Cardiac risk

Critical Elements for Risk Stratification in Patients

Undergoing Noncardiac Surgery

bull Risk-assessment tool must be accuratebull Predicts perioperative events (positive likelihood ratio 10)bull Predicts absence of perioperative events (negative likelihood

ratio 02)bull Risk-assessment tool must influence outcomebull Identifies subgroups in which surgery should be cancelled or

treatment changedbull Identifies subgroups that do or do not benefit from proven

therapy to reduce riskbull Risk-assessment tool must have a favorable harmsndashbenefit

tradeoff

Cardiac Risk Index in Noncardiac Surgery Criteria Finding

Age (yr) gt70 5

Cardiac status MI within 6 mo 10

Ventricular gallop or jugular venous distention (signs of heart failure)

11

Significant aortic stenosis 3

Arrhythmia other than sinus or premature atrial contractions 7

ge5 premature ventricular contractionsmin 7

General medical condition Po2 lt 60 mm Hg Pco2 gt 50 mm Hg K lt 3 mmolL HCO3 lt20 mmolL BUN gt 50 mgdL serum creatinine gt 3 mgdL elevated AST a chronic liver disorder or bedbound

3

Type of surgery needed Emergency surgery 4Intraperitoneal intrathoracic or aortic surgery 3

Risk is based on the total number of pointsLevel I 0ndash5Level II 6ndash12Level III 13ndash25Level IV gt25

Adapted from Goldman L et al Multifactorial index of cardiac risk in noncardiac surgical procedures New England Journal of Medicine 297845ndash850 1977

Valutazione del rischio cardiacoin chirurgia non cardiaca

CMelloniLibero professionista

Consulente di anestesia per Villa TorriVilla ChiaraPoliambulatorio Gynepro

Bologna

Revised cardiac index Lee TH Marcantonio ER Mangione CM Thomas EJ Polanczyk CA Cook EF

Sugarbaker DJ Donaldson MC Poss R Ho KK Ludwig LE Pedan A Goldman L Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac

Risk of Major Noncardiac Surgery Circulation 1999 100 1043-1049

bull bull High risk surgerybull ndash intraperitoneal intrathoracic or

suprainguinal vascular proceduresbull bull Ischemic heart diseasebull bull HO CHFbull bull HO Cerebrovascular diseasebull bull Insulin therapy for DMbull bull Preop Crgt20mgdl

bull Eagle KA Berger PB Calkins H Chaitman BR Ewy GA Fleischmann KE Fleisher LA Froehlich JB Gusberg RJ Leppo JA Ryan T Schlant RC Winters WL Jr Gibbons RJ Antman EM Alpert JSFaxon DP Fuster V Gregoratos G Jacobs AK Hiratzka LF Russell RO Smith SC Jr ACCAHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery---executive summary a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Circulation 2002105 1257-67

Weksler N Klein M Szendro G Rozentsveig V Schily M Brill S Tarnopolski A Ovadia L Gurman GM The dilemma of immediate preoperative hypertension to treat and operate or to postpone

surgery J Clin Anesth 2003 15 179-83

bull There is a great deal of debate regarding a trigger to delay or cancel a surgical procedure in a patient with poorly or untreated hypertension

bull In the absence of end-organ changes such as renal insufficiency or left ventricular hypertrophy with strain it would seem appropriate to proceed with surgery

bull A randomized trial of treated hypertensive patients without known CAD who presented the morning of surgery with an elevated diastolic blood pressure was unable to demonstrate any difference in outcome between those who were actively treated versus those in whom surgery was delayed

bull In contrast a patient with a markedly elevated blood pressure and the new onset of a headache should have surgery delayed for further evaluation and potential treatment

Howell SJ Sear YM Yeates D Goldacre M Sear JW Foeumlx P Hypertension admission blood pressure and perioperative

cardiovascular risk Anaesthesia 1996511000-1004

bull A retrospective case-controlled study which found that a history of hypertension was an important predictor for perioperative cardiac death but not admission blood pressure

bull The study implies that end-organ damage resulting from hypertension is the likely villain in this group of patients

bull Importance of Surgical Procedurebull The surgical procedure influences the extent of the preoperative

evaluation required by determining the potential range of changes in perioperative management There is little hard data to define the surgery specific incidence of complications and the rate may be very institution depedendent Eagle et al published data on the incidence of perioperative myocardial infarction and mortality by procedure for patients enrolled in the coronary artery surgery study (CASS)6 Higher risk procedures for which coronary artery bypass grafting reduced the risk of noncardiac surgery compared to medical therapy include major vascular abdominal thoracic and orthopedic surgery Ambulatory procedures denote low risk Vascular surgery represents a unique group of patients in whom there is extensive evidence regarding preoperative testing and perioperative interventions

bull Importance of exercise tolerancebull Exercise tolerance is one of the most important determinants of

perioperative risk and the need for invasive monitoring If a patient can walk a mile without becoming short of breath than the probability of extensive coronary artery disease is small Alternatively if patients become dyspneic associated with chest pain during minimal exertion then the probability of extensive coronary artery disease is high Reilly and colleagues demonstrated that the likelihood of a serious complication occurring was inversely related to the number of blocks that could be walked or flights of stairs that could be climbed7 Exercise tolerance can be assessed with formal treadmill testing or with a questionnaire that assesses activities of daily living

bull Reilly DF McNeely MJ Doerner D Greenberg DL Staiger TO Geist MJ Vedovatti PA Coffey JE Mora MW Johnson TR Guray ED Van Norman GA Fihn SD Self-reported exercise tolerance and the risk of serious perioperative complications Arch Intern Med 1999 159 2185-92

bull 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 Jr Jacobs AK Adams CD Anderson JL Antman EM Faxon DP Fuster V Halperin JL Hiratzka LF Hunt SA Lytle BW Nishimura R Page RL Riegel B ACCAHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery focused update on perioperative beta-blocker therapy a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Writing Committee to Update 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 and Society for Vascular Medicine and Biology Circulation 2006 113 2662-74

bull Yang H Raymer K Butler R Parlow J Roberts R The effects of perioperative beta-blockade results of the Metoprolol after Vascular Surgery (MaVS) study a randomized controlled trial Am Heart J 2006 152 983-90

bull Juul AB Wetterslev J Gluud C Kofoed-Enevoldsen A Jensen G Callesen T Norgaard P Fruergaard K Bestle M Vedelsdal R Miran A Jacobsen J Roed J Mortensen MB Jorgensen L Jorgensen J Rovsing ML Petersen PL Pott F Haas M Albret R Nielsen LL Johansson G Stjernholm P Molgaard Y Foss NB Elkjaer J Dehlie B Boysen K Zaric D Munksgaard A Madsen JB Oberg B Khanykin B Blemmer T Yndgaard S Perko G Wang LP Winkel P Hilden J Jensen P Salas N Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery randomised placebo controlled blinded multicentre trial Bmj 2006 332 1482

bull Wallace AW Galindez D Salahieh A Layug EL Lazo EA Haratonik KA Boisvert DM Kardatzke D Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery Anesthesiology 2004 101 284-93

bull Hindler K Shaw AD Samuels J Fulton S Collard CD Riedel B Improved postoperative outcomes associated with preoperative statin therapy Anesthesiology 2006 105 1260-72

Durazzo AE Machado FS Ikeoka DT De Bernoche C Monachini MC Puech-Leao P Caramelli B Reduction in cardiovascular events after vascular surgery with atorvastatin a randomized trial J Vasc Surg 200439 967-75

bull (httpwwwaccorgqualityandscienceclinicaltopictopichtm)

Key wordsbull perioperative riskbull cardiac risk bull noncardiac surgerybull intraoperative riskbull postoperative risk bull risk stratification bull cardiac complication bull cardiac evaluationbull perioperative care bull preoperative evaluationbull preoperative assessmentbull intraoperative complications

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Critical Elements for Risk Stratification in Patients

Undergoing Noncardiac Surgery

bull Risk-assessment tool must be accuratebull Predicts perioperative events (positive likelihood ratio 10)bull Predicts absence of perioperative events (negative likelihood

ratio 02)bull Risk-assessment tool must influence outcomebull Identifies subgroups in which surgery should be cancelled or

treatment changedbull Identifies subgroups that do or do not benefit from proven

therapy to reduce riskbull Risk-assessment tool must have a favorable harmsndashbenefit

tradeoff

Cardiac Risk Index in Noncardiac Surgery Criteria Finding

Age (yr) gt70 5

Cardiac status MI within 6 mo 10

Ventricular gallop or jugular venous distention (signs of heart failure)

11

Significant aortic stenosis 3

Arrhythmia other than sinus or premature atrial contractions 7

ge5 premature ventricular contractionsmin 7

General medical condition Po2 lt 60 mm Hg Pco2 gt 50 mm Hg K lt 3 mmolL HCO3 lt20 mmolL BUN gt 50 mgdL serum creatinine gt 3 mgdL elevated AST a chronic liver disorder or bedbound

3

Type of surgery needed Emergency surgery 4Intraperitoneal intrathoracic or aortic surgery 3

Risk is based on the total number of pointsLevel I 0ndash5Level II 6ndash12Level III 13ndash25Level IV gt25

Adapted from Goldman L et al Multifactorial index of cardiac risk in noncardiac surgical procedures New England Journal of Medicine 297845ndash850 1977

Valutazione del rischio cardiacoin chirurgia non cardiaca

CMelloniLibero professionista

Consulente di anestesia per Villa TorriVilla ChiaraPoliambulatorio Gynepro

Bologna

Revised cardiac index Lee TH Marcantonio ER Mangione CM Thomas EJ Polanczyk CA Cook EF

Sugarbaker DJ Donaldson MC Poss R Ho KK Ludwig LE Pedan A Goldman L Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac

Risk of Major Noncardiac Surgery Circulation 1999 100 1043-1049

bull bull High risk surgerybull ndash intraperitoneal intrathoracic or

suprainguinal vascular proceduresbull bull Ischemic heart diseasebull bull HO CHFbull bull HO Cerebrovascular diseasebull bull Insulin therapy for DMbull bull Preop Crgt20mgdl

bull Eagle KA Berger PB Calkins H Chaitman BR Ewy GA Fleischmann KE Fleisher LA Froehlich JB Gusberg RJ Leppo JA Ryan T Schlant RC Winters WL Jr Gibbons RJ Antman EM Alpert JSFaxon DP Fuster V Gregoratos G Jacobs AK Hiratzka LF Russell RO Smith SC Jr ACCAHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery---executive summary a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Circulation 2002105 1257-67

Weksler N Klein M Szendro G Rozentsveig V Schily M Brill S Tarnopolski A Ovadia L Gurman GM The dilemma of immediate preoperative hypertension to treat and operate or to postpone

surgery J Clin Anesth 2003 15 179-83

bull There is a great deal of debate regarding a trigger to delay or cancel a surgical procedure in a patient with poorly or untreated hypertension

bull In the absence of end-organ changes such as renal insufficiency or left ventricular hypertrophy with strain it would seem appropriate to proceed with surgery

bull A randomized trial of treated hypertensive patients without known CAD who presented the morning of surgery with an elevated diastolic blood pressure was unable to demonstrate any difference in outcome between those who were actively treated versus those in whom surgery was delayed

bull In contrast a patient with a markedly elevated blood pressure and the new onset of a headache should have surgery delayed for further evaluation and potential treatment

Howell SJ Sear YM Yeates D Goldacre M Sear JW Foeumlx P Hypertension admission blood pressure and perioperative

cardiovascular risk Anaesthesia 1996511000-1004

bull A retrospective case-controlled study which found that a history of hypertension was an important predictor for perioperative cardiac death but not admission blood pressure

bull The study implies that end-organ damage resulting from hypertension is the likely villain in this group of patients

bull Importance of Surgical Procedurebull The surgical procedure influences the extent of the preoperative

evaluation required by determining the potential range of changes in perioperative management There is little hard data to define the surgery specific incidence of complications and the rate may be very institution depedendent Eagle et al published data on the incidence of perioperative myocardial infarction and mortality by procedure for patients enrolled in the coronary artery surgery study (CASS)6 Higher risk procedures for which coronary artery bypass grafting reduced the risk of noncardiac surgery compared to medical therapy include major vascular abdominal thoracic and orthopedic surgery Ambulatory procedures denote low risk Vascular surgery represents a unique group of patients in whom there is extensive evidence regarding preoperative testing and perioperative interventions

bull Importance of exercise tolerancebull Exercise tolerance is one of the most important determinants of

perioperative risk and the need for invasive monitoring If a patient can walk a mile without becoming short of breath than the probability of extensive coronary artery disease is small Alternatively if patients become dyspneic associated with chest pain during minimal exertion then the probability of extensive coronary artery disease is high Reilly and colleagues demonstrated that the likelihood of a serious complication occurring was inversely related to the number of blocks that could be walked or flights of stairs that could be climbed7 Exercise tolerance can be assessed with formal treadmill testing or with a questionnaire that assesses activities of daily living

bull Reilly DF McNeely MJ Doerner D Greenberg DL Staiger TO Geist MJ Vedovatti PA Coffey JE Mora MW Johnson TR Guray ED Van Norman GA Fihn SD Self-reported exercise tolerance and the risk of serious perioperative complications Arch Intern Med 1999 159 2185-92

bull 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 Jr Jacobs AK Adams CD Anderson JL Antman EM Faxon DP Fuster V Halperin JL Hiratzka LF Hunt SA Lytle BW Nishimura R Page RL Riegel B ACCAHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery focused update on perioperative beta-blocker therapy a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Writing Committee to Update 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 and Society for Vascular Medicine and Biology Circulation 2006 113 2662-74

bull Yang H Raymer K Butler R Parlow J Roberts R The effects of perioperative beta-blockade results of the Metoprolol after Vascular Surgery (MaVS) study a randomized controlled trial Am Heart J 2006 152 983-90

bull Juul AB Wetterslev J Gluud C Kofoed-Enevoldsen A Jensen G Callesen T Norgaard P Fruergaard K Bestle M Vedelsdal R Miran A Jacobsen J Roed J Mortensen MB Jorgensen L Jorgensen J Rovsing ML Petersen PL Pott F Haas M Albret R Nielsen LL Johansson G Stjernholm P Molgaard Y Foss NB Elkjaer J Dehlie B Boysen K Zaric D Munksgaard A Madsen JB Oberg B Khanykin B Blemmer T Yndgaard S Perko G Wang LP Winkel P Hilden J Jensen P Salas N Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery randomised placebo controlled blinded multicentre trial Bmj 2006 332 1482

bull Wallace AW Galindez D Salahieh A Layug EL Lazo EA Haratonik KA Boisvert DM Kardatzke D Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery Anesthesiology 2004 101 284-93

bull Hindler K Shaw AD Samuels J Fulton S Collard CD Riedel B Improved postoperative outcomes associated with preoperative statin therapy Anesthesiology 2006 105 1260-72

Durazzo AE Machado FS Ikeoka DT De Bernoche C Monachini MC Puech-Leao P Caramelli B Reduction in cardiovascular events after vascular surgery with atorvastatin a randomized trial J Vasc Surg 200439 967-75

bull (httpwwwaccorgqualityandscienceclinicaltopictopichtm)

Key wordsbull perioperative riskbull cardiac risk bull noncardiac surgerybull intraoperative riskbull postoperative risk bull risk stratification bull cardiac complication bull cardiac evaluationbull perioperative care bull preoperative evaluationbull preoperative assessmentbull intraoperative complications

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Cardiac Risk Index in Noncardiac Surgery Criteria Finding

Age (yr) gt70 5

Cardiac status MI within 6 mo 10

Ventricular gallop or jugular venous distention (signs of heart failure)

11

Significant aortic stenosis 3

Arrhythmia other than sinus or premature atrial contractions 7

ge5 premature ventricular contractionsmin 7

General medical condition Po2 lt 60 mm Hg Pco2 gt 50 mm Hg K lt 3 mmolL HCO3 lt20 mmolL BUN gt 50 mgdL serum creatinine gt 3 mgdL elevated AST a chronic liver disorder or bedbound

3

Type of surgery needed Emergency surgery 4Intraperitoneal intrathoracic or aortic surgery 3

Risk is based on the total number of pointsLevel I 0ndash5Level II 6ndash12Level III 13ndash25Level IV gt25

Adapted from Goldman L et al Multifactorial index of cardiac risk in noncardiac surgical procedures New England Journal of Medicine 297845ndash850 1977

Valutazione del rischio cardiacoin chirurgia non cardiaca

CMelloniLibero professionista

Consulente di anestesia per Villa TorriVilla ChiaraPoliambulatorio Gynepro

Bologna

Revised cardiac index Lee TH Marcantonio ER Mangione CM Thomas EJ Polanczyk CA Cook EF

Sugarbaker DJ Donaldson MC Poss R Ho KK Ludwig LE Pedan A Goldman L Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac

Risk of Major Noncardiac Surgery Circulation 1999 100 1043-1049

bull bull High risk surgerybull ndash intraperitoneal intrathoracic or

suprainguinal vascular proceduresbull bull Ischemic heart diseasebull bull HO CHFbull bull HO Cerebrovascular diseasebull bull Insulin therapy for DMbull bull Preop Crgt20mgdl

bull Eagle KA Berger PB Calkins H Chaitman BR Ewy GA Fleischmann KE Fleisher LA Froehlich JB Gusberg RJ Leppo JA Ryan T Schlant RC Winters WL Jr Gibbons RJ Antman EM Alpert JSFaxon DP Fuster V Gregoratos G Jacobs AK Hiratzka LF Russell RO Smith SC Jr ACCAHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery---executive summary a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Circulation 2002105 1257-67

Weksler N Klein M Szendro G Rozentsveig V Schily M Brill S Tarnopolski A Ovadia L Gurman GM The dilemma of immediate preoperative hypertension to treat and operate or to postpone

surgery J Clin Anesth 2003 15 179-83

bull There is a great deal of debate regarding a trigger to delay or cancel a surgical procedure in a patient with poorly or untreated hypertension

bull In the absence of end-organ changes such as renal insufficiency or left ventricular hypertrophy with strain it would seem appropriate to proceed with surgery

bull A randomized trial of treated hypertensive patients without known CAD who presented the morning of surgery with an elevated diastolic blood pressure was unable to demonstrate any difference in outcome between those who were actively treated versus those in whom surgery was delayed

bull In contrast a patient with a markedly elevated blood pressure and the new onset of a headache should have surgery delayed for further evaluation and potential treatment

Howell SJ Sear YM Yeates D Goldacre M Sear JW Foeumlx P Hypertension admission blood pressure and perioperative

cardiovascular risk Anaesthesia 1996511000-1004

bull A retrospective case-controlled study which found that a history of hypertension was an important predictor for perioperative cardiac death but not admission blood pressure

bull The study implies that end-organ damage resulting from hypertension is the likely villain in this group of patients

bull Importance of Surgical Procedurebull The surgical procedure influences the extent of the preoperative

evaluation required by determining the potential range of changes in perioperative management There is little hard data to define the surgery specific incidence of complications and the rate may be very institution depedendent Eagle et al published data on the incidence of perioperative myocardial infarction and mortality by procedure for patients enrolled in the coronary artery surgery study (CASS)6 Higher risk procedures for which coronary artery bypass grafting reduced the risk of noncardiac surgery compared to medical therapy include major vascular abdominal thoracic and orthopedic surgery Ambulatory procedures denote low risk Vascular surgery represents a unique group of patients in whom there is extensive evidence regarding preoperative testing and perioperative interventions

bull Importance of exercise tolerancebull Exercise tolerance is one of the most important determinants of

perioperative risk and the need for invasive monitoring If a patient can walk a mile without becoming short of breath than the probability of extensive coronary artery disease is small Alternatively if patients become dyspneic associated with chest pain during minimal exertion then the probability of extensive coronary artery disease is high Reilly and colleagues demonstrated that the likelihood of a serious complication occurring was inversely related to the number of blocks that could be walked or flights of stairs that could be climbed7 Exercise tolerance can be assessed with formal treadmill testing or with a questionnaire that assesses activities of daily living

bull Reilly DF McNeely MJ Doerner D Greenberg DL Staiger TO Geist MJ Vedovatti PA Coffey JE Mora MW Johnson TR Guray ED Van Norman GA Fihn SD Self-reported exercise tolerance and the risk of serious perioperative complications Arch Intern Med 1999 159 2185-92

bull 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 Jr Jacobs AK Adams CD Anderson JL Antman EM Faxon DP Fuster V Halperin JL Hiratzka LF Hunt SA Lytle BW Nishimura R Page RL Riegel B ACCAHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery focused update on perioperative beta-blocker therapy a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Writing Committee to Update 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 and Society for Vascular Medicine and Biology Circulation 2006 113 2662-74

bull Yang H Raymer K Butler R Parlow J Roberts R The effects of perioperative beta-blockade results of the Metoprolol after Vascular Surgery (MaVS) study a randomized controlled trial Am Heart J 2006 152 983-90

bull Juul AB Wetterslev J Gluud C Kofoed-Enevoldsen A Jensen G Callesen T Norgaard P Fruergaard K Bestle M Vedelsdal R Miran A Jacobsen J Roed J Mortensen MB Jorgensen L Jorgensen J Rovsing ML Petersen PL Pott F Haas M Albret R Nielsen LL Johansson G Stjernholm P Molgaard Y Foss NB Elkjaer J Dehlie B Boysen K Zaric D Munksgaard A Madsen JB Oberg B Khanykin B Blemmer T Yndgaard S Perko G Wang LP Winkel P Hilden J Jensen P Salas N Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery randomised placebo controlled blinded multicentre trial Bmj 2006 332 1482

bull Wallace AW Galindez D Salahieh A Layug EL Lazo EA Haratonik KA Boisvert DM Kardatzke D Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery Anesthesiology 2004 101 284-93

bull Hindler K Shaw AD Samuels J Fulton S Collard CD Riedel B Improved postoperative outcomes associated with preoperative statin therapy Anesthesiology 2006 105 1260-72

Durazzo AE Machado FS Ikeoka DT De Bernoche C Monachini MC Puech-Leao P Caramelli B Reduction in cardiovascular events after vascular surgery with atorvastatin a randomized trial J Vasc Surg 200439 967-75

bull (httpwwwaccorgqualityandscienceclinicaltopictopichtm)

Key wordsbull perioperative riskbull cardiac risk bull noncardiac surgerybull intraoperative riskbull postoperative risk bull risk stratification bull cardiac complication bull cardiac evaluationbull perioperative care bull preoperative evaluationbull preoperative assessmentbull intraoperative complications

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Valutazione del rischio cardiacoin chirurgia non cardiaca

CMelloniLibero professionista

Consulente di anestesia per Villa TorriVilla ChiaraPoliambulatorio Gynepro

Bologna

Revised cardiac index Lee TH Marcantonio ER Mangione CM Thomas EJ Polanczyk CA Cook EF

Sugarbaker DJ Donaldson MC Poss R Ho KK Ludwig LE Pedan A Goldman L Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac

Risk of Major Noncardiac Surgery Circulation 1999 100 1043-1049

bull bull High risk surgerybull ndash intraperitoneal intrathoracic or

suprainguinal vascular proceduresbull bull Ischemic heart diseasebull bull HO CHFbull bull HO Cerebrovascular diseasebull bull Insulin therapy for DMbull bull Preop Crgt20mgdl

bull Eagle KA Berger PB Calkins H Chaitman BR Ewy GA Fleischmann KE Fleisher LA Froehlich JB Gusberg RJ Leppo JA Ryan T Schlant RC Winters WL Jr Gibbons RJ Antman EM Alpert JSFaxon DP Fuster V Gregoratos G Jacobs AK Hiratzka LF Russell RO Smith SC Jr ACCAHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery---executive summary a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Circulation 2002105 1257-67

Weksler N Klein M Szendro G Rozentsveig V Schily M Brill S Tarnopolski A Ovadia L Gurman GM The dilemma of immediate preoperative hypertension to treat and operate or to postpone

surgery J Clin Anesth 2003 15 179-83

bull There is a great deal of debate regarding a trigger to delay or cancel a surgical procedure in a patient with poorly or untreated hypertension

bull In the absence of end-organ changes such as renal insufficiency or left ventricular hypertrophy with strain it would seem appropriate to proceed with surgery

bull A randomized trial of treated hypertensive patients without known CAD who presented the morning of surgery with an elevated diastolic blood pressure was unable to demonstrate any difference in outcome between those who were actively treated versus those in whom surgery was delayed

bull In contrast a patient with a markedly elevated blood pressure and the new onset of a headache should have surgery delayed for further evaluation and potential treatment

Howell SJ Sear YM Yeates D Goldacre M Sear JW Foeumlx P Hypertension admission blood pressure and perioperative

cardiovascular risk Anaesthesia 1996511000-1004

bull A retrospective case-controlled study which found that a history of hypertension was an important predictor for perioperative cardiac death but not admission blood pressure

bull The study implies that end-organ damage resulting from hypertension is the likely villain in this group of patients

bull Importance of Surgical Procedurebull The surgical procedure influences the extent of the preoperative

evaluation required by determining the potential range of changes in perioperative management There is little hard data to define the surgery specific incidence of complications and the rate may be very institution depedendent Eagle et al published data on the incidence of perioperative myocardial infarction and mortality by procedure for patients enrolled in the coronary artery surgery study (CASS)6 Higher risk procedures for which coronary artery bypass grafting reduced the risk of noncardiac surgery compared to medical therapy include major vascular abdominal thoracic and orthopedic surgery Ambulatory procedures denote low risk Vascular surgery represents a unique group of patients in whom there is extensive evidence regarding preoperative testing and perioperative interventions

bull Importance of exercise tolerancebull Exercise tolerance is one of the most important determinants of

perioperative risk and the need for invasive monitoring If a patient can walk a mile without becoming short of breath than the probability of extensive coronary artery disease is small Alternatively if patients become dyspneic associated with chest pain during minimal exertion then the probability of extensive coronary artery disease is high Reilly and colleagues demonstrated that the likelihood of a serious complication occurring was inversely related to the number of blocks that could be walked or flights of stairs that could be climbed7 Exercise tolerance can be assessed with formal treadmill testing or with a questionnaire that assesses activities of daily living

bull Reilly DF McNeely MJ Doerner D Greenberg DL Staiger TO Geist MJ Vedovatti PA Coffey JE Mora MW Johnson TR Guray ED Van Norman GA Fihn SD Self-reported exercise tolerance and the risk of serious perioperative complications Arch Intern Med 1999 159 2185-92

bull 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 Jr Jacobs AK Adams CD Anderson JL Antman EM Faxon DP Fuster V Halperin JL Hiratzka LF Hunt SA Lytle BW Nishimura R Page RL Riegel B ACCAHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery focused update on perioperative beta-blocker therapy a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Writing Committee to Update 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 and Society for Vascular Medicine and Biology Circulation 2006 113 2662-74

bull Yang H Raymer K Butler R Parlow J Roberts R The effects of perioperative beta-blockade results of the Metoprolol after Vascular Surgery (MaVS) study a randomized controlled trial Am Heart J 2006 152 983-90

bull Juul AB Wetterslev J Gluud C Kofoed-Enevoldsen A Jensen G Callesen T Norgaard P Fruergaard K Bestle M Vedelsdal R Miran A Jacobsen J Roed J Mortensen MB Jorgensen L Jorgensen J Rovsing ML Petersen PL Pott F Haas M Albret R Nielsen LL Johansson G Stjernholm P Molgaard Y Foss NB Elkjaer J Dehlie B Boysen K Zaric D Munksgaard A Madsen JB Oberg B Khanykin B Blemmer T Yndgaard S Perko G Wang LP Winkel P Hilden J Jensen P Salas N Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery randomised placebo controlled blinded multicentre trial Bmj 2006 332 1482

bull Wallace AW Galindez D Salahieh A Layug EL Lazo EA Haratonik KA Boisvert DM Kardatzke D Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery Anesthesiology 2004 101 284-93

bull Hindler K Shaw AD Samuels J Fulton S Collard CD Riedel B Improved postoperative outcomes associated with preoperative statin therapy Anesthesiology 2006 105 1260-72

Durazzo AE Machado FS Ikeoka DT De Bernoche C Monachini MC Puech-Leao P Caramelli B Reduction in cardiovascular events after vascular surgery with atorvastatin a randomized trial J Vasc Surg 200439 967-75

bull (httpwwwaccorgqualityandscienceclinicaltopictopichtm)

Key wordsbull perioperative riskbull cardiac risk bull noncardiac surgerybull intraoperative riskbull postoperative risk bull risk stratification bull cardiac complication bull cardiac evaluationbull perioperative care bull preoperative evaluationbull preoperative assessmentbull intraoperative complications

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Revised cardiac index Lee TH Marcantonio ER Mangione CM Thomas EJ Polanczyk CA Cook EF

Sugarbaker DJ Donaldson MC Poss R Ho KK Ludwig LE Pedan A Goldman L Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac

Risk of Major Noncardiac Surgery Circulation 1999 100 1043-1049

bull bull High risk surgerybull ndash intraperitoneal intrathoracic or

suprainguinal vascular proceduresbull bull Ischemic heart diseasebull bull HO CHFbull bull HO Cerebrovascular diseasebull bull Insulin therapy for DMbull bull Preop Crgt20mgdl

bull Eagle KA Berger PB Calkins H Chaitman BR Ewy GA Fleischmann KE Fleisher LA Froehlich JB Gusberg RJ Leppo JA Ryan T Schlant RC Winters WL Jr Gibbons RJ Antman EM Alpert JSFaxon DP Fuster V Gregoratos G Jacobs AK Hiratzka LF Russell RO Smith SC Jr ACCAHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery---executive summary a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Circulation 2002105 1257-67

Weksler N Klein M Szendro G Rozentsveig V Schily M Brill S Tarnopolski A Ovadia L Gurman GM The dilemma of immediate preoperative hypertension to treat and operate or to postpone

surgery J Clin Anesth 2003 15 179-83

bull There is a great deal of debate regarding a trigger to delay or cancel a surgical procedure in a patient with poorly or untreated hypertension

bull In the absence of end-organ changes such as renal insufficiency or left ventricular hypertrophy with strain it would seem appropriate to proceed with surgery

bull A randomized trial of treated hypertensive patients without known CAD who presented the morning of surgery with an elevated diastolic blood pressure was unable to demonstrate any difference in outcome between those who were actively treated versus those in whom surgery was delayed

bull In contrast a patient with a markedly elevated blood pressure and the new onset of a headache should have surgery delayed for further evaluation and potential treatment

Howell SJ Sear YM Yeates D Goldacre M Sear JW Foeumlx P Hypertension admission blood pressure and perioperative

cardiovascular risk Anaesthesia 1996511000-1004

bull A retrospective case-controlled study which found that a history of hypertension was an important predictor for perioperative cardiac death but not admission blood pressure

bull The study implies that end-organ damage resulting from hypertension is the likely villain in this group of patients

bull Importance of Surgical Procedurebull The surgical procedure influences the extent of the preoperative

evaluation required by determining the potential range of changes in perioperative management There is little hard data to define the surgery specific incidence of complications and the rate may be very institution depedendent Eagle et al published data on the incidence of perioperative myocardial infarction and mortality by procedure for patients enrolled in the coronary artery surgery study (CASS)6 Higher risk procedures for which coronary artery bypass grafting reduced the risk of noncardiac surgery compared to medical therapy include major vascular abdominal thoracic and orthopedic surgery Ambulatory procedures denote low risk Vascular surgery represents a unique group of patients in whom there is extensive evidence regarding preoperative testing and perioperative interventions

bull Importance of exercise tolerancebull Exercise tolerance is one of the most important determinants of

perioperative risk and the need for invasive monitoring If a patient can walk a mile without becoming short of breath than the probability of extensive coronary artery disease is small Alternatively if patients become dyspneic associated with chest pain during minimal exertion then the probability of extensive coronary artery disease is high Reilly and colleagues demonstrated that the likelihood of a serious complication occurring was inversely related to the number of blocks that could be walked or flights of stairs that could be climbed7 Exercise tolerance can be assessed with formal treadmill testing or with a questionnaire that assesses activities of daily living

bull Reilly DF McNeely MJ Doerner D Greenberg DL Staiger TO Geist MJ Vedovatti PA Coffey JE Mora MW Johnson TR Guray ED Van Norman GA Fihn SD Self-reported exercise tolerance and the risk of serious perioperative complications Arch Intern Med 1999 159 2185-92

bull 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 Jr Jacobs AK Adams CD Anderson JL Antman EM Faxon DP Fuster V Halperin JL Hiratzka LF Hunt SA Lytle BW Nishimura R Page RL Riegel B ACCAHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery focused update on perioperative beta-blocker therapy a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Writing Committee to Update 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 and Society for Vascular Medicine and Biology Circulation 2006 113 2662-74

bull Yang H Raymer K Butler R Parlow J Roberts R The effects of perioperative beta-blockade results of the Metoprolol after Vascular Surgery (MaVS) study a randomized controlled trial Am Heart J 2006 152 983-90

bull Juul AB Wetterslev J Gluud C Kofoed-Enevoldsen A Jensen G Callesen T Norgaard P Fruergaard K Bestle M Vedelsdal R Miran A Jacobsen J Roed J Mortensen MB Jorgensen L Jorgensen J Rovsing ML Petersen PL Pott F Haas M Albret R Nielsen LL Johansson G Stjernholm P Molgaard Y Foss NB Elkjaer J Dehlie B Boysen K Zaric D Munksgaard A Madsen JB Oberg B Khanykin B Blemmer T Yndgaard S Perko G Wang LP Winkel P Hilden J Jensen P Salas N Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery randomised placebo controlled blinded multicentre trial Bmj 2006 332 1482

bull Wallace AW Galindez D Salahieh A Layug EL Lazo EA Haratonik KA Boisvert DM Kardatzke D Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery Anesthesiology 2004 101 284-93

bull Hindler K Shaw AD Samuels J Fulton S Collard CD Riedel B Improved postoperative outcomes associated with preoperative statin therapy Anesthesiology 2006 105 1260-72

Durazzo AE Machado FS Ikeoka DT De Bernoche C Monachini MC Puech-Leao P Caramelli B Reduction in cardiovascular events after vascular surgery with atorvastatin a randomized trial J Vasc Surg 200439 967-75

bull (httpwwwaccorgqualityandscienceclinicaltopictopichtm)

Key wordsbull perioperative riskbull cardiac risk bull noncardiac surgerybull intraoperative riskbull postoperative risk bull risk stratification bull cardiac complication bull cardiac evaluationbull perioperative care bull preoperative evaluationbull preoperative assessmentbull intraoperative complications

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

bull Eagle KA Berger PB Calkins H Chaitman BR Ewy GA Fleischmann KE Fleisher LA Froehlich JB Gusberg RJ Leppo JA Ryan T Schlant RC Winters WL Jr Gibbons RJ Antman EM Alpert JSFaxon DP Fuster V Gregoratos G Jacobs AK Hiratzka LF Russell RO Smith SC Jr ACCAHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery---executive summary a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Circulation 2002105 1257-67

Weksler N Klein M Szendro G Rozentsveig V Schily M Brill S Tarnopolski A Ovadia L Gurman GM The dilemma of immediate preoperative hypertension to treat and operate or to postpone

surgery J Clin Anesth 2003 15 179-83

bull There is a great deal of debate regarding a trigger to delay or cancel a surgical procedure in a patient with poorly or untreated hypertension

bull In the absence of end-organ changes such as renal insufficiency or left ventricular hypertrophy with strain it would seem appropriate to proceed with surgery

bull A randomized trial of treated hypertensive patients without known CAD who presented the morning of surgery with an elevated diastolic blood pressure was unable to demonstrate any difference in outcome between those who were actively treated versus those in whom surgery was delayed

bull In contrast a patient with a markedly elevated blood pressure and the new onset of a headache should have surgery delayed for further evaluation and potential treatment

Howell SJ Sear YM Yeates D Goldacre M Sear JW Foeumlx P Hypertension admission blood pressure and perioperative

cardiovascular risk Anaesthesia 1996511000-1004

bull A retrospective case-controlled study which found that a history of hypertension was an important predictor for perioperative cardiac death but not admission blood pressure

bull The study implies that end-organ damage resulting from hypertension is the likely villain in this group of patients

bull Importance of Surgical Procedurebull The surgical procedure influences the extent of the preoperative

evaluation required by determining the potential range of changes in perioperative management There is little hard data to define the surgery specific incidence of complications and the rate may be very institution depedendent Eagle et al published data on the incidence of perioperative myocardial infarction and mortality by procedure for patients enrolled in the coronary artery surgery study (CASS)6 Higher risk procedures for which coronary artery bypass grafting reduced the risk of noncardiac surgery compared to medical therapy include major vascular abdominal thoracic and orthopedic surgery Ambulatory procedures denote low risk Vascular surgery represents a unique group of patients in whom there is extensive evidence regarding preoperative testing and perioperative interventions

bull Importance of exercise tolerancebull Exercise tolerance is one of the most important determinants of

perioperative risk and the need for invasive monitoring If a patient can walk a mile without becoming short of breath than the probability of extensive coronary artery disease is small Alternatively if patients become dyspneic associated with chest pain during minimal exertion then the probability of extensive coronary artery disease is high Reilly and colleagues demonstrated that the likelihood of a serious complication occurring was inversely related to the number of blocks that could be walked or flights of stairs that could be climbed7 Exercise tolerance can be assessed with formal treadmill testing or with a questionnaire that assesses activities of daily living

bull Reilly DF McNeely MJ Doerner D Greenberg DL Staiger TO Geist MJ Vedovatti PA Coffey JE Mora MW Johnson TR Guray ED Van Norman GA Fihn SD Self-reported exercise tolerance and the risk of serious perioperative complications Arch Intern Med 1999 159 2185-92

bull 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 Jr Jacobs AK Adams CD Anderson JL Antman EM Faxon DP Fuster V Halperin JL Hiratzka LF Hunt SA Lytle BW Nishimura R Page RL Riegel B ACCAHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery focused update on perioperative beta-blocker therapy a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Writing Committee to Update 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 and Society for Vascular Medicine and Biology Circulation 2006 113 2662-74

bull Yang H Raymer K Butler R Parlow J Roberts R The effects of perioperative beta-blockade results of the Metoprolol after Vascular Surgery (MaVS) study a randomized controlled trial Am Heart J 2006 152 983-90

bull Juul AB Wetterslev J Gluud C Kofoed-Enevoldsen A Jensen G Callesen T Norgaard P Fruergaard K Bestle M Vedelsdal R Miran A Jacobsen J Roed J Mortensen MB Jorgensen L Jorgensen J Rovsing ML Petersen PL Pott F Haas M Albret R Nielsen LL Johansson G Stjernholm P Molgaard Y Foss NB Elkjaer J Dehlie B Boysen K Zaric D Munksgaard A Madsen JB Oberg B Khanykin B Blemmer T Yndgaard S Perko G Wang LP Winkel P Hilden J Jensen P Salas N Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery randomised placebo controlled blinded multicentre trial Bmj 2006 332 1482

bull Wallace AW Galindez D Salahieh A Layug EL Lazo EA Haratonik KA Boisvert DM Kardatzke D Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery Anesthesiology 2004 101 284-93

bull Hindler K Shaw AD Samuels J Fulton S Collard CD Riedel B Improved postoperative outcomes associated with preoperative statin therapy Anesthesiology 2006 105 1260-72

Durazzo AE Machado FS Ikeoka DT De Bernoche C Monachini MC Puech-Leao P Caramelli B Reduction in cardiovascular events after vascular surgery with atorvastatin a randomized trial J Vasc Surg 200439 967-75

bull (httpwwwaccorgqualityandscienceclinicaltopictopichtm)

Key wordsbull perioperative riskbull cardiac risk bull noncardiac surgerybull intraoperative riskbull postoperative risk bull risk stratification bull cardiac complication bull cardiac evaluationbull perioperative care bull preoperative evaluationbull preoperative assessmentbull intraoperative complications

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Weksler N Klein M Szendro G Rozentsveig V Schily M Brill S Tarnopolski A Ovadia L Gurman GM The dilemma of immediate preoperative hypertension to treat and operate or to postpone

surgery J Clin Anesth 2003 15 179-83

bull There is a great deal of debate regarding a trigger to delay or cancel a surgical procedure in a patient with poorly or untreated hypertension

bull In the absence of end-organ changes such as renal insufficiency or left ventricular hypertrophy with strain it would seem appropriate to proceed with surgery

bull A randomized trial of treated hypertensive patients without known CAD who presented the morning of surgery with an elevated diastolic blood pressure was unable to demonstrate any difference in outcome between those who were actively treated versus those in whom surgery was delayed

bull In contrast a patient with a markedly elevated blood pressure and the new onset of a headache should have surgery delayed for further evaluation and potential treatment

Howell SJ Sear YM Yeates D Goldacre M Sear JW Foeumlx P Hypertension admission blood pressure and perioperative

cardiovascular risk Anaesthesia 1996511000-1004

bull A retrospective case-controlled study which found that a history of hypertension was an important predictor for perioperative cardiac death but not admission blood pressure

bull The study implies that end-organ damage resulting from hypertension is the likely villain in this group of patients

bull Importance of Surgical Procedurebull The surgical procedure influences the extent of the preoperative

evaluation required by determining the potential range of changes in perioperative management There is little hard data to define the surgery specific incidence of complications and the rate may be very institution depedendent Eagle et al published data on the incidence of perioperative myocardial infarction and mortality by procedure for patients enrolled in the coronary artery surgery study (CASS)6 Higher risk procedures for which coronary artery bypass grafting reduced the risk of noncardiac surgery compared to medical therapy include major vascular abdominal thoracic and orthopedic surgery Ambulatory procedures denote low risk Vascular surgery represents a unique group of patients in whom there is extensive evidence regarding preoperative testing and perioperative interventions

bull Importance of exercise tolerancebull Exercise tolerance is one of the most important determinants of

perioperative risk and the need for invasive monitoring If a patient can walk a mile without becoming short of breath than the probability of extensive coronary artery disease is small Alternatively if patients become dyspneic associated with chest pain during minimal exertion then the probability of extensive coronary artery disease is high Reilly and colleagues demonstrated that the likelihood of a serious complication occurring was inversely related to the number of blocks that could be walked or flights of stairs that could be climbed7 Exercise tolerance can be assessed with formal treadmill testing or with a questionnaire that assesses activities of daily living

bull Reilly DF McNeely MJ Doerner D Greenberg DL Staiger TO Geist MJ Vedovatti PA Coffey JE Mora MW Johnson TR Guray ED Van Norman GA Fihn SD Self-reported exercise tolerance and the risk of serious perioperative complications Arch Intern Med 1999 159 2185-92

bull 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 Jr Jacobs AK Adams CD Anderson JL Antman EM Faxon DP Fuster V Halperin JL Hiratzka LF Hunt SA Lytle BW Nishimura R Page RL Riegel B ACCAHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery focused update on perioperative beta-blocker therapy a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Writing Committee to Update 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 and Society for Vascular Medicine and Biology Circulation 2006 113 2662-74

bull Yang H Raymer K Butler R Parlow J Roberts R The effects of perioperative beta-blockade results of the Metoprolol after Vascular Surgery (MaVS) study a randomized controlled trial Am Heart J 2006 152 983-90

bull Juul AB Wetterslev J Gluud C Kofoed-Enevoldsen A Jensen G Callesen T Norgaard P Fruergaard K Bestle M Vedelsdal R Miran A Jacobsen J Roed J Mortensen MB Jorgensen L Jorgensen J Rovsing ML Petersen PL Pott F Haas M Albret R Nielsen LL Johansson G Stjernholm P Molgaard Y Foss NB Elkjaer J Dehlie B Boysen K Zaric D Munksgaard A Madsen JB Oberg B Khanykin B Blemmer T Yndgaard S Perko G Wang LP Winkel P Hilden J Jensen P Salas N Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery randomised placebo controlled blinded multicentre trial Bmj 2006 332 1482

bull Wallace AW Galindez D Salahieh A Layug EL Lazo EA Haratonik KA Boisvert DM Kardatzke D Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery Anesthesiology 2004 101 284-93

bull Hindler K Shaw AD Samuels J Fulton S Collard CD Riedel B Improved postoperative outcomes associated with preoperative statin therapy Anesthesiology 2006 105 1260-72

Durazzo AE Machado FS Ikeoka DT De Bernoche C Monachini MC Puech-Leao P Caramelli B Reduction in cardiovascular events after vascular surgery with atorvastatin a randomized trial J Vasc Surg 200439 967-75

bull (httpwwwaccorgqualityandscienceclinicaltopictopichtm)

Key wordsbull perioperative riskbull cardiac risk bull noncardiac surgerybull intraoperative riskbull postoperative risk bull risk stratification bull cardiac complication bull cardiac evaluationbull perioperative care bull preoperative evaluationbull preoperative assessmentbull intraoperative complications

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Howell SJ Sear YM Yeates D Goldacre M Sear JW Foeumlx P Hypertension admission blood pressure and perioperative

cardiovascular risk Anaesthesia 1996511000-1004

bull A retrospective case-controlled study which found that a history of hypertension was an important predictor for perioperative cardiac death but not admission blood pressure

bull The study implies that end-organ damage resulting from hypertension is the likely villain in this group of patients

bull Importance of Surgical Procedurebull The surgical procedure influences the extent of the preoperative

evaluation required by determining the potential range of changes in perioperative management There is little hard data to define the surgery specific incidence of complications and the rate may be very institution depedendent Eagle et al published data on the incidence of perioperative myocardial infarction and mortality by procedure for patients enrolled in the coronary artery surgery study (CASS)6 Higher risk procedures for which coronary artery bypass grafting reduced the risk of noncardiac surgery compared to medical therapy include major vascular abdominal thoracic and orthopedic surgery Ambulatory procedures denote low risk Vascular surgery represents a unique group of patients in whom there is extensive evidence regarding preoperative testing and perioperative interventions

bull Importance of exercise tolerancebull Exercise tolerance is one of the most important determinants of

perioperative risk and the need for invasive monitoring If a patient can walk a mile without becoming short of breath than the probability of extensive coronary artery disease is small Alternatively if patients become dyspneic associated with chest pain during minimal exertion then the probability of extensive coronary artery disease is high Reilly and colleagues demonstrated that the likelihood of a serious complication occurring was inversely related to the number of blocks that could be walked or flights of stairs that could be climbed7 Exercise tolerance can be assessed with formal treadmill testing or with a questionnaire that assesses activities of daily living

bull Reilly DF McNeely MJ Doerner D Greenberg DL Staiger TO Geist MJ Vedovatti PA Coffey JE Mora MW Johnson TR Guray ED Van Norman GA Fihn SD Self-reported exercise tolerance and the risk of serious perioperative complications Arch Intern Med 1999 159 2185-92

bull 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 Jr Jacobs AK Adams CD Anderson JL Antman EM Faxon DP Fuster V Halperin JL Hiratzka LF Hunt SA Lytle BW Nishimura R Page RL Riegel B ACCAHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery focused update on perioperative beta-blocker therapy a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Writing Committee to Update 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 and Society for Vascular Medicine and Biology Circulation 2006 113 2662-74

bull Yang H Raymer K Butler R Parlow J Roberts R The effects of perioperative beta-blockade results of the Metoprolol after Vascular Surgery (MaVS) study a randomized controlled trial Am Heart J 2006 152 983-90

bull Juul AB Wetterslev J Gluud C Kofoed-Enevoldsen A Jensen G Callesen T Norgaard P Fruergaard K Bestle M Vedelsdal R Miran A Jacobsen J Roed J Mortensen MB Jorgensen L Jorgensen J Rovsing ML Petersen PL Pott F Haas M Albret R Nielsen LL Johansson G Stjernholm P Molgaard Y Foss NB Elkjaer J Dehlie B Boysen K Zaric D Munksgaard A Madsen JB Oberg B Khanykin B Blemmer T Yndgaard S Perko G Wang LP Winkel P Hilden J Jensen P Salas N Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery randomised placebo controlled blinded multicentre trial Bmj 2006 332 1482

bull Wallace AW Galindez D Salahieh A Layug EL Lazo EA Haratonik KA Boisvert DM Kardatzke D Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery Anesthesiology 2004 101 284-93

bull Hindler K Shaw AD Samuels J Fulton S Collard CD Riedel B Improved postoperative outcomes associated with preoperative statin therapy Anesthesiology 2006 105 1260-72

Durazzo AE Machado FS Ikeoka DT De Bernoche C Monachini MC Puech-Leao P Caramelli B Reduction in cardiovascular events after vascular surgery with atorvastatin a randomized trial J Vasc Surg 200439 967-75

bull (httpwwwaccorgqualityandscienceclinicaltopictopichtm)

Key wordsbull perioperative riskbull cardiac risk bull noncardiac surgerybull intraoperative riskbull postoperative risk bull risk stratification bull cardiac complication bull cardiac evaluationbull perioperative care bull preoperative evaluationbull preoperative assessmentbull intraoperative complications

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

bull Importance of Surgical Procedurebull The surgical procedure influences the extent of the preoperative

evaluation required by determining the potential range of changes in perioperative management There is little hard data to define the surgery specific incidence of complications and the rate may be very institution depedendent Eagle et al published data on the incidence of perioperative myocardial infarction and mortality by procedure for patients enrolled in the coronary artery surgery study (CASS)6 Higher risk procedures for which coronary artery bypass grafting reduced the risk of noncardiac surgery compared to medical therapy include major vascular abdominal thoracic and orthopedic surgery Ambulatory procedures denote low risk Vascular surgery represents a unique group of patients in whom there is extensive evidence regarding preoperative testing and perioperative interventions

bull Importance of exercise tolerancebull Exercise tolerance is one of the most important determinants of

perioperative risk and the need for invasive monitoring If a patient can walk a mile without becoming short of breath than the probability of extensive coronary artery disease is small Alternatively if patients become dyspneic associated with chest pain during minimal exertion then the probability of extensive coronary artery disease is high Reilly and colleagues demonstrated that the likelihood of a serious complication occurring was inversely related to the number of blocks that could be walked or flights of stairs that could be climbed7 Exercise tolerance can be assessed with formal treadmill testing or with a questionnaire that assesses activities of daily living

bull Reilly DF McNeely MJ Doerner D Greenberg DL Staiger TO Geist MJ Vedovatti PA Coffey JE Mora MW Johnson TR Guray ED Van Norman GA Fihn SD Self-reported exercise tolerance and the risk of serious perioperative complications Arch Intern Med 1999 159 2185-92

bull 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 Jr Jacobs AK Adams CD Anderson JL Antman EM Faxon DP Fuster V Halperin JL Hiratzka LF Hunt SA Lytle BW Nishimura R Page RL Riegel B ACCAHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery focused update on perioperative beta-blocker therapy a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Writing Committee to Update 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 and Society for Vascular Medicine and Biology Circulation 2006 113 2662-74

bull Yang H Raymer K Butler R Parlow J Roberts R The effects of perioperative beta-blockade results of the Metoprolol after Vascular Surgery (MaVS) study a randomized controlled trial Am Heart J 2006 152 983-90

bull Juul AB Wetterslev J Gluud C Kofoed-Enevoldsen A Jensen G Callesen T Norgaard P Fruergaard K Bestle M Vedelsdal R Miran A Jacobsen J Roed J Mortensen MB Jorgensen L Jorgensen J Rovsing ML Petersen PL Pott F Haas M Albret R Nielsen LL Johansson G Stjernholm P Molgaard Y Foss NB Elkjaer J Dehlie B Boysen K Zaric D Munksgaard A Madsen JB Oberg B Khanykin B Blemmer T Yndgaard S Perko G Wang LP Winkel P Hilden J Jensen P Salas N Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery randomised placebo controlled blinded multicentre trial Bmj 2006 332 1482

bull Wallace AW Galindez D Salahieh A Layug EL Lazo EA Haratonik KA Boisvert DM Kardatzke D Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery Anesthesiology 2004 101 284-93

bull Hindler K Shaw AD Samuels J Fulton S Collard CD Riedel B Improved postoperative outcomes associated with preoperative statin therapy Anesthesiology 2006 105 1260-72

Durazzo AE Machado FS Ikeoka DT De Bernoche C Monachini MC Puech-Leao P Caramelli B Reduction in cardiovascular events after vascular surgery with atorvastatin a randomized trial J Vasc Surg 200439 967-75

bull (httpwwwaccorgqualityandscienceclinicaltopictopichtm)

Key wordsbull perioperative riskbull cardiac risk bull noncardiac surgerybull intraoperative riskbull postoperative risk bull risk stratification bull cardiac complication bull cardiac evaluationbull perioperative care bull preoperative evaluationbull preoperative assessmentbull intraoperative complications

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

bull Importance of exercise tolerancebull Exercise tolerance is one of the most important determinants of

perioperative risk and the need for invasive monitoring If a patient can walk a mile without becoming short of breath than the probability of extensive coronary artery disease is small Alternatively if patients become dyspneic associated with chest pain during minimal exertion then the probability of extensive coronary artery disease is high Reilly and colleagues demonstrated that the likelihood of a serious complication occurring was inversely related to the number of blocks that could be walked or flights of stairs that could be climbed7 Exercise tolerance can be assessed with formal treadmill testing or with a questionnaire that assesses activities of daily living

bull Reilly DF McNeely MJ Doerner D Greenberg DL Staiger TO Geist MJ Vedovatti PA Coffey JE Mora MW Johnson TR Guray ED Van Norman GA Fihn SD Self-reported exercise tolerance and the risk of serious perioperative complications Arch Intern Med 1999 159 2185-92

bull 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 Jr Jacobs AK Adams CD Anderson JL Antman EM Faxon DP Fuster V Halperin JL Hiratzka LF Hunt SA Lytle BW Nishimura R Page RL Riegel B ACCAHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery focused update on perioperative beta-blocker therapy a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Writing Committee to Update 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 and Society for Vascular Medicine and Biology Circulation 2006 113 2662-74

bull Yang H Raymer K Butler R Parlow J Roberts R The effects of perioperative beta-blockade results of the Metoprolol after Vascular Surgery (MaVS) study a randomized controlled trial Am Heart J 2006 152 983-90

bull Juul AB Wetterslev J Gluud C Kofoed-Enevoldsen A Jensen G Callesen T Norgaard P Fruergaard K Bestle M Vedelsdal R Miran A Jacobsen J Roed J Mortensen MB Jorgensen L Jorgensen J Rovsing ML Petersen PL Pott F Haas M Albret R Nielsen LL Johansson G Stjernholm P Molgaard Y Foss NB Elkjaer J Dehlie B Boysen K Zaric D Munksgaard A Madsen JB Oberg B Khanykin B Blemmer T Yndgaard S Perko G Wang LP Winkel P Hilden J Jensen P Salas N Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery randomised placebo controlled blinded multicentre trial Bmj 2006 332 1482

bull Wallace AW Galindez D Salahieh A Layug EL Lazo EA Haratonik KA Boisvert DM Kardatzke D Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery Anesthesiology 2004 101 284-93

bull Hindler K Shaw AD Samuels J Fulton S Collard CD Riedel B Improved postoperative outcomes associated with preoperative statin therapy Anesthesiology 2006 105 1260-72

Durazzo AE Machado FS Ikeoka DT De Bernoche C Monachini MC Puech-Leao P Caramelli B Reduction in cardiovascular events after vascular surgery with atorvastatin a randomized trial J Vasc Surg 200439 967-75

bull (httpwwwaccorgqualityandscienceclinicaltopictopichtm)

Key wordsbull perioperative riskbull cardiac risk bull noncardiac surgerybull intraoperative riskbull postoperative risk bull risk stratification bull cardiac complication bull cardiac evaluationbull perioperative care bull preoperative evaluationbull preoperative assessmentbull intraoperative complications

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

bull Reilly DF McNeely MJ Doerner D Greenberg DL Staiger TO Geist MJ Vedovatti PA Coffey JE Mora MW Johnson TR Guray ED Van Norman GA Fihn SD Self-reported exercise tolerance and the risk of serious perioperative complications Arch Intern Med 1999 159 2185-92

bull 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 Jr Jacobs AK Adams CD Anderson JL Antman EM Faxon DP Fuster V Halperin JL Hiratzka LF Hunt SA Lytle BW Nishimura R Page RL Riegel B ACCAHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery focused update on perioperative beta-blocker therapy a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Writing Committee to Update 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 and Society for Vascular Medicine and Biology Circulation 2006 113 2662-74

bull Yang H Raymer K Butler R Parlow J Roberts R The effects of perioperative beta-blockade results of the Metoprolol after Vascular Surgery (MaVS) study a randomized controlled trial Am Heart J 2006 152 983-90

bull Juul AB Wetterslev J Gluud C Kofoed-Enevoldsen A Jensen G Callesen T Norgaard P Fruergaard K Bestle M Vedelsdal R Miran A Jacobsen J Roed J Mortensen MB Jorgensen L Jorgensen J Rovsing ML Petersen PL Pott F Haas M Albret R Nielsen LL Johansson G Stjernholm P Molgaard Y Foss NB Elkjaer J Dehlie B Boysen K Zaric D Munksgaard A Madsen JB Oberg B Khanykin B Blemmer T Yndgaard S Perko G Wang LP Winkel P Hilden J Jensen P Salas N Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery randomised placebo controlled blinded multicentre trial Bmj 2006 332 1482

bull Wallace AW Galindez D Salahieh A Layug EL Lazo EA Haratonik KA Boisvert DM Kardatzke D Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery Anesthesiology 2004 101 284-93

bull Hindler K Shaw AD Samuels J Fulton S Collard CD Riedel B Improved postoperative outcomes associated with preoperative statin therapy Anesthesiology 2006 105 1260-72

Durazzo AE Machado FS Ikeoka DT De Bernoche C Monachini MC Puech-Leao P Caramelli B Reduction in cardiovascular events after vascular surgery with atorvastatin a randomized trial J Vasc Surg 200439 967-75

bull (httpwwwaccorgqualityandscienceclinicaltopictopichtm)

Key wordsbull perioperative riskbull cardiac risk bull noncardiac surgerybull intraoperative riskbull postoperative risk bull risk stratification bull cardiac complication bull cardiac evaluationbull perioperative care bull preoperative evaluationbull preoperative assessmentbull intraoperative complications

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

bull 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 Jr Jacobs AK Adams CD Anderson JL Antman EM Faxon DP Fuster V Halperin JL Hiratzka LF Hunt SA Lytle BW Nishimura R Page RL Riegel B ACCAHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery focused update on perioperative beta-blocker therapy a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Writing Committee to Update 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 and Society for Vascular Medicine and Biology Circulation 2006 113 2662-74

bull Yang H Raymer K Butler R Parlow J Roberts R The effects of perioperative beta-blockade results of the Metoprolol after Vascular Surgery (MaVS) study a randomized controlled trial Am Heart J 2006 152 983-90

bull Juul AB Wetterslev J Gluud C Kofoed-Enevoldsen A Jensen G Callesen T Norgaard P Fruergaard K Bestle M Vedelsdal R Miran A Jacobsen J Roed J Mortensen MB Jorgensen L Jorgensen J Rovsing ML Petersen PL Pott F Haas M Albret R Nielsen LL Johansson G Stjernholm P Molgaard Y Foss NB Elkjaer J Dehlie B Boysen K Zaric D Munksgaard A Madsen JB Oberg B Khanykin B Blemmer T Yndgaard S Perko G Wang LP Winkel P Hilden J Jensen P Salas N Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery randomised placebo controlled blinded multicentre trial Bmj 2006 332 1482

bull Wallace AW Galindez D Salahieh A Layug EL Lazo EA Haratonik KA Boisvert DM Kardatzke D Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery Anesthesiology 2004 101 284-93

bull Hindler K Shaw AD Samuels J Fulton S Collard CD Riedel B Improved postoperative outcomes associated with preoperative statin therapy Anesthesiology 2006 105 1260-72

Durazzo AE Machado FS Ikeoka DT De Bernoche C Monachini MC Puech-Leao P Caramelli B Reduction in cardiovascular events after vascular surgery with atorvastatin a randomized trial J Vasc Surg 200439 967-75

bull (httpwwwaccorgqualityandscienceclinicaltopictopichtm)

Key wordsbull perioperative riskbull cardiac risk bull noncardiac surgerybull intraoperative riskbull postoperative risk bull risk stratification bull cardiac complication bull cardiac evaluationbull perioperative care bull preoperative evaluationbull preoperative assessmentbull intraoperative complications

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

bull Yang H Raymer K Butler R Parlow J Roberts R The effects of perioperative beta-blockade results of the Metoprolol after Vascular Surgery (MaVS) study a randomized controlled trial Am Heart J 2006 152 983-90

bull Juul AB Wetterslev J Gluud C Kofoed-Enevoldsen A Jensen G Callesen T Norgaard P Fruergaard K Bestle M Vedelsdal R Miran A Jacobsen J Roed J Mortensen MB Jorgensen L Jorgensen J Rovsing ML Petersen PL Pott F Haas M Albret R Nielsen LL Johansson G Stjernholm P Molgaard Y Foss NB Elkjaer J Dehlie B Boysen K Zaric D Munksgaard A Madsen JB Oberg B Khanykin B Blemmer T Yndgaard S Perko G Wang LP Winkel P Hilden J Jensen P Salas N Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery randomised placebo controlled blinded multicentre trial Bmj 2006 332 1482

bull Wallace AW Galindez D Salahieh A Layug EL Lazo EA Haratonik KA Boisvert DM Kardatzke D Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery Anesthesiology 2004 101 284-93

bull Hindler K Shaw AD Samuels J Fulton S Collard CD Riedel B Improved postoperative outcomes associated with preoperative statin therapy Anesthesiology 2006 105 1260-72

Durazzo AE Machado FS Ikeoka DT De Bernoche C Monachini MC Puech-Leao P Caramelli B Reduction in cardiovascular events after vascular surgery with atorvastatin a randomized trial J Vasc Surg 200439 967-75

bull (httpwwwaccorgqualityandscienceclinicaltopictopichtm)

Key wordsbull perioperative riskbull cardiac risk bull noncardiac surgerybull intraoperative riskbull postoperative risk bull risk stratification bull cardiac complication bull cardiac evaluationbull perioperative care bull preoperative evaluationbull preoperative assessmentbull intraoperative complications

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

bull (httpwwwaccorgqualityandscienceclinicaltopictopichtm)

Key wordsbull perioperative riskbull cardiac risk bull noncardiac surgerybull intraoperative riskbull postoperative risk bull risk stratification bull cardiac complication bull cardiac evaluationbull perioperative care bull preoperative evaluationbull preoperative assessmentbull intraoperative complications

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Key wordsbull perioperative riskbull cardiac risk bull noncardiac surgerybull intraoperative riskbull postoperative risk bull risk stratification bull cardiac complication bull cardiac evaluationbull perioperative care bull preoperative evaluationbull preoperative assessmentbull intraoperative complications

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Estimated Energy Requirements for Various Activities

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Beta blockersbull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat

angina symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)

bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the finding of ischemia on preoperative testing (Level of Evidence B)

bull CLASS IIa bull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIb bull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk

procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C)

bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who are not currently taking beta blockers (Level of Evidence B)

bull CLASS IIIbull Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidencebull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to

patients with an intermediate or high risk of cardiac complications

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlands

bull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in the incidence of perioperative mortality and nonfatal myocardial

infarction in patients undergoing abdominal aortic aneurysm surgeryKertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR

Poldermans Dbull 570 pazienti sottoposti a chirurgic dellrsquoaorta addominale bull Perioperative mortality or MI occurred in 51 (89) patients bull Perioperative mortality or MI significantly lower in statin users compared

to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001)

bull Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054)

bull Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

bull

Heart failure as a risk factor

Hammill BGCurtisLHBennett-Guerrior EOrsquoConnorCMJollis JCSchulman KAHernandez AFImpact of heart failure on patients

undergoing major noncardiac surgeryAnesthesiology 2008108559-67

bull Medicare 5 standard analytic filesbull Inpatients fee for service claims 2000-20004bull Patients gt65 for major noncardiac surgery

ndash Carotid endarterectomyndash Lower extr bypassndash Open AAAndash Hip replacementndash Knee replacementndash Spinal fusionndash Above and below knee amputationndash Open and laparoscopic cholecystectomyndash Cancer resection abdominallungcolon

Hammill et alImpact of heart failure on patients undergoing major noncardiac surgeryAnesthesiology

bull Main outcome ndash Operative mortalityndash 30 days readmission

Hammill et al Impact of heart failure on patients undergoing major noncardiac surgeryAnesthesiology 2008108(4) 559-567

bull I pazienti di etagrave ge65 annibull inseriti nel programma assicurativo statunitense Medicarebull sottoposti tra il 2000 e il 2004 ad uno tra tredici tipi di chirurgia maggiore non-

cardiaca bull esclusi dallrsquoanalisi i pazienti con insufficienza renale terminale e quelli che non

avessero soddisfatto da almeno un anno i criteri Medicarereg per la sottoscrizione di una polizza

bull 159327 interventi 18 eseguiti in pazienti con insufficienza cardiaca e il 34 in pazienti con cardiopatia ischemica

bull I rischi relativi corretti di mortalitagrave e riammissione per i pazienti con insufficienza cardiaca rispetto a quelli che non presentavano neacute insufficienza cardiaca neacute cardiopatia ischemica erano 163 (intervallo confidenza 95 152-174) e 151 (intervallo confidenza 95 145-158) rispettivamente

bull I rischi relativi corretti di mortalitagrave e riammissione per i pazienti con cardiopatia ischemica rispetto a quelli che non presentavano neacute insufficienza cardiaca neacute cardiopatia ischemica erano 108 (intervallo confidenza 95 101-116) e 116 (intervallo confidenza 95 112-120) rispettivamente

Hammill et al Impact of heart failure on patients undergoing major noncardiac surgeryAnesthesiology 2008108(4) 559-567

Characteristics of the study population by disease group

heart faliure Cad normal

etagrave 794 753 756

Masch i 42 488 344

nerii 85 52 56

teaching hospitali 169 197 163

admitted form a skilled nursing facilityi 15 04 04

urgent admissioni 192 138 145

emergent admissionji 30 19 167

COPDi 451 311 222

CADi 81 100 0

dementiai 91 51 41

diabetesi 434 305 196

histrory of strokei 269 215 114

hypertensioni 864 824 668

periph vascdiseasei 463 363 179

renal diseasei 152 52 27

Operative mortalityHF CAD normal

total 8 31 24

gt Knee amput 258 18 16

ltknee amput 128 104 72

Carotid endarterec tomy 25 12 09

Colon cancer resection 119 63 54

Hip replacement 84 39 28

Knee replacement 09 04 03

Laparoscopic cholecystectomy

56 21 18

Lower extremity bypass 81 37 41

Open AAA repair 103 58 48

Other abdominal cancer resections

118 43 49

Pulmonary cancer resection

102 60 41

Spinal fusion 38 21 13

30 day readmissionHF CAD normal

total 171 108 81

gt Knee amput 252 216 189

ltknee amput 241ns 234ns 199 ns

Carotid endarterectomy 152 108 87

Colon cancer resection 18 132 105

Hip replacement 166 103 88

Knee replacement 99 62 47

Laparoscopic cholecystectomy

164 101 84

Lower extremity bypass 272 182 162

Open AAA repair 148 103 114

Other abdominal cancer resections

173 126 118

Pulmonary cancer resection

174 155 113

Spinal fusion 133 94 77

Effect of heart failure and CAD on mortality per procedure

Operative mortality and readmission rate for HF patients with or without CAD

Conclusion from the study of Hammil et al

bull Heart Failure patients ndashmortality risk 63 ndashReadmission risk 51

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

Hammill BGCurtisLHBennett-Guerrior EOrsquoConnorCMJollis JCSchulman KAHernandez AFImpact of heart failure on patients

undergoing major noncardiac surgeryAnesthesiology 2008108559-67

bull Medicare 5 standard analytic filesbull Inpatients fee for service claims 2000-20004bull Patients gt65 for major noncardiac surgery

ndash Carotid endarterectomyndash Lower extr bypassndash Open AAAndash Hip replacementndash Knee replacementndash Spinal fusionndash Above and below knee amputationndash Open and laparoscopic cholecystectomyndash Cancer resection abdominallungcolon

Hammill et alImpact of heart failure on patients undergoing major noncardiac surgeryAnesthesiology

bull Main outcome ndash Operative mortalityndash 30 days readmission

Hammill et al Impact of heart failure on patients undergoing major noncardiac surgeryAnesthesiology 2008108(4) 559-567

bull I pazienti di etagrave ge65 annibull inseriti nel programma assicurativo statunitense Medicarebull sottoposti tra il 2000 e il 2004 ad uno tra tredici tipi di chirurgia maggiore non-

cardiaca bull esclusi dallrsquoanalisi i pazienti con insufficienza renale terminale e quelli che non

avessero soddisfatto da almeno un anno i criteri Medicarereg per la sottoscrizione di una polizza

bull 159327 interventi 18 eseguiti in pazienti con insufficienza cardiaca e il 34 in pazienti con cardiopatia ischemica

bull I rischi relativi corretti di mortalitagrave e riammissione per i pazienti con insufficienza cardiaca rispetto a quelli che non presentavano neacute insufficienza cardiaca neacute cardiopatia ischemica erano 163 (intervallo confidenza 95 152-174) e 151 (intervallo confidenza 95 145-158) rispettivamente

bull I rischi relativi corretti di mortalitagrave e riammissione per i pazienti con cardiopatia ischemica rispetto a quelli che non presentavano neacute insufficienza cardiaca neacute cardiopatia ischemica erano 108 (intervallo confidenza 95 101-116) e 116 (intervallo confidenza 95 112-120) rispettivamente

Hammill et al Impact of heart failure on patients undergoing major noncardiac surgeryAnesthesiology 2008108(4) 559-567

Characteristics of the study population by disease group

heart faliure Cad normal

etagrave 794 753 756

Masch i 42 488 344

nerii 85 52 56

teaching hospitali 169 197 163

admitted form a skilled nursing facilityi 15 04 04

urgent admissioni 192 138 145

emergent admissionji 30 19 167

COPDi 451 311 222

CADi 81 100 0

dementiai 91 51 41

diabetesi 434 305 196

histrory of strokei 269 215 114

hypertensioni 864 824 668

periph vascdiseasei 463 363 179

renal diseasei 152 52 27

Operative mortalityHF CAD normal

total 8 31 24

gt Knee amput 258 18 16

ltknee amput 128 104 72

Carotid endarterec tomy 25 12 09

Colon cancer resection 119 63 54

Hip replacement 84 39 28

Knee replacement 09 04 03

Laparoscopic cholecystectomy

56 21 18

Lower extremity bypass 81 37 41

Open AAA repair 103 58 48

Other abdominal cancer resections

118 43 49

Pulmonary cancer resection

102 60 41

Spinal fusion 38 21 13

30 day readmissionHF CAD normal

total 171 108 81

gt Knee amput 252 216 189

ltknee amput 241ns 234ns 199 ns

Carotid endarterectomy 152 108 87

Colon cancer resection 18 132 105

Hip replacement 166 103 88

Knee replacement 99 62 47

Laparoscopic cholecystectomy

164 101 84

Lower extremity bypass 272 182 162

Open AAA repair 148 103 114

Other abdominal cancer resections

173 126 118

Pulmonary cancer resection

174 155 113

Spinal fusion 133 94 77

Effect of heart failure and CAD on mortality per procedure

Operative mortality and readmission rate for HF patients with or without CAD

Conclusion from the study of Hammil et al

bull Heart Failure patients ndashmortality risk 63 ndashReadmission risk 51

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

Hammill et alImpact of heart failure on patients undergoing major noncardiac surgeryAnesthesiology

bull Main outcome ndash Operative mortalityndash 30 days readmission

Hammill et al Impact of heart failure on patients undergoing major noncardiac surgeryAnesthesiology 2008108(4) 559-567

bull I pazienti di etagrave ge65 annibull inseriti nel programma assicurativo statunitense Medicarebull sottoposti tra il 2000 e il 2004 ad uno tra tredici tipi di chirurgia maggiore non-

cardiaca bull esclusi dallrsquoanalisi i pazienti con insufficienza renale terminale e quelli che non

avessero soddisfatto da almeno un anno i criteri Medicarereg per la sottoscrizione di una polizza

bull 159327 interventi 18 eseguiti in pazienti con insufficienza cardiaca e il 34 in pazienti con cardiopatia ischemica

bull I rischi relativi corretti di mortalitagrave e riammissione per i pazienti con insufficienza cardiaca rispetto a quelli che non presentavano neacute insufficienza cardiaca neacute cardiopatia ischemica erano 163 (intervallo confidenza 95 152-174) e 151 (intervallo confidenza 95 145-158) rispettivamente

bull I rischi relativi corretti di mortalitagrave e riammissione per i pazienti con cardiopatia ischemica rispetto a quelli che non presentavano neacute insufficienza cardiaca neacute cardiopatia ischemica erano 108 (intervallo confidenza 95 101-116) e 116 (intervallo confidenza 95 112-120) rispettivamente

Hammill et al Impact of heart failure on patients undergoing major noncardiac surgeryAnesthesiology 2008108(4) 559-567

Characteristics of the study population by disease group

heart faliure Cad normal

etagrave 794 753 756

Masch i 42 488 344

nerii 85 52 56

teaching hospitali 169 197 163

admitted form a skilled nursing facilityi 15 04 04

urgent admissioni 192 138 145

emergent admissionji 30 19 167

COPDi 451 311 222

CADi 81 100 0

dementiai 91 51 41

diabetesi 434 305 196

histrory of strokei 269 215 114

hypertensioni 864 824 668

periph vascdiseasei 463 363 179

renal diseasei 152 52 27

Operative mortalityHF CAD normal

total 8 31 24

gt Knee amput 258 18 16

ltknee amput 128 104 72

Carotid endarterec tomy 25 12 09

Colon cancer resection 119 63 54

Hip replacement 84 39 28

Knee replacement 09 04 03

Laparoscopic cholecystectomy

56 21 18

Lower extremity bypass 81 37 41

Open AAA repair 103 58 48

Other abdominal cancer resections

118 43 49

Pulmonary cancer resection

102 60 41

Spinal fusion 38 21 13

30 day readmissionHF CAD normal

total 171 108 81

gt Knee amput 252 216 189

ltknee amput 241ns 234ns 199 ns

Carotid endarterectomy 152 108 87

Colon cancer resection 18 132 105

Hip replacement 166 103 88

Knee replacement 99 62 47

Laparoscopic cholecystectomy

164 101 84

Lower extremity bypass 272 182 162

Open AAA repair 148 103 114

Other abdominal cancer resections

173 126 118

Pulmonary cancer resection

174 155 113

Spinal fusion 133 94 77

Effect of heart failure and CAD on mortality per procedure

Operative mortality and readmission rate for HF patients with or without CAD

Conclusion from the study of Hammil et al

bull Heart Failure patients ndashmortality risk 63 ndashReadmission risk 51

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

Hammill et al Impact of heart failure on patients undergoing major noncardiac surgeryAnesthesiology 2008108(4) 559-567

bull I pazienti di etagrave ge65 annibull inseriti nel programma assicurativo statunitense Medicarebull sottoposti tra il 2000 e il 2004 ad uno tra tredici tipi di chirurgia maggiore non-

cardiaca bull esclusi dallrsquoanalisi i pazienti con insufficienza renale terminale e quelli che non

avessero soddisfatto da almeno un anno i criteri Medicarereg per la sottoscrizione di una polizza

bull 159327 interventi 18 eseguiti in pazienti con insufficienza cardiaca e il 34 in pazienti con cardiopatia ischemica

bull I rischi relativi corretti di mortalitagrave e riammissione per i pazienti con insufficienza cardiaca rispetto a quelli che non presentavano neacute insufficienza cardiaca neacute cardiopatia ischemica erano 163 (intervallo confidenza 95 152-174) e 151 (intervallo confidenza 95 145-158) rispettivamente

bull I rischi relativi corretti di mortalitagrave e riammissione per i pazienti con cardiopatia ischemica rispetto a quelli che non presentavano neacute insufficienza cardiaca neacute cardiopatia ischemica erano 108 (intervallo confidenza 95 101-116) e 116 (intervallo confidenza 95 112-120) rispettivamente

Hammill et al Impact of heart failure on patients undergoing major noncardiac surgeryAnesthesiology 2008108(4) 559-567

Characteristics of the study population by disease group

heart faliure Cad normal

etagrave 794 753 756

Masch i 42 488 344

nerii 85 52 56

teaching hospitali 169 197 163

admitted form a skilled nursing facilityi 15 04 04

urgent admissioni 192 138 145

emergent admissionji 30 19 167

COPDi 451 311 222

CADi 81 100 0

dementiai 91 51 41

diabetesi 434 305 196

histrory of strokei 269 215 114

hypertensioni 864 824 668

periph vascdiseasei 463 363 179

renal diseasei 152 52 27

Operative mortalityHF CAD normal

total 8 31 24

gt Knee amput 258 18 16

ltknee amput 128 104 72

Carotid endarterec tomy 25 12 09

Colon cancer resection 119 63 54

Hip replacement 84 39 28

Knee replacement 09 04 03

Laparoscopic cholecystectomy

56 21 18

Lower extremity bypass 81 37 41

Open AAA repair 103 58 48

Other abdominal cancer resections

118 43 49

Pulmonary cancer resection

102 60 41

Spinal fusion 38 21 13

30 day readmissionHF CAD normal

total 171 108 81

gt Knee amput 252 216 189

ltknee amput 241ns 234ns 199 ns

Carotid endarterectomy 152 108 87

Colon cancer resection 18 132 105

Hip replacement 166 103 88

Knee replacement 99 62 47

Laparoscopic cholecystectomy

164 101 84

Lower extremity bypass 272 182 162

Open AAA repair 148 103 114

Other abdominal cancer resections

173 126 118

Pulmonary cancer resection

174 155 113

Spinal fusion 133 94 77

Effect of heart failure and CAD on mortality per procedure

Operative mortality and readmission rate for HF patients with or without CAD

Conclusion from the study of Hammil et al

bull Heart Failure patients ndashmortality risk 63 ndashReadmission risk 51

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

Hammill et al Impact of heart failure on patients undergoing major noncardiac surgeryAnesthesiology 2008108(4) 559-567

Characteristics of the study population by disease group

heart faliure Cad normal

etagrave 794 753 756

Masch i 42 488 344

nerii 85 52 56

teaching hospitali 169 197 163

admitted form a skilled nursing facilityi 15 04 04

urgent admissioni 192 138 145

emergent admissionji 30 19 167

COPDi 451 311 222

CADi 81 100 0

dementiai 91 51 41

diabetesi 434 305 196

histrory of strokei 269 215 114

hypertensioni 864 824 668

periph vascdiseasei 463 363 179

renal diseasei 152 52 27

Operative mortalityHF CAD normal

total 8 31 24

gt Knee amput 258 18 16

ltknee amput 128 104 72

Carotid endarterec tomy 25 12 09

Colon cancer resection 119 63 54

Hip replacement 84 39 28

Knee replacement 09 04 03

Laparoscopic cholecystectomy

56 21 18

Lower extremity bypass 81 37 41

Open AAA repair 103 58 48

Other abdominal cancer resections

118 43 49

Pulmonary cancer resection

102 60 41

Spinal fusion 38 21 13

30 day readmissionHF CAD normal

total 171 108 81

gt Knee amput 252 216 189

ltknee amput 241ns 234ns 199 ns

Carotid endarterectomy 152 108 87

Colon cancer resection 18 132 105

Hip replacement 166 103 88

Knee replacement 99 62 47

Laparoscopic cholecystectomy

164 101 84

Lower extremity bypass 272 182 162

Open AAA repair 148 103 114

Other abdominal cancer resections

173 126 118

Pulmonary cancer resection

174 155 113

Spinal fusion 133 94 77

Effect of heart failure and CAD on mortality per procedure

Operative mortality and readmission rate for HF patients with or without CAD

Conclusion from the study of Hammil et al

bull Heart Failure patients ndashmortality risk 63 ndashReadmission risk 51

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

Characteristics of the study population by disease group

heart faliure Cad normal

etagrave 794 753 756

Masch i 42 488 344

nerii 85 52 56

teaching hospitali 169 197 163

admitted form a skilled nursing facilityi 15 04 04

urgent admissioni 192 138 145

emergent admissionji 30 19 167

COPDi 451 311 222

CADi 81 100 0

dementiai 91 51 41

diabetesi 434 305 196

histrory of strokei 269 215 114

hypertensioni 864 824 668

periph vascdiseasei 463 363 179

renal diseasei 152 52 27

Operative mortalityHF CAD normal

total 8 31 24

gt Knee amput 258 18 16

ltknee amput 128 104 72

Carotid endarterec tomy 25 12 09

Colon cancer resection 119 63 54

Hip replacement 84 39 28

Knee replacement 09 04 03

Laparoscopic cholecystectomy

56 21 18

Lower extremity bypass 81 37 41

Open AAA repair 103 58 48

Other abdominal cancer resections

118 43 49

Pulmonary cancer resection

102 60 41

Spinal fusion 38 21 13

30 day readmissionHF CAD normal

total 171 108 81

gt Knee amput 252 216 189

ltknee amput 241ns 234ns 199 ns

Carotid endarterectomy 152 108 87

Colon cancer resection 18 132 105

Hip replacement 166 103 88

Knee replacement 99 62 47

Laparoscopic cholecystectomy

164 101 84

Lower extremity bypass 272 182 162

Open AAA repair 148 103 114

Other abdominal cancer resections

173 126 118

Pulmonary cancer resection

174 155 113

Spinal fusion 133 94 77

Effect of heart failure and CAD on mortality per procedure

Operative mortality and readmission rate for HF patients with or without CAD

Conclusion from the study of Hammil et al

bull Heart Failure patients ndashmortality risk 63 ndashReadmission risk 51

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

Operative mortalityHF CAD normal

total 8 31 24

gt Knee amput 258 18 16

ltknee amput 128 104 72

Carotid endarterec tomy 25 12 09

Colon cancer resection 119 63 54

Hip replacement 84 39 28

Knee replacement 09 04 03

Laparoscopic cholecystectomy

56 21 18

Lower extremity bypass 81 37 41

Open AAA repair 103 58 48

Other abdominal cancer resections

118 43 49

Pulmonary cancer resection

102 60 41

Spinal fusion 38 21 13

30 day readmissionHF CAD normal

total 171 108 81

gt Knee amput 252 216 189

ltknee amput 241ns 234ns 199 ns

Carotid endarterectomy 152 108 87

Colon cancer resection 18 132 105

Hip replacement 166 103 88

Knee replacement 99 62 47

Laparoscopic cholecystectomy

164 101 84

Lower extremity bypass 272 182 162

Open AAA repair 148 103 114

Other abdominal cancer resections

173 126 118

Pulmonary cancer resection

174 155 113

Spinal fusion 133 94 77

Effect of heart failure and CAD on mortality per procedure

Operative mortality and readmission rate for HF patients with or without CAD

Conclusion from the study of Hammil et al

bull Heart Failure patients ndashmortality risk 63 ndashReadmission risk 51

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

30 day readmissionHF CAD normal

total 171 108 81

gt Knee amput 252 216 189

ltknee amput 241ns 234ns 199 ns

Carotid endarterectomy 152 108 87

Colon cancer resection 18 132 105

Hip replacement 166 103 88

Knee replacement 99 62 47

Laparoscopic cholecystectomy

164 101 84

Lower extremity bypass 272 182 162

Open AAA repair 148 103 114

Other abdominal cancer resections

173 126 118

Pulmonary cancer resection

174 155 113

Spinal fusion 133 94 77

Effect of heart failure and CAD on mortality per procedure

Operative mortality and readmission rate for HF patients with or without CAD

Conclusion from the study of Hammil et al

bull Heart Failure patients ndashmortality risk 63 ndashReadmission risk 51

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

Effect of heart failure and CAD on mortality per procedure

Operative mortality and readmission rate for HF patients with or without CAD

Conclusion from the study of Hammil et al

bull Heart Failure patients ndashmortality risk 63 ndashReadmission risk 51

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

Operative mortality and readmission rate for HF patients with or without CAD

Conclusion from the study of Hammil et al

bull Heart Failure patients ndashmortality risk 63 ndashReadmission risk 51

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

Conclusion from the study of Hammil et al

bull Heart Failure patients ndashmortality risk 63 ndashReadmission risk 51

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

N-TERMINAL PRO-BRAIN NATRIURETIC PEPTIDE

ENDOGENOUS NITRIC OXIDE SYNTHASE INHIBITOR ASYMMETRIC DIMETHYLARGININE

Laboratory markers for cardiac risk after noncardiac surgery

Yun KH Jeong MH Oh SK Choi JH Rhee SJ Park EM Yoo NJ Kim NH Ahn YK Jeong JWPreoperative plasma N-terminal pro-brain natriuretic peptide

concentration and perioperative cardiovascular risk in elderly patientsCirc

J2008 Feb72(2)195-9bull The purpose of this study was to determine whether the N-terminal pro-brain natriuretic peptide

(NT-proBNP) concentration before operation can be used to predict perioperative cardiovascular complications in elderly patients undergoing noncardiac surgery METHODS AND RESULTS The study group comprised 279 patients older than 60 years who were scheduled for elective surgery The plasma NT-proBNP concentration clinical cardiac indices and left ventricular ejection fraction were measured prior to operation The postoperative cardiac outcomes were followed and predictors for postoperative cardiac risk were identified Cardiovascular complications occurred in 25 patients (90) Age the incidence of prior ischemic heart disease or congestive heart failure and the plasma NT-proBNP concentration were significantly higher in patients with perioperative cardiovascular complications than in those without Using receiver operating characteristic analysis to predict perioperative cardiovascular events a cut-off value of 201 pgml was identified as the optimal predictor of perioperative complications showing a sensitivity of 800 and specificity of 811 Multivariate analysis revealed that NT-proBNP gt201 pgml (odds ratio (OR) 76 95 confidence interval (CI) 22-266 p=0003) and revised cardiac index gt or =2 (OR 63 95 CI 17-238 p=0007) were independent predictors for perioperative cardiovascular

complications CONCLUSIONS Elevated NT-proBNP levels are independently associated with an increase in the risk of perioperative cardiovascular KO

Yun KH Jeong MH Oh SK Choi JH Rhee SJ Park EM Yoo NJ Kim NH Ahn YK Jeong JWPreoperative plasma N-terminal pro-brain natriuretic peptide

concentration and perioperative cardiovascular risk in elderly patientsCirc

J2008 Feb72(2)195-9bull The purpose of this study was to determine whether the N-terminal pro-brain natriuretic peptide

(NT-proBNP) concentration before operation can be used to predict perioperative cardiovascular complications in elderly patients undergoing noncardiac surgery METHODS AND RESULTS The study group comprised 279 patients older than 60 years who were scheduled for elective surgery The plasma NT-proBNP concentration clinical cardiac indices and left ventricular ejection fraction were measured prior to operation The postoperative cardiac outcomes were followed and predictors for postoperative cardiac risk were identified Cardiovascular complications occurred in 25 patients (90) Age the incidence of prior ischemic heart disease or congestive heart failure and the plasma NT-proBNP concentration were significantly higher in patients with perioperative cardiovascular complications than in those without Using receiver operating characteristic analysis to predict perioperative cardiovascular events a cut-off value of 201 pgml was identified as the optimal predictor of perioperative complications showing a sensitivity of 800 and specificity of 811 Multivariate analysis revealed that NT-proBNP gt201 pgml (odds ratio (OR) 76 95 confidence interval (CI) 22-266 p=0003) and revised cardiac index gt or =2 (OR 63 95 CI 17-238 p=0007) were independent predictors for perioperative cardiovascular

complications CONCLUSIONS Elevated NT-proBNP levels are independently associated with an increase in the risk of perioperative cardiovascular KO

Leibowitz D Planer D Rott D Elitzur Y Chajek-Shaul T Weiss ATBrain natriuretic

peptide levels predict perioperative events in cardiac patients undergoing noncardiac surgery a prospective study Cardiology 2008110(4)266-70 Epub

2007 Dec 12bull OBJECTIVES Brain natriuretic peptide (BNP) levels correlate with prognosis in patients with cardiac

disease and may be useful in the risk stratification of cardiac patients undergoing noncardiac surgery (NCS) The objective of this study was to examine whether BNP levels predict perioperative events in cardiac patients undergoing NCS METHODS Patients undergoing NCS with at least 1 of the following criteria were included a clinical history of congestive heart failure (CHF) ejection fraction lt40 or severe aortic stenosis All patients underwent echocardiography and measurement of BNP performed using the ADVIA-Centaur BNP assay (Bayer HealthCare) Clinical endpoints were death myocardial infarction or pulmonary congestion requiring intravenous diuretics at 30 days of follow-up RESULTS Forty-four patients were entered into the study 15 patients (34) developed cardiac postoperative complications The mean BNP level was 1366 +- 1420 pgml in patients with events and 167 +- 194 pgml in patients without events indicating a highly significant difference (p lt 0001) The ROC area under the curve was 091 (95 CI 083-099)

with an optimal cutoff of gt165 pgml (100 sensitivity 70 specificity) CONCLUSIONS BNP levels may predict perioperative complications in cardiac patients undergoing NCS and the measurement of BNP should be considered to assess the preo

Maas R Dentz L Schwedhelm E Thoms W Kuss O Hiltmeyer N Haddad M Kloumlss T Standl T Boumlger RHElevated plasma concentrations of the endogenous nitric oxide synthase inhibitor asymmetric dimethylarginine predict adverse events in patients

undergoing noncardiac surgery Crit Care Med 2007 Aug35(8)1876-81

bull OBJECTIVE In patients with cardiovascular disease or organ failure elevated plasma concentrations of the endogenous nitric oxide synthase inhibitor asymmetric dimethylarginine (ADMA) are associated with an increased risk of future cardiovascular events We aimed to investigate elevated plasma ADMA concentrations as a prospective risk marker for adverse events in patients undergoing noncardiac surgery DESIGN Prospective observational study SETTING Two tertiary care centers PATIENTS Four hundred and two patients scheduled for elective noncardiac surgery INTERVENTIONS None MEASUREMENTS AND MAIN RESULTS Patients were followed for 30 days after surgery for a predefined composite end point (death myocardial infarctionacute coronary syndrome acute heart failure severe arrhythmia embolism or thrombosis) Plasma ADMA concentrations at baseline were determined by high-performance liquid chromatography ADMA was only weakly (-02 lt tau lt 02) correlated with other risk markers and risk scores In univariate logistic regression per 01-micromolL increment in plasma ADMA concentration the odds ratio to experience the primary end point increased by 126 (95 confidence interval 110-145 p = 001) In a multivariate logistic regression model adjusting for age gender current smoking plasma creatinine hypertension diabetes ischemic heart disease highly sensitive C-reactive protein revised cardiac risk index type of surgery high-risk surgery ASA class and study center ADMA was found to be an independent risk marker

bull Hernandez AF Whellan DJ Stroud S Sun JL OrsquoConnor CM Jollis JG

bull Outcomes in heart failure patients after major noncardiac surgery J Am Coll

bull Cardiol 200444(7)1446-1453

Perioperative mortality and 30 days readmission rate for patients with HF operated for noncardiac surgery

Preoperative evaluation at the Internal Medicine PreoperativeAssessment Consultation and Treatment (IMPACT)Center at the Cleveland Clinic

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

Postop survival time of HF patients after noncardiac major surgeryYE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M

WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-288

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM

ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

bull Our data suggest that perioperative mortality is surprisingly low (lt2) in patients with clinically stable HFmdash regardless of EFmdashundergoing elective noncardiac surgery

bull At 1 year crude mortality rates for patients with HF with reduced EF (135) or with preserved EF (63) were significantly higher than for controls (31) However we found no evidence to suggest that the immediate postoperative period was associated with a significantly higher risk of death than the subsequent months This raises the possibility that the long-term postoperative mortality rate that we observed in the patients with HF particularly those with low EF represents the background mortality expected in patients with chronic illnesses

bull Our findings contrast with previous studies that have focused on the perioperative outcomes of patients with HF

Levels of Thromboembolism Risk in Surgical Patients Without Prophylaxis

Livelli di rischio tromboembolico in pazienti senza profilassi (Goertz et al 114 AHAACC

DVT PE

Livello di rischio polpaccio

prossimale Evento clinico

fatale Strategia di prevenzione con successo

BassoChir minore in paz lt40 anni senza fattori di rischio

2 04 02 lt001 No profilassideambulazione precoceaggressiva

ModerataChir minore in paz con fattori di rischio aggiuntiviChir in paz 40-60 anni senza fattori di rischio aggiuntivi

10-20 2-4 1-2 02-04

Hep(ogni 12 h)LMWH lt3400GCSIPC

Altachir in pazgt60 a tra 40-60 con FRA(VTEcancroipercoagulabilitagrave molecolare)

20-40 4-8 2-4 04-1 HEP ogni 8 hLMWHgt3400Ipc

AltissimaChir in paz con fattori di rischio multipliArtroprotesi anca ginocchioFrattura ancaTrauma maggioreTrauma midollare spinale

40-80 10-20 4-10 02-5 LMWHgt3400fondaparinuxVit K antag p os(INR 2-3)IPC o GCS+LMWH o Hep

FRAfattori di rischio aggiuntivi

IPCcpmpressione penumatica intermittente

Hepeparina non frazionata

LMDWeparina a basso peso molecolare

GCScalze a compressione graduale intermittente

Choice of Anesthetic Technique andAgent

bull Recommendations for Use of Volatile Anesthetic Agents

bull CLASS Iia 1 It can be beneficial to use volatile anesthetic agents during noncardiac surgery for the maintenance of general anesthesia in hemodynamically stable patients at risk for myocardial ischemia (Level of Evidence B)

Preoperative and Long-term Cardiac Risk Assessment Predictive Value of23 Clinical Descriptors 7 Multivariate Scoring Systems and Quantitative Dipyridamole Imaging in 360 PatientsJEAN LETTE MDt DAVID WATERS MDt HELENE BERNIER PATRICK CHAMPAGNE BScJEAN LASSONDE MD MICHEL PICARD MD4 MICHEL CERINO MD

STANLEY NATTEL MDtYVAN BOUCHER MD FRANCOISE HEYEN MD and SERGE DUBE

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD []

Gerstenblith Gary MD Bray Paul F MD Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297

December 2004

bull Abstractbull Background Current perioperative cardiac risk assessment tools use historic

and surgical factors to stratify patient risk Polymorphisms in platelet glycoprotein (GP) IIIa and GPIb[alpha] are associated with myocardial ischemic risk in nonsurgical settings but their relation to perioperative ischemia is unclear The authors hypothesized that platelet genotype would be an independent predictor of postoperative myocardial ischemia and would improve risk assessment when added to clinical factors

bull Methods One hundred ninety-six patients who underwent infrainguinal abdominal aortic or thoracoabdominal vascular surgery were evaluated for clinical and genetic factors that might predict the development of postoperative myocardial ischemia Genomic DNA was genotyped for the Leu33Pro polymorphism of GPIIIa and the Thr145Met polymorphism of GPIb[alpha] Myocardial ischemic outcome was determined by review of the medical record for cardiac death or myocardial infarction and by surveillance troponin I and automated continuous 12-lead electrocardiographic analysis

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD [] Gerstenblith Gary MD Bray Paul F MD

Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297 December 2004bull Results Sixty-five patients (33) experienced one or more ischemic

endpoints (2 death 5 myocardial infarction 20 troponin+ 22 electrocardiogram+) The Pro33 (adjusted odds ratio [OR] 24 [95 confidence interval 12ndash62]) and Met145 (OR 34 [14ndash93]) genotypes were independent predictors of composite ischemic outcome by multivariate regression as were diabetes mellitus (OR 40 [17ndash125]) abdominal aortic surgery (OR 41 [17ndash144]) and thoracoabdominal aortic surgery (OR 64 [27ndash238]) The addition of platelet gene polymorphisms to clinical factors improved fit (likelihood ratio testing chi-square = 135 P lt 0001) of an ischemia prediction model The derived risk assessment tool had a receiver operator characteristic curve of 073 (065ndash081) compared with 064 (057ndash074) for a model excluding genetic factors (P = 004) A significant relation between the GPIb[alpha] polymorphism and ischemic outcome remained after excluding electrocardiographic ischemia from the composite endpoint

Perioperative mortality and 30 days readmission rate for patients with HF operated for noncardiac surgery

Preoperative evaluation at the Internal Medicine PreoperativeAssessment Consultation and Treatment (IMPACT)Center at the Cleveland Clinic

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

Postop survival time of HF patients after noncardiac major surgeryYE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M

WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-288

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM

ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

bull Our data suggest that perioperative mortality is surprisingly low (lt2) in patients with clinically stable HFmdash regardless of EFmdashundergoing elective noncardiac surgery

bull At 1 year crude mortality rates for patients with HF with reduced EF (135) or with preserved EF (63) were significantly higher than for controls (31) However we found no evidence to suggest that the immediate postoperative period was associated with a significantly higher risk of death than the subsequent months This raises the possibility that the long-term postoperative mortality rate that we observed in the patients with HF particularly those with low EF represents the background mortality expected in patients with chronic illnesses

bull Our findings contrast with previous studies that have focused on the perioperative outcomes of patients with HF

Levels of Thromboembolism Risk in Surgical Patients Without Prophylaxis

Livelli di rischio tromboembolico in pazienti senza profilassi (Goertz et al 114 AHAACC

DVT PE

Livello di rischio polpaccio

prossimale Evento clinico

fatale Strategia di prevenzione con successo

BassoChir minore in paz lt40 anni senza fattori di rischio

2 04 02 lt001 No profilassideambulazione precoceaggressiva

ModerataChir minore in paz con fattori di rischio aggiuntiviChir in paz 40-60 anni senza fattori di rischio aggiuntivi

10-20 2-4 1-2 02-04

Hep(ogni 12 h)LMWH lt3400GCSIPC

Altachir in pazgt60 a tra 40-60 con FRA(VTEcancroipercoagulabilitagrave molecolare)

20-40 4-8 2-4 04-1 HEP ogni 8 hLMWHgt3400Ipc

AltissimaChir in paz con fattori di rischio multipliArtroprotesi anca ginocchioFrattura ancaTrauma maggioreTrauma midollare spinale

40-80 10-20 4-10 02-5 LMWHgt3400fondaparinuxVit K antag p os(INR 2-3)IPC o GCS+LMWH o Hep

FRAfattori di rischio aggiuntivi

IPCcpmpressione penumatica intermittente

Hepeparina non frazionata

LMDWeparina a basso peso molecolare

GCScalze a compressione graduale intermittente

Choice of Anesthetic Technique andAgent

bull Recommendations for Use of Volatile Anesthetic Agents

bull CLASS Iia 1 It can be beneficial to use volatile anesthetic agents during noncardiac surgery for the maintenance of general anesthesia in hemodynamically stable patients at risk for myocardial ischemia (Level of Evidence B)

Preoperative and Long-term Cardiac Risk Assessment Predictive Value of23 Clinical Descriptors 7 Multivariate Scoring Systems and Quantitative Dipyridamole Imaging in 360 PatientsJEAN LETTE MDt DAVID WATERS MDt HELENE BERNIER PATRICK CHAMPAGNE BScJEAN LASSONDE MD MICHEL PICARD MD4 MICHEL CERINO MD

STANLEY NATTEL MDtYVAN BOUCHER MD FRANCOISE HEYEN MD and SERGE DUBE

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD []

Gerstenblith Gary MD Bray Paul F MD Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297

December 2004

bull Abstractbull Background Current perioperative cardiac risk assessment tools use historic

and surgical factors to stratify patient risk Polymorphisms in platelet glycoprotein (GP) IIIa and GPIb[alpha] are associated with myocardial ischemic risk in nonsurgical settings but their relation to perioperative ischemia is unclear The authors hypothesized that platelet genotype would be an independent predictor of postoperative myocardial ischemia and would improve risk assessment when added to clinical factors

bull Methods One hundred ninety-six patients who underwent infrainguinal abdominal aortic or thoracoabdominal vascular surgery were evaluated for clinical and genetic factors that might predict the development of postoperative myocardial ischemia Genomic DNA was genotyped for the Leu33Pro polymorphism of GPIIIa and the Thr145Met polymorphism of GPIb[alpha] Myocardial ischemic outcome was determined by review of the medical record for cardiac death or myocardial infarction and by surveillance troponin I and automated continuous 12-lead electrocardiographic analysis

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD [] Gerstenblith Gary MD Bray Paul F MD

Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297 December 2004bull Results Sixty-five patients (33) experienced one or more ischemic

endpoints (2 death 5 myocardial infarction 20 troponin+ 22 electrocardiogram+) The Pro33 (adjusted odds ratio [OR] 24 [95 confidence interval 12ndash62]) and Met145 (OR 34 [14ndash93]) genotypes were independent predictors of composite ischemic outcome by multivariate regression as were diabetes mellitus (OR 40 [17ndash125]) abdominal aortic surgery (OR 41 [17ndash144]) and thoracoabdominal aortic surgery (OR 64 [27ndash238]) The addition of platelet gene polymorphisms to clinical factors improved fit (likelihood ratio testing chi-square = 135 P lt 0001) of an ischemia prediction model The derived risk assessment tool had a receiver operator characteristic curve of 073 (065ndash081) compared with 064 (057ndash074) for a model excluding genetic factors (P = 004) A significant relation between the GPIb[alpha] polymorphism and ischemic outcome remained after excluding electrocardiographic ischemia from the composite endpoint

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

Postop survival time of HF patients after noncardiac major surgeryYE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M

WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-288

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM

ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

bull Our data suggest that perioperative mortality is surprisingly low (lt2) in patients with clinically stable HFmdash regardless of EFmdashundergoing elective noncardiac surgery

bull At 1 year crude mortality rates for patients with HF with reduced EF (135) or with preserved EF (63) were significantly higher than for controls (31) However we found no evidence to suggest that the immediate postoperative period was associated with a significantly higher risk of death than the subsequent months This raises the possibility that the long-term postoperative mortality rate that we observed in the patients with HF particularly those with low EF represents the background mortality expected in patients with chronic illnesses

bull Our findings contrast with previous studies that have focused on the perioperative outcomes of patients with HF

Levels of Thromboembolism Risk in Surgical Patients Without Prophylaxis

Livelli di rischio tromboembolico in pazienti senza profilassi (Goertz et al 114 AHAACC

DVT PE

Livello di rischio polpaccio

prossimale Evento clinico

fatale Strategia di prevenzione con successo

BassoChir minore in paz lt40 anni senza fattori di rischio

2 04 02 lt001 No profilassideambulazione precoceaggressiva

ModerataChir minore in paz con fattori di rischio aggiuntiviChir in paz 40-60 anni senza fattori di rischio aggiuntivi

10-20 2-4 1-2 02-04

Hep(ogni 12 h)LMWH lt3400GCSIPC

Altachir in pazgt60 a tra 40-60 con FRA(VTEcancroipercoagulabilitagrave molecolare)

20-40 4-8 2-4 04-1 HEP ogni 8 hLMWHgt3400Ipc

AltissimaChir in paz con fattori di rischio multipliArtroprotesi anca ginocchioFrattura ancaTrauma maggioreTrauma midollare spinale

40-80 10-20 4-10 02-5 LMWHgt3400fondaparinuxVit K antag p os(INR 2-3)IPC o GCS+LMWH o Hep

FRAfattori di rischio aggiuntivi

IPCcpmpressione penumatica intermittente

Hepeparina non frazionata

LMDWeparina a basso peso molecolare

GCScalze a compressione graduale intermittente

Choice of Anesthetic Technique andAgent

bull Recommendations for Use of Volatile Anesthetic Agents

bull CLASS Iia 1 It can be beneficial to use volatile anesthetic agents during noncardiac surgery for the maintenance of general anesthesia in hemodynamically stable patients at risk for myocardial ischemia (Level of Evidence B)

Preoperative and Long-term Cardiac Risk Assessment Predictive Value of23 Clinical Descriptors 7 Multivariate Scoring Systems and Quantitative Dipyridamole Imaging in 360 PatientsJEAN LETTE MDt DAVID WATERS MDt HELENE BERNIER PATRICK CHAMPAGNE BScJEAN LASSONDE MD MICHEL PICARD MD4 MICHEL CERINO MD

STANLEY NATTEL MDtYVAN BOUCHER MD FRANCOISE HEYEN MD and SERGE DUBE

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD []

Gerstenblith Gary MD Bray Paul F MD Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297

December 2004

bull Abstractbull Background Current perioperative cardiac risk assessment tools use historic

and surgical factors to stratify patient risk Polymorphisms in platelet glycoprotein (GP) IIIa and GPIb[alpha] are associated with myocardial ischemic risk in nonsurgical settings but their relation to perioperative ischemia is unclear The authors hypothesized that platelet genotype would be an independent predictor of postoperative myocardial ischemia and would improve risk assessment when added to clinical factors

bull Methods One hundred ninety-six patients who underwent infrainguinal abdominal aortic or thoracoabdominal vascular surgery were evaluated for clinical and genetic factors that might predict the development of postoperative myocardial ischemia Genomic DNA was genotyped for the Leu33Pro polymorphism of GPIIIa and the Thr145Met polymorphism of GPIb[alpha] Myocardial ischemic outcome was determined by review of the medical record for cardiac death or myocardial infarction and by surveillance troponin I and automated continuous 12-lead electrocardiographic analysis

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD [] Gerstenblith Gary MD Bray Paul F MD

Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297 December 2004bull Results Sixty-five patients (33) experienced one or more ischemic

endpoints (2 death 5 myocardial infarction 20 troponin+ 22 electrocardiogram+) The Pro33 (adjusted odds ratio [OR] 24 [95 confidence interval 12ndash62]) and Met145 (OR 34 [14ndash93]) genotypes were independent predictors of composite ischemic outcome by multivariate regression as were diabetes mellitus (OR 40 [17ndash125]) abdominal aortic surgery (OR 41 [17ndash144]) and thoracoabdominal aortic surgery (OR 64 [27ndash238]) The addition of platelet gene polymorphisms to clinical factors improved fit (likelihood ratio testing chi-square = 135 P lt 0001) of an ischemia prediction model The derived risk assessment tool had a receiver operator characteristic curve of 073 (065ndash081) compared with 064 (057ndash074) for a model excluding genetic factors (P = 004) A significant relation between the GPIb[alpha] polymorphism and ischemic outcome remained after excluding electrocardiographic ischemia from the composite endpoint

Postop survival time of HF patients after noncardiac major surgeryYE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M

WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-288

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM

ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

bull Our data suggest that perioperative mortality is surprisingly low (lt2) in patients with clinically stable HFmdash regardless of EFmdashundergoing elective noncardiac surgery

bull At 1 year crude mortality rates for patients with HF with reduced EF (135) or with preserved EF (63) were significantly higher than for controls (31) However we found no evidence to suggest that the immediate postoperative period was associated with a significantly higher risk of death than the subsequent months This raises the possibility that the long-term postoperative mortality rate that we observed in the patients with HF particularly those with low EF represents the background mortality expected in patients with chronic illnesses

bull Our findings contrast with previous studies that have focused on the perioperative outcomes of patients with HF

Levels of Thromboembolism Risk in Surgical Patients Without Prophylaxis

Livelli di rischio tromboembolico in pazienti senza profilassi (Goertz et al 114 AHAACC

DVT PE

Livello di rischio polpaccio

prossimale Evento clinico

fatale Strategia di prevenzione con successo

BassoChir minore in paz lt40 anni senza fattori di rischio

2 04 02 lt001 No profilassideambulazione precoceaggressiva

ModerataChir minore in paz con fattori di rischio aggiuntiviChir in paz 40-60 anni senza fattori di rischio aggiuntivi

10-20 2-4 1-2 02-04

Hep(ogni 12 h)LMWH lt3400GCSIPC

Altachir in pazgt60 a tra 40-60 con FRA(VTEcancroipercoagulabilitagrave molecolare)

20-40 4-8 2-4 04-1 HEP ogni 8 hLMWHgt3400Ipc

AltissimaChir in paz con fattori di rischio multipliArtroprotesi anca ginocchioFrattura ancaTrauma maggioreTrauma midollare spinale

40-80 10-20 4-10 02-5 LMWHgt3400fondaparinuxVit K antag p os(INR 2-3)IPC o GCS+LMWH o Hep

FRAfattori di rischio aggiuntivi

IPCcpmpressione penumatica intermittente

Hepeparina non frazionata

LMDWeparina a basso peso molecolare

GCScalze a compressione graduale intermittente

Choice of Anesthetic Technique andAgent

bull Recommendations for Use of Volatile Anesthetic Agents

bull CLASS Iia 1 It can be beneficial to use volatile anesthetic agents during noncardiac surgery for the maintenance of general anesthesia in hemodynamically stable patients at risk for myocardial ischemia (Level of Evidence B)

Preoperative and Long-term Cardiac Risk Assessment Predictive Value of23 Clinical Descriptors 7 Multivariate Scoring Systems and Quantitative Dipyridamole Imaging in 360 PatientsJEAN LETTE MDt DAVID WATERS MDt HELENE BERNIER PATRICK CHAMPAGNE BScJEAN LASSONDE MD MICHEL PICARD MD4 MICHEL CERINO MD

STANLEY NATTEL MDtYVAN BOUCHER MD FRANCOISE HEYEN MD and SERGE DUBE

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD []

Gerstenblith Gary MD Bray Paul F MD Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297

December 2004

bull Abstractbull Background Current perioperative cardiac risk assessment tools use historic

and surgical factors to stratify patient risk Polymorphisms in platelet glycoprotein (GP) IIIa and GPIb[alpha] are associated with myocardial ischemic risk in nonsurgical settings but their relation to perioperative ischemia is unclear The authors hypothesized that platelet genotype would be an independent predictor of postoperative myocardial ischemia and would improve risk assessment when added to clinical factors

bull Methods One hundred ninety-six patients who underwent infrainguinal abdominal aortic or thoracoabdominal vascular surgery were evaluated for clinical and genetic factors that might predict the development of postoperative myocardial ischemia Genomic DNA was genotyped for the Leu33Pro polymorphism of GPIIIa and the Thr145Met polymorphism of GPIb[alpha] Myocardial ischemic outcome was determined by review of the medical record for cardiac death or myocardial infarction and by surveillance troponin I and automated continuous 12-lead electrocardiographic analysis

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD [] Gerstenblith Gary MD Bray Paul F MD

Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297 December 2004bull Results Sixty-five patients (33) experienced one or more ischemic

endpoints (2 death 5 myocardial infarction 20 troponin+ 22 electrocardiogram+) The Pro33 (adjusted odds ratio [OR] 24 [95 confidence interval 12ndash62]) and Met145 (OR 34 [14ndash93]) genotypes were independent predictors of composite ischemic outcome by multivariate regression as were diabetes mellitus (OR 40 [17ndash125]) abdominal aortic surgery (OR 41 [17ndash144]) and thoracoabdominal aortic surgery (OR 64 [27ndash238]) The addition of platelet gene polymorphisms to clinical factors improved fit (likelihood ratio testing chi-square = 135 P lt 0001) of an ischemia prediction model The derived risk assessment tool had a receiver operator characteristic curve of 073 (065ndash081) compared with 064 (057ndash074) for a model excluding genetic factors (P = 004) A significant relation between the GPIb[alpha] polymorphism and ischemic outcome remained after excluding electrocardiographic ischemia from the composite endpoint

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM

ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

bull Our data suggest that perioperative mortality is surprisingly low (lt2) in patients with clinically stable HFmdash regardless of EFmdashundergoing elective noncardiac surgery

bull At 1 year crude mortality rates for patients with HF with reduced EF (135) or with preserved EF (63) were significantly higher than for controls (31) However we found no evidence to suggest that the immediate postoperative period was associated with a significantly higher risk of death than the subsequent months This raises the possibility that the long-term postoperative mortality rate that we observed in the patients with HF particularly those with low EF represents the background mortality expected in patients with chronic illnesses

bull Our findings contrast with previous studies that have focused on the perioperative outcomes of patients with HF

Levels of Thromboembolism Risk in Surgical Patients Without Prophylaxis

Livelli di rischio tromboembolico in pazienti senza profilassi (Goertz et al 114 AHAACC

DVT PE

Livello di rischio polpaccio

prossimale Evento clinico

fatale Strategia di prevenzione con successo

BassoChir minore in paz lt40 anni senza fattori di rischio

2 04 02 lt001 No profilassideambulazione precoceaggressiva

ModerataChir minore in paz con fattori di rischio aggiuntiviChir in paz 40-60 anni senza fattori di rischio aggiuntivi

10-20 2-4 1-2 02-04

Hep(ogni 12 h)LMWH lt3400GCSIPC

Altachir in pazgt60 a tra 40-60 con FRA(VTEcancroipercoagulabilitagrave molecolare)

20-40 4-8 2-4 04-1 HEP ogni 8 hLMWHgt3400Ipc

AltissimaChir in paz con fattori di rischio multipliArtroprotesi anca ginocchioFrattura ancaTrauma maggioreTrauma midollare spinale

40-80 10-20 4-10 02-5 LMWHgt3400fondaparinuxVit K antag p os(INR 2-3)IPC o GCS+LMWH o Hep

FRAfattori di rischio aggiuntivi

IPCcpmpressione penumatica intermittente

Hepeparina non frazionata

LMDWeparina a basso peso molecolare

GCScalze a compressione graduale intermittente

Choice of Anesthetic Technique andAgent

bull Recommendations for Use of Volatile Anesthetic Agents

bull CLASS Iia 1 It can be beneficial to use volatile anesthetic agents during noncardiac surgery for the maintenance of general anesthesia in hemodynamically stable patients at risk for myocardial ischemia (Level of Evidence B)

Preoperative and Long-term Cardiac Risk Assessment Predictive Value of23 Clinical Descriptors 7 Multivariate Scoring Systems and Quantitative Dipyridamole Imaging in 360 PatientsJEAN LETTE MDt DAVID WATERS MDt HELENE BERNIER PATRICK CHAMPAGNE BScJEAN LASSONDE MD MICHEL PICARD MD4 MICHEL CERINO MD

STANLEY NATTEL MDtYVAN BOUCHER MD FRANCOISE HEYEN MD and SERGE DUBE

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD []

Gerstenblith Gary MD Bray Paul F MD Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297

December 2004

bull Abstractbull Background Current perioperative cardiac risk assessment tools use historic

and surgical factors to stratify patient risk Polymorphisms in platelet glycoprotein (GP) IIIa and GPIb[alpha] are associated with myocardial ischemic risk in nonsurgical settings but their relation to perioperative ischemia is unclear The authors hypothesized that platelet genotype would be an independent predictor of postoperative myocardial ischemia and would improve risk assessment when added to clinical factors

bull Methods One hundred ninety-six patients who underwent infrainguinal abdominal aortic or thoracoabdominal vascular surgery were evaluated for clinical and genetic factors that might predict the development of postoperative myocardial ischemia Genomic DNA was genotyped for the Leu33Pro polymorphism of GPIIIa and the Thr145Met polymorphism of GPIb[alpha] Myocardial ischemic outcome was determined by review of the medical record for cardiac death or myocardial infarction and by surveillance troponin I and automated continuous 12-lead electrocardiographic analysis

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD [] Gerstenblith Gary MD Bray Paul F MD

Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297 December 2004bull Results Sixty-five patients (33) experienced one or more ischemic

endpoints (2 death 5 myocardial infarction 20 troponin+ 22 electrocardiogram+) The Pro33 (adjusted odds ratio [OR] 24 [95 confidence interval 12ndash62]) and Met145 (OR 34 [14ndash93]) genotypes were independent predictors of composite ischemic outcome by multivariate regression as were diabetes mellitus (OR 40 [17ndash125]) abdominal aortic surgery (OR 41 [17ndash144]) and thoracoabdominal aortic surgery (OR 64 [27ndash238]) The addition of platelet gene polymorphisms to clinical factors improved fit (likelihood ratio testing chi-square = 135 P lt 0001) of an ischemia prediction model The derived risk assessment tool had a receiver operator characteristic curve of 073 (065ndash081) compared with 064 (057ndash074) for a model excluding genetic factors (P = 004) A significant relation between the GPIb[alpha] polymorphism and ischemic outcome remained after excluding electrocardiographic ischemia from the composite endpoint

Levels of Thromboembolism Risk in Surgical Patients Without Prophylaxis

Livelli di rischio tromboembolico in pazienti senza profilassi (Goertz et al 114 AHAACC

DVT PE

Livello di rischio polpaccio

prossimale Evento clinico

fatale Strategia di prevenzione con successo

BassoChir minore in paz lt40 anni senza fattori di rischio

2 04 02 lt001 No profilassideambulazione precoceaggressiva

ModerataChir minore in paz con fattori di rischio aggiuntiviChir in paz 40-60 anni senza fattori di rischio aggiuntivi

10-20 2-4 1-2 02-04

Hep(ogni 12 h)LMWH lt3400GCSIPC

Altachir in pazgt60 a tra 40-60 con FRA(VTEcancroipercoagulabilitagrave molecolare)

20-40 4-8 2-4 04-1 HEP ogni 8 hLMWHgt3400Ipc

AltissimaChir in paz con fattori di rischio multipliArtroprotesi anca ginocchioFrattura ancaTrauma maggioreTrauma midollare spinale

40-80 10-20 4-10 02-5 LMWHgt3400fondaparinuxVit K antag p os(INR 2-3)IPC o GCS+LMWH o Hep

FRAfattori di rischio aggiuntivi

IPCcpmpressione penumatica intermittente

Hepeparina non frazionata

LMDWeparina a basso peso molecolare

GCScalze a compressione graduale intermittente

Choice of Anesthetic Technique andAgent

bull Recommendations for Use of Volatile Anesthetic Agents

bull CLASS Iia 1 It can be beneficial to use volatile anesthetic agents during noncardiac surgery for the maintenance of general anesthesia in hemodynamically stable patients at risk for myocardial ischemia (Level of Evidence B)

Preoperative and Long-term Cardiac Risk Assessment Predictive Value of23 Clinical Descriptors 7 Multivariate Scoring Systems and Quantitative Dipyridamole Imaging in 360 PatientsJEAN LETTE MDt DAVID WATERS MDt HELENE BERNIER PATRICK CHAMPAGNE BScJEAN LASSONDE MD MICHEL PICARD MD4 MICHEL CERINO MD

STANLEY NATTEL MDtYVAN BOUCHER MD FRANCOISE HEYEN MD and SERGE DUBE

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD []

Gerstenblith Gary MD Bray Paul F MD Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297

December 2004

bull Abstractbull Background Current perioperative cardiac risk assessment tools use historic

and surgical factors to stratify patient risk Polymorphisms in platelet glycoprotein (GP) IIIa and GPIb[alpha] are associated with myocardial ischemic risk in nonsurgical settings but their relation to perioperative ischemia is unclear The authors hypothesized that platelet genotype would be an independent predictor of postoperative myocardial ischemia and would improve risk assessment when added to clinical factors

bull Methods One hundred ninety-six patients who underwent infrainguinal abdominal aortic or thoracoabdominal vascular surgery were evaluated for clinical and genetic factors that might predict the development of postoperative myocardial ischemia Genomic DNA was genotyped for the Leu33Pro polymorphism of GPIIIa and the Thr145Met polymorphism of GPIb[alpha] Myocardial ischemic outcome was determined by review of the medical record for cardiac death or myocardial infarction and by surveillance troponin I and automated continuous 12-lead electrocardiographic analysis

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD [] Gerstenblith Gary MD Bray Paul F MD

Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297 December 2004bull Results Sixty-five patients (33) experienced one or more ischemic

endpoints (2 death 5 myocardial infarction 20 troponin+ 22 electrocardiogram+) The Pro33 (adjusted odds ratio [OR] 24 [95 confidence interval 12ndash62]) and Met145 (OR 34 [14ndash93]) genotypes were independent predictors of composite ischemic outcome by multivariate regression as were diabetes mellitus (OR 40 [17ndash125]) abdominal aortic surgery (OR 41 [17ndash144]) and thoracoabdominal aortic surgery (OR 64 [27ndash238]) The addition of platelet gene polymorphisms to clinical factors improved fit (likelihood ratio testing chi-square = 135 P lt 0001) of an ischemia prediction model The derived risk assessment tool had a receiver operator characteristic curve of 073 (065ndash081) compared with 064 (057ndash074) for a model excluding genetic factors (P = 004) A significant relation between the GPIb[alpha] polymorphism and ischemic outcome remained after excluding electrocardiographic ischemia from the composite endpoint

Livelli di rischio tromboembolico in pazienti senza profilassi (Goertz et al 114 AHAACC

DVT PE

Livello di rischio polpaccio

prossimale Evento clinico

fatale Strategia di prevenzione con successo

BassoChir minore in paz lt40 anni senza fattori di rischio

2 04 02 lt001 No profilassideambulazione precoceaggressiva

ModerataChir minore in paz con fattori di rischio aggiuntiviChir in paz 40-60 anni senza fattori di rischio aggiuntivi

10-20 2-4 1-2 02-04

Hep(ogni 12 h)LMWH lt3400GCSIPC

Altachir in pazgt60 a tra 40-60 con FRA(VTEcancroipercoagulabilitagrave molecolare)

20-40 4-8 2-4 04-1 HEP ogni 8 hLMWHgt3400Ipc

AltissimaChir in paz con fattori di rischio multipliArtroprotesi anca ginocchioFrattura ancaTrauma maggioreTrauma midollare spinale

40-80 10-20 4-10 02-5 LMWHgt3400fondaparinuxVit K antag p os(INR 2-3)IPC o GCS+LMWH o Hep

FRAfattori di rischio aggiuntivi

IPCcpmpressione penumatica intermittente

Hepeparina non frazionata

LMDWeparina a basso peso molecolare

GCScalze a compressione graduale intermittente

Choice of Anesthetic Technique andAgent

bull Recommendations for Use of Volatile Anesthetic Agents

bull CLASS Iia 1 It can be beneficial to use volatile anesthetic agents during noncardiac surgery for the maintenance of general anesthesia in hemodynamically stable patients at risk for myocardial ischemia (Level of Evidence B)

Preoperative and Long-term Cardiac Risk Assessment Predictive Value of23 Clinical Descriptors 7 Multivariate Scoring Systems and Quantitative Dipyridamole Imaging in 360 PatientsJEAN LETTE MDt DAVID WATERS MDt HELENE BERNIER PATRICK CHAMPAGNE BScJEAN LASSONDE MD MICHEL PICARD MD4 MICHEL CERINO MD

STANLEY NATTEL MDtYVAN BOUCHER MD FRANCOISE HEYEN MD and SERGE DUBE

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD []

Gerstenblith Gary MD Bray Paul F MD Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297

December 2004

bull Abstractbull Background Current perioperative cardiac risk assessment tools use historic

and surgical factors to stratify patient risk Polymorphisms in platelet glycoprotein (GP) IIIa and GPIb[alpha] are associated with myocardial ischemic risk in nonsurgical settings but their relation to perioperative ischemia is unclear The authors hypothesized that platelet genotype would be an independent predictor of postoperative myocardial ischemia and would improve risk assessment when added to clinical factors

bull Methods One hundred ninety-six patients who underwent infrainguinal abdominal aortic or thoracoabdominal vascular surgery were evaluated for clinical and genetic factors that might predict the development of postoperative myocardial ischemia Genomic DNA was genotyped for the Leu33Pro polymorphism of GPIIIa and the Thr145Met polymorphism of GPIb[alpha] Myocardial ischemic outcome was determined by review of the medical record for cardiac death or myocardial infarction and by surveillance troponin I and automated continuous 12-lead electrocardiographic analysis

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD [] Gerstenblith Gary MD Bray Paul F MD

Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297 December 2004bull Results Sixty-five patients (33) experienced one or more ischemic

endpoints (2 death 5 myocardial infarction 20 troponin+ 22 electrocardiogram+) The Pro33 (adjusted odds ratio [OR] 24 [95 confidence interval 12ndash62]) and Met145 (OR 34 [14ndash93]) genotypes were independent predictors of composite ischemic outcome by multivariate regression as were diabetes mellitus (OR 40 [17ndash125]) abdominal aortic surgery (OR 41 [17ndash144]) and thoracoabdominal aortic surgery (OR 64 [27ndash238]) The addition of platelet gene polymorphisms to clinical factors improved fit (likelihood ratio testing chi-square = 135 P lt 0001) of an ischemia prediction model The derived risk assessment tool had a receiver operator characteristic curve of 073 (065ndash081) compared with 064 (057ndash074) for a model excluding genetic factors (P = 004) A significant relation between the GPIb[alpha] polymorphism and ischemic outcome remained after excluding electrocardiographic ischemia from the composite endpoint

Choice of Anesthetic Technique andAgent

bull Recommendations for Use of Volatile Anesthetic Agents

bull CLASS Iia 1 It can be beneficial to use volatile anesthetic agents during noncardiac surgery for the maintenance of general anesthesia in hemodynamically stable patients at risk for myocardial ischemia (Level of Evidence B)

Preoperative and Long-term Cardiac Risk Assessment Predictive Value of23 Clinical Descriptors 7 Multivariate Scoring Systems and Quantitative Dipyridamole Imaging in 360 PatientsJEAN LETTE MDt DAVID WATERS MDt HELENE BERNIER PATRICK CHAMPAGNE BScJEAN LASSONDE MD MICHEL PICARD MD4 MICHEL CERINO MD

STANLEY NATTEL MDtYVAN BOUCHER MD FRANCOISE HEYEN MD and SERGE DUBE

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD []

Gerstenblith Gary MD Bray Paul F MD Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297

December 2004

bull Abstractbull Background Current perioperative cardiac risk assessment tools use historic

and surgical factors to stratify patient risk Polymorphisms in platelet glycoprotein (GP) IIIa and GPIb[alpha] are associated with myocardial ischemic risk in nonsurgical settings but their relation to perioperative ischemia is unclear The authors hypothesized that platelet genotype would be an independent predictor of postoperative myocardial ischemia and would improve risk assessment when added to clinical factors

bull Methods One hundred ninety-six patients who underwent infrainguinal abdominal aortic or thoracoabdominal vascular surgery were evaluated for clinical and genetic factors that might predict the development of postoperative myocardial ischemia Genomic DNA was genotyped for the Leu33Pro polymorphism of GPIIIa and the Thr145Met polymorphism of GPIb[alpha] Myocardial ischemic outcome was determined by review of the medical record for cardiac death or myocardial infarction and by surveillance troponin I and automated continuous 12-lead electrocardiographic analysis

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD [] Gerstenblith Gary MD Bray Paul F MD

Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297 December 2004bull Results Sixty-five patients (33) experienced one or more ischemic

endpoints (2 death 5 myocardial infarction 20 troponin+ 22 electrocardiogram+) The Pro33 (adjusted odds ratio [OR] 24 [95 confidence interval 12ndash62]) and Met145 (OR 34 [14ndash93]) genotypes were independent predictors of composite ischemic outcome by multivariate regression as were diabetes mellitus (OR 40 [17ndash125]) abdominal aortic surgery (OR 41 [17ndash144]) and thoracoabdominal aortic surgery (OR 64 [27ndash238]) The addition of platelet gene polymorphisms to clinical factors improved fit (likelihood ratio testing chi-square = 135 P lt 0001) of an ischemia prediction model The derived risk assessment tool had a receiver operator characteristic curve of 073 (065ndash081) compared with 064 (057ndash074) for a model excluding genetic factors (P = 004) A significant relation between the GPIb[alpha] polymorphism and ischemic outcome remained after excluding electrocardiographic ischemia from the composite endpoint

Preoperative and Long-term Cardiac Risk Assessment Predictive Value of23 Clinical Descriptors 7 Multivariate Scoring Systems and Quantitative Dipyridamole Imaging in 360 PatientsJEAN LETTE MDt DAVID WATERS MDt HELENE BERNIER PATRICK CHAMPAGNE BScJEAN LASSONDE MD MICHEL PICARD MD4 MICHEL CERINO MD

STANLEY NATTEL MDtYVAN BOUCHER MD FRANCOISE HEYEN MD and SERGE DUBE

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD []

Gerstenblith Gary MD Bray Paul F MD Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297

December 2004

bull Abstractbull Background Current perioperative cardiac risk assessment tools use historic

and surgical factors to stratify patient risk Polymorphisms in platelet glycoprotein (GP) IIIa and GPIb[alpha] are associated with myocardial ischemic risk in nonsurgical settings but their relation to perioperative ischemia is unclear The authors hypothesized that platelet genotype would be an independent predictor of postoperative myocardial ischemia and would improve risk assessment when added to clinical factors

bull Methods One hundred ninety-six patients who underwent infrainguinal abdominal aortic or thoracoabdominal vascular surgery were evaluated for clinical and genetic factors that might predict the development of postoperative myocardial ischemia Genomic DNA was genotyped for the Leu33Pro polymorphism of GPIIIa and the Thr145Met polymorphism of GPIb[alpha] Myocardial ischemic outcome was determined by review of the medical record for cardiac death or myocardial infarction and by surveillance troponin I and automated continuous 12-lead electrocardiographic analysis

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD [] Gerstenblith Gary MD Bray Paul F MD

Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297 December 2004bull Results Sixty-five patients (33) experienced one or more ischemic

endpoints (2 death 5 myocardial infarction 20 troponin+ 22 electrocardiogram+) The Pro33 (adjusted odds ratio [OR] 24 [95 confidence interval 12ndash62]) and Met145 (OR 34 [14ndash93]) genotypes were independent predictors of composite ischemic outcome by multivariate regression as were diabetes mellitus (OR 40 [17ndash125]) abdominal aortic surgery (OR 41 [17ndash144]) and thoracoabdominal aortic surgery (OR 64 [27ndash238]) The addition of platelet gene polymorphisms to clinical factors improved fit (likelihood ratio testing chi-square = 135 P lt 0001) of an ischemia prediction model The derived risk assessment tool had a receiver operator characteristic curve of 073 (065ndash081) compared with 064 (057ndash074) for a model excluding genetic factors (P = 004) A significant relation between the GPIb[alpha] polymorphism and ischemic outcome remained after excluding electrocardiographic ischemia from the composite endpoint

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD []

Gerstenblith Gary MD Bray Paul F MD Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297

December 2004

bull Abstractbull Background Current perioperative cardiac risk assessment tools use historic

and surgical factors to stratify patient risk Polymorphisms in platelet glycoprotein (GP) IIIa and GPIb[alpha] are associated with myocardial ischemic risk in nonsurgical settings but their relation to perioperative ischemia is unclear The authors hypothesized that platelet genotype would be an independent predictor of postoperative myocardial ischemia and would improve risk assessment when added to clinical factors

bull Methods One hundred ninety-six patients who underwent infrainguinal abdominal aortic or thoracoabdominal vascular surgery were evaluated for clinical and genetic factors that might predict the development of postoperative myocardial ischemia Genomic DNA was genotyped for the Leu33Pro polymorphism of GPIIIa and the Thr145Met polymorphism of GPIb[alpha] Myocardial ischemic outcome was determined by review of the medical record for cardiac death or myocardial infarction and by surveillance troponin I and automated continuous 12-lead electrocardiographic analysis

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD [] Gerstenblith Gary MD Bray Paul F MD

Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297 December 2004bull Results Sixty-five patients (33) experienced one or more ischemic

endpoints (2 death 5 myocardial infarction 20 troponin+ 22 electrocardiogram+) The Pro33 (adjusted odds ratio [OR] 24 [95 confidence interval 12ndash62]) and Met145 (OR 34 [14ndash93]) genotypes were independent predictors of composite ischemic outcome by multivariate regression as were diabetes mellitus (OR 40 [17ndash125]) abdominal aortic surgery (OR 41 [17ndash144]) and thoracoabdominal aortic surgery (OR 64 [27ndash238]) The addition of platelet gene polymorphisms to clinical factors improved fit (likelihood ratio testing chi-square = 135 P lt 0001) of an ischemia prediction model The derived risk assessment tool had a receiver operator characteristic curve of 073 (065ndash081) compared with 064 (057ndash074) for a model excluding genetic factors (P = 004) A significant relation between the GPIb[alpha] polymorphism and ischemic outcome remained after excluding electrocardiographic ischemia from the composite endpoint

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD []

Gerstenblith Gary MD Bray Paul F MD Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297

December 2004

bull Abstractbull Background Current perioperative cardiac risk assessment tools use historic

and surgical factors to stratify patient risk Polymorphisms in platelet glycoprotein (GP) IIIa and GPIb[alpha] are associated with myocardial ischemic risk in nonsurgical settings but their relation to perioperative ischemia is unclear The authors hypothesized that platelet genotype would be an independent predictor of postoperative myocardial ischemia and would improve risk assessment when added to clinical factors

bull Methods One hundred ninety-six patients who underwent infrainguinal abdominal aortic or thoracoabdominal vascular surgery were evaluated for clinical and genetic factors that might predict the development of postoperative myocardial ischemia Genomic DNA was genotyped for the Leu33Pro polymorphism of GPIIIa and the Thr145Met polymorphism of GPIb[alpha] Myocardial ischemic outcome was determined by review of the medical record for cardiac death or myocardial infarction and by surveillance troponin I and automated continuous 12-lead electrocardiographic analysis

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD [] Gerstenblith Gary MD Bray Paul F MD

Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297 December 2004bull Results Sixty-five patients (33) experienced one or more ischemic

endpoints (2 death 5 myocardial infarction 20 troponin+ 22 electrocardiogram+) The Pro33 (adjusted odds ratio [OR] 24 [95 confidence interval 12ndash62]) and Met145 (OR 34 [14ndash93]) genotypes were independent predictors of composite ischemic outcome by multivariate regression as were diabetes mellitus (OR 40 [17ndash125]) abdominal aortic surgery (OR 41 [17ndash144]) and thoracoabdominal aortic surgery (OR 64 [27ndash238]) The addition of platelet gene polymorphisms to clinical factors improved fit (likelihood ratio testing chi-square = 135 P lt 0001) of an ischemia prediction model The derived risk assessment tool had a receiver operator characteristic curve of 073 (065ndash081) compared with 064 (057ndash074) for a model excluding genetic factors (P = 004) A significant relation between the GPIb[alpha] polymorphism and ischemic outcome remained after excluding electrocardiographic ischemia from the composite endpoint

Ann Surg 1990 Jan211(1)84-90 LinksPostoperative myocardial infarction

and cardiac death Predictive value of dipyridamole-thallium imaging and

five clinical scoring systems based on multifactorial analysis

Lette J Waters D Lassonde J Dubeacute S Heyen F Picard M Morin M

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD []

Gerstenblith Gary MD Bray Paul F MD Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297

December 2004

bull Abstractbull Background Current perioperative cardiac risk assessment tools use historic

and surgical factors to stratify patient risk Polymorphisms in platelet glycoprotein (GP) IIIa and GPIb[alpha] are associated with myocardial ischemic risk in nonsurgical settings but their relation to perioperative ischemia is unclear The authors hypothesized that platelet genotype would be an independent predictor of postoperative myocardial ischemia and would improve risk assessment when added to clinical factors

bull Methods One hundred ninety-six patients who underwent infrainguinal abdominal aortic or thoracoabdominal vascular surgery were evaluated for clinical and genetic factors that might predict the development of postoperative myocardial ischemia Genomic DNA was genotyped for the Leu33Pro polymorphism of GPIIIa and the Thr145Met polymorphism of GPIb[alpha] Myocardial ischemic outcome was determined by review of the medical record for cardiac death or myocardial infarction and by surveillance troponin I and automated continuous 12-lead electrocardiographic analysis

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD [] Gerstenblith Gary MD Bray Paul F MD

Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297 December 2004bull Results Sixty-five patients (33) experienced one or more ischemic

endpoints (2 death 5 myocardial infarction 20 troponin+ 22 electrocardiogram+) The Pro33 (adjusted odds ratio [OR] 24 [95 confidence interval 12ndash62]) and Met145 (OR 34 [14ndash93]) genotypes were independent predictors of composite ischemic outcome by multivariate regression as were diabetes mellitus (OR 40 [17ndash125]) abdominal aortic surgery (OR 41 [17ndash144]) and thoracoabdominal aortic surgery (OR 64 [27ndash238]) The addition of platelet gene polymorphisms to clinical factors improved fit (likelihood ratio testing chi-square = 135 P lt 0001) of an ischemia prediction model The derived risk assessment tool had a receiver operator characteristic curve of 073 (065ndash081) compared with 064 (057ndash074) for a model excluding genetic factors (P = 004) A significant relation between the GPIb[alpha] polymorphism and ischemic outcome remained after excluding electrocardiographic ischemia from the composite endpoint

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD []

Gerstenblith Gary MD Bray Paul F MD Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297

December 2004

bull Abstractbull Background Current perioperative cardiac risk assessment tools use historic

and surgical factors to stratify patient risk Polymorphisms in platelet glycoprotein (GP) IIIa and GPIb[alpha] are associated with myocardial ischemic risk in nonsurgical settings but their relation to perioperative ischemia is unclear The authors hypothesized that platelet genotype would be an independent predictor of postoperative myocardial ischemia and would improve risk assessment when added to clinical factors

bull Methods One hundred ninety-six patients who underwent infrainguinal abdominal aortic or thoracoabdominal vascular surgery were evaluated for clinical and genetic factors that might predict the development of postoperative myocardial ischemia Genomic DNA was genotyped for the Leu33Pro polymorphism of GPIIIa and the Thr145Met polymorphism of GPIb[alpha] Myocardial ischemic outcome was determined by review of the medical record for cardiac death or myocardial infarction and by surveillance troponin I and automated continuous 12-lead electrocardiographic analysis

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD [] Gerstenblith Gary MD Bray Paul F MD

Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297 December 2004bull Results Sixty-five patients (33) experienced one or more ischemic

endpoints (2 death 5 myocardial infarction 20 troponin+ 22 electrocardiogram+) The Pro33 (adjusted odds ratio [OR] 24 [95 confidence interval 12ndash62]) and Met145 (OR 34 [14ndash93]) genotypes were independent predictors of composite ischemic outcome by multivariate regression as were diabetes mellitus (OR 40 [17ndash125]) abdominal aortic surgery (OR 41 [17ndash144]) and thoracoabdominal aortic surgery (OR 64 [27ndash238]) The addition of platelet gene polymorphisms to clinical factors improved fit (likelihood ratio testing chi-square = 135 P lt 0001) of an ischemia prediction model The derived risk assessment tool had a receiver operator characteristic curve of 073 (065ndash081) compared with 064 (057ndash074) for a model excluding genetic factors (P = 004) A significant relation between the GPIb[alpha] polymorphism and ischemic outcome remained after excluding electrocardiographic ischemia from the composite endpoint

Faraday Nauder MD Martinez Elizabeth A MD + Scharpf Robert B MS ++ Kasch-Semenza Laura MS [S] Dorman Todd MD Pronovost Peter J MD PhD Perler Bruce MD [] Gerstenblith Gary MD Bray Paul F MD

Fleisher Lee A MD ++ Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297 December 2004bull Results Sixty-five patients (33) experienced one or more ischemic

endpoints (2 death 5 myocardial infarction 20 troponin+ 22 electrocardiogram+) The Pro33 (adjusted odds ratio [OR] 24 [95 confidence interval 12ndash62]) and Met145 (OR 34 [14ndash93]) genotypes were independent predictors of composite ischemic outcome by multivariate regression as were diabetes mellitus (OR 40 [17ndash125]) abdominal aortic surgery (OR 41 [17ndash144]) and thoracoabdominal aortic surgery (OR 64 [27ndash238]) The addition of platelet gene polymorphisms to clinical factors improved fit (likelihood ratio testing chi-square = 135 P lt 0001) of an ischemia prediction model The derived risk assessment tool had a receiver operator characteristic curve of 073 (065ndash081) compared with 064 (057ndash074) for a model excluding genetic factors (P = 004) A significant relation between the GPIb[alpha] polymorphism and ischemic outcome remained after excluding electrocardiographic ischemia from the composite endpoint