Related Experiment Videos
Preoperative cardiac risk management
1Department of Surgery, University of Colorado Health Sciences Center, Denver, USA.
Insights
Coronary artery disease (CAD) is common in peripheral arterial disease patients undergoing vascular surgery. Preoperative cardiac evaluation should guide management, but prophylactic interventions are not routinely recommended.
Area of Science:
- Cardiology
- Vascular Surgery
- Perioperative Medicine
Background:
- Coronary artery disease (CAD) is prevalent in patients with peripheral arterial disease (PAD) and significantly contributes to morbidity and mortality following vascular operations.
- Clinical risk assessment tools aim to stratify patients into low, intermediate, or high cardiac risk categories for adverse cardiac events.
- For low-risk patients, additional cardiac testing provides minimal incremental information beyond clinical scoring.
Purpose of the Study:
- To evaluate the utility of preoperative cardiac work-up in patients undergoing vascular surgery.
- To determine the appropriate management strategy for patients with varying degrees of cardiac risk.
- To assess the role of prophylactic coronary interventions in enhancing surgical safety.
Main Methods:
- Review of clinical risk assessment strategies for perioperative cardiac events.
- Analysis of the impact of additional cardiac testing on patient management.
- Consideration of the timing and indication for coronary angiography and revascularization.
Main Results:
- High-risk patients may require coronary angiography, intensive monitoring, or surgical modification, but further testing is only indicated if it alters management.
- Intermediate-risk patients may benefit from further cardiac investigations, including coronary arteriography, if vascular surgery can be delayed for revascularization.
- The urgency of vascular surgery (e.g., threatened limb) often precludes extensive preoperative cardiac work-up.
Conclusions:
- Preoperative cardiac evaluation should be tailored to individual patient risk and the potential to alter management.
- Prophylactic coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA) should not be routinely performed to enhance vascular surgery safety.
- Decisions regarding coronary interventions should be based on cardiac symptoms and coronary anatomy, not solely on the planned vascular procedure.
Abstract:
CAD is present in most patients with peripheral arterial disease and is the leading cause of morbidity and mortality after vascular operations. Clinical risk assessment attempts to identify those patients at low, intermediate, or high cardiac risk for adverse cardiac outcomes. Additional tests add little information to the estimates obtained by clinical scoring in patients at low risk. Patients with high cardiac risk scores are clearly at increased risk of experiencing postoperative complications, but further investigations are needed only if knowledge of the functional severity or degree of myocardial ischemia will alter subsequent management. In general, high-risk patients should proceed to coronary angiography, intensive perioperative monitoring, alteration in the planned operation, or avoidance of surgery altogether if indications are less than compelling. Those patients identified as intermediate risk by clinical scoring benefit most from additional tests. In these patients special studies or even coronary arteriography may be useful if the vascular surgery can be delayed until myocardial revascularization is completed. Practically, preoperative cardiac work-up must also consider the indication for surgery. Patients who have threatened limbs or ruptured aneurysms or are severely symptomatic cannot afford the time involved for obtaining additional tests. Moreover, the question of what to do with the information provided by special studies is problematic in these patients. For example, if significant symptomatic or asymptomatic CAD is present in a patient with a gangrenous foot, what is gained by the delay in lower extremity revascularization required when prophylactic CABG is performed? Reports supporting prophylactic CAD intervention are nonrandomized and uncontrolled. CABG and PTCA should be performed only on the merits of the patient's cardiac symptoms and coronary artery anatomy, not to enhance safety of the proposed vascular procedure, because advances in surgical and anesthetic techniques and intraoperative and postoperative monitoring have resulted in lower morbidity and mortality of elective vascular surgery.