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[Assessment of cardiovascular perioperative risk in non-cardiac surgery]
D Sirieix1, L Lamonerie-Alvarez, P Olivier
1Service Nadia-du-Bouchet, anesthésie-réanimation, hôpital Broussais, Paris, France.
Insights
Patients with cardiovascular disease face cardiac risks during non-cardiac surgery. A simplified algorithm aids in assessing perioperative cardiac risk, guiding further investigations for better patient outcomes.
Area of Science:
- Cardiology
- Anesthesiology
- Internal Medicine
Context:
- Patients with cardiovascular disease undergoing non-cardiac surgery face significant perioperative cardiac risks, including myocardial infarction, heart failure, and death.
- Accurate estimation of cardiac risk is crucial for optimizing patient management and outcomes.
- Current guidelines for assessing perioperative cardiac risk can be complex, necessitating simpler tools.
Purpose:
- To present a simplified algorithm for assessing perioperative cardiac risk in patients with cardiovascular disease undergoing non-cardiac surgery.
- To aid clinicians in determining the need for further cardiac investigations.
- To improve the efficiency and accuracy of preoperative cardiac risk assessment.
Summary:
- The algorithm considers factors like emergency surgery, prior coronary revascularization, recent coronary evaluation, clinical predictors of cardiac risk, and surgery type (high, intermediate, low risk).
- It guides the selection of further investigations, such as exercise testing, dipyridamole thallium scintigraphy, or dobutamine stress echocardiography.
- These tests have similar accuracy, high negative predictive value, and low positive predictive value.
Impact:
- Facilitates informed decision-making regarding preoperative cardiac investigations.
- Potentially improves patient treatment, intraoperative monitoring, and postoperative outcomes.
- Offers a more user-friendly approach compared to existing complex algorithms.
Abstract:
Patients with cardiovascular disease undergoing non cardiac surgery are exposed to three cardiac risks: myocardial infarction, heart failure and death. To estimate cardiac risk, clinical predictors of perioperative cardiovascular risk are classified as major, intermediate and minor and non cardiac surgery is stratified in high risk (greater than 5%), intermediate (from 1 to 5%), minor (lower than 1%) procedures. Efficient perioperative assessment of cardiac patients is obtained by teamwork and usually, indications for further cardiac investigations are the same as those in the nonoperative setting. An simplified algorithm, easier to use than original algorithm given in the guidelines of the American college of cardiology and the American heart association, may be helpful for the indication of further investigations. Five questions must be answered before using algorithm: is it an emergency surgical procedure?, was a coronary revascularization required in the past five years? has the patient had a coronary evaluation in the past two years?, are there identified clinical predictors of cardiac risk?, is it major or minor surgery? Three tests evaluate the preoperative cardiac risk: exercise testing, dipyridamole thallium scintigraphy, dobutamine stress echocardiography. Their accuracy is similar, their negative predictive value is high, their positive predictive value is low. These guidelines may be helpful to indicate further cardiac investigations which will have an impact on patient's treatment, monitoring during or after surgery and outcome.