrest that is sudden Type 1: Spontaneous Myocardial Infarction
and unexpected, with symptoms suggestive of myocardial Spontaneous myocardial infarction related to atherosclerotic
ischemia, occurring before cardiac biomarkers could be obtained plaque rupture, ulceration, assuring, erosion, or dissection, with
or before they appear in the blood.4 resulting intraluminal thrombus in one or more of the coronary
arteries leading to decreased myocardial blood flow or distal
platelet emboli with ensuing myocyte necrosis. The patient may
have underlying severe CAD but on occasion nonobstructive or no
THE PATHOPHYSIOLOGY CAD.
OF PERIOPERATIVE Type 2: Myocardial Infarction Secondary to an Ischemic

Imbalance
MYOCARDIAL INFARCTION In instances of myocardial injury with necrosis where a condition
The high prevalence of CAD in vascular surgery patients and other than CAD contributes to an imbalance between myocardial
oxygen supply and/or demand, e.g. coronary endothelial
the strong perioperative physiologic and emotional stresses, dysfunction, coronary artery spasm, coronary embolism, tachy-/
including catecholamine surge, hemodynamic instability, brady-arrhythmias, anemia, respiratory failure, hypotension, and
vasospasm, reduced fibrinolytic activity, platelet activation, and hypertension with or without LVH.
hypercoagulability, predispose the vascular patients to a high CAD, Coronary artery disease; LVH, left ventricular hypertrophy.
incidence of postoperative cardiac complications. Interestingly,
however, numerous studies showed that postoperative STEMI
is disproportionately rare compared with the common occurrence
of NSTEMI and that tachycardia is a frequent cause of post-
operative myocardial ischemia.6,8-10 Studies using continuous who underwent major vascular surgery had at least minor
perioperative 12-lead ECG monitoring with online ST-segment postoperative troponin elevations (troponin-T > 0.03 ng/mL),
analysis showed that prolonged, reversible episodes of ST-segment yet only 30% of these patients with troponin elevations exhibited
depression, indicative of subendocardial myocardial ischemia, myocardial ischemia on continuous 12-lead EKG monitoring
occur in up to 41% of vascular surgery patients and precede with ST-segment analysis and 82% of them had no symptoms
the occurrence of troponin elevation.11 These ST-depression- related to MI (Tables 42.1 and 42.2). When a higher cutoff
type ischemic events peak early after surgery and troponin level of troponin elevation (troponin-T > 0.1 ng/mL) was
elevations are maximal within the first 2 days.12-14 In contrast, selected, 8.7% of the patients had such troponin elevation yet
postoperative ST-elevation type ischemia is rare.6-10 The data 56% of these patients were still asymptomatic. Regardless if
suggest, therefore, that perioperative MI is most commonly patients were symptomatic or not, even minor troponin elevation
type-2 MI, caused by a prolonged ST-depression-type ischemia in the first 3 days after vascular surgery was associated with
that is the result of an imbalance between myocardial oxygen increased 5-year mortality, and higher postoperative troponin
supply and demand,15 usually as a result of tachycardia and elevation was associated with worse long-term survival (Fig.
increase in myocardial load. Anemia, hypoxemia, increased 42.2). LeManach and colleagues studied more than 1100 patients
myocardial oxygen demand, ventricular overload or underload, undergoing open abdominal aortic aneurysmectomy.14 Fourteen
systolic or diastolic dysfunction, and neuroendocrine responses percent of these patients had troponin elevations, and in their
to the stresses of surgery all contribute to the decreased ischemic study, too, minor troponin elevation was associated with greater
threshold early after surgery and with the increase in heart rate 30-day postoperative mortality.4 Van Waes and colleagues found
may lead to prolonged ischemia and infarction.15 Although similar results.9,10 Similarly, the VISION prospective multicenter
small pathologic studies showed that plaque disruption or study that included more than 15,000 patients and the single
hemorrhage can be found in postmortem analyses in up to center retrospective study that included more than 10,000 have
half of patients who died after postoperative MI,16,17 it is confirmed that troponin elevations on the first 3 days after
now well recognized that vulnerable plaques are ubiquitous surgery predict early (30-day) mortality in a dose-dependent
in patients with CAD and most of them are not related manner.13,18,19
to MIs. The reasons for this lack of symptomatology in most patients
with postoperative troponin elevations remain elusive. Elderly,
diabetic, and vascular patients in particular are known to have
Perioperative Myocardial Injury and Mortality a high incidence of silent ischemia. The concomitant use of
Studies that used routine postoperative troponin measurements narcotics and other competing somatic postoperative sensations
showed that most patients with postoperative troponin elevations may contribute to masking cardiac symptoms. The ECG, which
do not fulfill the additional diagnostic criteria necessary for the is central for the diagnosis of MI, is less specific and sensitive
diagnosis of postoperative MI and that postoperative troponin in the presence of preexisting changes such as left or right
elevation is predominately clinically silent. Landesberg and bundle branch block, pacemaker rhythms, or baseline ST-T
colleagues8 first showed that almost 24% of all 447 patients wave changes.20,21 Moreover, the ischemic EKG changes may
TABLE 42.2 Association of Longest Ischemia Duration With Biochemical Markers of Myocardial Infarction
Myocardial Infarction Ischemia >15 min n Ischemia Ischemia Symptoms
Defined As Total n (%)a (%)b >30 min n (%)b >60 min 11 (%)b Attributable to MIc
CK > 170 IU and MB >5% 34 (6.7) 17 (50.0) 14 (41.2) 12 (35.3) 7 (20.5)
CK > 170 IU and MB >10% 14 (2.9) 8 (57.1) 7 (50.0) 7 (50.0) 5 (35.7)
cTn-I >0.6 ng/mi and/or 107 (23.9) 34 (31.8) 29 (27.1) 21 (19.6) 19 (17.7)
cTn-T >0.03 ng/mL
cTn-I >1.5 ng/mL and/or 41 (8.7) 38 (87.8) 24 (58.3) 19 (46.3) 18 (43.9)
cTn-T >0.1 ng/mL
cTn-I >3.1 ng/mL and/or 21 (4.2) 19 (90.5) 17 (81.0) 17 (81.0) 13 (61.9)
cTn-T >0.2 ng/mL
a
Percent of all 501 vascular operations.
b
All four biochemical criteria of infarction were significantly associated (P < .001) with both >30 min and >60 min ischemia duration using chi-square analysis.
c
Prolonged chest pain, congestive heart failure, or new onset arrhythmia.
CK, Creatine kinase; cTn-I, cardiac troponin-I; cTn-T, cardiac troponin-T; ID, international units; MB, MB fraction; MI, myocardial infarction.
Adapted from Landesberg G, Shatz V, Akopnik I, et al. Association of cardiac troponin, CK-MB, and postoperative myocardial ischemia with long-term survival
after major vascular surgery. J Am Coll Cardiol. 2003;42:1547-1554.
1.0 predict not only cardiac but also noncardiac complications and
mortality.22 Noncardiac complications pose a higher demand
0.9 on the patient’s heart, and thus it is not surprising that
mortality is increased in those with underlying heart disease.
0.8 Conversely, primary cardiac injury may lead to cardiac failure
P = .047
and a deterioration in other important systems, such as the
0.7 kidneys, leading to what may appear to be a noncardiac cause
Survival
P = .007 of death.23
0.6
P < .001
0.5
Incidence of Cardiac Complications Following
0.4 Major Vascular Surgery
Abdominal Aortic Surgery
0.3
The incidence of major cardiac complications is dependent on
0 10 20 30 40 50 60
patient characteristics, risk factors, symptomatology, and type
Months after surgery
of surgery. The incidence of major cardiac complications is
cTn-I ≤0.6 and cTn-T ≤0.03
displayed in Table 42.3.
0.6< cTn-I ≤1.5 and/or 0.03< cTn-T ≤0.1
Aortic surgery has the highest incidence of cardiac morbidity,
1.5< cTn-I ≤3.1 and/or 0.1< cTn-T ≤0.2
which ranges from 1% in endovascular repair to more than
cTn-I >3.1 and/or cTn-T >0.2
14% in open abdominal aortic aneurysm repair.31 Generally,
the events rates in randomized trials are half of those in registries.
Figure 42.2 Long-term survival in 447 vascular surgery patients divided according In addition, the cardiac event rate is higher in patients with
to the highest troponin-T level in the first 3 postoperative days. (From Landesberg larger aneurysms, in open versus endovascular repairs, in patients
G, Luria MH, Cotev S, Eidelman LA, et al. Importance of long-duration postopera- with known preoperative cardiac comorbidity, and in operations
tive ST-segment depression in cardiac morbidity after vascular surgery. Lancet.
requiring higher aortic cross clamps (e.g., suprarenal vs. infra-
1993, JACC 2003;341:715-719.)
renal).29 Recently a comprehensive systematic review of all studies
reporting survival after abdominal aortic aneurysm repair in
the last 25 years, including altogether 65,557 patients, was
published.32 It showed that chronic obstructive pulmonary
be of transient nature, and the lack of routine monitoring of disease (COPD) requiring supplementary oxygen and/or ESRD/
postoperative 12-lead EKG with ST-segment analysis leads to dialysis was associated with the highest risk of long-term mortal-
underdetection of postoperative ischemia.16 ity. Increased age, female gender, cardiac failure, renal impair-
Recently it has been shown that postoperative troponin ment, COPD, cerebrovascular disease, PVD, diabetes, and IHD
elevations in patients undergoing major abdominal surgery also significantly increased mortality.
TABLE 42.3 Incidence of In-Hospital Cardiac Morbidity and Mortality by Surgery Type
CARDIAC MORBIDITY ALL CAUSE MORTALITY
Open (%) Endovascular (%) Open (%) Endovascular (%)
Abdominal Aortic
DREAM study24 2.9 2.9 4.5 1.2
OVER trial25 2.8 1.3 2.9 0.5
EVAR (1&2)26,27 2.7 1.4 6.2 2.1
VSG(NE)28 AAA size <5.5 cm 9.5 2.5
VSG(NE)28 AAA size >5.5 cm 14.8
Ferrante et al.29 12.8
Low Extremity Bypass
VGE(NE) claudication only28 3.4
VGE(NE) critical limb ischemia 10.1
Carotid
CREST30 2.3 1.1 0.3 0.7
VGE(NE) asymptomatic 2.3
VGE(NE) symptomatic 3.4
OVER, Open versus endovascular repair; VSG(NE), Vascular Study Group of New England.
perioperative and long-term cardiac risk. (3) Accurate preopera-

Lower-Extremity Bypass tive knowledge of the patient’s cardiac function and risk will
The cardiac event rate in lower extremity vascular surgery is allow better intraoperative and postoperative treatment and
dependent on symptoms, where patients with critical limb resource utilization, such as intraoperative monitoring and the
ischemia have more than 10% cardiac event rate that is three need for postoperative intensive care unit (ICU) utilization.
times that of patients with claudication only. One recent study (4) Finally, understanding a patient’s perioperative and long-term
reported that the presence of low-extremity arterial disease is risks will allow the treating physician to provide the best possible
associated with a twofold increase in the prevalence of CHF, consultation for optimal risk-benefit decision.
and that CHF increases the complication rates for perioperative
pneumonia, prolonged intubation, sepsis, return to the operating
room, and mortality.33
Cardiac Risk Indices
Numerous clinical risk indexes have been proposed. These include
Carotid Endarterectomy the seminal Goldman Cardiac Risk index,34 the following
Carotid surgery is associated with an approximately 2% to Detsky’s Risk index,35 l’Italien,36 and others. None of these has
3% rate of perioperative cardiac morbidity. The results from gained wide and lasting acceptance. In 1999, Lee and his col-
randomized trials are similar to those from registry data. The leagues constructed a simplified Revised Cardiac Risk Index
CREST trial30 suggested a doubling in cardiac morbidity for (RCRI).37 In a derivation cohort of 2893 consecutive patients,
surgery as opposed to a carotid stent procedure; however, this they identified six independent risk factors, including (1) a
was offset by an increased stroke rate in patients having a stenting history of heart disease, (2) a history of CHF, (3) cerebral
procedures. vascular disease, (4) insulin therapy, (5) chronic renal failure
(defined as a preoperative creatinine of 177 mmol/L [2 g/L]),
and (6) high-risk surgery (major vascular, thoracic, and upper
PREOPERATIVE CARDIAC abdominal). The validation cohort of 1422 patients showed
that patients with none, one, two, and three of these factors
EVALUATION had cardiac complications of 0.4%. 0.9%, 7%, and 11%,
respectively. The overall accuracy ranged between 0.75 and 0.80,
Clinical Risk Assessment and was superior in their population to the other cardiac risk
Preoperative cardiac risk assessment is important, since it affects indices and the American Society of Anesthesiologists (ASA)
perioperative decision-making: (1) A high cardiac risk may classification. Since its publication, it has been widely used and
influence both perioperative or long-term risk-benefit ratio adopted by the ACC/AHA guidelines committee for the pre-
of an elective vascular surgery and may therefore lead to its operative stratification of patients perioperative cardiac risk.38
deferral. (2) Good cardiac risk assessment will enable preoperative A recent meta-analysis of 24 studies including more than
optimization by using optimal medical therapy and in 750,000 patients showed that the RCRI discriminated moderately
specific cases by preoperative coronary interventions to reduce well in mixed surgical population with a sensitivity of 0.65 and
transfusion requirements that have been secondarily shown to

TABLE 42.4 Comparison of Two Cardiac Risk Indices increase cardiac morbidity. In particular, surgical patients
Vascular Study Group of chronically on beta-blockers do not tolerate acute anemia, which
Revised Cardiac Risk Index39 New England—CRI28 may lead to increased cardiac morbidity.41
Age 60-69 Creatinine
70-79
≥80 The RCRI and the VSG-CRI show that chronic renal failure
Smoking is independently associated with increased cardiac morbidity.
However, creatinine is closely related to lean muscle mass. Thus
Diabetes—insulin dependent Diabetes—insulin dependent
many elderly patients with normal creatinine levels have chronic
CAD CAD renal failure. The conversion of creatinine to glomerular filtration
CHF CHF rate, through either the MDRD or Cockcroft-Gault equations
Cerebrovascular disease COPD that take account for patient age, may increase the sensitivity
Creatinine ≥ 2 mg/mL Creatinine ≥ 1.8 mg/mL and specificity of the measurement.42
High-risk surgery Abnormal cardiac stress test
Blood Sugar
Chronic β-blockade
Diabetes is a common comorbidity in up to 50% of vascular
CAD, Coronary artery disease; CHF, congestive heart failure; COPD, chronic surgical patients. Diabetes is strongly associated with most other
obstructive pulmonary disease; CRI, cardiac risk index. risk factors, coronary disease, renal disease, and cerebral vascular
disease. It is interesting to note that while insulin therapy was
independently associated with cardiac morbidity in the derivation
set of the RCRI, it was not in the validation set. Several
observational trials have suggested that elevated levels of glycosyl-
specificity of 0.76.39 When this meta-analysis was limited strictly ated hemoglobin (HbgA1c) are related to perioperative cardio-
of studies of vascular surgical populations, the RCRI had an vascular outcomes. Certainly HbA1c above 6.7% has been
aggregate sensitivity and specificity of 0.70 and 0.55, respectively. shown to be associated with increased morbidity after cardiac
Therefore the RCRI alone is inadequate to reliably screen vascular surgery43 and PCIs. However, there is no good prospective data
surgery patients, and further information gained through labora- in vascular surgery to suggest that elevated HbA1c improves
tory testing were proposed to increase the accuracy of the diagnostic accuracy over a history of diabetes alone. Tight glucose
preoperative cardiac investigation. control in the perioperative period, the focus of several critical
In 2010, the Vascular Study Group of New England (VSGNE; care randomized trials, failed to show any improvement in
Table 42.4) developed a vascular surgery-specific model for the outcomes.44
prediction of cardiac events following vascular surgery.28
The authors studied 10,081 total patients who underwent Natriuretic Peptides
various major arterial vascular procedures. They found that the Increased preoperative levels of Plasma NT-proBNP and BNP
RCRI predicted risk after carotid endarterectomy (CEA) reason- have been associated with increased postoperative adverse
ably well, but substantially underestimated the other procedures outcomes. Rodseth and colleagues have completed a meta-analysis
for low- and higher-risk patients. In a multivariate analysis of of six prospective observational trials of 850 vascular surgical
the VSGNE cohort, the independent predictors of adverse patients.45 Using a composite outcome of cardiovascular death
cardiac events that were found included: increasing age, smoking, and nonfatal MI, this meta-analysis showed that a BNP below
insulin-dependent diabetes, CAD, congestive heart failure, 30 pg/mL has a low likelihood ratio of 0.11 for a postoperative
abnormal cardiac stress test, long-term beta-blocker therapy, cardiac event. For levels between 30 and 116 pg/mL, the positive
COPD, and elevated creatinine. The rates of cardiac complica- likelihood ratio was 3.6. For levels above 116 pg/mL, the
tions for patients with zero to three, four, five, and greater than positive likelihood ratio was found to be 6.4.
or equal to six Vascular Study Group of New England Cardiac
Risk Index (VSG-CRI) risk factors were 3.1%, 5.0%, 6.8%, Cardiac Troponin
and 11.6% in the derivation cohort and 3.8%, 5.2%, 8.1%, The advent of high sensitivity troponin assays has led
and 10.1% in the validation cohort, respectively. The authors to the awareness that patients with cardiovascular anomalies
concluded that the VSG-CRI risk model more accurately have elevated troponin levels. Recently two studies have
predicted the actual risk of cardiac complications in vascular evaluated preoperative troponin levels as a prognostic indi
surgery patients than the RCRI. cator.46,47 In a multicentered observational study, RCRI,
BNP, and preoperative high sensitivity troponin elevation
Preoperative Laboratory Testing were associated with an increase in mortality. Preoperative
troponin outperformed both RCRI and BNP as a prognostic
Complete Blood Count indicator, suggesting that low-level troponin elevation existing
Preoperative anemia has been linked to increased cardiac before surgery represents preexisting cardiac abnormality or
morbidity.40 Preoperative anemia is also linked to increased dysfunction.
Severe aortic valvular stenosis is common in elderly patients

C-Reactive Protein and has been shown to correlate with perioperative complications
Patients with systemic inflammation as evidenced by an elevated and death. Severe aortic stenosis is also a relative contraindication
C-reactive protein (CRP; >5 mg/L) before surgery had higher for regional anesthesia. Significant mitral valvular disease
major postoperative vascular event rates (60%) compared with predisposes the patient to congestive failure in the perioperative
a 32% rate in those with a baseline CRP of <5 mg/L (P = period, and its recognition before surgery may alter the approach
.004). Following multivariable analysis, elevated CRP correlated to patients and their perioperative clinical management. Other
with adverse graft-related or cardiovascular events.48 Vascular important indications for preoperative echocardiography are to
surgery patients with high preintervention values of both high evaluate significantly reduced LV and/or right ventricular (RV)
sensitivity CRP and NT-BNP were 10.6 times more likely to function, cardiomyopathies such as hypertrophic obstructive
experience major adverse cardiac events (MACE = stroke, MI, cardiomyopathy or dilated cardiomyopathy, and the presence
or death) than were patients with normal CRP and NT-BNP and severity of pulmonary hypertension.40 Resting echocardiog-
values.49 raphy is not a good method to evaluate the severity of CAD
and the risk of perioperative MI.
Rest Electrocardiogram
The resting EKG is mandatory tool for screening patients with
suspected cardiac disease. ST-segment changes, either ST-
Ambulatory ST Segment Monitoring
elevation or depression, indicative of acute or recent ischemia, Silent myocardial ischemia, defined as episodes of ST-segment
should be correlated with symptoms and compared with previous depression on ambulatory EKG with ST-segment trend analysis
EKGs. Most other EKG changes represent chronic patterns of that are not accompanied by chest pain, is a well-known
injury or conduction abnormalities. Pathologic Q-waves represent phenomenon in elderly patients with CAD and has been shown
old MIs, and the more EKG leads with pathologic Q-waves, to predict worse prognosis. Similarly, the detection of silent
the wider the territory of infarcted myocardium. Tall R preoperative ischemia on preoperative Holter monitoring has
waves and wide QRS complexes with or without ST-T changes been associated with increased postoperative morbidity. Raby
and inverted T-waves represent myocardial hypertrophy or and colleagues used Holter monitoring for 24 hours before
dilation. EKG also detects and helps define abnormal rates and vascular surgery and found that preoperative ischemia predicted
rhythms. These chronic pathologic ECG changes are associated postoperative cardiac complications with a sensitivity of 75%
with an increased risk for perioperative events.37 In patients and specificity of 83%.52 In contrast, however, meta-analysis
undergoing noncardiac surgery, Van Klei and colleagues found of eight studies with more than 800 patients found a cumulative
that while preoperative bundle branch blocks, Q waves, and sensitivity of 52% and a specificity of 70%.53 One major reason
ST-T changes were significant predictors of postoperative cardiac for this relative insensitivity is related to the fact that as many
events, these EKG abnormalities did not remain predictive in as 30% of vascular patients have preexisting ST-T changes,
a multivariable logistic regression that includes the six inde- bundle branch block, or pacemakers, which make the interpreta-
pendent risk factors of the RCRI.50 EKG changes are common tion of ST segments difficult. In addition, Holter monitoring
in vascular surgery patients. A study in vascular surgery patients uses only two, and rarely three modified EKG leads, and is
showed that 33% had pathologic Q-waves, 22% had baseline susceptible to motion and other artifacts during normal daily
ST-segment changes, 38% had T-wave inversions, and 16% activity.
had voltage criteria for LVH. Patients with pathologic Q-waves
or LVH are more likely to have perioperative ischemia or Preoperative Investigation for Coronary
infarction51
Artery Disease
While coronary angiography is the gold standard for deter
Chest X-Ray mining the existence and severity of CAD, its invasiveness and
The chest x-ray is also an essential qualitative tool in screening cost make it unsuitable for routine preoperative screening. Coro-
cardiac patients, and its main value is to supplement the history nary angiography provides information on the major coronary
and physical examination in identifying and assessing the severity anatomy but less so on the downstream minor vessels or on
of cardiac failure. Signs of cardiac failure on chest x-ray, recogniz- functional consequences of that anatomy. Nevertheless, Hertzer
able by abnormal cardiac size and increased pulmonary vascu- and colleagues performed routine coronary angiographies on all
lature, should trigger further examination to gain better patients scheduled for major vascular surgery in the early 1980s,
understanding of the causes of cardiac dysfunction. and patients with significant left main and triple vessel disease
were treated with CABG.51 In a retrospective analysis of 1522 of
these patients, Ellis and Hertzer found that 81% of the patients
Echocardiography with postoperative MI or cardiac death had at least one total
Routine preoperative echocardiography is not recommended coronary artery occlusion with collaterals compared with 29%
for routine screening in the absence of specific indications. in match-controlled patients without cardiac complications. In
Echocardiography is justified before major surgery to verify or every other respect, patients with postoperative complications
evaluate significant valvular disease—in particular aortic stenosis. also had more severe CAD prior to surgery as compared with
the control group.54 Based on this observation, it is possible to of 114 articles showed that the sensitivity and specificity of
conclude that postoperative cardiac complications most likely SPECT for detecting CAD with ≥50% stenosis are 88% and
occur in patients with preoperative long-standing severe CAD. 61%, respectively55 SPECT has a time-honored and important
This is also consistent with the previously described observations value in predicting long-term risk in patients with suspected
that postoperative MI and cardiac complications are the result CAD. A meta-analysis of 14 articles comprising more than
of prolonged stress-induced ischemia in the presence of severe 12,000 patients showed that negative and positive stress SPECT
yet stable CAD. Therefore identifying patients with severe and are associated with 0.6% and 7.4% annualized rate of hard
often clinically silent coronary disease should be the focus of events (nonfatal MI or death), respectively.56 SPECT can also
preoperative coronary investigations. provide calculation of left ventricular ejection fraction during
stress and rest. Transient left ventricular dilation and increased
lung uptake during stress are additional parameters used to
Noninvasive (Stress) Testing evaluate higher cardiac risk. A meta-analysis by Etchells and
The ACC/AHA guidelines suggest that patients who report colleagues that investigated the prognostic value of semiquantita-
limited functional capacity—that is, inability to climb at least tive dipyridamole myocardial perfusion imaging (MPI) for
two flights of stairs without chest pain or shortness of breath, determining perioperative cardiac risk in patients undergoing
the equivalent of four metabolic equivalents (METs)—are vascular surgery found that reversible ischemia in less than
candidates for noninvasive cardiac stress testing before major 20% of the myocardial segments did not change the likelihood
noncardiac surgery.40 Limited functional capacity is indeed a of perioperative complications, whereas greater extents of
marker of higher perioperative risk. However, limited exercise reversibility of myocardial perfusion defects were associated
tolerance may be due to numerous causes, including cardiac, with increased risk of perioperative cardiac complications.57 In
pulmonary, orthopedic, neurologic, peripheral vascular, obesity, contrast, however, a normal SPECT scan may occur in up to
advanced age, or poor physical fitness. The noninvasive cardiac 15% of patients (false negative rate) with left main disease on
testing can help sort out the cardiac from other causes. account of balanced ischemia in multivessel disease. False positive
tests are also common as a result of attenuation artifacts in
Exercise Stress Testing obese patients, due to elevated diaphragm or breast artifacts.
The most common physiologic stress test for detecting myocardial
ischemia uses a treadmill or cycle ergometer. Among its advan- Dobutamine Stress Echocardiography
tages, this test provides an estimate of functional capacity and This is a relatively low-cost, widely available test based on the
hemodynamic response and detects myocardial ischemia through assessment of increasing or new global or regional myocardial
ST-segment changes. The accuracy of an exercise ECG varies wall motion abnormalities during stress that are induced by
widely among studies. A meta-analysis by Kertai and colleagues increasing doses of dobutamine. Meta-analysis of 62 studies
for the detection of myocardial ischemia with treadmill testing showed that the sensitivity of dobutamine stress echocardiography
in vascular surgery patients showed a rather low sensitivity (DSE) is 83% in patients without prior MI but decreases to
(74%) and specificity (69%).54 The extremely low effort capacity 74% when patients with prior MI were included. The specificity
in some vascular surgical patients limits the utility of this test of DSE for detecting significant CAD is also approximately
and often leads to the use of pharmacologic stress testing. The 80%. Long-term, a negative DSE test is associated with a 0.5%
most recent ACC/AHA guidelines (2014) designate only a Class to 0.8% annualized risk of death or MI. A recent meta-analysis
IIb recommendation for preoperative cardiac exercise testing: by Beattie and coworkers compared the value of DSE with
(1) “In patients with elevated risk and unknown functional MPI in predicting postoperative MI or in-hospital death.58 This
capacity, it may be reasonable to perform exercise testing to report included 25 studies (3373 patients) of mainly DSE, and
assess for functional capacity if it will change management 50 MPI studies with marked variability in results among the
(level of evidence: B).” (2) “In patients with elevated risk and studies. The likelihood ratio for positive test was greater for
poor (<4 METs) or unknown functional capacity, it may be DSE than for MPI, 4.1 versus 1.8, respectively, and the area
reasonable to perform exercise testing with cardiac imaging to under the ROC curve for the tests was 0.8 and 0.75, respectively.
assess for myocardial (level of evidence: C).”40 The recent ACC/AHA guidelines (2014) designate only a Class
IIa recommendation for preoperative cardiac pharmacologic
Myocardial Perfusion Imaging testing: “It is reasonable for patients who are at an elevated risk
Single photon emission tomography (SPECT) with thallium-201 for noncardiac surgery and have poor functional capacity (<4
or technetium-based agents has been available since the 1970s METs) to undergo noninvasive pharmacologic stress testing
and is still the most widely used noninvasive test. The test (either dobutamine stress echocardiogram [DSE] or pharma-
can be done with physiologic (treadmill/cycle ergometer) or cologic stress MPI) if it will change management (level of
pharmacologic (dipyridamole) stress. When the cardiac images evidence: B).”
acquired in a resting state are compared with the stressed state,
the investigation is able to differentiate fixed from reversible Positron Emission Tomography
filling defects in myocardial tracer uptake. These differences are It is a newer, more expensive modality that is not widely available.
suggestive of areas of infarct versus ischemia. A meta-analysis Positron emission tomography (PET) includes both perfusion
(by Ru-82, N-13 ammonia or O-15 water) and functional Preoperative Coronary Angiography
metabolic (F-18 fluorodeoxyglucose [FDG]) imaging. Mismatch
between perfusion and metabolism suggests viable ischemic
and Revascularization
area, while matched reduction in both blood flow and metabolism The detection of significant CAD by noninvasive testing is only
suggests an area of infarct. A meta-analysis of 19 studies showed the first step in investigating cardiac patients undergoing vascular
that PET had a sensitivity of 92% and specificity of 85% for surgery. The decision to proceed to coronary angiography based
diagnosing significant CAD.59 on the noninvasive testing depends on an assessment of whether
the benefits of an intervention (prophylactic preoperative coro-
Cardiac Magnetic Resonance Imaging nary revascularization) outweigh the risks associated with the
This is another new technology that may become the standard intervention and delaying surgery.
preoperative screening test in the future. Unlike SPECT and Earlier retrospective studies suggested that preoperative
PET, cardiac MRI (CMR) has excellent spatial resolution and coronary revascularization in vascular surgery patients was
can provide accurate information on transient (ischemia) or associated with better postoperative and long-term survival.64,65
fixed (infarction) hypoperfusion and scar tissue, even in small However, these studies suffered from the limitations of retrospec-
areas of the sub-endocardium. Myocardial perfusion is imaged tive studies, among which was failure to include all patients
during the first pass of a bolus of gadolinium during stress who died or had serious complications from the preoperative
(achieved by adenosine or dipyridamole), rest and late gadolinium revascularization and therefore could not undergo the expected
enhancement. In a meta-analysis, CMR was shown to have vascular surgery. In 2004, McFalls and coworkers published
better sensitivity (89%) and specificity (76%) than SPECT for the randomized Coronary Artery Prophylaxis (CARP)3 trial
detecting significant CAD.60 Contraindications to the CMR that included 510 candidates for major vascular surgery.66 After
include patients with implanted metal, hypersensitivity to screening for cardiac risk, patients who had coronary angiography
gadolinium, renal insufficiency, or sensitivity to the vasodilating that showed one or more major coronary vessels with ≥70%
agents, adenosine and dipyridamole, and patients with severe stenosis were randomized to either coronary revascularization
asthma or COPD. (by PCI or CABG) before vascular surgery or no coronary
intervention prior to surgery. Patients were followed for a mean
Computed Tomography Coronary Angiography period of 2.5 years after surgery. The study showed no difference
This is an established noninvasive method for evaluating in survival between the two groups. However, this trial had
coronary anatomy as well as myocardial function. Studies two important limitations: (1) The screening process did not
showed that computed tomography coronary angiography rigorously follow the ACC/AHA guidelines, so that only a
(CTCA) has a high diagnostic accuracy for detecting the pres- minority of the patients had evidence of severe ischemia on
ence of coronary artery stenosis. A meta-analysis of 27 studies noninvasive testing and the study was underpowered to assess
showed the sensitivity, specificity, PPV, and NPV were 97%, this key aspect. (2) Patients with left main CAD and patients
91%, 93%, and 96% compared with conventional coronary with severely reduced LVEF were excluded. Nevertheless, this
angiography.61 A more recent study showed that while the trial had a strong impact worldwide on perioperative patient
sensitivity of CTCA remains strong, the specificity declines to management by shifting the paradigm toward less coronary
66% in patients with coronary calcifications. One prospective investigations and interventions before major noncardiac and
study in 290 consecutive patients undergoing CTCA with a vascular surgery. This trial coincided with the COURAGE trial,67
64 row detector found that a higher RCRI, a high coronary which showed that PCI does not confer better survival than
artery calcium score (CACS >113), the presence of significant optimal medical treatment in patients with stable CAD, creating
coronary artery stenosis, and multivessel CAD were significantly evidence that prophylactic re-vascularization by PCI was unwar-
associated with postoperative cardiovascular events.62 The promise ranted in vascular surgery. Importantly however, subsequent
of this technology will be realized with higher resolution publications from the CARP trial and registry reported that
scans. the following: (1) Patients who had CABG with more complete
Ahn and colleagues studied 239 patients who underwent coronary revascularization had better survival than those re-
CTCA before intermediate-risk noncardiac surgery, and noted vascularized by PCI.68 (2) Patients with left main disease,
that RCRI, CAC score, the presence of significant coronary excluded from the trial, had markedly better survival with
artery stenosis (diameter stenosis ≥50%), and multivessel coronary re-vascularization than without it.69 (3) In a subset
CAD were the strongest predictors of postoperative cardiac of 109 patients with ischemia on preoperative MPI, patients
complications. Hwang and colleagues studied 844 patients who randomized to preoperative coronary revascularization had
underwent coronary CTA for screening of CAD before non- significantly better long-term survival free of MI than patients
cardiac surgery.63 The risk of perioperative major cardiac events without revascularization, particularly if ischemia was in the
was 14.0% in patients with significant CTA findings (>3 lesions), anterior wall.67
versus 2.2% in patients without significant CTA findings Monaco and associates3 randomized 208 consecutive patients
regardless of RCRI score. The sensitivity, specificity, positive, with RCRI ≥ 2 scheduled for elective abdominal aortic surgery
and negative predictive values were 76%, 73%, 8%, and 99%, to either a “selective strategy” with coronary angiography only if
respectively. their stress test was positive or a “systematic strategy” with routine
coronary angiography. The systematic strategy discovered 50% observational trial showed that although chronic beta blockade
more patients with significant CAD than the selective strategy, in patients with prior MI is associated with improved long-term
had more subsequent coronary revascularizations (58% vs. 40%, survival,73 patients with CAD but without MI do not benefit
respectively), and was associated with significantly better long- after 4 years of follow-up, and patients with no CAD have an
term survival and freedom from major adverse cardiac events. 18% increase in morbidity after 4 years compared with all other
While this small study supports the concept of prophylactic forms of therapy.
preoperative coronary angiography and revascularization among Postoperative MI is preceded by prolonged ST-depression
patients at high clinical risk (RCRI ≥ 2), the routine use of type ischemia, and the ischemia itself is associated with a sig-
coronary angiography without prior noninvasive screening nificant increase in heart rate. These findings gave impetus to
is not established practice and merits further investigation. the theory that perioperative beta blockade would reduce
Another large sample (16,478 patients) representing real-world perioperative MI, leading to numerous clinical trials. In a
practice suggested that patients with a recent MI benefit from high-quality meta-analysis of 33 trials involving more 12,000
preoperative revascularization and that CABG improves outpatients, Bangalore and colleagues demonstrated that perioperative
comes more than coronary stenting, especially when surgery beta blockade was indeed associated with a 35% (95% CI 54%
is deemed necessary within 1 month of the revascularization.70 to 79%) reduction of nonfatal MI.74 This was achieved, however,
In contrast, another study that included 1104 vascular surgery at the expense of a doubling in the stroke rate with no significant
patients confirmed the significance of ischemic heart disease effect on all-cause mortality. The largest trial (POISE) in that
(IHD) for postoperative survival of vascular surgery patients meta-analysis showed that the beneficial effect on nonfatal MI
and that CR is associated with lower IHD-related death rates, was at the expense of both an increase in stroke and a 30%
yet CR in that study failed to provide an overall survival benefit increase in all-cause mortality.75 The POISE trial also showed
because of increased rate of cardiovascular mortality unrelated that mortality was significantly higher in patients receiving
to IHD.71 beta-blockade if they developed serious infection or sepsis
The latest ACC/AHA update “On Evaluation and Care for postoperatively. Lindenaurer, in an analysis of the Premier
Non-Cardiac Surgery” (2014)40 states the following: Prospective database, showed that postoperative mortality was
reduced only in patients with RCRI of ≥2, but in patients with
no risk factors mortality was increased by 30%.74 A recent
CLASS I Cochrane meta-analysis also found no clear evidence that
Revascularization before noncardiac surgery is recommended prophylactic perioperative beta-blockade reduces postoperative
in circumstances in which revascularization is indicated accord- cardiac morbidity.76
ing to existing clinical practice guidelines (CPGs). (Level of On the basis of no improvement or even an increase
Evidence: C) in mortality and a doubling in postoperative strokes, the
recommendation for prophylactic perioperative beta-blockade
that was strongly advocated a decade ago (based on two
CLASS III: NO BENEFIT relatively small, high-impact, yet questionable studies77,78) was
It is not recommended that routine coronary revascularization stopped. Two independent investigations showed that major
be performed before noncardiac surgery exclusively to reduce blood loss (or acute anemia) is associated with increased morbid-
perioperative cardiac events. (Level of Evidence: B) ity in beta-blocked patients.43,79 Hence the increased mortality
and stroke rate caused by prophylactic beta-blockade, despite
the decrease in nonfatal MI, is most likely related to
MEDICAL PROPHYLAXIS the potential detrimental effects of beta-blockade—that is,
slowing heart rate and decreasing myocardial contractility in
Beta Blockade patients with postoperative anemia or infection who are at the
Up to 25% of patients assessed for vascular surgery are taking greatest need for tachycardia and high cardiac output after
beta-blockers. Beta blockade is indicated for the treatment of surgery.
various comorbidities, including hypertension, CAD (both stable
angina, and after acute MI), and congestive heart failure. Studies
on stable angina pectoris show that beta-blockers provide
Statins
excellent symptomatic improvement. Patients who are maintained A recent meta-analysis in patients at risk of cardiovascular events,
on beta-blockers after MI show moderately improved long-term combining 27 prospective trials and over 174,000 patients,
survival. In patients with congestive failure, beta-blockers also showed that for each 1 mmol decrease in LDL, statins reduced
improve long-term survival. Nevertheless, there is a growing the long-term relative risk of a cardiovascular event by 24%
body of evidence showing that chronic beta blockade may also (95% CI 21 to 27).80 This reduction was seen across all
be harmful. A meta-analysis comparing beta blockade to other risk populations, and reduced the need for revascularization,
forms of antihypertensive therapies such as ASA and carotid incidence of stroke, and other vascular events. Furthermore,
endarterectomy (ACE) inhibitors and calcium channel blockers these benefits far exceeded the risks of elevated liver enzymes,
suggested that beta-blockers are associated with an increase in myopathy, or rhabdomyolysis. This study suggests that all vascular
cerebral vascular accidents.72 A recent large prospective patients who have atherosclerosis should receive statins, if
tolerated, for management of their cardiovascular disease irrespec- doses of aspirin. Unfortunately, the ACE trial did not have a
tive of the need for surgery. The Vascular Quality Initiative placebo control. Another prospective two-arm comparative study
(VQI), including more than 14,000 patients who underwent in patients undergoing CEA showed that the overall cardiac
major vascular surgery, found no association between the rate and neurologic complication rate was lower in the aspirin group
of in-hospital MI/death and the use of antiplatelet agents or compared with the group not on aspirin (5.2% vs. 17.6%,
statins.81 Antiplatelet agents and statin medications appear respectively), with no significant increase of postoperative
to be more useful in reducing late mortality than early bleeding necessitating revision.90
postoperative MI/death in VQI. However, they were not harmful, Despite the clear advantages of secondary prevention, the
so their long-term benefit argues for continued use. Therefore effectiveness of low dose ASA, and grade 1A evidence of a low
regardless of the procedure or stress testing results, patients incidence of excess bleeding with a low dose ASA, this drug
with symptomatic atherosclerosis (e.g., PAD, cerebrovascular continues to be withdrawn prior to many nonvascular operations.
disease) should be on antiplatelet and statin therapy according Two meta-analyses of retrospective studies91,92 demonstrated
to the ACC/AHA guidelines.81 Although no RCT showed that aspirin withdrawal was associated with a threefold increased
improved in-hospital morbidity or mortality with statins, a risk of a major adverse cardiovascular events on an average of
recent meta-analysis of statin use in vascular surgery patients 7 days after cessation. The major reason for withdrawal was an
showed a significant risk reduction in postoperative cardiac upcoming elective surgical procedure. The authors concluded
morbidity as well as death.82 In addition, a large institutional that ASA should be maintained in all patients except for those
study including nearly 166 patients and a large registry study who had the highest risk of bleeding. Unfortunately, there are
demonstrated a significant reduction in perioperative stroke no prospective studies assessing withdrawal of ASA in any surgical
and MI rates among patient undergoing CEA on statins population.
compared to nonusers83,84 Further, compliance with both
antiplatelet therapy and statins in vascular surgical patients was Dual Antiplatelet Therapy After
associated with significantly improved long-term survival.85
Currently, there is no clear prospective evidence to indicate
Coronary Stenting
how soon statins must be started preoperatively, if not admin- More than 1 million PCI procedures are conducted annually
istered chronically, to achieve a reduction in perioperative adverse in North America93 alone, and more than 5% of these patients
events. will undergo elective surgery within 1 year.94 Patients who
had recent revascularization using PCI and stents are treated
initially with dual antiplatelet therapy for a variable period of
Aspirin time, aspirin, and a P2Y12 platelet receptor–inhibitor, usually
While the primary prevention of cardiovascular events by aspirin clopidogrel, to prevent stent thrombosis. These patients require
is still controversial,86 the utility of aspirin as a secondary preven- special consideration. Kaluza95 drew attention to the increased
tion of cardiovascular events is well established.87 The benefits mortality in patients having elective surgical procedures shortly
of aspirin in terms of reduction of re-infarction, stroke, and after PCI. Mortality was related either to excessive bleeding
ischemia far outweigh the increased risks of bleeding in nonsurgi- due to continuation of the dual-antiplatelet therapy through
cal patients. The Anti-Thrombotic Trialist’s Collaboration surgery or to acute stent thrombosis and type-1 MI after the
conducted a meta-analysis of 287 trials in more than 130,000 abrupt discontinuation of the antiplatelet medications. This
high-risk patients (with acute or previous vascular disease or case series was then quickly followed by a myriad of other case
some other predisposing condition) compared with a control series showing increased morbidity when procedures were carried
group. MI was reduced by one-third, nonfatal stroke by out within 90 days of PCI.96,97 A retrospective analysis of 8116
one quarter, and vascular death by one-sixth. The absolute stent patients from large a comprehensive stent registry linked
reduction in cardiovascular morbidity in high risk patients was to a Medicare administrative database confirmed that surgical
22 per 1000 patients after 2 years of therapy.88 These results procedures conducted within 45 days of a PCI are associated
confirm that patients at risk of any recurrent vascular morbidity with high mortality.98 However, after 45 days the risk was
should be treated with ASA irrespective of their need similar to patients with a RCRI of equal to or greater than
of surgery. 2% for both patients with bare metal or drug eluting stents.
In the perioperative setting, the large-scale POISE-2 RCT After 180 days, the risk of major cardiac morbidity is approxi-
that included 10,010 noncardiac surgery patients (5% of them mately 1%, which is similar to the morbidity of patients after
had vascular surgery) showed that aspirin given before surgery PCI who do not undergo surgery. A recent retrospective study
and throughout the early postsurgical period had no effect on matched 20,590 surgical patients to 41,180 nonsurgical patients
composite death or nonfatal MI but increased the risk of major who underwent PCI in the Veterans Affairs (VA) hospital
bleeding.88 Among vascular surgery patients, the ACE (Aspirin between the years 2000 and 2010.99 During the 30-day interval
in Carotid Endarterectomy) randomized trial compared four following noncardiac surgery, the surgical cohort had higher
doses of aspirin in patients having elective CEA 89 and found rates of the composite cardiac endpoint (3.1% vs. 1.9%). The
that the risk of stroke, MI, and death within 30 days and 3 incremental risk of noncardiac surgery adjusted for surgical
months of endarterectomy is lower for patients taking 81 mg characteristics ranged from 3.5% immediately following stent
or 325 mg acetylsalicylic acid daily than for those taking higher implantation to 1% at 6 months, after which it remained
TABLE 42.5 Focused Update on Duration of Dual Antiplatelet Therapy

COR LOE Recommendations
I B-NR Elective noncardiac surgery should be delayed 30 days after BMS implantation and optimally 6 months after
DES implantation (101-103, 143-146).
I C-EO In patients treated with DAPT after coronary stent implantation who must undergo surgical
procedures that mandate the discontinuation of P2Y12 inhibitor therapy, it is recommended that aspirin be
continued if possible and the P2Y12 platelet receptor inhibitor be restarted as soon as possible
after surgery.
IIa C-EO When noncardiac surgery is required in patients currently taking a P2Y12 inhibitor, a consensus decision
among treating clinicians as to the relative risks of surgery and discontinuation or continuation of
antiplatelet therapy can be useful.
IIb C-EO Elective noncardiac surgery after DES implantation in patients for whom P2Y12 inhibitor therapy will need to
be discontinued may be considered after 3 months if the risk of further delay of surgery is greater than the
expected risks of stent thrombosis.
III: Harm B-NR Elective noncardiac surgery should not be performed within 30 days after BMS implantation or within
3 months after DES implantation in patients in whom DAPT will need to be discontinued perioperatively
(101-103, 143-146).
stable out to 24 months. In addition, the authors observed of suspicion for silent cardiac complication is of greatest
that approximately 50% of the risk of adverse cardiac importance when dealing with cardiac patients undergoing
events was due to underlying cardiac risk factors and approxi- major vascular surgery. If a patient is suspected of having
mately 50% was due to surgical factors. After matching for postoperative ischemia or cardiac failure, the first diagnostic
cardiac risk factors, no significant difference was found in step would be to perform a 12-lead EKG. The presence of
cumulative incidence of adverse cardiac event rates between ST-segment elevation ischemia or MI is a medical emergency,105
the surgical population and the nonsurgical matches over the especially after surgery. A cardiologist must be consulted, and
24 months following stenting, although there was a higher the possibility of immediate reperfusion with percutaneous
mortality in the surgical population from noncardiac causes. transluminal coronary angioplasty with stenting should be
There was also no significant difference in postoperative cardiac considered. A special subset of patients who are prone to develop
complications between patients with bare-metal stents and acute postoperative coronary thrombosis are those with fresh
drug-eluting stents. coronary stents in whom the antiplatelet therapy was stopped
In patients undergoing CEA (the VQI)100 patients on before surgery.
dual therapy were more likely to have multiple comorbidities, The more common situation is the occurrence of ST-segment
including CAD, congestive heart failure, and diabetes, and had depression type ischemia or MI. In these patients, diagnostic
increased rate of reoperation for bleeding but experienced a effort to find the potential causes for stress-induced, supply-
reduced rate of TIAs, stroke, and stroke/death. demand imbalance type ischemia should be started and medical
See Table 42.5 for the most recent (2016) ACC/AHA therapy should be implemented to relieve ischemia.106 The
guidelines for dual antiplatelet therapy in patients undergoing importance of preventing even modest increases in heart rate
noncardiac surgery.101 cannot be overemphasized. The treatment of tachycardia and
hypertension can be achieved with beta-blockers or calcium
channel blockers or pain-killing medications. In contrast,
treatment of tachycardia associated with hypotension is par-
TREATMENT ticularly challenging and requires an understanding of the
In treating patients at risk for postoperative cardiac complications, patient’s baseline and postoperative myocardial, valvular, and
it is most important to recognize that the majority of postopera- coronary physiology. These patients will require additional
tive cardiac complications are silent or begin as silent. High-risk diagnostic tests, invasive monitoring, bedside echocardiography,
vascular surgery patients have a high rate of silent ischemia, and other imaging devices. Frequently, vasopressors to maintain
silent myocardial injury, and infarction, all of which are blood pressure and beta-blockers to slow heart rate while
associated with higher in-hospital and long-term mortality.102 fine tuning blood volume, postoperative pain, and respiratory
Silent and overt cardiac complications are strongly linked to function are necessary (Fig. 42.3). Management of patients
noncardiac complications, and both types precipitate each with ischemia in the face of hypotension and hypoperfusion is
other.103 For instance, perioperative hypotension,104 systemic often challenging, and the assistance of an intensive care unit
infection, serious bleeding, and anemia were all linked to and consultation with anesthesiologists, intensivists, and cardiolo-
postoperative cardiac morbidity and mortality. A high index gists is warranted.
Suspected postoperative myocardial ischemia/infarction

(Cardiac symptoms/hemodynamic instability/tachycardia/pulmonary congestion)
12-Lead ECG evidence of ischemia
ST-segment ST-segment elevation (rare)

Additional tests and treatments: depression (common)
• Arterial blood gases: Treat hypoxemia/
• Cardiology consultation (especially
hypercarbia/acid-base abnormality, if
if troponin elevated)
present
• Consider coronary angiography and
• Hemoglobin: Treat anemia
reperfusion
(Hb 10 gr%)
• Troponin
Tachycardia with normo-/hypertension Tachycardia with hypotension (100 mm Hg)
• Control heart rate and blood pressure with beta- • Evaluate and treat causes of hypotension
blockers/calcium channel blockers and if necessary (hypovolemia/vasodilation/cardiac failure)
additional drugs
• Invasive hemodynamic monitoring and/or
• Check appropriate pain control echocardiography to determine cardiac function and
volume status can be helpful
• If tachyarrhythmia present (atrial flutter/fibrillation)—
treat rate and rhythm • If tachyarrhythmia present (atrial flutter/fibrillation)
- cardioversion may be necessary
• Careful with beta-blockers/calcium channel blockers
Figure 42.3 Suggested perioperative myocardial infarction treatment algorithm. ECG, Electrocardiogram.
Review article explaining the pathophysiology of postoperative myocardial

SELECTED KEY REFERENCES infarction.
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The largest randomized controlled trial that tested the effect of preoperative
coronary revascularization in major vascular surgery patients. Outlines the prognostic importance of silent troponin elevation in patients
undergoing major vascular surgery.
Devereaux PJ, Chan MT, onso-Coello P, et al. Association between
postoperative troponin levels and 30-day mortality among patients Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of
undergoing noncardiac surgery. JAMA. 2012;307:2295–2304. myocardial infarction. J Am Coll Cardiol. 2012;60:1581–1598.
The largest report on the association of even minor postoperative troponin Presents the latest universal definition of myocardial infarction.
elevations and 30-day mortality.
A complete reference list can be found online at www.expertconsult.com.
Landesberg G, Beattie WS, Mosseri M, Jaffe AS, Alpert JS. Perioperative
myocardial infarction. Circulation. 2009;119:2936–2944.
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Systemic Complications: Cardiac: Giora Landesberg and Chen Rubinstein

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SECTION 7 COMPLICATIONS

EPIDEMIOLOGY 531 Cardiac Troponin 536

branch block; (3) development of new pathologic Q waves; (4)

Unstable coronary plaques Severe, yet stable CAD

Hemodynamic ↑ Myocardial O2 ↓ Subendocardial

↓ Fibrinolysis Acute Coronary vasoconstriction

ACS—type-1 MI Prolonged ST-depression ischemia >> type-2 MI

Cardiac Death TABLE 42.1 Universal Classification of

OF PERIOPERATIVE Type 2: Myocardial Infarction Secondary to an Ischemic

perioperative and long-term cardiac risk. (3) Accurate preopera-

transfusion requirements that have been secondarily shown to

Severe aortic valvular stenosis is common in elderly patients

TABLE 42.5 Focused Update on Duration of Dual Antiplatelet Therapy

Suspected postoperative myocardial ischemia/infarction

12-Lead ECG evidence of ischemia

ST-segment ST-segment elevation (rare)

Tachycardia with normo-/hypertension Tachycardia with hypotension (100 mm Hg)

• Careful with beta-blockers/calcium channel blockers

Review article explaining the pathophysiology of postoperative myocardial

predicting myocardial infarction after noncardiac surgery. Ann

You might also like

Systemic Complications: Cardiac: Giora Landesberg and Chen Rubinstein

Uploaded by

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Copyright

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Systemic Complications: Cardiac: Giora Landesberg and Chen Rubinstein

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Copyright:

Available Formats

SECTION 7 COMPLICATIONS

EPIDEMIOLOGY 531 Cardiac Troponin 536

branch block; (3) development of new pathologic Q waves; (4)

Unstable coronary plaques Severe, yet stable CAD

Hemodynamic ↑ Myocardial O2 ↓ Subendocardial

↓ Fibrinolysis Acute Coronary vasoconstriction

ACS—type-1 MI Prolonged ST-depression ischemia >> type-2 MI

Cardiac Death TABLE 42.1 Universal Classification of

OF PERIOPERATIVE Type 2: Myocardial Infarction Secondary to an Ischemic

perioperative and long-term cardiac risk. (3) Accurate preopera-

transfusion requirements that have been secondarily shown to

Severe aortic valvular stenosis is common in elderly patients

TABLE 42.5 Focused Update on Duration of Dual Antiplatelet Therapy

Suspected postoperative myocardial ischemia/infarction

12-Lead ECG evidence of ischemia

ST-segment ST-segment elevation (rare)

Tachycardia with normo-/hypertension Tachycardia with hypotension (100 mm Hg)

• Careful with beta-blockers/calcium channel blockers

Review article explaining the pathophysiology of postoperative myocardial

predicting myocardial infarction after noncardiac surgery. Ann

You might also like

Tachycardia with normo-/hypertension Tachycardia with hypotension (100 mm Hg)