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From the Division of Cardiology, Department of Medicine, Centre Hospitalier de l’Université de Montréal (CHUM), Université de Montréal, Montréal, Québec, Canada.
Address correspondence to: Dr. Stéphane Rinfret, Centre Hospitalier de l’Université de Montréal (CHUM), 3850 Saint-Urbain, Montreal, Quebec H2W 1T7, Canada. Phone: 514-890-8000, ext. 14080; Fax: 514-412-7174; E-mail: s.rinfret{at}umontreal.ca
Purpose: The purpose of this article, with a specific focus on patients undergoing vascular surgery, is to review controversial issues related to mechanisms of perioperative myocardial infarction (MI), coronary artery disease detection, and strategies to reduce perioperative complications. We propose explanations for the many conflicting results that have recently emerged in the literature.
Source documents: We searched MEDLINE and reviewed all relevant manuscripts and scientific statements regarding management of patients undergoing non-cardiac surgery.
Principal findings: Identification and prevention of ischemia in patients undergoing vascular surgery remains controversial. While the identification of preoperative ischemia is a marker of a higher perioperative risk, the value of identifying such ischemia has been questioned. We believe this may be, at least in part, due to our limited understanding of perioperative MI. Appropriate management of patients, based on the results of such testing, is likely the key to improving outcomes, and deserves further investigation. Efforts aimed at reducing the ischemic consequences of severe coronary plaques (by revascularization or β-blocker therapy) have yielded conflicting results. The use of high doses of preoperative β-blocker therapy may be harmful. Some studies suggest a promising role for statin therapy. Benefits of acetylsalicylic acid must be weighted against the risk of bleeding.
Conclusion: Many questions remain unanswered about the impact of detecting inducible ischemia, and the role of revascularization or β-blockers in patients undergoing vascular surgery. A better understanding of the pathophysiology of perioperative MI is critical, in order to identify the best approach to improve cardiac outcomes in these patients.
1 Ashton CM, Petersen NJ, Wray NP, et al. The incidence of perioperative myocardial infarction in men undergoing noncardiac surgery. Ann Intern Med 1993; 118: 504–10.
2 Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999; 100: 1043–9.[Medline]
3 Devereaux PJ, Goldman L, Cook DJ, Gilbert K, Leslie K, Guyatt GH. Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. CMAJ 2005; 173: 627–34.
4 Krupski WC. Update on perioperative evaluation and management of cardiac disease in vascular surgery patients. J Vasc Surg 2002; 36: 1292–308.[Medline]
5 Koskas F, Kieffer E. Long-term survival after elective repair of infrarenal abdominal aortic aneurysm: results of a prospective multicentric study. Association for Academic Research in Vascular Surgery (AURC). Ann Vasc Surg 1997; 11: 473–81.[Medline]
6 Fleisher LA, Eagle KA, Shaffer T, Anderson GF. Perioperative- and long-term mortality rates after major vascular surgery: the relationship to preoperative testing in the medicare population. Anesth Analg 1999; 89: 849–55.
7 Shah KB, Kleinman BS, Rao TL, Jacobs HK, Mestan K, Schaafsma M. Angina and other risk factors in patients with cardiac diseases undergoing noncardiac operations. Anesth Analg 1990; 70: 240–7.
8 Mangano DT, Browner WS, Hollenberg M, Li J, Tateo IM. Long-term cardiac prognosis following noncardiac surgery. The Study of Perioperative Ischemia Research Group. JAMA 1992; 268: 233–9.[Abstract]
9 Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined--a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol 2000; 36: 959–69.
10 Landesberg G, Shatz V, Akopnik I, et al. Association of cardiac troponin, CK-MB, and postoperative myocardial ischemia with long-term survival after major vascular surgery. J Am Coll Cardiol 2003; 42: 1547–54.
11 Liu LL, Wiener-Kronish JP. Preoperative cardiac evaluation of women for noncardiac surgery. Cardiol Clin 1998; 16: 59–66.[Medline]
12 Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery--executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation 2002; 105: 1257–67.[Medline]
13 Devereaux PJ, Goldman L, Yusuf S, Gilbert K, Leslie K, Guyatt GH. Surveillance and prevention of major perioperative ischemic cardiac events in patients undergoing noncardiac surgery: a review. CMAJ 2005; 173: 779–88.
14 Falk E. Plaque rupture with severe pre-existing stenosis precipitating coronary thrombosis. Characteristics of coronary atherosclerotic plaques underlying fatal occlusive thrombi. Br Heart J 1983; 50: 127–34.
15 Horie T, Sekiguchi M, Hirosawa K. Coronary thrombosis in pathogenesis of acute myocardial infarction. Histopathological study of coronary arteries in 108 necropsied cases using serial section. Br Heart J 1978; 40: 153–61.
16 Falk E, Shah PK, Fuster V. Coronary plaque disruption. Circulation 1995; 92: 657–71.[Medline]
17 Little WC, Constantinescu M, Applegate RJ, et al. Can coronary angiography predict the site of a subsequent myocardial infarction in patients with mild-to-moderate coronary artery disease? Circulation 1988; 78: 1157–66.[Medline]
18 Giroud D, Li JM, Urban P, Meier B, Rutishauer W. Relation of the site of acute myocardial infarction to the most severe coronary arterial stenosis at prior angiography. Am J Cardiol 1992; 69: 729–32.[Medline]
19 Mintz GS, Painter JA, Pichard AD, et al. Atherosclerosis in angiographically "normal" coronary artery reference segments: an intravascular ultrasound study with clinical correlations. J Am Coll Cardiol 1995; 25: 1479–85.[Abstract]
20 Alderman EL, Corley SD, Fisher LD, et al. Five-year angiographic follow-up of factors associated with progression of coronary artery disease in the Coronary Artery Surgery Study (CASS). CASS Participating Investigators and Staff. J Am Coll Cardiol 1993; 22: 1141–54.[Abstract]
21 Davies MJ, Bland JM, Hangartner JR, Angelini A, Thomas AC. Factors influencing the presence or absence of acute coronary artery thrombi in sudden ischaemic death. Eur Heart J 1989; 10: 203–8.
22 Mann JM, Davies MJ. Vulnerable plaque. Relation of characteristics to degree of stenosis in human coronary arteries. Circulation 1996; 94: 928–31.[Medline]
23 Ge J, Chirillo F, Schwedtmann J, et al. Screening of ruptured plaques in patients with coronary artery disease by intravascular ultrasound. Heart 1999; 81: 621–7.
24 von Birgelen C, Klinkhart W, Mintz GS, et al. Plaque distribution and vascular remodeling of ruptured and nonruptured coronary plaques in the same vessel: an intravascular ultrasound study in vivo. J Am Coll Cardiol 2001; 37: 1864–70.
25 Ellis SG, Hertzer NR, Young JR, Brener S. Angiographic correlates of cardiac death and myocardial infarction complicating major nonthoracic vascular surgery. Am J Cardiol 1996; 77: 1126–8.[Medline]
26 Dawood MM, Gutpa DK, Southern J, Walia A, Atkinson JB, Eagle KA. Pathology of fatal perioperative myocardial infarction: implications regarding pathophysiology and prevention. Int J Cardiol 1996; 57: 37–44.[Medline]
27 Cohen MC, Aretz TH. Histological analysis of coronary artery lesions in fatal postoperative myocardial infarction. Cardiovasc Pathol 1999; 8: 133–9.[Medline]
28 Landesberg G, Mosseri M, Zahger D, et al. Myocardial infarction after vascular surgery: the role of prolonged stress-induced, ST depression-type ischemia. J Am Coll Cardiol 2001; 37: 1839–45.
29 Davenport DL, Ferraris VA, Hosokawa P, Henderson WG, Khuri SF, Mentzer RM Jr. Multivariable predictors of postoperative cardiac adverse events after general and vascular surgery: results from the patient safety in surgery study. J Am Coll Surg 2007; 204: 1199–210.[Medline]
30 Rinfret S, Goldman L, Polanczyk CA, Cook EF, Lee TH. Value of immediate postoperative electrocardiogram to update risk stratification after major noncardiac surgery. Am J Cardiol 2004; 94: 1017–22.[Medline]
31 Kertai MD, Boersma E, Klein J, Van Urk H, Bax JJ, Poldermans D. Long-term prognostic value of asymptomatic cardiac troponin T elevations in patients after major vascular surgery. Eur J Vasc Endovasc Surg 2004; 28: 59–66.[Medline]
32 Bursi F, Babuin L, Barbieri A, et al. Vascular surgery patients: perioperative and long-term risk according to the ACC/AHA guidelines, the additive role of post-operative troponin elevation. Eur Heart J 2005; 26: 2448–56.
33 Kim LJ, Martinez EA, Faraday N, et al. Cardiac troponin I predicts short-term mortality in vascular surgery patients. Circulation 2002; 106: 2366–71.[Medline]
34 Higham H, Sear JW, Sear YM, Kemp M, Hooper RJ, Foex P. Peri-operative troponin I concentration as a marker of long-term postoperative adverse cardiac outcomes – a study in high-risk surgical patients. Anaesthesia 2004; 59: 318–23.[Medline]
35 Fleisher LA, Beckman JA, Brown KA, et al. ACC/ AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol 2007; 50: e159–241.
36 Eagle KA, Coley CM, Newell JB, et al. Combining clinical and thallium data optimizes preoperative assessment of cardiac risk before major vascular surgery. Ann Intern Med 1989; 110: 859–66.[Medline]
37 Lette J, Waters D, Lassonde J, et al. Multivariate clinical models and quantitative dipyridamole-thallium imaging to predict cardiac morbidity and death after vascular reconstruction. J Vasc Surg 1991; 14: 160–9.[Medline]
38 Rao TL, Jacobs KH, El-Etr AA. Reinfarction following anesthesia in patients with myocardial infarction. Anesthesiology 1983; 59: 499–505.[Medline]
39 McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med 2004; 351: 2795–804.
40 Poldermans D, Bax JJ, Schouten O, et al. Should major vascular surgery be delayed because of preoperative cardiac testing in intermediate-risk patients receiving beta-blocker therapy with tight heart rate control? J Am Coll Cardiol 2006; 48: 964–9.
41 Coley CM, Field TS, Abraham SA, Boucher CA, Eagle KA. Usefulness of dipyridamole-thallium scanning for preoperative evaluation of cardiac risk for nonvascular surgery. Am J Cardiol 1992; 69: 1280–5.[Medline]
42 Underwood SR, Anagnostopoulos C, Cerqueira M, et al. Myocardial perfusion scintigraphy: the evidence. Eur J Nucl Med Mol Imaging 2004; 31: 261–91.[Medline]
43 Kertai MD, Boersma E, Bax JJ, et al. A meta-analysis comparing the prognostic accuracy of six diagnostic tests for predicting perioperative cardiac risk in patients undergoing major vascular surgery. Heart 2003; 89: 1327–34.
44 Boersma E, Poldermans D, Bax JJ, et al. Predictors of cardiac events after major vascular surgery: role of clinical characteristics, dobutamine echocardiography, and beta-blocker therapy. JAMA 2001; 285: 1865–73.
45 Etchells E, Meade M, Tomlinson G, Cook D. Semiquantitative dipyridamole myocardial stress perfusion imaging for cardiac risk assessment before noncardiac vascular surgery: a meta-analysis. J Vasc Surg 2002; 36: 534–40.[Medline]
46 Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation 2004; 110: e340–437.[Medline]
47 Chikamori T, Doi YL, Yonezawa Y, Yamada M, Seo H, Ozawa T. Noninvasive identification of significant narrowing of the left main coronary artery by dipyridamole thallium scintigraphy. Am J Cardiol 1991; 68: 472–7.[Medline]
48 Nygaard TW, Gibson RS, Ryan JM, Gascho JA, Watson DD, Beller GA. Prevalence of high-risk thallium-201 scintigraphic findings in left main coronary artery stenosis: comparison with patients with multiple- and single-vessel coronary artery disease. Am J Cardiol 1984; 53: 462–9.[Medline]
49 Rehn T, Griffith LS, Achuff SC, et al. Exercise thallium-201 myocardial imaging in left main coronary artery disease: sensitive but not specific. Am J Cardiol 1981; 48: 217–23.[Medline]
50 Kostkiewicz M, Tracz W, Przewlocki T, Kawalec E. Predictive potential of noninvasive methods, inclusive of exercise SPECT Tc99m MIBI imaging, in recognition of high-risk patients with left main coronary artery stenosis. Int J Cardiovasc Imaging 2001; 17: 347–52.[Medline]
51 Wakasugi S, Shibata N, Kobayashi T, Fudemoto Y, Hasegawa Y, Nakano S. Specific perfusion pattern in stress 201Tl myocardial scintigraphy of left main coronary artery disease. Eur J Nucl Med 1986; 12: 369–74.[Medline]
52 Mahajan NM, Thekkott DT, Hollander GH, Greengart AG, Shani JS, Lichstein EL. Role of nuclear stress test as a noninvasive tool in detection of isolated and significant left main coronary artery disease : there is no unique pattern of perfusion deficit. J Nuclear Cardiol 2005; 12: s121.
53 Andrade MJ, Picano E, Pingitore A, et al. Dipyridamole stress echocardiography in patients with severe left main coronary artery narrowing. Echo Persantine International Cooperative (EPIC) Study Group--Subproject «Left Main Detection». Am J Cardiol 1994; 73: 450–5.[Medline]
54 Thompson C, Bergstrome D, Parlow JL. Limitations of preoperative dobutamine stress echocardiography in identifying severe left main coronary artery stenosis: a report of two cases and a brief review. Can J Anesth 2003; 50: 933–9.
55 Pierpont GL, Moritz TE, Goldman S, et al. Disparate opinions regarding indications for coronary artery revascularization before elective vascular surgery. Am J Cardiol 2004; 94: 1124–8.[Medline]
56 Boden WE, O’Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007; 356: 1503–16.
57 Hertzer NR, Beven EG, Young JR, et al. Coronary artery disease in peripheral vascular patients. A classification of 1000 coronary angiograms and results of surgical management. Ann Surg 1984; 199: 223–33.[Medline]
58 Budoff MJ, Achenbach S, Blumenthal RS, et al. Assessment of coronary artery disease by cardiac computed tomography: a scientific statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology. Circulation 2006; 114: 1761–91.[Medline]
59 Foster ED, Davis KB, Carpenter JA, Abele S, Fray D. Risk of noncardiac operation in patients with defined coronary disease: The Coronary Artery Surgery Study (CASS) registry experience. Ann Thorac Surg 1986; 41: 42–50.[Abstract]
60 Hassan SA, Hlatky MA, Boothroyd DB, et al. Outcomes of noncardiac surgery after coronary bypass surgery or coronary angioplasty in the Bypass Angioplasty Revascularization Investigation (BARI). Am J Med 2001; 110: 260–6.[Medline]
61 Ward HB, Kelly RF, Thottapurathu L, et al. Coronary artery bypass grafting is superior to percutaneous coronary intervention in prevention of perioperative myocardial infarctions during subsequent vascular surgery. Ann Thorac Surg 2006; 82: 795–800; discussion 800–1.
62 Kaluza GL, Joseph J, Lee JR, Raizner ME, Raizner AE. Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol 2000; 35: 1288–94.
63 Schouten O, van Domburg RT, Bax JJ, et al. Noncardiac surgery after coronary stenting: early surgery and interruption of antiplatelet therapy are associated with an increase in major adverse cardiac events. J Am Coll Cardiol 2007; 49: 122–4.
64 Vicenzi MN, Meislitzer T, Heitzinger B, Halaj M, Fleisher LA, Metzler H. Coronary artery stenting and non-cardiac surgery--a prospective outcome study. Br J Anaesth 2006; 96: 686–93.
65 Wilson SH, Fasseas P, Orford JL, et al. Clinical outcome of patients undergoing non-cardiac surgery in the two months following coronary stenting. J Am Coll Cardiol 2003; 42: 234–40.
66 Chapman TW, Bowley DM, Lambert AW, Walker AJ, Ashley SA, Wilkins DC. Haemorrhage associated with combined clopidogrel and aspirin therapy. Eur J Vasc Endovasc Surg 2001; 22: 478–9.[Medline]
67 Dalal AR, D’Souza S, Shulman MS.B rief review: Coronary drug-eluting stents and anesthesia. Can J Anesth 2006; 53: 1230–43.
68 Saw J, Bhatt DL, Moliterno DJ, et al. The influence of peripheral arterial disease on outcomes: a pooled analysis of mortality in eight large randomized percutaneous coronary intervention trials. J Am Coll Cardiol 2006; 48: 1567–72.
69 Spertus JA, Kettelkamp R, Vance C, et al. Prevalence, predictors, and outcomes of premature discontinuation of thienopyridine therapy after drug-eluting stent placement: results from the PREMIER registry. Circulation 2006; 113: 2803–9.[Medline]
70 Pfisterer M, Brunner-La Rocca HP, Buser PT, et al. Late clinical events after clopidogrel discontinuation may limit the benefit of drug-eluting stents: an observational study of drug-eluting versus bare-metal stents. J Am Coll Cardiol 2006; 48: 2584–91.
71 Eisenstein EL, Anstrom KJ, Kong DF, et al. Clopidogrel use and long-term clinical outcomes after drug-eluting stent implantation. JAMA 2007; 297: 159–68.
72 Bavry AA, Kumbhani DJ, Helton TJ, Borek PP, Mood GR, Bhatt DL. Late thrombosis of drug-eluting stents: a meta-analysis of randomized clinical trials. Am J Med 2006; 119: 1056–61.[Medline]
73 Brilakis ES, Orford JL, Fasseas P, et al. Outcome of patients undergoing balloon angioplasty in the two months prior to noncardiac surgery. Am J Cardiol 2005; 96: 512–4.[Medline]
74 Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. N Engl J Med 1999; 341: 1789–94.
75 Mangano DT, Layug EL, Wallace A, Tateo I. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group. N Engl J Med 1996; 335: 1713–20.
76 Lindenauer PK, Pekow P, Wang K, Mamidi DK, Gutierrez B, Benjamin EM. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med 2005; 353: 349–61.
77 Brady AR, Gibbs JS, Greenhalgh RM, Powell JT, Sydes MR; POBBLE Trial Investigators. Perioperative beta-blockade (POBBLE) for patients undergoing infrarenal vascular surgery: results of a randomized double-blind controlled trial. J Vasc Surg 2005; 41: 602–9.[Medline]
78 Juul AB, Wetterslev J, Gluud C, et al. Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial. BMJ 2006; 332: 1482.
79 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.[Medline]
80 Devereaux PJ, Beattie WS, Choi PT, et al. How strong is the evidence for the use of perioperative beta blockers in non-cardiac surgery? Systematic review and meta-analysis of randomised controlled trials. BMJ 2005; 331: 313–21.
81 Auerbach A, Goldman L. Assessing and reducing the cardiac risk of noncardiac surgery. Circulation 2006; 113: 1361–76.[Medline]
82 Redelmeier D, Scales D, Kopp A. Beta blockers for elective surgery in elderly patients: population based, retrospective cohort study. BMJ 2005; 331: 932.
83 Rinfret S, Abrahamowicz M, Tu J, et al. A population-based analysis of the class effect of beta-blockers after myocardial infarction. Am Heart J 2007; 153: 224–30.[Medline]
84 Clark LL, Ikonomidis JS, Crawford FA Jr, et al. Preoperative statin treatment is associated with reduced postoperative mortality and morbidity in patients undergoing cardiac surgery: an 8-year retrospective cohort study. J Thorac Cardiovasc Surg 2006; 131: 679–85.
85 Lindenauer PK, Pekow P, Wang K, Gutierrez B, Benjamin EM. Lipid-lowering therapy and in-hospital mortality following major noncardiac surgery. JAMA 2004; 291: 2092–9.
86 O’Neil-Callahan K, Katsimaglis G, Tepper MR, et al. Statins decrease perioperative cardiac complications in patients undergoing noncardiac vascular surgery: the Statins for Risk Reduction in Surgery (StaRRS) study. J Am Coll Cardiol 2005; 45: 336–42.
87 Hindler K, Eltzschig HK, Fox AA, Body SC, Shernan SK, Collard CD. Influence of statins on perioperative outcomes. J Cardiothorac Vasc Anesth 2006; 20: 251–8.[Medline]
88 Durazzo AE, Machado FS, Ikeoka DT, et al. Reduction in cardiovascular events after vascular surgery with atorvastatin: a randomized trial. J Vasc Surg 2004; 39: 967–75; discussion 975–6.[Medline]
89 Robless P, Mikhailidis DP, Stansby G. Systematic review of antiplatelet therapy for the prevention of myocardial infarction, stroke or vascular death in patients with peripheral vascular disease. Br J Surg 2001; 88: 787–800.[Medline]
90 Anonymous. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial. Lancet 2000; 355: 1295–302.[Medline]
91 Clagett GP, Sobel M, Jackson MR, Lip GY, Tangelder M, Verhaeghe R. Antithrombotic therapy in peripheral arterial occlusive disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126: 609S–26S.[Medline]
92 Merritt JC, Bhatt DL. The efficacy and safety of perioperative antiplatelet therapy. J Thromb Thrombolysis 2004; 17: 21–7.[Medline]
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