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Kassab K, Saltiel F. Current management of coronary artery disease prior to vascular surgery: A clinical dilemma. J Perioper Pract 2023; 33:148-152. [PMID: 36285610 PMCID: PMC10160823 DOI: 10.1177/17504589221123285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Here we present a case of an elderly man who underwent cardiac stress testing as a preoperative evaluation prior to femoral-popliteal bypass surgery. He subsequently underwent a preoperative coronary angiogram after a high-risk stress test with the latter demonstrating obstructive three-vessel coronary artery disease. We discuss the clinical challenges that such a common clinical scenario presents particularly when it comes to preoperative coronary revascularisation prior to vascular surgery. We examine the case within the framework of the latest revascularisation guidelines and discuss the available evidence for preoperative revascularisation and its limitations.
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Affiliation(s)
- Kameel Kassab
- Division of Cardiology, Borgess Heart Institute, Kalamazoo, MI, USA
- Michigan State University, East Lansing, MI, USA
| | - Frank Saltiel
- Division of Cardiology, Borgess Heart Institute, Kalamazoo, MI, USA
- Michigan State University, East Lansing, MI, USA
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Ayubcha D, Grosh T, Fleisher LA. Perioperative Cardiac Risk Assessment in Noncardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00005-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Vernooij LM, van Klei WA, Moons KG, Takada T, van Waes J, Damen JA. The comparative and added prognostic value of biomarkers to the Revised Cardiac Risk Index for preoperative prediction of major adverse cardiac events and all-cause mortality in patients who undergo noncardiac surgery. Cochrane Database Syst Rev 2021; 12:CD013139. [PMID: 34931303 PMCID: PMC8689147 DOI: 10.1002/14651858.cd013139.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The Revised Cardiac Risk Index (RCRI) is a widely acknowledged prognostic model to estimate preoperatively the probability of developing in-hospital major adverse cardiac events (MACE) in patients undergoing noncardiac surgery. However, the RCRI does not always make accurate predictions, so various studies have investigated whether biomarkers added to or compared with the RCRI could improve this. OBJECTIVES Primary: To investigate the added predictive value of biomarkers to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery. Secondary: To investigate the prognostic value of biomarkers compared to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery. Tertiary: To investigate the prognostic value of other prediction models compared to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery. SEARCH METHODS We searched MEDLINE and Embase from 1 January 1999 (the year that the RCRI was published) until 25 June 2020. We also searched ISI Web of Science and SCOPUS for articles referring to the original RCRI development study in that period. SELECTION CRITERIA We included studies among adults who underwent noncardiac surgery, reporting on (external) validation of the RCRI and: - the addition of biomarker(s) to the RCRI; or - the comparison of the predictive accuracy of biomarker(s) to the RCRI; or - the comparison of the predictive accuracy of the RCRI to other models. Besides MACE, all other adverse outcomes were considered for inclusion. DATA COLLECTION AND ANALYSIS We developed a data extraction form based on the CHARMS checklist. Independent pairs of authors screened references, extracted data and assessed risk of bias and concerns regarding applicability according to PROBAST. For biomarkers and prediction models that were added or compared to the RCRI in ≥ 3 different articles, we described study characteristics and findings in further detail. We did not apply GRADE as no guidance is available for prognostic model reviews. MAIN RESULTS We screened 3960 records and included 107 articles. Over all objectives we rated risk of bias as high in ≥ 1 domain in 90% of included studies, particularly in the analysis domain. Statistical pooling or meta-analysis of reported results was impossible due to heterogeneity in various aspects: outcomes used, scale by which the biomarker was added/compared to the RCRI, prediction horizons and studied populations. Added predictive value of biomarkers to the RCRI Fifty-one studies reported on the added value of biomarkers to the RCRI. Sixty-nine different predictors were identified derived from blood (29%), imaging (33%) or other sources (38%). Addition of NT-proBNP, troponin or their combination improved the RCRI for predicting MACE (median delta c-statistics: 0.08, 0.14 and 0.12 for NT-proBNP, troponin and their combination, respectively). The median total net reclassification index (NRI) was 0.16 and 0.74 after addition of troponin and NT-proBNP to the RCRI, respectively. Calibration was not reported. To predict myocardial infarction, the median delta c-statistic when NT-proBNP was added to the RCRI was 0.09, and 0.06 for prediction of all-cause mortality and MACE combined. For BNP and copeptin, data were not sufficient to provide results on their added predictive performance, for any of the outcomes. Comparison of the predictive value of biomarkers to the RCRI Fifty-one studies assessed the predictive performance of biomarkers alone compared to the RCRI. We identified 60 unique predictors derived from blood (38%), imaging (30%) or other sources, such as the American Society of Anesthesiologists (ASA) classification (32%). Predictions were similar between the ASA classification and the RCRI for all studied outcomes. In studies different from those identified in objective 1, the median delta c-statistic was 0.15 and 0.12 in favour of BNP and NT-proBNP alone, respectively, when compared to the RCRI, for the prediction of MACE. For C-reactive protein, the predictive performance was similar to the RCRI. For other biomarkers and outcomes, data were insufficient to provide summary results. One study reported on calibration and none on reclassification. Comparison of the predictive value of other prognostic models to the RCRI Fifty-two articles compared the predictive ability of the RCRI to other prognostic models. Of these, 42% developed a new prediction model, 22% updated the RCRI, or another prediction model, and 37% validated an existing prediction model. None of the other prediction models showed better performance in predicting MACE than the RCRI. To predict myocardial infarction and cardiac arrest, ACS-NSQIP-MICA had a higher median delta c-statistic of 0.11 compared to the RCRI. To predict all-cause mortality, the median delta c-statistic was 0.15 higher in favour of ACS-NSQIP-SRS compared to the RCRI. Predictive performance was not better for CHADS2, CHA2DS2-VASc, R2CHADS2, Goldman index, Detsky index or VSG-CRI compared to the RCRI for any of the outcomes. Calibration and reclassification were reported in only one and three studies, respectively. AUTHORS' CONCLUSIONS Studies included in this review suggest that the predictive performance of the RCRI in predicting MACE is improved when NT-proBNP, troponin or their combination are added. Other studies indicate that BNP and NT-proBNP, when used in isolation, may even have a higher discriminative performance than the RCRI. There was insufficient evidence of a difference between the predictive accuracy of the RCRI and other prediction models in predicting MACE. However, ACS-NSQIP-MICA and ACS-NSQIP-SRS outperformed the RCRI in predicting myocardial infarction and cardiac arrest combined, and all-cause mortality, respectively. Nevertheless, the results cannot be interpreted as conclusive due to high risks of bias in a majority of papers, and pooling was impossible due to heterogeneity in outcomes, prediction horizons, biomarkers and studied populations. Future research on the added prognostic value of biomarkers to existing prediction models should focus on biomarkers with good predictive accuracy in other settings (e.g. diagnosis of myocardial infarction) and identification of biomarkers from omics data. They should be compared to novel biomarkers with so far insufficient evidence compared to established ones, including NT-proBNP or troponins. Adherence to recent guidance for prediction model studies (e.g. TRIPOD; PROBAST) and use of standardised outcome definitions in primary studies is highly recommended to facilitate systematic review and meta-analyses in the future.
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Affiliation(s)
- Lisette M Vernooij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Wilton A van Klei
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Anesthesiologist and R. Fraser Elliott Chair in Cardiac Anesthesia, Department of Anesthesia and Pain Management Toronto General Hospital, University Health Network and Professor, Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Karel Gm Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Judith van Waes
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Johanna Aag Damen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Jung JC, Park KH. Coronary artery disease in aortic aneurysm and dissection. Indian J Thorac Cardiovasc Surg 2021; 38:115-121. [PMID: 35463718 PMCID: PMC8980968 DOI: 10.1007/s12055-021-01265-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/17/2021] [Accepted: 08/23/2021] [Indexed: 11/30/2022] Open
Abstract
Coexisting coronary artery disease is a significant risk factor of untoward outcomes after surgical and endovascular aortic repair. This article reviewed the data, consensus, and remaining controversy about the diagnosis and management of coexisting coronary artery disease in the patients who require intervention for aortic aneurysm and dissection. It can be summarized as follows: (1) the current guidelines generally recommend the same diagnostic algorithm, including indications of coronary artery angiography, as one for non-surgical patients; (2) they also recommend the same indications of coronary revascularization; and (3) there are minor, but important, remaining issues regarding the details of management and surgical techniques most of which are still at the discretion of individual surgeons and institutions. Because it is not likely to get large-scale investigational data about these issues, the collection of individual experiences should be promoted in future scientific meetings to build up the consensus.
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Affiliation(s)
- Joon Chul Jung
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Bundang-gu, Seongnam-si, Gyeonggi-do 13620 Republic of Korea
| | - Kay-Hyun Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Bundang-gu, Seongnam-si, Gyeonggi-do 13620 Republic of Korea
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Zhang L, Li Z, Ye X, Chen Z, Chen ZS. Mechanisms of thrombosis and research progress on targeted antithrombotic drugs. Drug Discov Today 2021; 26:2282-2302. [PMID: 33895314 DOI: 10.1016/j.drudis.2021.04.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 04/14/2021] [Accepted: 04/15/2021] [Indexed: 12/26/2022]
Abstract
Globally, the incidence of thromboembolic diseases has increased in recent years, accompanied by an increase in patient mortality. Currently, several targeting delivery strategies have been developed to treat thromboembolic diseases. In this review, we discuss the mechanisms of thrombolysis and current anticoagulant drugs, particularly those with targeting capability, highlighting advances in the accurate treatment of thrombolysis with fewer adverse effects. Such approaches include magnetic drug-loading systems combined with molecular imaging to recanalize blood vessels and systems based on chimeric Arg-Gly-Asp (RGD) sequences that can target platelet glycoprotein receptor. With such progress in targeted antithrombotic drugs, targeted thrombolysis treatment shows significant potential benefit for patients.
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Affiliation(s)
- Lei Zhang
- State Key Laboratory of Structural Chemistry, Fujian Institute of Research on the Structure of Matter, Chinese Academy of Sciences, Fuzhou 350002, China; University of Chinese Academy of Sciences, Beijing 100049, China
| | - Zhen Li
- Fujian Cancer Hospital, Fujian Provincial Cancer Hospital of Fujian Medical University, Fuzhou 350014, China
| | - Xianren Ye
- Fujian Cancer Hospital, Fujian Provincial Cancer Hospital of Fujian Medical University, Fuzhou 350014, China.
| | - Zhuo Chen
- State Key Laboratory of Structural Chemistry, Fujian Institute of Research on the Structure of Matter, Chinese Academy of Sciences, Fuzhou 350002, China; University of Chinese Academy of Sciences, Beijing 100049, China.
| | - Zhe-Sheng Chen
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences, St. John's University, NY 11439, USA.
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Jo MS, Lee J, Kim SY, Kwon HJ, Lee HK, Park DJ, Kim Y. Comparison between creatine kinase MB, heart-type fatty acid-binding protein, and cardiac troponin T for detecting myocardial ischemic injury after cardiac surgery. Clin Chim Acta 2018; 488:174-178. [PMID: 30389460 DOI: 10.1016/j.cca.2018.10.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 10/29/2018] [Accepted: 10/29/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Heart-type fatty acid-binding protein (H-FABP) is a cytoplasmic protein and is released form necrotic cardiac myocytes, as well as ischemic cardiac myocytes. In this study, we compared creatine kinase MB (CK-MB), H-FABP, and cardiac troponin T (cTnT) after coronary artery bypass grafting (CABG), heart valve surgery, or septal defect surgery to evaluate the difference in detecting myocardial injury between three markers. METHODS A total of 69 patients (CABG, 32; valve surgery, 27; and septal defect surgery, 10) were prospectively enrolled. Blood samples were taken at specific intervals. RESULTS Mean amount (AUC0-72h) of CK-MB and cTnT released for 72 h in the patients with valve surgery were 2446 h·ng/ml and 93.2 h·ng/ml, which were significantly larger than those in the patients with CABG or septal defect surgery (p < .05). Mean amount (AUC0-72h) of H-FABP released for 72 h in the patients with CABG was 1939 h·ng/ml, which was significantly larger than that in the patients with septal defect surgery (700.1 h·ng/ml) (p < .05). CONCLUSION H-FABP would be a more useful marker for detecting myocardial ischemic injury than CK-MB and cTnT. CK-MB and cTnT would be more sensitive to myocardial injury with surgical trauma than with ischemic injury in the patients with cardiac surgery.
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Affiliation(s)
- Min Seop Jo
- Department of Thoracic and Cardiovascular surgery, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Republic of Korea
| | - Jehoon Lee
- Department of Laboratory Medicine, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Republic of Korea
| | - Soo-Young Kim
- Department of Laboratory Medicine, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Republic of Korea
| | - Hi Jeong Kwon
- Department of Laboratory Medicine, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Republic of Korea
| | - Hae Kyung Lee
- Department of Laboratory Medicine, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Republic of Korea
| | - Dong Jin Park
- Department of Laboratory Medicine, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Republic of Korea
| | - Yeongsic Kim
- Department of Laboratory Medicine, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Republic of Korea.
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Park J, Lee SH, Kim J, Park M, Gwon HC, Tak Lee Y, Maria Lee S. Clinical Outcome of Noncardiac Surgery in Patients With History of Coronary Artery Revascularization by Percutaneous Coronary Intervention Versus Coronary Artery Bypass Graft Surgery. JAPANESE CLINICAL MEDICINE 2018; 9:1179670717748945. [PMID: 29434482 PMCID: PMC5804996 DOI: 10.1177/1179670717748945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 11/05/2017] [Indexed: 11/23/2022]
Abstract
Objective: Although safety concerns still remain among patients undergoing unanticipated noncardiac surgery after prior percutaneous coronary intervention (PCI), it has not been directly compared with coronary artery bypass grafting (CABG). The objective of this study was to compare clinical outcomes after noncardiac surgery in patients with prior (>6 months) coronary revascularization by PCI or CABG. Methods: From February 2010 to December 2015, 413 patients with a history of coronary revascularization, scheduled for noncardiac surgery were identified. Patients were divided into PCI group and CABG group and postoperative clinical outcome was compared between 2 groups. The primary outcome was composite of all-cause death, myocardial infarction, and stroke in 1-year follow-up. Results: The 413 patients were divided according to prior coronary revascularization types: 236 (57.1%) into PCI and 177 (42.9%) into CABG group. In multivariate analysis within 1-year follow-up, there was no significant difference in clinical outcome which was composite of all-cause death, myocardial infarction, and stroke (hazard ratio [HR]: 1.50; 95% confidence interval [CI]: 0.76-2.93; P = .24). The same result was present in propensity-matched population analysis (HR: 1.43; 95% CI: 0.68-3.0; P = .34). Conclusions: In patients undergoing noncardiac surgery with prior coronary revascularization by PCI or CABG performed on an average of 42 months after PCI and 50 months after CABG, postoperative clinical outcome at 1-year follow-up is comparable.
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Affiliation(s)
- Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Seung Hwa Lee
- Division of Cardiology, Heart Vascular Stroke Institute, Department of Medicine, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Jeayoun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Myungsoo Park
- Division of Cardiology, Heart Vascular Stroke Institute, Department of Medicine, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Heart Vascular Stroke Institute, Department of Medicine, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Young Tak Lee
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Sangmin Maria Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
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Rafiq A, Sklyar E, Bella JN. Cardiac Evaluation and Monitoring of Patients Undergoing Noncardiac Surgery. Health Serv Insights 2017; 9:1178632916686074. [PMID: 28469459 PMCID: PMC5398290 DOI: 10.1177/1178632916686074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 09/24/2016] [Indexed: 12/25/2022] Open
Abstract
Surgical management of disease has a tremendous impact on our health system. Millions of people worldwide undergo surgeries every year. Cardiovascular complications in the perioperative period are one of the most common events leading to increased morbidity and mortality. Although such events are very small in number, they are associated with a high mortality rate making it essential for physicians to understand the importance of perioperative cardiovascular risk assessment and evaluation. Its involves a detailed process of history taking, patient's medical profile, medications being used, functional status of the patient, and knowledge about the surgical procedure and its inherent risks. Different risk assessment tools and calculators have also been developed to aid in this process, each with their own advantages and limitations. After such a comprehensive evaluation, a physician will be able to provide a risk assessment or it may all lead to further testing if it is believed that a change in management after such testing will help to reduce perioperative morbidity and mortality. There is extensive literature on the significance of multiple perioperative testing modalities and how they can change management. The purpose of our review is to provide a concise but comprehensive analysis on all such aspects of perioperative cardiovascular risk assessment for noncardiac surgeries and provide a basic methodology toward such assessment and decision making.
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Affiliation(s)
- Arsalan Rafiq
- Division of Cardiology, Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA
- Internal medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eduard Sklyar
- Division of Cardiology, Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA
- Internal medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jonathan N Bella
- Division of Cardiology, Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA
- Internal medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Armstrong EJ, Graham LA, Waldo SW, Valle JA, Maddox TM, Hawn MT. Incomplete Revascularization Is Associated With an Increased Risk for Major Adverse Cardiovascular Events Among Patients Undergoing Noncardiac Surgery. JACC Cardiovasc Interv 2017; 10:329-338. [PMID: 28161261 DOI: 10.1016/j.jcin.2016.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/24/2016] [Accepted: 11/03/2016] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The aim of this study was to determine whether incomplete revascularization is associated with a higher risk for major adverse cardiovascular events (MACE) and myocardial infarction (MI) among patients undergoing noncardiac surgery. BACKGROUND Patients with coronary artery disease and prior percutaneous coronary intervention (PCI) frequently undergo noncardiac surgery. These patients may have had PCI either on all obstructive lesions (i.e., complete revascularization) or only on some (i.e., incomplete revascularization). METHODS Patients were identified using the Veterans Affairs Clinical Assessment, Reporting, and Tracking program. Veterans Affairs and non-Veterans Affairs surgical records were used to link patients who underwent noncardiac surgery within 2 years after stent placement. Incomplete revascularization was defined as a residual stenosis of ≥50% in the left main coronary artery or ≥70% in another major epicardial coronary artery on the basis of operator visual estimate. RESULTS In total, 4,332 patients (34.7%) had incomplete revascularization. A total of 567 MACE occurred within 1 month post-operatively. Patients with incomplete revascularization had an unadjusted 19% increased odds of post-operative MACE, compared with those with complete revascularization (odds ratio: 1.19; 95% confidence interval [CI]: 1.00 to 1.41). Among the MACE components, post-operative MI appears to contribute the most, with a 37% increased risk for post-operative MI among patients with incomplete revascularization (odds ratio: 1.37; 95% CI: 1.10 to 1.70). After adjustment, there was a significant interaction between time from PCI and outcomes after noncardiac surgery; incomplete revascularization was associated with significantly increased risk for post-operative MI primarily if surgery was performed within 6 weeks after PCI (adjusted odds ratio: 1.84; 95% CI: 1.04 to 2.38). The number of vessels with incomplete revascularization was also associated with an increased risk for post-operative MI: for each additional vessel with incomplete revascularization, there was a 17% increased odds of post-operative MI. CONCLUSIONS Incomplete revascularization among patients with coronary artery disease is associated with an increased risk for MI after noncardiac surgery.
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Affiliation(s)
- Ehrin J Armstrong
- Section of Cardiology, Denver VA Medical Center and University of Colorado School of Medicine, Aurora, Colorado.
| | | | - Stephen W Waldo
- Section of Cardiology, Denver VA Medical Center and University of Colorado School of Medicine, Aurora, Colorado
| | - Javier A Valle
- Section of Cardiology, Denver VA Medical Center and University of Colorado School of Medicine, Aurora, Colorado
| | - Thomas M Maddox
- Section of Cardiology, Denver VA Medical Center and University of Colorado School of Medicine, Aurora, Colorado
| | - Mary T Hawn
- Department of Surgery, Stanford University, Stanford, California
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Fleisher LA. Preoperative Assessment of the Patient with Cardiac Disease Undergoing Noncardiac Surgery. Anesthesiol Clin 2016; 34:59-70. [PMID: 26927739 DOI: 10.1016/j.anclin.2015.10.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The American College of Cardiology/American Heart Association has published Guidelines on Perioperative Evaluation. Preoperative evaluation should focus on identifying patients with symptomatic and asymptomatic coronary artery disease. The guidelines advocate using the American College of Surgeons National Surgical Quality Improvement Project Risk Index to determine perioperative risk. Diagnostic testing should be reserved for those at increased risk with poor exercise capacity. Indications for coronary interventions are the same in the perioperative period as in the nonoperative setting. In patients with a prior coronary stent, optimal antiplatelet therapy and timing of elective noncardiac surgery is evolving.
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Affiliation(s)
- Lee A Fleisher
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19437, USA.
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Kaw R. Cardiac Risk Stratification Among Ambulatory Patients Undergoing Non-Cardiac Surgery. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0188-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Gaudino M, Niccoli G, Roberto M, Cammertoni F, Cosentino N, Falcioni E, Panebianco M, D'Amario D, Crea F, Massetti M. The Same Angiographic Factors Predict Venous and Arterial Graft Patency: A Retrospective Study. Medicine (Baltimore) 2016; 95:e2068. [PMID: 26735525 PMCID: PMC4706245 DOI: 10.1097/md.0000000000002068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
To evaluate the value of angiographic factors in predicting failure of both venous and arterial coronary artery bypass graft. We retrieved from our angiographic database 148 patients who underwent venous and/or arterial CABG and for whom a control coronary angiography at more than 1 month after surgery was available. Pre-CABG and follow-up angiographies were analyzed in order to evaluate diameter stenosis (DS,%), stenosis length (mm), Bogaty score (extent index), Sullivan score, and Gensini score for the extent of coronary artery disease, and Jeopardy Duke score for the extent of myocardial area supplied by an artery. Thirty-nine patients (26%) experienced graft failure at follow-up (mean follow-up 11.3 ± 4.6 months). Patients with venous graft failure [26 (20%)] had significantly smaller DS (P = 0.013), shorter stenosis length (P = 0.01), and lower extent index (P = 0.015), Sullivan score (P = 0.013), Gensini score (P = 0.04) as compared with those without venous graft failure. Patients with arterial graft failure [13 (11%)] had significantly lower DS (P = 0.008), shorter stenosis length (P = 0.001), and lower extent index (P = 0.03) and Sullivan score (P = 0.023) as compared with those without arterial graft failure. Venous and arterial graft failure are associated with less severe stenosis and less extensive atherosclerosis of the grafted vessel.
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Affiliation(s)
- Mario Gaudino
- From the Department of Cardiovascular Science, Catholic University of the Sacred Heart, Rome, Italy
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Illuminati G, Schneider F, Greco C, Mangieri E, Schiariti M, Tanzilli G, Barillà F, Paravati V, Pizzardi G, Calio’ F, Miraldi F, Macrina F, Totaro M, Greco E, Mazzesi G, Tritapepe L, Toscano M, Vietri F, Meyer N, Ricco JB. Long-term Results of a Randomized Controlled Trial Analyzing the Role of Systematic Pre-operative Coronary Angiography before Elective Carotid Endarterectomy in Patients with Asymptomatic Coronary Artery Disease. Eur J Vasc Endovasc Surg 2015; 49:366-74. [DOI: 10.1016/j.ejvs.2014.12.030] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Accepted: 12/22/2014] [Indexed: 11/28/2022]
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Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol 2014; 64:e77-137. [PMID: 25091544 DOI: 10.1016/j.jacc.2014.07.944] [Citation(s) in RCA: 823] [Impact Index Per Article: 82.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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15
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Levin AI, Coetzee AR. Statins and perioperative myocardial infarction. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2007.10872486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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16
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Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:e278-333. [PMID: 25085961 DOI: 10.1161/cir.0000000000000106] [Citation(s) in RCA: 190] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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17
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Flu WJ, van Kuijk JP, Winkel T, Hoeks S, Bax J, Poldermans D. Prevention of acute coronary events in noncardiac surgery: β-blocker therapy and coronary revascularization. Expert Rev Cardiovasc Ther 2014; 7:521-32. [DOI: 10.1586/erc.09.28] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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18
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The Incidence and Timing of Noncardiac Surgery after Cardiac Stent Implantation. J Am Coll Surg 2012; 214:658-66; discussion 666-7. [DOI: 10.1016/j.jamcollsurg.2011.12.011] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Accepted: 12/15/2011] [Indexed: 11/23/2022]
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19
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Omar HR, Mangar D, Camporesi EM. Preoperative cardiac evaluation of the vascular surgery patient--an anesthesia perspective. Vasc Endovascular Surg 2012; 46:201-11. [PMID: 22407429 DOI: 10.1177/1538574412438950] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The morbidity and mortality associated with vascular surgery procedures are largely the results of cardiac events. National guidelines have been regularly proposed and updated by the American College of Cardiology (ACC)/American Heart Association (AHA) to ensure optimal perioperative management and risk stratification. Controversy remains between experts and other cardiology societies regarding several patient care issues including revascularization before surgery, timing of β-blocker therapy, and the administration of antiplatelet therapy. Several landmark articles recently published have helped to modify the guidelines in the hope of improving vascular patient outcomes. In this review, we searched all recent available literature pertaining to perioperative cardiac evaluation before major vascular surgery. We propose an algorithm for preoperative cardiac evaluation, which is a modification to the AHA recommendations. Incorporated in this algorithm are recent published pivotal articles that can help in guiding physicians caring for the vascular patient requiring major operative or endovascular interventions.
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Affiliation(s)
- Hesham R Omar
- Internal Medicine Department, Mercy Hospital and Medical Center, Chicago, IL, USA
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Abstract
PURPOSE OF REVIEW Three topics are at the forefront of the investigation and treatment of patients with coronary artery disease (CAD) undergoing major noncardiac surgery: prophylactic perioperative beta-blockade (PPBB), prophylactic statins and prophylactic preoperative coronary revascularization (PCR). The purpose of the review is to summarize the investigational efforts in each one of these fields and to provide a subjective evaluation as to their impact on perioperative patient care. RECENT FINDINGS The data on PPBB are still controversial. Most recent studies are observational with contradicting results on whether PPBB improves perioperative survival and whether chronic beta-blockade is better than beta-blockers added acutely postoperatively. The data on statins are still evolving and the main question remains whether the proven long-term pleiotrophic, plaque-stabilizing effects of statins translate into measurable improvements in hard outcome in the acute, perioperative setting. The data on PCR are also incomplete. The study that previously reported lack of any perioperative benefit to PCR now provides data that in selected patients PCR may nevertheless improve outcome. SUMMARY These topics demonstrate how difficult it is to prove a significant change in outcome in high-risk CAD patients by prophylactic preoperative measures and that there is no alternative to clinical judgment and individualized patient care.
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Priebe HJ. Preoperative cardiac management of the patient for non-cardiac surgery: an individualized and evidence-based approach. Br J Anaesth 2011; 107:83-96. [DOI: 10.1093/bja/aer121] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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22
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Bock M, Wiedermann CJ, Motsch J, Fritsch G, Paulmichl M. Minimizing cardiac risk in perioperative practice – interdisciplinary pharmacological approaches. Wien Klin Wochenschr 2011; 123:393-407. [DOI: 10.1007/s00508-011-1595-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2010] [Accepted: 03/02/2011] [Indexed: 10/18/2022]
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23
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Coronary Revascularization after Myocardial Infarction Can Reduce Risks of Noncardiac Surgery. J Am Coll Surg 2011; 212:1018-26. [DOI: 10.1016/j.jamcollsurg.2011.02.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Revised: 02/08/2011] [Accepted: 02/09/2011] [Indexed: 12/31/2022]
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24
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Cohn SL. Cardiac Disease. Perioper Med (Lond) 2011. [DOI: 10.1007/978-0-85729-498-2_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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25
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Poh CL, Ho P, Lee CH. Noncardiac surgery following percutaneous coronary intervention. Interv Cardiol 2010. [DOI: 10.2217/ica.10.77] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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26
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Affiliation(s)
- Giora Landesberg
- Department of Anesthesiology and C.C.M., Hebrew University, Hadassah Medical Center, Jerusalem, Israel 91120
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27
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Biccard BM, Rodserth RN. A reply. Anaesthesia 2010. [DOI: 10.1111/j.1365-2044.2009.06216_2.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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28
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol 2009; 54:e13-e118. [PMID: 19926002 DOI: 10.1016/j.jacc.2009.07.010] [Citation(s) in RCA: 232] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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29
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Kertai MD, Gál J. Preoperative coronary revascularization for the reduction of perioperative ischemic complications in patients undergoing major vascular surgery. Interv Med Appl Sci 2009. [DOI: 10.1556/imas.1.2009.1.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
AbstractPatients undergoing vascular surgery are at increased risk for perioperative cardiac complications related to the frequent prevalence of underlying coronary artery disease. Cardiac evaluation and noninvasive tests may often identify patients at increased cardiac risk in whom coronary angiography is often considered with subsequent coronary revascularization for the purpose of improving perioperative and long-term cardiac outcomes. However, there has been controversy as to the indications and efficacy for type of revascularization and how coronary revascularization may add to the effect of optimized medical therapy for the reduction of cardiac complications. The aim of this review is to summarize the role of preoperative coronary revascularization in the reduction of perioperative cardiac complications in patients with coronary artery disease undergoing major vascular surgery.
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Affiliation(s)
- Miklós D. Kertai
- 1 Department of Anesthesiology and Intensive Care Medicine, Semmelweis University, Budapest, Hungary
- 2 Department of Anesthesiology, Washington University School of Medicine, St Louis, USA
- 3 Department of Anesthesiology and Intensive Care Medicine, Semmelweis University, Kútvölgyi út 4, H-1125, Budapest, Hungary
| | - János Gál
- 1 Department of Anesthesiology and Intensive Care Medicine, Semmelweis University, Budapest, Hungary
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30
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF. 2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. Circulation 2009; 120:e169-276. [PMID: 19884473 DOI: 10.1161/circulationaha.109.192690] [Citation(s) in RCA: 209] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Abstract
PURPOSE OF REVIEW Perioperative cardiac complications remain a major area of concern as our surgical population increases in volume, age and frequency of comorbidity. A variety of strategies can be used to optimize patients and potentially reduce the incidence of these serious complications. RECENT FINDINGS Recent literature suggests a trend towards less invasive testing for detection and quantification of coronary artery disease and greater interest in pharmacologic 'cardioprotection' using beta-blockers, statins and other agents targeting heart rate control and other mechanisms (e.g. reducing inflammatory responses). The recent Perioperative Ischemic Evaluation study has substantially altered this approach at least towards widespread application to lower/intermediate risk cohorts. Considerable attention has been focused on ensuring optimal standardized perioperative management of patients with a recent percutaneous coronary intervention, particularly those with an intracoronary stent. Widespread surveillance of postoperative troponin release and increasing recognition of the prognostic potential of elevated preoperative brain natriuretic peptides point towards changing strategies for long-term risk stratification. SUMMARY The complexity of a particular patient's physiologic responses to a wide variety of surgical procedures, which are undergoing constant technological refinement generally associated with lesser degrees of invasivity and stress make calculation of patients' perioperative risk very challenging. At the present time, adequate information is available for the clinician to screen patients with high-risk preoperative predictors, delay elective surgery for patients with recent intracoronary stents and continue chronic beta-blockade in appropriate patients. New large-scale database and subanalyses of major trials (e.g. Perioperative Ischemic Evaluation and Coronary Artery Revascularization Prophylaxis) should provide additional information to minimize perioperative cardiac risk.
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32
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Marret E, Piriou V. Impact de la chirurgie non cardiaque sur l’évolution des cardiopathies ischémiques. Presse Med 2009; 38:1630-40. [DOI: 10.1016/j.lpm.2009.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2009] [Revised: 06/28/2009] [Accepted: 07/08/2009] [Indexed: 10/20/2022] Open
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33
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Biccard BM, Rodseth RN. A meta-analysis of the prospective randomised trials of coronary revascularisation before noncardiac vascular surgery with attention to the type of coronary revascularisation performed. Anaesthesia 2009; 64:1105-13. [DOI: 10.1111/j.1365-2044.2009.06010.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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34
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Landesberg G, Mosseri M. Prophylactic Pre-Operative Coronary Revascularization. J Am Coll Cardiol 2009; 54:997-8. [DOI: 10.1016/j.jacc.2009.05.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Accepted: 05/26/2009] [Indexed: 10/20/2022]
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35
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Piriou V. Prise en charge des patients à risque coronaire avant une anesthésie. Presse Med 2009; 38:1110-9. [DOI: 10.1016/j.lpm.2008.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2008] [Revised: 07/24/2008] [Accepted: 08/27/2008] [Indexed: 10/20/2022] Open
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36
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37
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Assessment of Graft Patency During Coronary Artery Bypass Graft Surgery. JACC Cardiovasc Imaging 2009; 2:613-5. [DOI: 10.1016/j.jcmg.2009.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2009] [Accepted: 01/26/2009] [Indexed: 11/18/2022]
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38
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Mauck KF, Manjarrez EC, Cohn SL. Perioperative cardiac evaluation: assessment, risk reduction, and complication management. Clin Geriatr Med 2009; 24:585-605, vii. [PMID: 18984375 DOI: 10.1016/j.cger.2008.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Perioperative cardiac complications are among the most feared outcomes after surgery. Using evidence-based guidelines and expert opinion, physicians can perform a risk assessment and decide whether further cardiac testing, medical therapy, or coronary intervention is necessary to optimize the patient's medical condition prior to surgery. This article reviews the major concepts and recommendations from the ACC guidelines for preoperative cardiac evaluation and perioperative management to reduce risk. Medical management of the major postoperative cardiac complications is also discussed.
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Affiliation(s)
- Karen F Mauck
- Division of General Internal Medicine, Mayo Clinic and Mayo College of Medicine, 200 1st Street SW, Rochester, MN 55905, USA
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39
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Rácz K, Tiszai-Szucs T, Gál J, Kertai D M. [Preoperative revascularization in high-risk patients undergoing vascular surgery]. Orv Hetil 2009; 150:341-52. [PMID: 19218144 DOI: 10.1556/oh.2009.28545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Patients undergoing vascular surgery are at increased risk for cardiac complications related to the presence of underlying coronary artery disease. Preoperative cardiac evaluation may help to identify high-risk patients in whom coronary angiography may be planned with subsequent coronary revascularization for the purpose of improving perioperative and long-term cardiac outcomes. However, the indications and efficacy for type of revascularization for the reduction of cardiac complications compared to medical therapy have been controversial. The aim of the review was to summarize the role of preoperative revascularization compared to conservative medical therapy before elective vascular surgery using current evidence from published studies.
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Affiliation(s)
- Kristóf Rácz
- Semmelweis Egyetem, Altalános Orvostudományi Kar Aneszteziológiai és Intenzív Terápiás Tanszék Budapest, Hungary
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40
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The unresolved issues with risk stratification and management of patients with coronary artery disease undergoing major vascular surgery. Can J Anaesth 2008; 55:542-56. [PMID: 18676390 DOI: 10.1007/bf03016675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE The purpose of this article, with a specific focus on patients undergoing vascular surgery, is to review controversial issues related to mechanisms of perioperative myocardial infarction (MI), coronary artery disease detection, and strategies to reduce perioperative complications. We propose explanations for the many conflicting results that have recently emerged in the literature.Source documents: We searched MEDLINE and reviewed all relevant manuscripts and scientific statements regarding management of patients undergoing non-cardiac surgery. PRINCIPAL FINDINGS Identification and prevention of ischemia in patients undergoing vascular surgery remains controversial. While the identification of preoperative ischemia is a marker of a higher perioperative risk, the value of identifying such ischemia has been questioned. We believe this may be, at least in part, due to our limited understanding of perioperative MI. Appropriate management of patients, based on the results of such testing, is likely the key to improving outcomes, and deserves further investigation. Efforts aimed at reducing the ischemic consequences of severe coronary plaques (by revascularization or beta-blocker therapy) have yielded conflicting results. The use of high doses of preoperative beta-blocker therapy may be harmful. Some studies suggest a promising role for statin therapy. Benefits of acetylsalicylic acid must be weighted against the risk of bleeding. CONCLUSION Many questions remain unanswered about the impact of detecting inducible ischemia, and the role of revascularization or beta-blockers in patients undergoing vascular surgery. A better understanding of the pathophysiology of perioperative MI is critical, in order to identify the best approach to improve cardiac outcomes in these patients.
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41
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Landesberg G, Mosseri M. PRO: Preoperative coronary revascularization in high-risk patients undergoing vascular surgery. Anesth Analg 2008; 106:759-63. [PMID: 18292414 DOI: 10.1213/ane.0b013e3181685054] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Giora Landesberg
- Department of Anesthesiology, Critical Care Medicine, Hebrew University-Hadassah Medical Center, Jerusalem, Israel.
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42
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Kertai MD. Preoperative Coronary Revascularization in High-Risk Patients Undergoing Vascular Surgery: A Core Review. Anesth Analg 2008; 106:751-8. [DOI: 10.1213/ane.0b013e31816072b3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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43
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44
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45
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Levin AI. Till death us do part? Postoperative statin discontinuation. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2008. [DOI: 10.1080/22201173.2008.10872514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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46
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Sun JZ, Maguire D. How to prevent perioperative myocardial injury: the conundrum continues. Am Heart J 2007; 154:1021-8. [PMID: 18035070 DOI: 10.1016/j.ahj.2007.07.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2007] [Accepted: 07/24/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Perioperative myocardial injury (PMI) remains a major cause of perioperative morbidity and mortality but clinical strategies to prevent PMI are still uncertain. METHODS AND RESULTS We comprehensively searched PubMed for major research articles concerning clinical strategies to prevent PMI. The key findings are as follows: (1) the American College of Cardiology/American Heart Association guideline update for perioperative cardiovascular evaluation for noncardiac surgery is very useful to stratify cardiac risk preoperatively; (2) cardiac troponin has emerged as a biomarker to diagnose postoperative PMI and to predict clinical outcomes; (3) coronary revascularization before noncardiac surgery probably would provide cardiac protection in select patients, especially in patients with high-risk coronary artery disease; (4) elective noncardiac surgery should be postponed in patients who received coronary stenting recently because of high incidence of serious cardiac complications (minimum 6-8 weeks for bare metal stents and 6-12 months for drug-eluting stents); and (5) beta-blockers and statins are very promising drugs and probably would prevent PMI in a select patient population, especially in patients with intermediate risk and stable coronary artery disease. CONCLUSIONS Further studies, especially randomized clinical trials and mechanistic investigation are needed to find the best and effective clinical strategies to prevent/reduce PMI.
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW. 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. J Am Coll Cardiol 2007; 50:e159-241. [PMID: 17950159 DOI: 10.1016/j.jacc.2007.09.003] [Citation(s) in RCA: 257] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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48
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Tarkington LG, Yancy CW. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. Circulation 2007; 116:e418-99. [PMID: 17901357 DOI: 10.1161/circulationaha.107.185699] [Citation(s) in RCA: 377] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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49
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Affiliation(s)
- John W. Riddell
- From the Services de Cardiologie (J.W.R., M.H.), Chirurgie Digestive (L.C.), and Anesthesiologie (B.P.), University Hospital of Caen, Normandy, France
| | - Laurence Chiche
- From the Services de Cardiologie (J.W.R., M.H.), Chirurgie Digestive (L.C.), and Anesthesiologie (B.P.), University Hospital of Caen, Normandy, France
| | - Benoît Plaud
- From the Services de Cardiologie (J.W.R., M.H.), Chirurgie Digestive (L.C.), and Anesthesiologie (B.P.), University Hospital of Caen, Normandy, France
| | - Martial Hamon
- From the Services de Cardiologie (J.W.R., M.H.), Chirurgie Digestive (L.C.), and Anesthesiologie (B.P.), University Hospital of Caen, Normandy, France
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50
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Abstract
Patients in whom any kind of stent, particularly a drug-eluting stent (DES), was recently implanted are at risk for stent thrombosis when they undergo noncardiac surgery, even months or years after their implantation. The risk of DES thrombosis is likely decreased by delaying noncardiac surgery for as long as possible and continuing dual or at least single antiplatelet therapy in the perioperative period. Preoperative identification and close monitoring of patients with DES may allow prevention and prompt detection and treatment of this catastrophic complication.
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