Reducing cardiovascular risk in patients undergoing noncardiac surgery

Current Predictors of Mortality in Veteran Patients Undergoing Major Lower Extremity Amputations: Risk Factors Have Not Changed and Mortality Remains High

Major lower extremity amputation (LEA-above the ankle) carries a high rate of mortality. In the present study, we performed an institutional review of all patients submitting to LEAs at a Veteran Administration Hospital (between 2009 and 2021) accompanied with a review of the literature.For the past 12 years, 1042 LEAs were performed in 603 patients at our hospital. The 30-day, 1-year, and 5-year mortalities were 8.5%, 28.9%, and 53.0%, respectively. Age, hypoalbuminemia, and Clavien-Dindo Class were independent predictors of mortality in all the time intervals in the analysis. Cardiac disease was not an independent predictor of mortality. In 39 studies reviewed, the average 30-day, 1-year, and 5-year mortality was 14%, 36%, and 56%, respectively. There was no difference in mortality in multiple studies analyzed. No significant temporal variation was identified between 1950 and 2000 vs. 2001 and 2021. Predictors of mortality were not substantially different from our institutional experience.The mortality rate for LEAs remains constant over time. Increasing age and hypoalbuminemia are strong predictors of short- and long-term mortality.

Is the anesthesiologist actually prepared for loss of airway or respiratory function? A cross-sectional study conducted in a tertiary hospital

OBJECTIVE

To identify compliance with the procedures for securing the airway of patients submitted to anesthesia, defined as highly recommended in the World Health Organization Surgical Safety Checklist.

METHODS

A prospective, cross-sectional, observational study was conducted with 87 patients aged 18 to 60 years, classified as ASA grade 1 or 2 according to the American Society of Anesthesiologists' Physical Status Classification. The study variables consisted of: whether the Mallampati test had been performed, whether equipment was readily available for orotracheal intubation, whether the correct placement of the endotracheal tube was verified, whether patient ventilation was monitored and whether fasting was confirmed. Prevalence ratios and their respective 95% confidence intervals were calculated as measures of relative risk. Statistical significance was defined at 5%.

RESULTS

It was found that in 87.4% of patients, the airway was not evaluated using the Mallampati classification and in 51.7% of cases, preoperative fasting was not confirmed. In 29.9% of cases, the ready availability of equipment for orotracheal intubation was not verified. In all of the cases in which the availability of this equipment was not checked, the patient was submitted to regional anesthesia, with a statistically significant difference compared to the cases in which the patient was submitted to general anesthesia.

CONCLUSION

Measures considered essential for the safety of the patient during surgery are still being ignored.

Computed tomography and scintigraphy vs. cardiac catheterization for coronary disease screening prior to noncardiac surgery

OBJECTIVE

The goal of this study was to investigate the utility of multidetector-row computed tomography (MDCT) and adenosine triphosphate stress cardiac single photon emission computed tomography (ATP-SPECT) in evaluating coronary artery disease (CAD) in patients scheduled for non-cardiac surgery.

PATIENTS AND METHODS

We routinely performed echocardiography and exercise stress electrocardiography as preoperative cardiac screening examinations for patients scheduled for non-cardiac surgery under general anesthesia. Of 848 consecutive preoperative patients (Non-invasive Group), 49 patients with abnormalities of these screening examinations had MDCT and ATP-SPECT. Of 809 consecutive preoperative patients studied at an earlier time (Invasive Group), 58 patients with abnormalities of these screening examinations had cardiac catheterization as an additional cardiac examination.

RESULTS

The number of patients in the non-invasive and invasive subgroups having additional screening examinations was comparable, and there was no significant difference in perioperative cardiac events between the two subgroups. Based on results of the additional tests in the two subgroups, preoperative prophylactic invasive treatment for CAD was carried out in a small number of patients, again with no significant differences between the groups. However, total medical expenses for the additional cardiac examinations were significantly reduced in the non-invasive subgroup compared with the invasive subgroup (140,030+/-34,800 vs. 187,170+/-26,120 yen, respectively, p=0.0002).

CONCLUSION

Non-invasive examination prior to noncardiac surgery using MDCT and ATP-SPECT in a subgroup of patients suspected of having CAD appears to be a useful screening procedure. Compared with invasive cardiac catheterization, CT testing has comparable diagnostic utility without an increase in perioperative cardiac events, and in addition, it has an improved cost-benefit profile.

Cardiac screening before noncardiac surgery

Cardiovascular complications are infrequent but can result in significant morbidity following noncardiac surgery, especially in patients with peripheral vascular disease or increased age. All patients require some level of preoperative screening to identify and minimize immediate and future risk, with a careful focus on known coronary artery disease or risks for coronary artery disease and functional capacity. The 2007 American College of Cardiology/American Heart Association Guidelines are clear that noninvasive and invasive testing should be limited to circumstances in which results will clearly affect patient management or in which testing would otherwise be indicated. beta-Blocker therapy has become controversial in light of recent publications but should be continued in patients already on therapy, and started in patients with high cardiac risk undergoing intermediate- or high-risk surgery.

Perioperative use of beta-blockers in the elderly patient

Elderly patients are increasingly referred for complex surgery, but are at particular risk for coronary artery disease. One strategy to prevent perioperative cardiac events in elderly patients is to employ perioperative beta-blockade, but doing so has the potential to increase the incidence of congestive heart failure, perioperative hypotension, bradycardia, and stroke. This article examines common comorbidities in the elderly who may benefit from the chronic use of beta-blockers, prophylactic perioperative use of beta-blockers including timing, dosage, and choice of beta-blocker, the pharmacologic effects of aging, and recommendations on the use of beta-blockers.

The preoperative cardiovascular evaluation of the intermediate-risk patient: new data, changing strategies

The intermediate-risk preoperative patient can be defined as a patient without severely symptomatic or unstable heart disease who, nonetheless, has clinical predictors of adverse perioperative cardiovascular events. Newer data have created an awareness of competing considerations in managing these patients. There is still debate about how to appropriately select patients for noninvasive cardiac testing, invasive coronary testing, coronary revascularization, beta-blockers, or a combination of these. In this article, we review the evidence pertaining to these issues. We conclude that intermediate-risk preoperative patients are best managed by an approach that emphasizes the following points: intermediate-risk patients should be identified and risk stratified using a clinical tool (eg, the Revised Cardiac Risk Index); noninvasive cardiac testing should be reserved for those patients with multiple clinical predictors of risk or the presence of other modifying factors; preoperative coronary revascularization does not appear to reduce perioperative risk in patients with significant but stable coronary artery disease; and medical therapy should be optimized for these patients, including the application of beta-blockers in all intermediate-risk patients that do not have contraindications.

Hip fracture in the older patient: reasons for delay in hospitalization and timing of surgical repair

OBJECTIVES

To quantify the interval between injury and hospitalization in older hip fracture patients, to quantify the time from hospital arrival to surgical repair of hip fracture, and to describe factors contributing to extended intervals between injury, hospitalization, and surgical repair of hip fracture.

DESIGN

Prospective cohort study.

SETTING

Four hospitals in the New York City metropolitan area.

PARTICIPANTS

Consecutive patients aged 50 and older admitted with diagnosis of hip fracture to these four hospitals between August 1997 and August 1998.

MEASUREMENTS

Time of injury, time of arrival to the emergency room, and time of surgery were recorded and used to calculate intervals between injury and hospital arrival and between hospital arrival and surgical repair.

RESULTS

Of the 571 patients enrolled, 99 (17%) arrived at the hospital more than 24 hours after injury. After hospital arrival, 17 (3%) patients did not have surgery, 166 (29%) had surgery within 24 hours of arrival, and 388 (68.0%) had surgery more than 24 hours after arrival (median 41 hours, range 25-584). For those patients who had surgery after 24 hours, 163 (29.4%) had surgery 25 to 36 hours after hospital arrival, 102 (18.4%) had surgery 37 to 48 hours after arrival, and 123 (22.2%) had surgery more than 48 hours after arrival. The primary reasons for delaying surgery more than 24 hours after hospital arrival were waiting for routine medical clearance (52%) and unavailability of the operating suite or surgeon (29%). Stabilization of associated medical conditions resulted in the lengthiest periods of delay.

CONCLUSION

A wait time of more than 24 hours from hospitalization to surgical repair of hip fracture in older patients is common. Some of this delay time is patient related and some occurs because of systems factors and may be avoidable. The extent to which surgical timing affects survival and functional recovery needs more detailed examination.

Perioperative beta-blockers in high-risk patients

One major risk to patients in the preoperative period is that of myocardial ischemia or infarction and cardiovascular death in high-risk patients. Historically, attempts to decrease the incidence of perioperative cardiac complications have focused on preoperative evaluation and identification of patients at risk for complications with referral for additional testing and/or revascularization. Evidence suggests that the use of perioperative beta-blockers in high-risk individuals can reduce the incidence of perioperative cardiac events. The Agency for Healthcare Research and Quality has identified that the use of perioperative beta-blockers can reduce perioperative morbidity and mortality. The focus of this article is to describe the evidence supporting perioperative beta-blocker use, to discuss potential barriers to their use, and to propose a strategy to improve their use.

Prediction of cardiac risk before abdominal aortic reconstruction: comparison of a revised Goldman Cardiac Risk Index and radioisotope ejection fraction

BACKGROUND

A revised Goldman Cardiac Risk Index has been suggested to identify patients at higher risk for cardiac complications in patients who undergo major noncardiac surgery. The aim of this study was to test the usefulness of this model in an independent series of patients who underwent abdominal aortic surgery and to compare the index with the multiple gated acquisition (MUGA) scan in the prediction of cardiac complications.

METHODS

We studied 77 patients who underwent MUGA scan before elective abdominal aortic reconstruction. The revised index was calculated for each patient after recording the following five risk factors: history of ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin-dependent diabetes, and creatinine level more than 2 mg/dL. Technetium-99m MUGA scan provided information about the resting left ventricular ejection fraction (LVEF) and the presence of regional wall motion abnormalities.

RESULTS

Fourteen patients (18%) had cardiac complications develop. The index proved to be a satisfactory predictor of postoperative cardiac events (P =.008), and an abnormal LVEF failed to do so (P =.1). The presence of wall abnormalities, with or without an abnormal LVEF, predicted cardiac complications (P =.004 and P =.006). Patients with a higher index score showed a tendency to have a lower LVEF (Spearman rank correlation, r = -0.43; P <.001). Wall abnormalities, with or without an abnormal LVEF, were more frequent in patients with higher scores (P =.03 and P =.009). Combining the index with the LVEF or the wall abnormalities or both could further stratify the cardiac risk (P =.004, P =.0003 and P =.0006, with chi(2) test for trend).

CONCLUSION

For those patients who undergo elective abdominal aortic surgery, the revised Goldman Cardiac Risk Index is a simple method of evaluating cardiac risk with minimum resource implications. MUGA scan can offer additional stratification in patients judged with the index to be at high risk.

Patient outcomes after peripheral revascularization surgery

Acquired peripheral vascular disease (PVD) is a significant problem in the United States, resulting in both morbidity and mortality. The purpose of the pilot study was to determine patient outcomes after peripheral revascularization surgery. The specific aims of the pilot study were to examine peripheral revascularization surgical patient outcomes (PVD-related clinical symptoms, functioning, atherosclerotic disease risk factor reduction, and patient satisfaction) and to determine the influence of selected patient demographic characteristics (gender, age) on selected patient outcomes (PVD-related clinical symptoms, functioning, atherosclerotic disease risk factor reduction, and patient satisfaction). A prospective, repeated measures design was used for the study. A total of 39 patients, 18 women and 21 men, participated in the study, with a mean age of 68.86 years (SD = 13.61). The average length of hospitalization after surgery was 4.05 days. At 1 month after discharge, the majority of patients had relief from claudication and paresthesia. In regard to outcomes related to atherosclerotic risk factor modification, patients reported that they exercised on a routine basis, an average of 5.31 +/- 1.97 times per week. Before surgery, 21 patients reported that they smoked; 6 patients reported that they continued to smoke at follow-up. There were no significant differences in mean total scores of atherosclerotic risk modification by either gender or age groups (<65 or > or =65 years) with the use of one-way analyses of variance (ANOVAs). By using a Likert scale (ie, 0 to 10), the mean level of functioning was 8.18 +/- 2.76, with women having significantly higher mean levels of functioning (F = 4.26, P <.05). Comparing baseline scores of functioning on the Medical Outcomes Study Short-Form 36 (MOS SF-36), there was a significant improvement (F = 2.11, P <.05) in general health subscale scores at 1 month after surgery. Subjects' mean overall satisfaction with the results of surgery, with a 0 to 10 scale, was 7.33 +/- 2.84. Again, by using one-way ANOVAs, females had significantly higher mean satisfaction rating than males (F = 4.52, P <.05). Although findings from this pilot study are limited in their generalizability, clinicians need to continue to evaluate opportunities to further reduce variability in clinical practice patterns for optimal patient outcomes. Study findings also indicated that additional interventions are warranted to educate and provide rehabilitation for patients regarding an exercise program and overall behavior modification strategies to reduce risk for atherosclerotic disease.

Cardiac risk assessment for noncardiac surgery: current concepts

Strategies for perioperative risk assessment in patients undergoing noncardiac surgery vary among physicians and are aimed to estimate the risk and minimize complications. We propose simplistic guidelines for assessing and modifying risk for patients undergoing a wide variety of procedures.

Postoperative and late survival outcomes after major amputation: findings from the Department of Veterans Affairs National Surgical Quality Improvement Program

BACKGROUND

A surgical risk model is used to analyze postoperative mortality and late survival for older veterans who underwent above- or below-knee amputations in 119 Veterans Affairs (VA) hospitals from 1991 to 1995.

METHODS

Preoperative medical conditions and laboratory values abstracted by the VA National Surgical Quality Improvement Program were linked to subsequent hospitalization and survival through 1999. Logistic regression and proportional hazards models were used to develop risk indexes for postoperative mortality and long-term survival.

RESULTS

Thirty-day postoperative mortality was 6.3% for 1909 below-knee and 13.3% for 2152 above-knee amputees. Mortality varied greatly between the lowest-highest risk index quartiles (0.8%-18.4% for below-knee amputation and 2.3%-31.1% for above-knee amputation). Surviving patients had 10,827 subsequent VA hospitalizations during a median 32-month follow-up. Survival probabilities for below- and above-knee amputees were 77% and 59% at 1 year, 57% and 39% at 3 years, and 28% and 20% at 7.5 years. The lowest quartile of survival risk had a 61% five-year survival compared with 14% for the highest-risk quartile.

CONCLUSION

A generic surgical risk model can be of use in stratifying prognosis after major amputation. The heavy burden of hospital use by these patients suggests the need for better disease management for this high-risk, high-cost patient population.

Gaining control: can we reduce perioperative cardiovascular complications?

Cardiovascular complications are common in patients at risk for coronary disease undergoing surgery. The role of hyperactivity of the sympathetic nervous system and impaired parasympathetic control mechanisms in the genesis and consequences of perioperative myocardial ischemia has been discussed. Sympathetic blocking drugs of the beta blocker and alpha₂ agonist classes have been used extensively in the perioperative setting to control hemodynamic responses and reduce episodes of myocardial ischemia. To date, perioperative beta blockade is the only strategy shown to improve long-term outcome after surgery in this population.

Cardiac Investigation and Intervention Prior to Thoraco-abdominal Aneurysm Repair: Coronary Angiography in 35 Patients

OBJECTIVE

retrospective studies indicate a high risk of cardiac events in patients undergoing thoraco-abdominal aneurysm repair. We aimed to determine the prevalence of coronary disease in these patients, define the role of non-invasive cardiac testing and assess the short-term outcome of coronary re-vascularisation.

DESIGN

a prospective cohort study of consecutive patients referred to a single surgeon.

MATERIALS AND METHODS

forty patients recruited over 16 months (Type I, 6; II, 11; III, 8; IV, 15). Dobutamine stress echocardiography, coronary angiography and coronary re-vascularisation (PTCA or CABG) were performed according to a pragmatic protocol. Main outcome measures were the prevalence of coronary artery disease, sensitivity and specificity of clinical assessment and non-invasive cardiac testing, and adverse events associated with coronary investigation and intervention.

RESULTS

seven patients (17.5%) were stratified as having high perioperative cardiac risk. The majority of patients (23, 57.5%) had no cardiac risk factor other than the operation type. Five patients (12.5%) had inducible ischaemia on non-invasive testing. Fourteen patients (40%) had haemodynamically significant coronary artery stenoses, of whom 12 (34%) underwent coronary revascularisation. Dobutamine stress echocardiography demonstrated 100% specificity and 71% sensitivity for the detection of significant coronary artery lesions. Coronary re-vascularisation by three-vessel bypass grafting was complicated by non-fatal stroke in one patient. Thirty-five patients (87.5%) proceeded to aneurysm repair. No patient who had been adequately investigated suffered a cardiac complication.

CONCLUSIONS

the 40% prevalence of coronary artery disease in these patients is comparable to that of other patients undergoing arterial surgery. Non-invasive testing proved beneficial, both in screening low-risk patients and planning intervention in patients at higher risk. An aggressive approach to intervention was associated with an acceptable complication rate and favourable short-term outcome.

Cardiac risk assessment in noncardiac thoracic surgery

Preoperative cardiac risk assessment for noncardiac thoracic surgery is limited by the lack of data specific to this type of surgery, especially prospective, controlled data. However, the value of clinical predictors in determining accurate postoperative cardiac outcomes is a reliable tool. Thus, the approach is similar to traditional cardiac risk assessment for noncardiac surgery. The essential elements of cardiovascular evaluation as it pertains to noncardiac thoracic surgery are reviewed with a specific focus on coronary artery disease, perioperative arrhythmias, and selected topics relevant to noncardiac thoracic surgery. The core recommendations of the clinical guidelines by the American College of Cardiology and American Heart Association are discussed in the context of noncardiac thoracic surgery.

Measures of success and health-related quality of life in lower-extremity vascular surgery

Lower-extremity vascular surgery is most often indicated for patients with critical leg ischemia but has increasingly been used for patients with disabling intermittent claudication. This article reviews indications, follow-up protocols, and procedure-related outcomes including perioperative and late mortality, complications, and long-term patency rates, which vary with patient risk factors, vascular disease severity, and hospital volume. Population-based studies have yet to establish whether rates of limb-preserving bypass surgery are related to overall amputation rates, partly because of the continued high rate of primary amputation. The functional benefits of vascular surgery have been traditionally assessed by treadmill protocols and batteries of physical tests. Claudication treatment is increasingly being measured by both generic and disease-specific functional and health-related quality-of-life questionnaires. Patient self-reported measures of physical functioning and walking ability are reviewed. Finally, conclusions are presented about trends in lower-extremity bypass surgery rates.

Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery

BACKGROUND

Cardiac complications are important causes of morbidity after noncardiac surgery. The purpose of this prospective cohort study was to develop and validate an index for risk of cardiac complications.

METHODS AND RESULTS

We studied 4315 patients aged > or = 50 years undergoing elective major noncardiac procedures in a tertiary-care teaching hospital. The main outcome measures were major cardiac complications. Major cardiac complications occurred in 56 (2%) of 2893 patients assigned to the derivation cohort. Six independent predictors of complications were identified and included in a Revised Cardiac Risk Index: high-risk type of surgery, history of ischemic heart disease, history of congestive heart failure, history of cerebrovascular disease, preoperative treatment with insulin, and preoperative serum creatinine >2.0 mg/dL. Rates of major cardiac complication with 0, 1, 2, or > or = 3 of these factors were 0.5%, 1.3%, 4%, and 9%, respectively, in the derivation cohort and 0.4%, 0.9%, 7%, and 11%, respectively, among 1422 patients in the validation cohort. Receiver operating characteristic curve analysis in the validation cohort indicated that the diagnostic performance of the Revised Cardiac Risk Index was superior to other published risk-prediction indexes.

CONCLUSIONS

In stable patients undergoing nonurgent major noncardiac surgery, this index can identify patients at higher risk for complications. This index may be useful for identification of candidates for further risk stratification with noninvasive technologies or other management strategies, as well as low-risk patients in whom additional evaluation is unlikely to be helpful.

Recognition and management of preoperative risk

Internists are frequently asked to do preoperative consultations and to manage perioperative complications. Realistic goals are to identify patient factors that increase the risk of surgery, to quantify this risk in order to make decisions about the appropriateness of and timing of the surgery, to provide recommendations on how to minimize the risk, to identify and manage coexisting medical conditions and their associated medication requirements, to monitor the patient for perioperative problems, and to make recommendations to deal with these problems when they occur. With few exceptions, nonselective imaging and laboratory screening tests have repeatedly been shown to be of little value when the history and physical do not suggest a problem. The risk associated with the planned surgery can be estimated, with the most common serious complications being cardiac events. Updated versions of Goldman's risk indices are particularly helpful for this. Clinical variables are optimally combined with selective stress testing to discern which patients will benefit from preoperative revascularization. This has been studied best in the setting of vascular surgery. A critical guiding principle is that the value of revascularization must be judged in terms of long term gains rather than just immediate perioperative benefit. Other interventions include the selective use of beta blockers, adequate analgesia for all, control of hypertension, and appropriate volume management, especially in the settings of preexisting CHF or valvular disease. It must also be recognized that perioperative ischemia and CHF often present atypically. An approach that combines aspects of both the ACC/AHA and the ACP guidelines seems optimal. A variety of noncardiac issues must also be addressed. Postoperative pulmonary complications are common, especially with preexisting pulmonary disease, thoracic and upper abdominal surgery, and obesity. PFTs and ABGs are indicated in selected patients. Stopping smoking, incentive spirometry, and selective use of bronchodilators and antibiotics are helpful. Patients with rheumatologic diseases have specific concerns based on systemic manifestations of disease including anemia, thrombocytopenia, pulmonary fibrosis, pericarditis, and hypercoagulability; medication effects particularly from steroids and nonsteroidal anti-inflammatory drugs; and specific joint problems including contractures and atlantoaxial joint instability. Diabetes increases the risk of infection and cardiac complications. Prevention of ketoacidosis and glucose control are necessary and can be achieved through a variety of approaches, depending on whether the patient suffers from Type 1 or Type 2 diabetes. The threshold for transfusion has increased in recent years, as has the use of erythropoietin and autologous blood donation. There is no longer an absolute hemoglobin that requires transfusion, although most require transfusion for hemoglobins less than 8 mg/dL, especially in the setting of cardiac disease and bloody surgery. The elderly require surgery at an increased rate and often do not do as well as younger patients. The primary issues are, however, not their age but their increased frequency of underlying disease and diminished reserve. The latter makes them prone to postoperative delirium, sensitivity to medications, and cardiac and pulmonary problems. Despite the many diseases that patients often have and the stresses of surgery itself, modern anesthetic and surgical techniques allow almost all patients to undergo necessary procedures at acceptable risk. The internist plays a critical role in minimizing this risk even further.

Information needs in a changing health care system: capitation and the need for a population-oriented view

Information systems needed for managing the health care of populations under at-risk (capitation) contracts must be designed differently than those used in fee-for-service practice. Under capitation, providers must deliver health care to enrollees with financial resources that are fixed in advance. Therefore, the information systems they use must enable them to understand the health status of health plan enrollees and how health care is provided. These systems should facilitate the detection of underservice and of inadequate quality of health care as well as overuse of health care resources. They should permit clinical-epidemiologic and statistical analysis; facilitate disease management and the adoption of preventive programs, and lend themselves to use by planners, group leaders, and practicing physicians.

Prognosis of patients with vascular disease after clinical evaluation and dobutamine stress echocardiography

BACKGROUND

Coronary disease is an important cause of long-term morbidity in patients needing major vascular surgery. We sought to assess the efficacy of preoperative clinical evaluation and the detection of inducible ischemia for prediction of immediate and long-term cardiac outcomes of patients undergoing vascular surgery.

METHODS

In 233 patients undergoing vascular procedures, we assessed risk clinically on the basis of Eagle's criteria. Dobutamine echocardiography was performed with a standard protocol and results were classified as showing ischemia, scar, or a normal response. Patients were observed perioperatively, and late follow-up (28 +/- 13 months) was completed in all surgical survivors. A composite end point of cardiac death, myocardial infarction, and unstable and progressive angina requiring late revascularization was used to judge event-free survival.

RESULTS

Of 233 patients undergoing preoperative dobutamine echocardiography, 39 (17%) had inducible ischemia and 36 (15%) had scar. Perioperative events occurred in 8 patients (3%). None of the patients with ischemia had perioperative events, reflecting the effect of revascularization in 9 patients. Late events occurred in 36 patients; ischemia on preoperative stress testing was a predictor of these events even after adjusting for clinical variables and left ventricular dysfunction (relative risk = 3.3; 95% confidence interval 1.6 to 6.8; P =.001). The association of ischemia with clinical predictors was associated with incrementally worse outcome.

CONCLUSION

In addition to perioperative assessment, the combined use of clinical and dobutamine echocardiographic evaluation may stratify the risk of late cardiac events.

A Therapeutic Commentary

ABSTRACT: Thirty-one million patients in the United States undergo surgical procedures every year. Approximately 10%-the majority of these with hypertension-are at an increased risk for perioperative and postoperative cardiovascular morbidity and mortality. Thus, hypertensive patients requiring surgery, especially the 2.1 million undergoing noncardiac procedures, should be evaluated carefully for the magnitude, and if severe, the cause of the hypertension. Additionally, their associated metabolic and cardiovascular status should be characterized and corrected with aggressive therapy. Hypertensive patients with known ischemic heart disease, those with multiple risk factors for ischemic heart disease (IHD), some with valvular heart disease, and those with congestive heart failure should be evaluated for their ability to perform the physical and social activities of everyday life, and, when necessary, have formal stress testing. Most studies suggest that blood pressures of 180/110 mm Hg or greater are associated with a greater risk for perioperative ischemic events. Therefore, the goals of blood pressure control should be to reduce the blood pressure without jeopardizing organ function. Antihypertensive medication should be administered until the time of surgery. beta-Receptor blockers should be instituted or continued in patients with angina and in some patients with congestive heart failure. Those without prior antihypertensive therapy might be best treated with beta-blocker therapy perioperatively as evidenced by the Multicenter Study of Perioperative Research Group with atenolol and those earlier studies with metoprolol. The risks of the surgery should be discussed with the patient so the risks can be weighed against the expected benefit. Studies suggest that perioperative risk for any patient, and especially patients with hypertension, are in part related to the adrenergic arousal before, during, and after the procedure as evidenced by the rise in heart rate and blood pressure, along with the liberation of clotting facators and increased risk for plaque rupture, coronary vasoplasm, and consequent myocardial infarction and fibrosis.

Assessment of operative risk for patients with advanced lung disease

Increasingly, patients with advanced lung disease are being offered operative procedures. The assessment of the perioperative risk of these patients must include not only the assessment of their lung disease, but the assessment of the patient's cardiovascular disease, their age, and their other medical problems. Knowledge of the stress of particular surgical procedures is also of importance in risk assessment, and is addressed in this article.