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Cornelissen LL, Kreuger AL, Caram-Deelder C, Huisman MV, Middelburg RA, Kerkhoffs JLH, von dem Borne PA, Beckers EAM, de Vooght KMK, Kuball J, van der Bom JG, Zwaginga JJ. Association between cardiovascular risk factors and intracranial hemorrhage in patients with acute leukemia. Eur J Haematol 2021; 108:310-318. [PMID: 34923665 DOI: 10.1111/ejh.13737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/14/2021] [Accepted: 12/16/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Intracranial hemorrhage is seen more frequently in acute leukemia patients compared to the general population. Besides leukemia related risk factors, also risk factors that are present in the general population might contribute to hemorrhagic complications in leukemia patients. Of those, cardiovascular risk factors leading to chronic vascular damage could modulate the occurrence of intracranial hemorrhage in these patients, as during their disease and treatment acute endothelial damage occurs due to factors like thrombocytopenia and inflammation. OBJECTIVES Our aim was to explore if cardiovascular risk factors can predict intracranial hemorrhage in acute leukemia patients. METHODS In a case control study nested in a cohort of acute leukemia patients, including 17 cases with intracranial hemorrhage and 55 matched control patients without intracranial hemorrhage, data on cardiovascular risk factors was collected for all patients. Analyses were performed via conditional logistic regression. RESULTS Pre-existing hypertension and ischemic heart disease in the medical history were associated with intracranial hemorrhage, with an incidence rate ratio of 12.9 (95% confidence interval (CI) 1.5 to 109.2) and 12.1 (95% CI 1.3 to110.7), respectively. CONCLUSION Both pre-existing hypertension and ischemic heart disease seem to be strong predictors of an increased risk for intracranial hemorrhage in leukemia patients.
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Affiliation(s)
- Loes L Cornelissen
- Jon J van Rood Center for Clinical Transfusion Research, LUMC/Sanquin Leiden, The Netherlands.,Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Hematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Aukje L Kreuger
- Jon J van Rood Center for Clinical Transfusion Research, LUMC/Sanquin Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Camila Caram-Deelder
- Jon J van Rood Center for Clinical Transfusion Research, LUMC/Sanquin Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Rutger A Middelburg
- Jon J van Rood Center for Clinical Transfusion Research, LUMC/Sanquin Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jean Louis H Kerkhoffs
- Jon J van Rood Center for Clinical Transfusion Research, LUMC/Sanquin Leiden, The Netherlands.,Department of Hematology, Haga teaching hospital, Den Haag, The Netherlands
| | | | - Erik A M Beckers
- Department of Hematology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Karen M K de Vooght
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jürgen Kuball
- Department of Hematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johanna G van der Bom
- Jon J van Rood Center for Clinical Transfusion Research, LUMC/Sanquin Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - J J Zwaginga
- Jon J van Rood Center for Clinical Transfusion Research, LUMC/Sanquin Leiden, The Netherlands.,Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
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2
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Is Peripheral Artery Disease an Independent Predictor of Isolated Coronary Artery Bypass Outcome? Heart Lung Circ 2020; 29:1502-1510. [PMID: 32165084 DOI: 10.1016/j.hlc.2020.01.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 12/14/2019] [Accepted: 01/11/2020] [Indexed: 11/20/2022]
Abstract
AIM The aim was to use a propensity score-based analysis to determine the impact of peripheral artery disease (PAD) on early outcomes after coronary artery bypass surgery grafting (CABG) in patients with PAD. METHOD We conducted a multicentre retrospective analysis of 11,311 consecutive patients who underwent CABG between 1997 and 2017. Patients with previous or concomitant vascular surgery were excluded. The main endpoints were death, stroke, and limb ischaemia requiring percutaneous or surgical revascularisation. Subgroup analyses were performed to test the interaction of PAD with concomitant factors. RESULTS There was no difference in mortality in patients with and without PAD (p=0.06 and p=0.179, respectively). Patients with PAD had a greater incidence of stroke (p=0.04), acute kidney disease (p=0.003), and limb ischaemia requiring interventions (p<0.001) than those without PAD. The use of off-pump or no-touch aortic techniques did not influence the effect of PAD on the outcomes. Early mortality rate increased in patients with PAD when associated with long cardiopulmonary bypass, cross-clamp times (both p<0.001), and postoperative low cardiac output (p=0.01). CONCLUSIONS The presence of PAD is associated, independently of other factors, with greater incidence of stroke, acute kidney disease, and limb ischaemia following CABG, irrespective of the technique employed. Operative mortality was greater in patients with PAD only when associated with long cardiopulmonary bypass and aortic cross-clamp times, and low cardiac output.
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3
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Bonacchi M, Parise O, Matteucci F, Tetta C, Moula AI, Micali LR, Prifti E, Sani G, Gelsomino S. Early outcomes following isolated coronary artery bypass surgery: Influence of peripheral artery disease. J Card Surg 2019; 34:1470-1477. [PMID: 31536148 DOI: 10.1111/jocs.14263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Massimo Bonacchi
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine University of Florence Firenze Italy
| | - Orlando Parise
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine University of Florence Firenze Italy
- Cardiothoracic Surgery Department ‐ CARIM Maastricht University Medical Center Maastricht The Netherlands
| | - Francesco Matteucci
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine University of Florence Firenze Italy
- Cardiothoracic Surgery Department ‐ CARIM Maastricht University Medical Center Maastricht The Netherlands
| | - Cecilia Tetta
- Cardiothoracic Surgery Department ‐ CARIM Maastricht University Medical Center Maastricht The Netherlands
| | - Amalia Ioanna Moula
- Cardiothoracic Surgery Department ‐ CARIM Maastricht University Medical Center Maastricht The Netherlands
| | - Linda Renata Micali
- Cardiothoracic Surgery Department ‐ CARIM Maastricht University Medical Center Maastricht The Netherlands
| | - Edvin Prifti
- Division of Cardiac Surgery University Hospital Center of Tirana Tirana Albania
| | - Guido Sani
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine University of Florence Firenze Italy
- Cardiac Surgery Unit, Department of Medical Biotechnologies University of Siena Siena Italy
| | - Sandro Gelsomino
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine University of Florence Firenze Italy
- Cardiothoracic Surgery Department ‐ CARIM Maastricht University Medical Center Maastricht The Netherlands
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4
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Suh B, Song YS, Shin DW, Lim J, Kim H, Min SH, Lee SP, Park EA, Lee W, Lee H, Park JH, Cho B. Incidentally detected atherosclerosis in the abdominal aorta or its major branches on computed tomography is highly associated with coronary heart disease in asymptomatic adults. J Cardiovasc Comput Tomogr 2018; 12:305-311. [DOI: 10.1016/j.jcct.2018.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 03/01/2018] [Accepted: 03/13/2018] [Indexed: 12/21/2022]
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5
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Feng B, Lin J, Jin J, Qian W, Cao S, Weng X. The Effect of Previous Coronary Artery Revascularization on the Adverse Cardiac Events Ninety days After Total Joint Arthroplasty. J Arthroplasty 2018; 33:235-240. [PMID: 28993080 DOI: 10.1016/j.arth.2017.08.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 08/05/2017] [Accepted: 08/10/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Although coronary artery revascularization therapies are effective for treating coronary artery disease (CAD), these patients may be more susceptible to adverse cardiac events during later non-cardiac surgeries. The purpose of this study is to evaluate post-operative 90-day complications of total joint arthroplasty (TJA) in CAD patients with a history of CAD and to study the risk factors for cardiac complications. METHODS We performed a retrospective analysis of TJA patients between 2005 and 2015 at our institute by summarizing the history of CAD, cardiac revascularization, and cardiac complications within 90 days after the operation. Multivariate logistic regression was performed to identify the factors that predicted cardiac complications within 90 days after the operation. RESULTS A total of 4414 patients were included; of these, 64 underwent cardiac revascularization and 201 CAD patients underwent medical therapy other than revascularization. All the revascularization had history of myocardial infarction (MI). The rate of cardiac complications within 90 days for the CAD with revascularization was 18.7%, 18.4% for the CAD without revascularization, and 2.0% for the non-CAD group. A history of CAD and revascularization, bilateral TJA, general anesthesia, body mass index ≥30 kg/m2, and history of MI were associated with a higher risk of cardiac complications. Patients who underwent TJA within 2 years after cardiac revascularization had a significantly higher cardiac complication rate, and the risk decreased with time. CONCLUSION There is an increased risk of cardiac complications within 90 days after the operation among TJA patients with a history of CAD. Revascularization cannot significantly reduce the risk of cardiac complications after TJA for CAD patients. However, the risk decreased as the interval between revascularization and TJA increased.
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Affiliation(s)
- Bin Feng
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, People's Republic of China
| | - Jin Lin
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, People's Republic of China
| | - Jin Jin
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, People's Republic of China
| | - Wenwei Qian
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, People's Republic of China
| | - Shiliang Cao
- Peking Union Medical College, School of Clinical Medicine, Beijing, People's Republic of China
| | - Xisheng Weng
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, People's Republic of China
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6
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Stable Angina Pectoris. Coron Artery Dis 2018. [DOI: 10.1016/b978-0-12-811908-2.00011-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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7
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Mantha S. Rational Cardiac Risk Stratification Before Peripheral Vascular Surgery: Application of Evidence-Based Medicine and Bayesian Analysis. Semin Cardiothorac Vasc Anesth 2016. [DOI: 10.1177/108925320000400402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Srinivas Mantha
- Department of Anesthesiology & Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, India
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8
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Tabatabaee RM, Rasouli MR, Rezapoor M, Maltenfort MG, Ong AC, Parvizi J. Coronary revascularization and adverse events in joint arthroplasty. J Surg Res 2015; 198:135-42. [PMID: 26044875 DOI: 10.1016/j.jss.2015.05.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Revised: 04/24/2015] [Accepted: 05/07/2015] [Indexed: 01/22/2023]
Abstract
BACKGROUND There is a paucity of literature about outcome of total joint arthroplasty in patients with the history of angioplasty and/or stent or coronary artery bypass graft (CABG). The present study aimed to evaluate perioperative complications and mortality in these patients. METHODS We used the Nationwide Inpatient Sample data from 2002-2011. Using the Ninth Revision of the International Classification of Disease, Clinical Modification codes for disorders and procedures, we identified patients with a history of coronary revascularization (angioplasty and/or stent or CABG) and compared the inhospital adverse events in these patients with patients without a history of coronary revascularization. RESULTS Cardiac complications occurred in 1.06% patients with a history of CABG; 0.95% of patients with a coronary angioplasty and/or stent and 0.82% of the control patients. In the multivariate analysis, neither the history of CABG (P = 0.07) nor the history of angioplasty and/or stenting (P = 0.86) was associated with a higher risk of cardiac complications. However, myocardial infarction occurred in a significantly higher proportion of patients with the history of CABG (0.66%, odds ratio, 1.24, P = 0.001) and coronary angioplasty and/or stenting (0.67%, odds ratio, 1.96, P < 0.001) compared with that in the controls (0.27%). History of coronary revascularization did not increase the risk of respiratory, renal, and wound complications, surgical site infection, and mortality. CONCLUSIONS Based on the findings of this study, it appears that there is no increased risk of inhospital mortality and complications (except for myocardial infarction) in patients with a history of coronary artery revascularization undergoing total joint arthroplasty. We also found perioperative cardiac arrhythmia, particularly atrial fibrillation, to be an independent predictor of inhospital adverse events.
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Affiliation(s)
| | - Mohammad R Rasouli
- Rothman Institute of Orthopaedics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Maryam Rezapoor
- Rothman Institute of Orthopaedics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mitchell G Maltenfort
- Rothman Institute of Orthopaedics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alvin C Ong
- Rothman Institute of Orthopaedics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Rothman Institute of Orthopaedics, Thomas Jefferson University, Philadelphia, Pennsylvania.
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Pannell LMK, Reyes EM, Underwood SR. Cardiac risk assessment before non-cardiac surgery. Eur Heart J Cardiovasc Imaging 2013; 14:316-22. [PMID: 23288896 DOI: 10.1093/ehjci/jes288] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Cardiovascular events account for half of the deaths related to non-cardiac surgery. Identification of a patient's risk and perioperative management appropriate to that risk is important to optimize the clinical outcome of surgery. Key concepts of preoperative cardiac risk assessment are contained within American and European guidelines. Risk indices stratify patients according to clinical and surgery-specific predictors. The most widely used is the Lee index; however, all have limitations. Patients at intermediate and high risk following risk index stratification and assessment of functional capacity require further non-invasive assessment to detect myocardial ischaemia using, for instance, exercise electrocardiography, myocardial perfusion scintigraphy, or stress echocardiography. It can be difficult, however, to decide which technique and predictor is most effective and local practice differs. Invasive coronary angiography is not recommended unless it would be performed in the absence of surgery. Appropriate pain management should be considered in all patients and beta-blockade may improve the outcome in intermediate- and high-risk patients. Identifying patients with risk factors or previously undiagnosed coronary artery disease enables the preoperative cardiac risk assessment to guide long-term treatment.
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Affiliation(s)
- Laura M K Pannell
- National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney St, SW3 6LY London, UK
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10
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Frequency of coronary artery disease in patients undergoing peripheral artery disease surgery. Am J Cardiol 2012; 110:736-40. [PMID: 22633203 DOI: 10.1016/j.amjcard.2012.04.059] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Revised: 04/26/2012] [Accepted: 04/26/2012] [Indexed: 11/20/2022]
Abstract
The prevalence of coronary artery disease (CAD) in patients with peripheral arterial disease (PAD) varies widely in published reports. This is likely due at least in part to significant differences in how PAD and CAD were both defined and diagnosed. In this report, the investigators describe 78 patients with PAD who underwent preoperative coronary angiography before elective peripheral revascularization and provide a review of published case series. Among the patients included, the number with concomitant CAD varied from 55% in those with lower-extremity stenoses to as high as 80% in those with carotid artery disease. The number of coronary arteries narrowed by ≥ 50% was 1 in 28%, 2 in 24%, and 3 in 19%; 28% did not have any angiographic evidence of CAD. The review of published research resulted in the identification of 19 case series in which a total of 3,969 patients underwent preoperative coronary angiography before elective PAD surgery; in the 2,687 who were described according to the location of the PAD, 55% had ≥ 1 epicardial coronary artery with ≥ 70% diameter narrowing. The highest prevalence of concomitant CAD was in patients with severe carotid artery disease (64%). In conclusion, despite sharing similar risk factors, the prevalence of obstructive CAD in patients with PAD ranges widely and appears to differ across PAD locations. Thus, the decision to perform coronary angiography should be based on indications independent of the planned PAD surgery.
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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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Batt M, Ferrari E, Staccini P, Hassen-Khodja R, Declemy S, Morand P, Le Bas P. Severity of tibio peroneal arterial disease: A marker for coronary artery disease. Int J Angiol 2011. [DOI: 10.1007/bf01618378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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ZNAChENIE STRESS-EKhOKARDIOGRAFII S DOBUTAMINOM V DOOPERATsIONNOY OTsENKE RISKA KARDIAL'NYKh OSLOZhNENIY U BOL'NYKh S ATEROSKLEROZOM AORTY I MAGISTRAL'NYKh ARTERIY. КЛИНИЧЕСКАЯ ПРАКТИКА 2010. [DOI: 10.17816/clinpract1252-58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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14
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Lee HC, Hwang YH, Wi JH, Jun HJ, Lee YH, Cho KH. Myocardial Perfusion SPECT as a Screening Test before Planned Vascular Surgery for Predicting Perioperative Cardiac Complications. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2010. [DOI: 10.5090/kjtcs.2010.43.1.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Hyung-chae Lee
- Department of Thoracic and Cardiovascular Surgery, Busan-Paik Hospital, College of Medicine, Inje University
| | - Youn-Ho Hwang
- Department of Thoracic and Cardiovascular Surgery, Busan-Paik Hospital, College of Medicine, Inje University
| | - Jin-Hong Wi
- Department of Thoracic and Cardiovascular Surgery, Busan-Paik Hospital, College of Medicine, Inje University
| | - Hee Jae Jun
- Department of Thoracic and Cardiovascular Surgery, Busan-Paik Hospital, College of Medicine, Inje University
| | - Yang-Haeng Lee
- Department of Thoracic and Cardiovascular Surgery, Busan-Paik Hospital, College of Medicine, Inje University
| | - Kwang-Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Busan-Paik Hospital, College of Medicine, Inje University
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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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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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Bartus S, Rakowski T, Siudak Z, Chyrchel M, Zabek A, Jakala J, Dubiel JS, Dudek D. Recanalization of peripheral arteries by interventional cardiologists: rationale and results. Int J Cardiol 2008; 129:304-6. [PMID: 17689715 DOI: 10.1016/j.ijcard.2007.06.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2007] [Accepted: 06/30/2007] [Indexed: 11/28/2022]
Abstract
The coexistence of peripheral artery disease (PAD) and multilevel atherosclerosis increases death and stroke rates in patients with coronary artery disease (CAD). These patients are often treated conservatively without revascularisation of inferior limbs. We included 66 consecutive patients with complex CAD diagnosed by coronary angiography. All patients underwent percutaneous coronary intervention (PCI) for non-ST elevation acute coronary syndrome (NSTEACS) before or simultaneously with peripheral angioplasty (PTA). Major adverse cardiac and cerebrovascular events (MACCE) during long-term follow-up were assessed. There were 3 deaths, one myocardial infarction, two urgent PCIs, two ischaemic strokes and two TIAs, 8 repeated PTAs in previously treated peripheral lesions, 7 elective PTAs of other vessels after the index procedure in different hospitalisations and no amputation. Patients with concomitant CAD and PAD could safely undergo percutaneous cardiovascular interventions with promising long-term follow-up.
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Abstract
Management of advanced obstructive vascular disease affecting the extremities poses tremendous challenges for physicians and patients. Peripheral arterial disease is often a consequence of obstructive atherosclerosis affecting the ileofemoral circulation but is also rarely a result of nonatherosclerotic conditions such as thromboangiitis obliterans (Buerger's disease). Consequences range from the presence of asymptomatic obstruction to intermittent claudication, development of rest pain, ulceration, gangrene, and amputation. A relatively new and promising approach using cell therapy has recently been developed to treat intractable symptoms related to ischemia in subjects with peripheral arterial disease in whom conventional medical therapy and revascularization modalities have been exhausted.
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Affiliation(s)
- Ibhar Al Mheid
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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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, 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). Anesth Analg 2008; 106:685-712. [PMID: 18292406 DOI: 10.1213/01/ane.0000309024.28586.70] [Citation(s) in RCA: 156] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Howard-Alpe GM, De Bono J, Hudsmith L, Foëx P, Sear JW. Do percutaneous coronary interventions protect the surgical patient? SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2008. [DOI: 10.1080/22201173.2008.10872535] [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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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; 50:1707-32. [PMID: 17950159 DOI: 10.1016/j.jacc.2007.09.001] [Citation(s) in RCA: 402] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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22
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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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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, Riegel B, Tarkington LG, Yancy CW. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary. Circulation 2007; 116:1971-96. [PMID: 17901356 DOI: 10.1161/circulationaha.107.185700] [Citation(s) in RCA: 501] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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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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Howard-Alpe GM, de Bono J, Hudsmith L, Orr WP, Foex P, Sear JW. Coronary artery stents and non-cardiac surgery. Br J Anaesth 2007; 98:560-74. [PMID: 17456488 DOI: 10.1093/bja/aem089] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The utility of interventional cardiology has developed significantly over the last two decades with the introduction of coronary angioplasty and stenting, with the associated antiplatelet medications. Acute coronary stent occlusion carries a high morbidity and mortality, and the adoption of therapeutic strategies for prophylaxis against stent thrombosis has major implications for surgeons and anaesthetists involved in the management of these patients in the perioperative period. Currently, there is limited published information to guide the clinician in the optimal care of patients who have had coronary stents inserted when they present for non-cardiac surgery. This review examines the available literature on the perioperative management of these patients. A number of key issues are identified: the role of surgery vs percutaneous coronary intervention for coronary revascularization in the preoperative period; the different types of coronary stents currently available; the emerging issues related to drug-eluting stents; the pathophysiology of coronary stent occlusion; and the recommended antiplatelet regimes that the patient with a coronary stent will be receiving. The role of preoperative platelet function testing is also discussed, and the various available tests are listed. Appropriate management by all the clinicians involved with patients with coronary stents undergoing a variety of non-cardiac surgical procedures is essential to avoid a high incidence of postoperative cardiac mortality and morbidity. The review examines the evidence available for the perioperative strategies aimed at reducing adverse outcomes in a number of different clinical scenarios.
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Affiliation(s)
- G M Howard-Alpe
- Nuffield Department of Anaesthetics, University of Oxford and John Radcliffe Hospital, UK.
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Wu YW, Lin MS, Lin YH, Chao CL, Kao HL. Prevalence of concomitant atherosclerotic arterial diseases in patients with significant cervical carotid artery stenosis in Taiwan. Int J Cardiovasc Imaging 2006; 23:433-9. [PMID: 17120098 DOI: 10.1007/s10554-006-9180-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2006] [Accepted: 10/09/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Atherosclerotic stenosis of extracranial carotid arteries is an important cause of ischemic stroke in Taiwan, an ethnic Chinese population. Concurrent atherosclerotic arterial disease is an important issue in the management of patients with carotid stenosis, but its prevalence and extent are unknown. METHODS One hundred and sixty-three consecutive patients with angiographically proven significant cervical carotid artery stenosis (>or=50% stenosis) were enrolled in this study. Angiography was done to document concurrent coronary, renal, and limb artery stenosis. Clinical symptoms and signs were also correlated with the angiographic findings. RESULTS One or more significant concurrent arterial stenotic disease was found in 73% of the patients. The most frequent were coronary artery disease, found in 68% of the patients, while renal artery stenosis and limb artery stenosis were found in 20% and 21% of the patients, respectively. Age, diabetes, history of angina pectoris, intermittent claudication, and asymmetric arm blood pressures were significantly associated with the presence of concurrent arterial stenosis. However, 41% of the patients with concurrent coronary artery disease did not have any clinical symptoms or history of myocardial infarction. CONCLUSIONS Our data indicated that concurrent advanced and extensive arterial disease is common in patients with significant cervical carotid stenosis, and also suggest the importance of global evaluation of systemic atherosclerosis in these patients to achieve optimal management.
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Affiliation(s)
- Yen-Wen Wu
- Cardiology Section, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung-Shan South Rd, Taipei 10002, Taiwan, ROC
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Sonmez K, Eskisar AO, Demir D, Yazicioglu MV, Mutlu B, Dogan Y, Izgi A, Mansuroglu D, Bakal RB, Elonu OH, Turan F. Increased urinary albumin excretion rates can be a marker of coexisting coronary artery disease in patients with peripheral arterial disease. Angiology 2006; 57:15-20. [PMID: 16444452 DOI: 10.1177/000331970605700103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Coexisting coronary artery disease (CAD) is an important cause of morbidity and mortality in patients with peripheral arterial disease (PAD). Clinical evaluation and noninvasive tests have some important limitations for the detection of CAD in patients with PAD. The purpose of this study was to investigate whether urinary albumin excretion (UAE) was a sign of atherosclerotic involvement of coronary arteries in patients with PAD. Our study consisted of 65 consecutive patients (56 men, 9 women, mean age; 59.7+/-7.9 years) with PAD who underwent coronary angiography. Urinary albumin excretion was measured in 24-hour urine samples by immunoprecipitation technique. PAD was defined as the presence of > or =50% stenotic lesions in at least 1 of the iliac, femoral, popliteal, tibialis anterior, tibialis posterior, or peroneal arteries. CAD was defined as > or =25% diameter stenosis in at least 1 coronary artery. Patients without any coronary lesions were accepted as having normal coronaries. Age, sex, distributions of coronary risk factors, and UAE rates were compared between patients with and without CAD. Mean UAE was 17.9+/-15.6 mg/day in the total population. Thirty-seven percent of patients had CAD, and 63% had no coronary lesion. UAE rates were 22.33+/-18.74 and 15.32+/-13.01 mg/day in patients with CAD and those with normal coronary arteries, respectively (p = 0.021). Microalbuminuria was detected in 25% in patients with CAD and 12% in those without coronary artery lesions (p = 0.184). The difference was not statistically significant. The distributions of other risk factors and sex were not different between the 2 groups. These data suggest that in patients with PAD, urinary albumin excretion rates may be used to determine those with a high probability of CAD. Further studies are required to decide whether this noninvasive testing is appropriate in detecting high-risk patients.
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Affiliation(s)
- Kenan Sonmez
- Koşuyolu Heart Education and Research Hospital, Istanbul, Turkey.
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Hecker JG, Laslett L, Campbell E, Nunnally M, O'Connor A, Ellis JE, Frogel JK, Fleisher LA. Case 2-2006: Catastrophic cardiovascular collapse during carotid endarterectomy. J Cardiothorac Vasc Anesth 2006; 20:259-68. [PMID: 16616674 DOI: 10.1053/j.jvca.2005.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2005] [Indexed: 11/11/2022]
Affiliation(s)
- James G Hecker
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA 19104-6112, USA.
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Karthik S, Musleh G, Grayson AD, Keenan DJM, Pullan DM, Dihmis WC, Hasan R, Fabri BM. Coronary surgery in patients with peripheral vascular disease: effect of avoiding cardiopulmonary bypass. Ann Thorac Surg 2004; 77:1245-9. [PMID: 15063245 DOI: 10.1016/j.athoracsur.2003.09.054] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/10/2003] [Indexed: 11/22/2022]
Abstract
BACKGROUND An increasing number of patients with peripheral vascular disease are undergoing coronary artery bypass grafting. Such patients have an increased risk of adverse outcomes. Our aim was to quantify the effect of avoiding cardiopulmonary bypass in this group of patients. METHODS Between April 1997 and March 2002, 3,771 consecutive patients underwent coronary artery bypass grafting performed by five surgeons. Four hundred and twenty-two (11.2%) had peripheral vascular disease and of these, 211 (50%) received off-pump surgery. We used multivariate logistic regression analysis to assess the effect of off-pump surgery on in-hospital mortality and morbidity, while adjusting for treatment selection bias. Treatment selection bias was controlled for by constructing a propensity score, which was the probability of receiving off-pump surgery and included core patient characteristics. The C statistic for this model was 0.8. RESULTS Off-pump patients were more likely to have preoperative renal dysfunction, previous gastrointestinal surgery, and less extensive disease. The left internal mammary artery was used more in off-pump compared to on-pump cases (90.1% vs 82.9%; p = 0.033). In the univariate analyses, off-pump patients were less likely to have a postoperative stroke (p = 0.007), and had shorter postoperative hospital stays (p < 0.001). However, the incidence of new atrial arrhythmia was higher (p = 0.028). After adjustment for differences in case-mix (propensity score), avoidance of cardiopulmonary bypass was still associated with a significant reduction in postoperative stroke (adjusted odds ratio 0.09 [95% confidence interval 0.02 to 0.50]; p = 0.005), and shorter postoperative hospital stay (p = 0.001). CONCLUSIONS Off-pump coronary surgery is safe in patients with peripheral vascular disease, with acceptable results. The incidence of postoperative stroke is substantially reduced when avoiding cardiopulmonary bypass in patients with peripheral vascular disease.
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Affiliation(s)
- Shishir Karthik
- Department of Cardiothoracic Surgery, The Cardiothoracic Centre, Liverpool, United Kingdom
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Lachat M, Witzke H, Pfammatter T, Bettex D, Slankamenac K, Wolfensberger U, Turina M. Aortic stent-grafting: successful introduction into the combined procedure for coronary artery bypass grafting and aortic aneurysm repair. Eur J Cardiothorac Surg 2003; 23:532-6. [PMID: 12694772 DOI: 10.1016/s1010-7940(02)00838-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Coronary artery bypass grafting (CABG) and combined stent-grafting (SG) were evaluated to reduce morbidity and mortality of patients with descending or infrarenal aortic aneurysm. METHODS CABG and SG (thoracic n=6, infrarenal n=36) were performed during the same hospitalization in 42 patients (mean age of 73+/-14 years). In 29 patients (mean Euroscore: 9), SG was performed under local anesthesia 9+/-3 days after coronary surgery (simultaneous) and in 13 patients (mean Euroscore: 7) during the same anesthesia (synchronous). In the latter group, 11 out of 13 patients underwent off-pump CABG. All aneurysms were treated by implantation of commercially available self-expanding grafts. RESULTS CABG was successful in all, but one patient with left internal mammary artery hypoperfusion syndrome, requiring an additional distal saphenous graft to the left anterior descending coronary artery. SG was uneventful in 98% (41/42 patients). Postoperative computerized tomography showed incomplete sealing in seven patients (17%), but only the two attachment endoleaks had to be treated by one proximal and one distal SG extension. Overall hospital stay for the synchronous repair was 12.5+/-6 days and that of the simultaneous group 17.5+/-7 days. Thirty-day mortality was 5% (2/42) as one patient of the simultaneous group experienced a lethal cerebral embolism during SG and one patient of the synchronous group developed an untreatable infection. In the follow-up of 4 years, there were two vascular reinterventions but no additional procedure-related morbidity or mortality. CONCLUSIONS This experience shows that combined CABG and SG of thoracic or infrarenal aortic aneurysm is a safe and less-invasive alternative to the open graft repair, especially in the older patients or patients with severe comorbidities.
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Affiliation(s)
- M Lachat
- Clinic for Cardiovascular Surgery, University Hospital Zurich, 100 Rämistrasse, CH-8091 Zurich, Switzerland.
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Loponen P, Taskinen P, Laakkonen E, Nissinen J, Peltola T, Wistbacka JO, Luther M. Peripheral vascular disease as predictor of outcome after coronary artery bypass grafting. Scand J Surg 2003; 91:160-5. [PMID: 12164516 DOI: 10.1177/145749690209100205] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND AIMS Understanding and objective assessment of risks is crucial in cardiac surgery. The aim of this study was to assess the influence of peripheral vascular disease (PVD) on morbidity, mortality and outcome in coronary artery bypass grafting (CABG) patients. MATERIAL AND METHODS The ankle-brachial pressure index (ABPI) was used as indicator of PVD and was measured in 178 CABG patients. Two groups were established: 1. normal ABPI (0.9-1.3) (n = 136) and 2. lowered ABPI (< 0.9) (n = 35). The mean follow-up was 26 months. RESULTS The presence of PVD was 20.5 %. Patients with PVD were older (p < 0.05), more often of female sex (p < 0.05), had higher Higgins's risk score (p = 0.001) and more often intermittent claudication (IC) (p < 0.001). PVD significantly predicted atrial fibrillation (FA) (p < 0.05) and relatively postoperative myocardial infarction (MI) (p = 0.058). CONCLUSIONS The presence of PVD is relatively high in CABG patients and increases with age. PVD predicts some morbidity but seems to have fairly little influence on short-term or middle-term outcome of CABG patients. ABPI may be of only limited value in identifying patients with high operative risk in CABG.
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Affiliation(s)
- P Loponen
- Department of Surgery, Vaasa Central Hospital, Finland.
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Chassot PG, Delabays A, Spahn DR. Preoperative evaluation of patients with, or at risk of, coronary artery disease undergoing non-cardiac surgery. Br J Anaesth 2002. [DOI: 10.1093/bja/89.5.747] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Rangel A, Albarrán H, Solorio S, Hernández-González MA. Angiographic concurrence of coronary artery disease and aortoiliac lesions. Angiology 2002; 53:685-92. [PMID: 12463622 DOI: 10.1177/000331970205300609] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The importance of recognizing the association between aortoiliac disease and coronary artery disease includes the following: (1) Long-term morbidity is higher and survival ratio poorer in patients with coronary heart disease compared with isolated lower extremity revascularization surgery. (2) Coronary artery bypass grafting is a relatively high-risk procedure in patients with severe vascular disease. (3) There is the prospect that the patient will eventually face simultaneous coronary artery and vascular surgery, or coronary artery angioplasty previous to aortoiliac surgery. The aim of this investigation is to know the frequency of the association of coronary artery disease with aortoiliac lesions and to stratify the risk factors related to such an association. In total, 65 men and 19 women (30 to 76 years of age) with a history of coronary heart disease underwent abdominal aortography after selective coronary artery and left ventricle angiography. Aortoiliac lesions were identified at angiograms. Relevant coronary artery disease was diagnosed when at least 1 coronary artery was obstructed > 50%. The frequency of association between aortoiliac and coronary artery lesions was established, as well as the relationship of these lesions to the following clinical variables: age, weight, height, smoking habit, history of coronary heart disease, systemic arterial hypertension, diabetes mellitus, intermittent claudication, glycemia, uricemia, and triglyceridemia. There were 36 patients (42.9%) with aortoiliac lesions. In 34 patients (40.5%) coronary artery disease was associated with aortoiliac lesions. Abdominal aortic dilations were found in 10 instances, abdominal aortic stenosis in 13 patients, and stenosis of the iliac arteries or their branches on 28 occasions. The variables statistically related to the presence of aortoiliac lesions were smoking habit and a history of intermittent claudication. The number of affected coronary arteries was directly related to the frequency of aortoiliac lesions. In the entire sample, 11 patients (13%) had no coronary artery disease, and 15 (17.9%) had 1-vessel, 24 (28.6%) 2-vessel, and 34 (40.5%) 3-vessel disease. The extent of coronary disease was directly related to the frequency and extent of aortoiliac lesions. Frequencies of aortoiliac lesions were strongly related to a history of smoking habit and intermittent claudication and directly related to the extent of coronary artery disease.
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Affiliation(s)
- Alberto Rangel
- Servicio de Hemodinamia, Hospital de Especialidades, Centro Medico Nacional La Raza, IMMS, Mexico, DF, Mexico.
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Abstract
No distinct advantage is apparent between regional and general anesthesia when considering perioperative cardiac morbidity and mortality in peripheral vascular surgery. However, there is some evidence to support regional anesthesia over general anesthesia in an effort to optimize graft patency if the regional technique is extended into the postoperative period to provide neuraxial analgesia. An inadequate number of randomized, controlled trials have been conducted to determine whether regional or general anesthesia should be performed for carotid endarterectomy. The nonrandomized trials do support regional anesthesia by virtue of reductions in stroke, myocardial infarction, and death. A randomized, prospective trial is needed to verify these outcomes. The choice of technique does not appear to affect mortality in patients requiring hip fracture surgery, although Urwin et al. (29) reported less 1-month mortality in patients receiving regional anesthesia. General anesthesia has been associated with increased blood loss and thromboembolic complications in patients undergoing hip fracture repair. Epidural anesthesia has been shown to promote quicker return of bowel function postoperatively when the catheter has been sited at T12 or higher. Anastomotic breakdown in patients with epidural anesthesia/analgesia has rarely been reported. Most studies tend to show quicker return of bowel function when local anesthetics alone are administered epidurally.
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Affiliation(s)
- Patrick Breen
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
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Abstract
PURPOSE The aim of this study was to define very late survival in veterans who routinely underwent preoperative assessment of left ventricular function using radionuclide ventriculography (RNVG) before elective major vascular surgery from 7/84 to 7/88 at one Veterans Affairs Medical Center. METHODS RNVG defined left ventricular ejection fraction (EF) and determined the presence of ventricular wall motion abnormalities. Patients undergoing elective vascular surgery (n = 310) who had preoperative RNVG were then followed over the years using direct contact, VA administrative databases, and, most recently, the Social Security Death Index. RESULTS Follow-up was 6.64 +/- 4.62 years (range 0 to 16.2 years). Current survival is 10% (11/107) after carotid surgery, 12% (10/82) after aortic aneurysm repair, 15% (17/111) after extremity reconstruction, and 0% (0/10) after visceral artery reconstruction (ns). There was no statistically significant difference in mortality between the different types of vascular surgery at 30 days or at 1, 5, and 10 years after surgery (ns). Actual survival rates at 5 years after carotid surgery, aneurysm repair, extremity reconstruction, and visceral reconstruction were 55, 61, 59, and 50%, respectively. Stepwise logistic regression analysis was performed which included preoperatively defined cardiovascular risk factors, type of surgery, and results of RNVG. The final regression model indicated that age, diabetes, smoking at the time of surgery, and low EF were independently associated with overall mortality while angina, prior myocardial infarction (MI), and type of operation were not. Mean survival duration with normal EF (>50%) was 7.99 years versus 4.78 years with low EF (P < 0.001). No patient with severe left ventricular dysfunction (EF < or = 35%; n = 39) or who had postoperative cardiac complications (MI, CHF, ventricular arrhythmia; n = 38) survived to the present. CONCLUSIONS Very late survival after major vascular surgery was related to the presence of diabetes, active smoking at the time of surgery, left ventricular function, and postoperative cardiac complications. Since there was no association of overall mortality with angina or prior MI, an aggressive approach to coronary evaluation in such patients might not alter very late survival.
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Affiliation(s)
- Andris Kazmers
- Division of Vascular Surgery, Wayne State University School of medicine, Detroit, MI 48201, USA
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El-Sabrout RA, Reul GJ, Cooley DA. Outcome after simultaneous abdominal aortic aneurysm repair and aortocoronary bypass. Ann Vasc Surg 2002; 16:321-30. [PMID: 11981688 DOI: 10.1007/s10016-001-0046-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Myocardial infarction remains the leading cause of early and late death after abdominal aortic aneurysm (AAA) repair. Myocardial revascularization is staged either before or concomitant with AAA resection, but results are far from uniform. We retrospectively analyzed our experience with patients who underwent concomitant AAA resection and aortocoronary bypass (ACB) to examine the factors affecting early morbidity/mortality and early results. Forty-two patients (all men; mean age, 67.2 years) underwent simultaneous ACB grafting and AAA repair between 1975 and 1998. All were managed postoperatively in the cardiothoracic intensive care unit (mean stay, 6.1 days). The mean total hospital stay was 17.2 days. Two died in the early postoperative period (4.8%): 1 of sustained myocardial failure following a third ACB, and 1 of coagulopathy after concomitant ACB, aortic valve replacement, and AAA. One patient developed a nonfatal MI on postoperative day 3. The incidence of wound and bleeding complications was higher for patients undergoing both ACB and AAA repair than for patients undergoing AAA resection alone. On follow-up (mean, 10 years; range, 7 months to 15 years), only 2 of 10 late deaths were due to cardiovascular causes. We believe that concomitant myocardial revascularization is warranted in select patients requiring elective or urgent AAA resection in order to decrease perioperative risk and improve late survival. Cardiac failure or ischemia during aortic surgery can be prevented by proper perfusion with or without cardiopulmonary bypass. In patients undergoing simultaneous procedures, the increased risk is related to the severity of the vascular and coronary artery disease and not to the combined operations.
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Affiliation(s)
- Rafik A El-Sabrout
- Department of Cardiovascular Surgery, Texas Heart Institute at St. Luke's Episcopal Hospital, Houston 77225, USA
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Thomas TA, Taylor SM, Crane MM, Cornett WR, Langan EM, Snyder BA, Cull DL. An analysis of limb-threatening lower extremity wound complications after 1090 consecutive coronary artery bypass procedures. Vasc Med 2001; 4:83-8. [PMID: 10406454 DOI: 10.1177/1358836x9900400205] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The objective of this study was to examine and characterize limb-threatening lower extremity wound or soft tissue complications after coronary artery bypass (CABG) and determine risk factors for their cause. While minor wound problems of the leg after CABG are not uncommon, serious limb-threatening complications, though less frequent, do occur and are often de-emphasized in the surgical literature. A review of 1090 consecutive CABG procedures performed from January 1, 1995 through December 31, 1995 was instituted, which screened for limb-threatening lower extremity wound or soft tissue complications defined as wounds that: required additional surgery for treatment; prolonged the length of stay; or which required lengthy home health nursing for treatment. Minor lymph leaks, leg swelling, infections or wound problems treated as an outpatient were excluded. Of 1090 patients, 54 (5.0%) experienced a limb-threatening lower extremity complication. Complications were categorized as vein harvest incision non-healing (n = 36, 66.7%), decubitus ulceration (n = 11, 20.4%), forefoot ischemia/embolization (n = 10, 18.5%), groin hematoma/abscess (n = 6, 11.1%), severe cellulitis (n = 3, 5.6%), or a combination (n = 12, 22.2%). Statistically significant risk factors by univariate and bivariate analysis for a complication included older age (68 years vs 62 years, p = 0.007), female sex (57% vs 28%, p < 0.001), diabetes (57% vs 33%, p = 0.005) and longer pump time (129 min vs 114 min, p = 0.009). These complications necessitated five major lower extremity amputations and nine revascularization procedures. Chronic lower extremity ischemia from peripheral vascular disease (PVD) was a major contributing factor for the development of wounds in at least 23 (42.6%) of these patients, though suspected in only 10 (43.5%) preoperatively. A non-healing vein harvest incision below the knee of a patient retrospectively found to have inadequate distal circulation for healing occurred in 17 (31.5%) of the total 54 cases. It was concluded that non-healing vein incisions, decubitus ulcers and forefoot ischemic lesions frequently occurring in older diabetic females with undetected pre-existing PVD, comprise the majority of limb-threatening leg complications after CABG. Nearly one-third of the complications may have been avoided had the vein harvest incision not been made at the ankle of a patient with unappreciated PVD.
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Affiliation(s)
- T A Thomas
- Department of Surgical Education, Greenville Hospital System, South Carolina 29605, USA
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Angerer P, Negut C, Störk S, von Schacky C. Endothelial function of the popliteal artery in patients with coronary artery disease. Atherosclerosis 2001; 155:187-93. [PMID: 11223441 DOI: 10.1016/s0021-9150(00)00536-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Coronary artery disease (CAD) is associated more closely with atherosclerosis in the popliteal than in the brachial artery. This case-control study aimed at clarifying whether endothelial dysfunction of patients with CAD can be detected non-invasively in the popliteal artery by means of ischemia-induced flow-mediated dilation (FMD) and cold pressor reaction (CPR), and how it compares with the brachial artery. We further investigated a new mode of evaluation of the CPR. Eleven cases with CAD were compared with 16 matched healthy controls. Popliteal and brachial arterial diameter was monitored by ultrasound for 20 min following ischemia and cold pressor. For CPR, the difference between maximum and minimum diameter was defined as maximum vasomotion. In the popliteal artery, maximum vasomotion and FMD were significantly smaller in cases than in controls, the difference being more pronounced than in the brachial artery, where only maximum vasomotion was significantly smaller. After exclusion of current smokers, only the difference in maximum vasomotion of both arteries remained significant. We conclude that maximum vasomotion may be more sensitive for detection of endothelial dysfunction than FMD. Endothelial dysfunction in patients with CAD is more pronounced in the popliteal artery than in the brachial artery.
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Affiliation(s)
- P Angerer
- Medizinische Klinik, Klinikum der Universität München-Innenstadt, Ziemssenstrasse 1, 80336, Munich, Germany.
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Wall RT. Anesthesia. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Minakata K, Konishi Y, Matsumoto M, Aota M, Sugimoto A, Nonaka M, Yamada N. Influence of peripheral vascular occlusive disease on the morbidity and mortality of coronary artery bypass grafting. JAPANESE CIRCULATION JOURNAL 2000; 64:905-8. [PMID: 11194280 DOI: 10.1253/jcj.64.905] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The impact of peripheral vascular occlusive disease (PVD) on outcome for patients who have undergone coronary artery bypass grafting (CABG) was assessed by comparing preoperative and intraoperative patient characteristics and outcome in 2 groups of patients who underwent CABG (patients with PVD, n=96; patients without PVD, n=593). Patients with PVD were significantly older (69+/-8.4 vs 63+/-8.7; p<0.0001), and had a higher incidence of diabetes mellitus (48% vs 32%; p<0.01), hypertension (62% vs 46%; p<0.01), preoperative cerebral infarction (26% vs 12%; p<0.001) and chronic renal dysfunction (11% vs 4.4%; p<0.01) than those without PVD. Postoperative morbidity and mortality were assessed, after those risk factors were adjusted, using multivariate logistic regression analysis. The perioperative myocardial infarction (PMI) rate and in-hospital mortality rate were significantly higher in patients with PVD than in patients without PVD (9.4% vs 3.0%; p=0.0108, 17% vs 2.7%; p=0.0003, respectively). The odds ratio of PMI and in-hospital mortality were 3.4 (95% confidence intervals (CI): 1.3-8.6) and 4.3 (95% CI: 2.0-9.5), respectively. Although the excess mortality rate was mainly the result of cardiac problems, such as low output syndrome or arrhythmia, in most of the cases, PVD, which may frequently prevent the use of the intraaortic balloon pump, also seemed to have a strong relation to postoperative morbidity and mortality.
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Affiliation(s)
- K Minakata
- Department of Cardiovascular Surgery, Japanese Red Cross Society Wakayama Medical Center.
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41
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Gangemi JJ, Kron IL, Ross SD, Tribble CG, Kern JA. The safety of combined cardiac and vascular operations: how much is too much? CARDIOVASCULAR SURGERY (LONDON, ENGLAND) 2000; 8:452-6. [PMID: 10996099 DOI: 10.1016/s0967-2109(00)00063-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The purpose of this study was to identify factors correlating with a poor outcome following combined cardiac and vascular procedures. METHODS We reviewed 45 consecutive patients undergoing combined cardiac and vascular operations. These included cardiac/CEA (n=27), cardiac/AAA (n=13), cardiac/AAA/one other vascular reconstruction (n=4), and cardiac/renal artery bypass (n=1). Group I included all patients with no morbidity or mortality (n=41) and Group II included patients who died or suffered significant morbidity (stroke, renal failure) (n=4). RESULTS Overall mortality was 4.4% (2/45). These two patients underwent cardiac surgery combined with two additional vascular procedures (cardiac/AAA/other). In patients undergoing cardiac/CEA or cardiac/AAA, there were no deaths and one stroke (contralateral to CEA). Group II had significantly decreased ejection fraction (39%+/-6% vs 52%+/-1%) and an increased number of procedures (2.75 vs 2.04). CONCLUSIONS Combined cardiac surgery and vascular reconstruction can be performed safely. However, multiple vascular reconstructions or the presence of decreased ejection fraction increased operative risk.
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Affiliation(s)
- J J Gangemi
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health Sciences Center, Charlottesville, VA 22908, USA.
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Kron IL, Kern JA, Beller GA, Bergin J, Fiser SM, Gangemi JJ, McPherson JA, Powers ER. Cardiac screening before non-cardiac operations. Curr Probl Surg 2000; 37:385-454. [PMID: 10858727 DOI: 10.1016/s0011-3840(00)80008-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- I L Kron
- University of Virginia, Charlottesville, USA
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Abstract
Survival following emergency surgery for ruptured abdominal aortic aneurysm remains poor and is in stark contrast to that for elective repair. We have carried out a 5-year retrospective observational study to determine the long-term (5-year) survival of patients following emergency surgery for ruptured abdominal aortic aneurysm at a district general hospital in East Anglia. A total of 99 patients presented to the operating theatre for emergency repair of ruptured abdominal aortic aneurysm in this 5-year study period. In-hospital mortality was 70% and was unchanged over the 5 years. Overall long-term survival in those patients discharged from hospital was good. The ICU cost per long-term survivor was calculated to be pound sterling 36750.
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Affiliation(s)
- Q J Milner
- Specialist Registrar in Anasthesia, Intensive Care Medicine, Department of Anasthesia, Queen Elizabeth II Hospital, Kings Lynn, Norfolk PE30 4ET, UK
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Fusari M, Parolari A, Agostinelli A, Spirito R, Rubini P, Esposito G, Alamanni F, Biglioli P. Coronary and major vascular disease: aggressive screening and priority-based therapy. CARDIOVASCULAR SURGERY (LONDON, ENGLAND) 2000; 8:22-30. [PMID: 10661700 DOI: 10.1016/s0967-2109(99)00088-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
It is well know that atherosclerosis can simultaneously affect different vascular subsystems, and patients with diffuse atherosclerosis can be a major management problem both for preoperative evaluation and for intraoperative management. The authors have conducted a prospective study to evaluate the prevalence of coronary artery disease in arteriopathic patients, and vice versa, to assess the effectiveness of aggressive screening together with a priority-based approach. Study 1 consisted of 1,000 consecutive non-emergent patients who were affected by abdominal aortic or carotid disease and were screened for the presence of coronary artery disease before surgery with a newly developed clinical risk assessment. They were stratified into three risk categories with different preoperative evaluation strategies. When coronary artery disease was concomitantly demonstrated in these patients, the choice of surgical method was based on priorities, and the use of combined surgical procedures as required. In study 2, 1,000 consecutive patients that required coronary angiography for suspected coronary artery disease were screened for the presence of carotid or abdominal aortic pathology, directly in the cardiac catheter laboratory during coronary angiography, by obtaining views of the aortic arch and abdominal aorta. Surgical approaches paralleled those of study 1. The results for study 1 showed that 720 patients (72%) were affected by abdominal aortic disease, 238 (24%) by carotid disease and 42 (4%) by both pathologies. Significant coronary artery disease was found in 152 patients (15%), of these 123 (81.5%) were affected by abdominal aortic disease and 29 (18.5%) by carotid artery disease. Abdominal aortic surgery was performed directly or after myocardial revascularization, with an overall mortality rate of 4/718 (0.6%), and a perioperative myocardial infarction rate of 10/718 (1.4%). For patients with carotid artery disease, the completed screening and possible therapy for coronary artery disease resulted in an in-hospital mortality rate of 2/238 (0.8%), and a perioperative myocardial infarction rate of 2/238 (0.8%). There were no significant differences in these rates between patients with or without coronary artery disease. Results for study 2 showed that of the 1000 consecutive patients enrolled for suspicion of coronary artery disease, 767 (77%) were affected by significant coronary artery disease. Among these, 38 (4.9%) had a surgically correctable aortic disease and 31 (4%) a surgically correctable carotid disease, which was monolateral and bilateral in 22 (74%) and nine (26%) patients, respectively, and four (0.5%) were diagnosed with both pathologies. These arteriopathic patients were treated for their coronary and vascular disease with no in-hospital mortality nor perioperative myocardial infarction. In patients with multiple vascular involvement, both coronary and vascular surgery can be performed with low risk when aggressive screening and priority-based therapy are adopted.
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Affiliation(s)
- M Fusari
- Department of Cardiac Surgery, University of Milano, Italy
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45
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Eagle KA, Guyton RA, Davidoff R, Ewy GA, Fonger J, Gardner TJ, Gott JP, Herrmann HC, Marlow RA, Nugent WC, O'Connor GT, Orszulak TA, Rieselbach RE, Winters WL, Yusuf S, Gibbons RJ, Alpert JS, Eagle KA, Garson A, Gregoratos G, Russell RO, Smith SC. ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery). American College of Cardiology/American Heart Association. J Am Coll Cardiol 1999; 34:1262-347. [PMID: 10520819 DOI: 10.1016/s0735-1097(99)00389-7] [Citation(s) in RCA: 329] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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46
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McGovern I. Identifying high-risk surgical patients. Best Pract Res Clin Anaesthesiol 1999. [DOI: 10.1053/bean.1999.0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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47
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Therre T, Ribal JP, Motreff P, Lusson JR, Espeut JB, Cassagnes J, Glanddier G. Assessment of cardiac risk before aortic reconstruction: noninvasive work-up using clinical examination, exercise testing, and dobutamine stress echocardiography versus routine coronary arteriography. Ann Vasc Surg 1999; 13:501-8. [PMID: 10466994 DOI: 10.1007/s100169900290] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
In this prospective study we evaluated the efficacy of a battery of noninvasive tests including clinical evaluation (CE), exercise testing (ET), and dobutamine stress echocardiography (DSE) for assessment of cardiac risk in 90 patients indicated for aortic reconstruction. As the gold-standard reference technique, coronary arteriography was performed in each patient after noninvasive evaluation. The sensitivity of CE was low (61%). ET proved to be more sensitive (71.4%) and highly specific (95.8%) but feasibility (77%) and diagnostic accuracy (42%) were low. DSE demonstrated acceptable sensitivity (78%) and specificity (75.5%) with high feasibility (94.5%) and diagnostic accuracy (100%). None of the four patients with false negative ET results and only one of seven with false-negative DSE required coronary bypass. On the basis of these findings we conclude that a combination of CE and ET with DES, if necessary, can reliably assess cardiac risk before aortic reconstruction. Noninvasive assessment is a reliable alternative to routine coronary arteriography.
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Affiliation(s)
- T Therre
- Service de Chirurgie Vasculaire and Service de Cardiologie, Hôpital G. Montpied, Clermont-Ferrand, France
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Glance LG. Selective preoperative cardiac screening improves five-year survival in patients undergoing major vascular surgery: a cost-effectiveness analysis. J Cardiothorac Vasc Anesth 1999; 13:265-71. [PMID: 10392675 DOI: 10.1016/s1053-0770(99)90261-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate the long-term outcomes (5-year survival) and cost-effectiveness of selective coronary revascularization before major vascular surgery. DESIGN A decision-tree model was constructed to compare the cost-effectiveness of four preoperative screening strategies from the perspective of the health care system. SETTING Based on patient mortality, morbidity, and cost data from a literature review. PARTICIPANTS Hypothetical cohort of patients scheduled for elective abdominal aortic aneurysm repair followed up over a 5-year period. INTERVENTIONS Patients either proceeded directly to surgery or were screened using one of three possible preoperative screening strategies. In the first strategy, all patients were screened with a dipyridamole-thallium test. In the second strategy, all patients underwent coronary angiography. The third strategy, selective screening, first divided patients into high-, intermediate-, and low-risk groups using clinical criteria. High-risk patients underwent preoperative angiography. Intermediate-risk patients were screened noninvasively, and low-risk patients proceeded directly to surgery without further testing. MEASUREMENT AND MAIN RESULTS Proceeding directly to vascular surgery resulted in the poorest 5-year survival rate (77.4%) compared with preoperative risk stratification followed by selective coronary revascularization, routine noninvasive testing (86.1%), selective testing (86.0%), and routine angiography (87.9%; p = 0.00). The incremental cost-effectiveness ratio for selective testing was significantly lower than for routine angiography ($44,800/years of life saved (YLS) v $93,300/YLS; p < 0.02). Routine noninvasive testing was not cost-effective. Thirty-day mortality was the same for all four strategies (p = 0.84). CONCLUSION Selective screening before vascular surgery may improve 5-year survival and be cost-effective. Neither routine noninvasive testing nor routine angiography appears to be cost-effective compared with currently accepted medical therapies.
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Affiliation(s)
- L G Glance
- Department of Anesthesiology, University of Rochester, NY, USA
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Sirieix D, Lamonerie-Alvarez L, Olivier P, Souron V, Baron JF. [Assessment of cardiovascular perioperative risk in non-cardiac surgery]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1999; 17:1225-31. [PMID: 9881190 DOI: 10.1016/s0750-7658(99)80028-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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.
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Affiliation(s)
- D Sirieix
- Service Nadia-du-Bouchet, anesthésie-réanimation, hôpital Broussais, Paris, France
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