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How to avoid cardiac ischemic events associated with aortic surgery
1Division of Vascular Surgery, Department of Surgery, University of Colorado Health Sciences Center, 4200 East Ninth Ave., Denver, CO 80262, USA.
Insights
Preoperative cardiac evaluation before vascular surgery can lead to complications. Beta-blocker therapy significantly reduces cardiac events in patients with coronary artery disease (CAD).
Area of Science:
- Cardiology
- Vascular Surgery
- Perioperative Medicine
Background:
- Coronary artery disease (CAD) is common in patients needing vascular surgery, but consensus on preventing perioperative cardiac ischemic events is lacking.
- Adverse cardiac outcomes occur frequently after infrainguinal operations, similar to aortic procedures, making findings relevant across vascular surgery types.
Purpose of the Study:
- To analyze adverse outcomes associated with preoperative cardiac evaluation and intervention in vascular surgery patients.
- To review current strategies for preoperative cardiac testing and management of CAD in vascular surgery.
Main Methods:
- Retrospective analysis of 153 patients undergoing vascular procedures at the Denver Department of Veterans Affairs Medical Center.
- Review of existing literature and ongoing trials (e.g., CARP trial) on cardiac evaluation and management strategies.
Main Results:
- Of 42 patients with extended cardiac evaluations, 16 (38%) experienced untoward events.
- Extensive cardiac evaluation can lead to morbidity, delays, and patient refusal of necessary vascular surgery.
- Perioperative beta-blocker therapy has been shown to reduce adverse cardiac outcomes by 55% in vascular patients with CAD.
Conclusions:
- The risks of preoperative cardiac evaluation and intervention must be weighed against potential benefits, considering the primary surgical indication and local complication rates.
- Perioperative beta-adrenergic blockade is a proven strategy to mitigate cardiac risk in vascular surgery patients with CAD.
- Further research, like the CARP trial, is needed to compare invasive cardiac intervention versus best medical care for these patients.
Abstract:
Whereas there is some degree of coronary artery disease (CAD) in most patients undergoing vascular surgery, there is no consensus regarding how to avoid perioperative cardiac ischemic events. Although this edition of Seminars in Vascular Surgery is devoted to aortic surgery, it must be remembered that the incidence of adverse cardiac outcomes after infrainguinal operations is at least as great as after aortic procedures. Thus, much of the information discussed herein will be applicable to patients undergoing all varieties of vascular surgery. Numerous strategies exist for preoperative cardiac testing before vascular operations. These strategies range from routine evaluation before surgery to a "minimalist" approach, treating all patients as though CAD was present. Although advocates of various algorithms often are unwavering in their convictions, there are no randomized, prospective studies comparing different strategies for evaluation and management of patients with CAD undergoing vascular surgery. Potential adverse effects of evaluation and cardiac intervention should be considered before undertaking screening studies. The authors analyzed the adverse outcomes of preoperative cardiac evaluation and intervention before vascular operations in patients treated at the Denver Department of Veterans Affairs Medical Center. Of 153 patients undergoing vascular procedures, 42 had extended cardiac evaluations. Sixteen (38%) patients had untoward events related to this evaluation. Extensive cardiac evaluation before vascular operations can result in morbidity, delays, and refusal to undergo vascular surgery. The underlying indication for vascular operations and the local iatrogenic cardiac complication rates should be considered before ordering special studies. Several recent randomized, prospective studies have established that perioperative beta-adrenergic blockade is beneficial in vascular patients with CAD. Beta-Blocker therapy can reduce the risk of perioperative adverse cardiac outcomes by 55%. The Coronary Artery Revascularization Prophylaxis (CARP) trial currently underway is a multicenter, prospective comparison of invasive intervention for CAD versus best medical care in patients undergoing aortic and lower extremity vascular surgery funded by the Department of Veterans Affairs Cooperative Studies Program.