Perioperative cardiovascular evaluation: heads or tails?

Abstract

When dealing with surgical patients, a perioperative evaluation is essential to anticipate complications and institute measures to reduce the risks. Several algorithms and exams have been used to identify postoperative cardiovascular events, which account for more than 50% of perioperative mortality. However, they are far from ideal. Some of these algorithms and exams were proposed before important advances in cardiology, at a time when pharmacological risk reduction strategies for surgical patients were not available. New biomarkers and exams, such as C-reactive protein, brain natriuretic peptide, and multislice computed tomography have been used in cardiology and have provided important prognostic information. The ankle-brachial index is another significant marker of atherosclerosis. However, specific information regarding the perioperative context of all these methods is still needed. The objective of this article is to evaluate cardiovascular risk prediction models after noncardiac surgery.

3rd GUIDELINE FOR PERIOPERATIVE CARDIOVASCULAR EVALUATION OF THE BRAZILIAN SOCIETY OF CARDIOLOGY

“… 94 Although ABI is a promising method because of its low cost, rapid standardization, good acceptance by patients, and low intra- and inter-observer variability, it is poorly investigated in the perioperative context. 95 Flu et al. 96 showed that patients with ABI ≤0.9 submitted to vascular surgery had an odds ratio (OR) of 2.4 for the occurrence of myocardial injury.…”

Preoperative assessment of cardiovascular risk in patients undergoing noncardiac surgery: the Orion study

“…Both sexes were similarly represented and more than one-quarter of the total study population was aged over 65 years. The derivation and validation cohorts were similar (Table 1) except for a slightly higher prevalence of elective surgery in the validation cohort, as well as a higher prevalence of intermediate-risk noncardiac surgery, GFR <30 ml/min/1.73m 2 , cancer and dyslipidemia. The type of surgery performed is reported in Table 2 Original Article The primary endpoint occurred in 127 patients (1.7%), with 39 cardiac deaths (0.5%).…”

“…The need to elaborate a new algorithm for risk stratification is due to intrinsic limitations [2,11] of the indexes currently recommended by international guidelines: the RCRI [7] and NSQIP-MICA risk calculator [8]. The RCRI was formulated based on patient data gathered between 1989 and 1994 (i.e.…”

“…Preoperative cardiovascular risk estimation is important to facilitate patients making informed decisions about the appropriateness of surgery and to identify at-risk patients who may benefit from enhanced monitoring after noncardiac surgery [1]. Cultural shifts towards advanced care for the elderly along with improvements in surgical techniques and anesthetic techniques have resulted in a substantial increase in the number of older patients with multiple comorbidities undergoing non-cardiac surgery [2]. This evolution has produced a new high-risk patient group that is associated with a high incidence of cardiac death (1-1.5%) and major cardiac complications (2-3.5%) after noncardiac surgery [3,4].…”

The Ankle-Brachial Index is Associated With Cardiovascular Complications After Noncardiac Surgery

“…Cardiovascular complications, especially acute myocardial infarction (AMI), represent a potentially preventable cause of death after noncardiac surgery. 1,2 In this setting, unfortunately, AMI is associated with a worse prognosis most likely related to late diagnosis and delayed treatment delivery. 3 Preventive strategies include scores and algorithms used in clinical practice to estimate perioperative cardiovascular risk and the need for specific coronary stratification before the intervention.…”