Questions non résolues concernant la stratification du risque et la prise en charge des patients atteints de maladie coronarienne subissant une chirurgie vasculaire majeure

Abstract

Purpose:The purpose of this article, with a specific focus on patients undergoing vascular surgery, is to review controversial issues related to mechanisms of perioperative myocardial infarction (MI), coronary artery disease detection, and strategies to reduce perioperative complications. We propose explanations for the many conflicting results that have recently emerged in the literature. Source documents:We searched MEDLINE and reviewed all relevant manuscripts and scientific statements regarding management of patients undergoing non-cardiac surgery.Principal findings: Identification and prevention of ischemia in patients undergoing vascular surgery remains controversial. While the identification of preoperative ischemia is a marker of a higher perioperative risk, the value of identifying such ischemia has been questioned. We believe this may be, at least in part, due to our limited understanding of perioperative MI. Appropriate management of patients, based on the results of such testing, is likely the key to improving outcomes, and deserves further investigation. Efforts aimed at reducing the ischemic consequences of severe coronary plaques (by revascularization or β-blocker therapy) have yielded conflicting results. The use of high doses of preoperative β-blocker therapy may be harmful. Some studies suggest a promising role for statin therapy. Benefits of acetylsalicylic acid must be weighted against the risk of bleeding. Conclusion:Many questions remain unanswered about the impact of detecting inducible ischemia, and the role of revascularization or β-blockers in patients undergoing vascular surgery. A better understanding of the pathophysiology of perioperative MI is critical, in order to identify the best approach to improve cardiac outcomes in these patients.

Relation between Preoperative and Intraoperative New Wall Motion Abnormalities in Vascular Surgery Patients

“…This would explain the higher rates of subclinical ischemic events (increased cTnT or transient NWMAs) over harder cardiac events in our and other populations. 23,25,35 Intraoperative TEE showed an additional incremental value on the prediction of postoperative cardiac events. Both preoperative NWMAs during DE and intraoperative NWMAs detected by TEE had a significant association with the composite cardiac outcome (P Ͻ 0.001).…”

“…The purpose of this study was to determine which of the two prophylactic measures is optimal to provide better postoperative cardiac outcome. 22,23 Autopsy studies have shown the pathologic similarity of perioperative MI to that occurring in the nonoperative setting; however, they were unsuccessful in predicting the site of vulnerable plaque rupture in most instances of perioperative MI based on the severity of coronary stenosis. 6,7 This means that selective targeting of isolated culprit plaques by means of a focused revascularization technique as a prophylactic measure cannot be used with adequate results.…”

Anesthesia for Open Abdominal Aortic Aneurysm Repair

“…Routine CAG is not advised before AAA repair because of its inherent risk, cost, and manpower. 37 Risk of CAG, mortality of revascularization procedure before AAA repair, hazards of AAA rupture during the waiting period, and risk of AAA surgery, all these put together do not justify routine CAG in all patients presenting for AAA repair.…”

“…The lack of benefit of revascularization is not fully understood, though plaque rupture induced by the perioperative stress response in nonsignificant coronary lesions, which are not revascularized, may be the culprit. 37 Noninvasive stress testing has a low positive predictive value and is not routinely recommended in intermediate and low-risk groups. High risk (>2 risk factors) with poor functional status may be referred for stress testing for risk stratification, though the benefits of revascularization in patients with extensive ischemia are not well demonstrated.…”