Preoperative Cardiac Evaluation Before Aortic Surgery

  • Kyung W. Park


Each year in the USA, nearly 30 million patients are estimated to undergo noncardiac surgery, and about one third of these patients have coronary artery disease (CAD) or risk factors for CAD.1 About one million of those patients have perioperative cardiac complications that result in more than $20 billion in health-care expenditures.1 The current standards for preoperative cardiac evaluation of these patients are the guidelines published by the American College of Cardiology (ACC) and the American Heart Association (AHA), initially in 19962 and updated in 2002 3 and again in 2007.4 These guidelines were developed based on a review of the then-available literature and the opinions of experts from the disciplines of anesthesiology, cardiology, electrophysiology, vascular medicine, vascular surgery, and noninvasive cardiac testing.


Coronary Artery Bypass Graft Clinical Risk Factor Dobutamine Stress Echocardiography Noncardiac Surgery Major Vascular Surgery 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Mangano DT, Goldman L. Preoperative assessment of patients with known or suspected coronary disease. N Engl J Med. 1995;333:1750–1756.CrossRefPubMedGoogle Scholar
  2. 2.
    ACC/AHA Task Force Report. Special report: guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Circulation. 1996;93:1278–1317.Google Scholar
  3. 3.
    Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery – executive summary: a report of the ACC/AHA task force on practice guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol. 2002;39:542–553.CrossRefPubMedGoogle Scholar
  4. 4.
    Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation. 2007 Oct 23;116(17):1971–1996.CrossRefPubMedGoogle Scholar
  5. 5.
    Jette M, Sidney K, Blumchen G. Metabolic equivalents (METS) in exercise testing, exercise prescription, and evaluation of functional capacity. Clin Cardiol. 1990;13:555–565.CrossRefPubMedGoogle Scholar
  6. 6.
    Rossi E, Citterio F, Vescio MF, et al. Risk stratification of patients undergoing peripheral vascular revascularization by combined resting and dipyridamole echocardiography. Am J Cardiol. 1998;82:306–310.CrossRefPubMedGoogle Scholar
  7. 7.
    Kontos MC, Brath LK, Akosah KP, Mohanty PK. Cardiac complications in noncardiac surgery: relative value of resting two-dimensional echocardiography and dipyridamole thallium imaging. Am Heart J. 1996;132:559–566.CrossRefPubMedGoogle Scholar
  8. 8.
    Halm EA, Browner WS, Tubau JF, Tateo IM, Mangano DT. Echocardiography for assessing cardiac risk in patients having noncardiac surgery. Ann Intern Med. 1996;125:433–441.PubMedGoogle Scholar
  9. 9.
    Guidelines for assessing and managing the perioperative risk from coronary artery disease associated with major noncardiac surgery. Ann Intern Med 1997; 127:309–12.Google Scholar
  10. 10.
    Soufer R, Wohlgelernter D, Vita NA, et al. Intact systolic left ventricular function in clinical congestive heart failure. Am J Cardiol. 1985;55:1032–1036.CrossRefPubMedGoogle Scholar
  11. 11.
    Rakowski H, Appleton CP, Chan KL, et al. Canadian consensus recommendations for the measurement and reporting of diastolic dysfunction by echocardiography: from the investigators of consensus on diastolic dysfunction by echocardiography. J Am Soc Echocardiogr. 1996;9:736–760.CrossRefPubMedGoogle Scholar
  12. 12.
    O’Halloran TD, Kannam JP. Preoperative transthoracic echocardiography: when is it useful? Int Anesthesiol Clin. 2008;46:1–10.CrossRefPubMedGoogle Scholar
  13. 13.
    Liao T, Park KW. Noninvasive tests of myocardial perfusion: stress tests and their values. Int Anesth Clin. 2001;39(4):1–10.CrossRefGoogle Scholar
  14. 14.
    Selbst J, Comunale ME. Myocardial ischemia monitoring. Int Anesthesiol Clin. 2002;40(1):133–146.PubMedGoogle Scholar
  15. 15.
    Grayburn PA, Hillis LD. Cardiac events in patients undergoing noncardiac surgery: shifting the paradigm from noninvasive risk stratification to therapy. Ann Intern Med. 2003;138:506–511.PubMedGoogle Scholar
  16. 16.
    Morgan PB, Panomitros GE, Nelson AC, Smith DF, Solanki DR, Zornow MH. Low utility of dobutamine stress echocardiograms in the preoperative evaluation of patients scheduled for noncardiac surgery. Anesth Analg. 2002;95:512–516.CrossRefPubMedGoogle Scholar
  17. 17.
    Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100:1043–1049.PubMedGoogle Scholar
  18. 18.
    Mangano DT, Layug EI, Wallace A, Tateo I, Multicenter study of perioperative ischemia research group. Effect of atenolol on mortality and cardiovascular­ morbidity after noncardiac surgery. N Engl J Med. 1996;335:1713–1720.CrossRefPubMedGoogle Scholar
  19. 19.
    Wallace A, Layug B, Tateo I, et al. Prophylactic atenolol reduces postoperative myocardial ischemia. Anesthesiology. 1998;88:7–17.CrossRefPubMedGoogle Scholar
  20. 20.
    Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. N Engl J Med. 1999;341:1789–1794.CrossRefPubMedGoogle Scholar
  21. 21.
    Poldermans D, Boersma E, Bax JJ, et al. Bisoprolol reduces cardiac death and myocardial infarction in high-risk patients as long as 2 years after successful major vascular surgery. Eur Heart J. 2001;22:1353–1358.CrossRefPubMedGoogle Scholar
  22. 22.
    Raby KE, Brull SJ, Timimi F, et al. The effect of heart rate control on myocardial ischemia among high-risk patients after vascular surgery. Anesth Analg. 1999;88:477–482.CrossRefPubMedGoogle Scholar
  23. 23.
    Stone JG, Foex P, Sear JW, Johnson LL, Khambatta HJ, Triner L. Myocardial ischemia in untreated hypertensive patients: effect of a single small oral dose of a beta-adrenergic blocking agent. Anesthesiology. 1988;68:495–500.CrossRefPubMedGoogle Scholar
  24. 24.
    Urban MK, Markowitz SM, Gordon MA, Urquhart BL, Kligfield P. Postoperative prophylactic administration of b-adrenergic blockers in patients at risk for myocardial ischemia. Anesth Analg. 2000;90:1257–1261.CrossRefPubMedGoogle Scholar
  25. 25.
    POISE Study Group, Devereaux PJ, Yang H, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008;371:1839–1847.CrossRefPubMedGoogle Scholar
  26. 26.
    Sear JW, Giles JW, Howard-Alpe G, Foex P. Perioperative beta-blockade, 2008: what does POISE tell us, and was our earlier caution justified? Br J Anaesth. 2008;101:135–138.CrossRefPubMedGoogle Scholar
  27. 27.
    Shammash JB, Trost JC, Gold JM, Berlin JA, Golden MA, Kimmel SE. Perioperative beta-blocker withdrawal and mortality in vascular surgical patients. Am Heart J. 2001;141:148–153.CrossRefPubMedGoogle Scholar
  28. 28.
    Boersma E, Poldermans D, Bax JJ, et al. Predictors of cardiac events after major vascular surgery. JAMA. 2001;285:1865–1873.CrossRefPubMedGoogle Scholar
  29. 29.
    Lee JW. Statins and cardiovascular risks. Int Anesthesiol Clin. 2005;43:55–68.CrossRefPubMedGoogle Scholar
  30. 30.
    Lindenauer PK, Pekow P, Wang K, Gutierrez B, Benjamin E. Lipid-lowering therapy and in-hospital mortality following major noncardiac surgery. JAMA. 2004;291:2092–2099.CrossRefPubMedGoogle Scholar
  31. 31.
    Poldermans D, Bax JJ, Kertai MD, et al. Statins are associated with a reduced incidence of perioperative mortality in patients undergoing major noncardiac vascular surgery. Circulation. 2003;107:1848–1851.CrossRefPubMedGoogle Scholar
  32. 32.
    Kertai MD, Boersma E, Westerhout CM, et al. A combination of statins and beta-blockers is independently associated with a reduction in the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery. Eur J Vasc Endovasc Surg. 2004;28:343–352.CrossRefPubMedGoogle Scholar
  33. 33.
    Kertai MD, Boersma E, Westerhout CM, et al. Association between long-term statin use and mortality after successful abdominal aortic aneurysm surgery. Am J Med. 2004;116:96–103.CrossRefPubMedGoogle Scholar
  34. 34.
    Durazzo AES, Machado FS, Ikeoka DT, et al. Reduction in cardiovascular events after vascular surgery with atorvastatin: a randomized trial. J Vasc Surg. 2004;39:967–976.CrossRefPubMedGoogle Scholar
  35. 35.
    Park KW. Angiotensin converting enzyme inhibitors, AG receptor blockers, and aldosterone receptor antagonists. Int Anesthesiol Clin. 2005;43:23–37.CrossRefPubMedGoogle Scholar
  36. 36.
    Park KW. Na+-K+ exchange inhibitors. Int Anesthesiol Clin. 2005;43:69–75.CrossRefPubMedGoogle Scholar
  37. 37.
    Li Y, Cohen R. Caspase inhibitors and myocardial apoptosis. Int Anesthesiol Clin. 2005;43:77–89.CrossRefPubMedGoogle Scholar
  38. 38.
    Licker M, Bednarkiewicz M, Neidhart P, et al. Preoperative inhibition of angiotensin-converting enzyme improves systemic and renal haemodynamic changes during aortic abdominal surgery. Br J Anaesth. 1996;76:632–639.PubMedGoogle Scholar
  39. 39.
    Bonow RO, Epstein SE. Indications for coronary artery bypass surgery in patients with chronic angina pectoris: implications of the multicenter randomized trials. Circulation. 1985;72:V23–V30.PubMedGoogle Scholar
  40. 40.
    Hueb WA, Bellotti G, de Oliveira SA, et al. The Medicine, Angioplasty or Surgery Study (MASS): a prospective, randomized trial of medical therapy, balloon angioplasty or bypass surgery for single proximal left anterior descending artery stenosis. J Am Coll Cardiol. 1995;26:1600–1605.CrossRefPubMedGoogle Scholar
  41. 41.
    Parisi AF, Folland ED, Hartigan P, Veterans Affairs ACME Investigators. A comparison of angioplasty with medical therapy in the treatment of single-vessel coronary artery disease. N Engl J Med. 1992;326:10–16.CrossRefPubMedGoogle Scholar
  42. 42.
    Coronary angioplasty versus medical therapy for angina: the second Randomised Intervention Treatment of Angina (RITA-2) trial. Lancet 1997; 350:461–468.Google Scholar
  43. 43.
    Mason JJ, Owens DK, Harris RA, Cooke JP, Hlatky MA. The role of coronary angiography and coronary revascularization before noncardiac vascular surgery. JAMA. 1995;273:1919–1925.CrossRefPubMedGoogle Scholar
  44. 44.
    The Society of Thoracic Surgeons national database. Available at: Accessed November 14, 2008.
  45. 45.
    Eagle KA, Rihal CS, Mickel MC, Holmes DR, Foster ED, Gersh BJ. Cardiac risk of noncardiac surgery: influence of coronary disease and type of surgery in 3368 operations. Circulation. 1997;96:1882–1887.PubMedGoogle Scholar
  46. 46.
    McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med. 2004;351:2795–2804.CrossRefPubMedGoogle Scholar
  47. 47.
    Posner KL, van Norman GA, Chan V. Adverse cardiac outcomes after noncardiac surgery in patients with prior percutaneous transluminal coronary angioplasty. Anesth Analg. 1999;89:553–560.CrossRefPubMedGoogle Scholar
  48. 48.
    Kaluza GL, Joseph J, Lee JR, Raizner ME, Raizner AE. Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol. 2000;35:1288–1294.CrossRefPubMedGoogle Scholar
  49. 49.
    Park KW. Intracoronary brachytherapy and drug-eluting coronary stents. Int Anesthesiol Clin. 2005;43:91–100.CrossRefPubMedGoogle Scholar
  50. 50.
    Reul GJ Jr, Cooley DA, Duncan JM, et al. The effect of coronary bypass on the outcome of peripheral vascular operations in 1093 patients. J Vasc Surg. 1986;3:788–798.CrossRefPubMedGoogle Scholar
  51. 51.
    Breen P, Lee JW, Pomposelli F, Park KW. Timing of high-risk vascular surgery following coronary artery bypass surgery: a 10-year experience from an academic medical centre. Anaesthesia. 2004;59:422–427.CrossRefPubMedGoogle Scholar
  52. 52.
    O’Keefe JH Jr, Shub C, Rettke SR. Risk of noncardiac surgical procedures in patients with aortic stenosis. Mayo Clin Proc. 1989;64:400–405.PubMedGoogle Scholar
  53. 53.
    Raymer K, Yang H. Patients with aortic stenosis: cardiac complications in noncardiac surgery. Can J Anaesth. 1998;45:855–859.CrossRefPubMedGoogle Scholar
  54. 54.
    Haering JM, Comunale ME, Parker RA, et al. Cardiac risk of noncardiac surgery in patients with asymmetric septal hypertrophy. Anesthesiology. 1996;85:254–259.CrossRefPubMedGoogle Scholar
  55. 55.
    Kuroiwa M, Arai M, Ueno T, Takenaka T, Okamoto H, Hoka S. Perioperative cardiovascular complications in patients with hypertrophic cardiomyopathy. Masui. 2003;52:733–739.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Departments of Anesthesia and of SurgeryThe Ohio State University Medical CenterColumbusUSA

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