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Evaluation and management of patients with both peripheral vascular and coronary artery disease
B J Gersh1, C S Rihal, T W Rooke
1Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905.
Insights
Patients with peripheral vascular disease often have serious coronary artery disease. Standard criteria don't predict cardiac risk; functional testing is crucial for perioperative stratification.
Area of Science:
- Cardiology
- Vascular Surgery
- Perioperative Medicine
Background:
- Significant prevalence (37-78%) of coronary artery disease in peripheral vascular disease patients.
- Standard clinical criteria inadequately predict cardiac outcomes post-peripheral vascular surgery.
Purpose of the Study:
- To review perioperative cardiac risk stratification and management in patients with peripheral vascular disease.
- To highlight the importance of functional cardiac testing in this high-risk population.
Main Methods:
- Review of clinical studies on cardiac outcomes after peripheral vascular surgery.
- Evaluation of predictive value of various cardiac assessment methods.
- Discussion of perioperative risk stratification strategies.
Main Results:
- Exercise workload, left ventricular function, and thallium redistribution are key for risk stratification.
- Hemodynamic stress varies by procedure (aortic vs. carotid/femoral), but cardiac risk is significant across the board.
- Late cardiac morbidity and mortality are substantial in all atherosclerotic disease patients.
Conclusions:
- Functional cardiac testing is essential for perioperative risk stratification in peripheral vascular disease patients.
- Decisions on coronary angiography and revascularization should be independent of the vascular procedure.
- Lifelong cardiac risk necessitates continuous evaluation and management.
Abstract:
The prevalence of serious angiographic coronary artery disease ranges from 37% to 78% in patients undergoing operation for peripheral vascular disease. Clinical studies have demonstrated that cardiac outcome after peripheral vascular surgery is not adequately predicted by the standard criteria of history, physical findings and rest electrocardiogram. An adequate exercise work load, left ventricular function and thallium redistribution have proved important in perioperative risk stratification. The choice of a perioperative functional cardiac test depends on patient-related factors and the nature of the peripheral vascular operation. Although procedures involving aortic cross-clamping exert a greater hemodynamic stress than do carotid endarterectomy and femoral popliteal surgery, late cardiac morbidity and mortality are significant in all patients with atherosclerotic disease. The decision to proceed with preoperative coronary angiography and myocardial revascularization should be based primarily on indications independent of the peripheral vascular procedure. However, peripheral vascular surgery may influence the timing of myocardial revascularization. Patients with high risk or unstable coronary artery disease may benefit from preoperative coronary revascularization, although this hypothesis remains unproved. In all patients, careful monitoring during and after operation is essential. All patients with peripheral vascular disease should be considered to be at lifelong risk for fatal and nonfatal cardiac events and should undergo appropriate clinical and laboratory evaluation and be treated accordingly.