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Published on: April 17, 2021
Perioperative assessment and management of risk from coronary artery disease
1University of Toronto, Ontario, Canada.
Insights
Internists can use clinical findings to stratify perioperative cardiac risk. Noninvasive stress testing may benefit intermediate-risk patients, especially before vascular surgery.
Area of Science:
- Cardiology
- Internal Medicine
- Perioperative Medicine
Background:
- Preoperative cardiac risk stratification is crucial for patient management.
- Identifying patients at risk for myocardial infarction and death before surgery is essential.
Purpose of the Study:
- To summarize evidence on preoperative cardiac risk stratification.
- To guide internists in using clinical and electrocardiographic findings for risk assessment.
- To inform decisions regarding further testing and coronary revascularization before noncardiac surgery.
Main Methods:
- MEDLINE search and reference list review.
- Calculation of sensitivities, specificities, and likelihood ratios for diagnostic tests.
- Application of quality ratings to study methods and outcomes (myocardial infarction and mortality).
Main Results:
- Clinical and electrocardiographic findings effectively stratify patients into low, intermediate, and high perioperative risk categories.
- Pharmacologic stress imaging may improve risk stratification for intermediate-risk patients undergoing vascular surgery.
- Coronary revascularization before elective surgery appears to carry risks outweighing benefits; beta-blocker use shows a survival benefit in at-risk patients.
Conclusions:
- Clinical indices should be used for all surgical patients' risk evaluation.
- Low-risk patients require no further cardiac evaluation; high-risk patients need optimal management, potentially including beta-blockers and procedure cancellation.
- Intermediate-risk patients, particularly those undergoing vascular surgery, may benefit from noninvasive stress testing.
Purpose:
To summarize available evidence on preoperative cardiac risk stratification so that the internist may 1) use clinical and electrocardiographic findings to stratify a patient's perioperative risk for myocardial infarction and death; 2) decide which tests provide useful additional risk-related information; and 3) understand the benefits, risks, and evidence surrounding the decision to undertake coronary revascularization before elective noncardiac surgery.
Data Sources:
A MEDLINE search and review of the reference lists of identified articles. Sensitivities, specificities, and likelihood ratios for diagnostic tests were calculated, and a quality rating for study methods was applied.
Data Extraction:
Myocardial infarction and mortality were the major outcomes considered, and a quality rating for study methods was applied.
Data Synthesis:
Clinical and electrocardiographic findings, organized by multivariate prediction indices, accurately identify patients as having low, intermediate, or high risk for myocardial infarction or death. Pharmacologic stress imaging with thallium or echocardiography probably improves risk stratification for intermediate-risk patients having vascular surgery. These tests have not been shown to be effective prognostic indicators for patients having nonvascular surgery. No studies of angiography for risk prediction have been reported. Decision analyses and retrospective series suggest that the risks incurred by doing coronary angiography and revascularization before elective surgery outweigh the benefits. Prospective, controlled studies of coronary revascularization are lacking. Evidence from a randomized, controlled trial has shown a survival benefit with the perioperative use of beta-blockers in patients at risk for coronary artery disease.
Conclusions:
Evaluation of all surgical patients by use of clinical indices is recommended. Low-risk patients need no further evaluation before surgery. High-risk patients need optimal management of their high-risk problems, including (if appropriate) beta-blocker use, and may need to have their elective procedures canceled. Intermediate-risk patients probably benefit from further noninvasive stress testing, especially if they are having vascular surgery. Further clinical trials are needed for most areas of concern.
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