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Preoperative cardiovascular assessment in noncardiac surgery: an update

De Hert, Stefan G

European Journal of Anaesthesiology (EJA): June 2009 - Volume 26 - Issue 6 - p 449–457
doi: 10.1097/EJA.0b013e3283297512

Cardiac complications are a major cause of perioperative morbidity and mortality. These are caused by either myocardial ischaemia or acute coronary thrombosis. The preoperative assessment aims to collect information on the extent and the stability of the cardiovascular disease in order to predict the patient's risk for developing perioperative cardiac complications. This assessment allows measures to be taken that aim to reduce such risks. The present review summarizes the current state of knowledge on the preoperative assessment of the cardiac patient scheduled for noncardiac surgery.

Department of Anesthesiology, Division of Cardiothoracic and Vascular Anesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands

Received 14 January, 2009

Accepted 16 January, 2009

Correspondence to Stefan G. De Hert, MD, PhD, Professor of Anesthesiology and Chair of the Division, Department of Anesthesiology, Division of Cardiothoracic and Vascular Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1100DD Amsterdam, The Netherlands Tel: +31 20 5662533; fax: +31 20 6979441; e-mail:

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Cardiac complications are a major cause of perioperative morbidity and mortality. In particular, vascular surgery patients are at increased risk with reported mortality rates of 1.5–2% for endovascular and 3–4% for open procedures [1,2]. Mortality is mainly caused by the occurrence of perioperative myocardial infarction (accounting for 10–40% of the postoperative deaths) but the nonfatal perioperative myocardial infarction may also compromise long-term outcome as it is associated with an increased risk of late mortality [3–5].

Perioperative cardiac complications are caused by either myocardial ischaemia or acute coronary thrombosis. Myocardial ischaemia may result from an increase in myocardial oxygen demand (tachycardia, hypertension, pain) or be caused by a decreased supply (hypotension, vasospasm, tachycardia, hypoxia, anaemia). Coronary plaque rupture may be caused by all factors that increase intracoronary wall stress but the presence of a hypercoagulable state, leucocyte activation and activation of the inflammatory response may also greatly participate in the pathophysiology of coronary artery occlusion (Fig. 1).

Fig. 1

Fig. 1

The ultimate goal of the preoperative assessment is to collect information on the extent and the stability of the cardiovascular disease in order to predict the patient's cardiac risk and to develop preoperative and intraoperative strategies that may help to decrease this risk and improve short-term and long-term outcomes.

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Prediction of cardiac risk

Risk stratification aims at identifying the different perioperative variables that might influence the risk for each particular patient to suffer an adverse outcome when being operated. Ultimately, such risk stratification will help to guide medical decisions and to determine optimal therapy for the patients at risk.

Over the years, different risk models have been proposed based on risk factors that had been identified by multivariate analysis. Initially, such scoring systems assigned different weights to different risk factors in order to arrive at a composite risk [6]. More recently, Lee et al. [7] derived and validated a simpler index for the prediction of cardiac risk for stable patients undergoing nonurgent noncardiac surgery. This Revised Cardiac Risk Index (RCRI) assigns one point for the presence of one of the following six risk factors: high-risk surgical procedure, history of ischaemic heart disease, history of congestive heart failure, history of cerebrovascular accident, preoperative treatment with insulin, or a serum creatinine greater than 2.0 mg dl−1. The estimated risks of major cardiac complications for indices 0, 1, 2, and 3 or higher are 0.4 (0.1–0.8)%, 1.0 (0.5–1.4)%, 2.4 (1.3–3.5)%, and 5.4 (2.8–7.9)%, respectively. This index provides an easy way for identifying patients who are at increased risk and has become one of the most widely used risk indices.

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Preoperative assessment

Cardiac indices are used to assess the prior probability of perioperative cardiac risk in a given patient. This information may help in the decision whether or not to develop further strategies for diagnosis and perioperative management. However, a simple estimate of risk as such does not allow any clear definition of the specific needs of each individual patient with regard to further testing and perioperative strategies. This necessitates information on the extent and stability of the patient's individual cardiovascular disease. Such information is usually obtained from clinical assessment and potentially from additional technical testing.

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Clinical assessment

There are a number of active cardiac conditions that are considered to indicate a major clinical risk for perioperative complications. According to the American College of Cardiology/American Heart Association (ACC/AHA) 2007 guidelines [8], the presence of one or more of these conditions necessitates further evaluation and adapted management, which may result in delay of surgery unless the surgery is urgent [class I recommendation, level of evidence (LOE) B]. The major risk factors that necessitate further evaluation and treatment before noncardiac surgery are summarized as follows:

  1. Unstable coronary syndromes
    1. unstable or severe angina
    2. recent myocardial infarction (within 30 days)
  2. Decompensated heart failure
  3. Significant arrhythmias
    1. high-grade atrioventricular block
    2. symptomatic ventricular arrhythmias
    3. supraventricular arrhythmias with uncontrolled ventricular rate (>100 bpm at rest)
    4. symptomatic bradycardia
    5. newly recognized ventricular tachycardia
  4. Severe valvular disease
    1. severe aortic stenosis (mean pressure gradient >40 mmHg, area <1 cm2 or symptomatic)
    2. symptomatic mitral stenosis

The recent ACC/AHA guidelines [8] have proposed a stepwise approach for the perioperative cardiac assessment and management of cardiac patients scheduled for noncardiac surgery. The first step determines the urgency of the operation. In some cases, the necessity for immediate surgery is such that no time is left for further cardiac assessment or treatment or both. In such instances, adequate measures for perioperative surveillance and treatment should be anticipated while further risk stratification and risk factor management will be planned during the postoperative period.

If there is no need for emergency surgery, the second step is to screen patients for the presence of active cardiac conditions. These include history of ischaemic heart disease, history of compensated or prior heart failure and history of cerebrovascular disease, diabetes mellitus and renal insufficiency (creatinine level >2.0 mg dl−1). If one of these conditions is present, patients should be further evaluated and when necessary treated. For all these conditions, the potential benefits of delaying surgery to optimize the effects of treatment must be weighed against the risk of delaying the surgical procedure. With respect to a previous recent myocardial infarction, it is recommended to wait for 4–6 weeks before performing elective surgery, even if there are no adequate clinical trials on the subject. If no active cardiac conditions are present, the third step is to assess the risk of surgery. Risks of cardiac death and nonfatal myocardial infarction for noncardiac operations are mentioned as follows:

  1. High risk (cardiac risk >5%)
    1. aortic surgery
    2. major vascular surgery
    3. peripheral vascular surgery
  2. Intermediate risk (cardiac risk 1–5%)
    1. intraperitoneal and intrathoracic surgery
    2. carotid endarterectomy
    3. head and neck surgery
    4. orthopaedic surgery
    5. prostate surgery
  3. Low risk (cardiac risk <1%)
    1. endoscopic procedures
    2. superficial procedures
    3. cataract surgery
    4. breast surgery
    5. ambulatory surgery

Many surgical procedures are associated with a low risk of perioperative complications even in high-risk patients. In such cases, it is recommended to proceed with planned surgery. In the case of intermediate-risk or high-risk surgery, further assessment of the patient's physical status is indicated. The fourth step will evaluate whether the patient can sustain a functional capacity equal to or greater than four metabolic equivalents (METs) without symptoms. If so, the recommendation is to proceed with surgery. If, however, the patient is symptomatic or the functional capacity of the patient is unknown, further assessment is necessary.

The fifth step will determine the need for further evaluation and potential treatment prior to surgery based on the presence of a number of clinical risk factors. These include history of ischaemic heart disease, history of congestive heart failure, history of cerebrovascular disease, diabetes mellitus, and a preoperative creatinine level more than 2.0 mg dl−1. If there are no clinical risk factors, surgery can be planned. If the patient has one or two risk factors, then it is recommended to proceed to planned surgery but with adequate heart rate control. Alternatively, further assessment of the cardiac status by noninvasive testing can be considered, but only if it will change management. In high-risk surgery patients with three or more risk factors, it is suggested that testing should be considered only if the results of such tests will change management. For intermediate-risk surgery patients, there are to date insufficient data to determine the best strategy (proceed to surgery with heart rate control or perform further testing).

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Noninvasive testing

The ultimate aim of additional preoperative testing is to provide an objective measure of functional capacity and to identify the importance of preoperative myocardial ischaemia and rhythm disturbances. Several noninvasive tests have been suggested to answer these questions.

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Resting 12-lead electrocardiogram

Preoperative resting 12-lead electrocardiogram is recommended for patients with at least one clinical risk factor who will undergo vascular surgical procedures (class I, LOE: B) and for patients with known coronary heart disease, peripheral arterial disease, or cerebrovascular disease who are undergoing intermediate-risk surgical procedures (class I, LOE: C). It is considered reasonable to perform a 12-lead electrocardiogram in patients with no clinical risk factors undergoing vascular surgical procedures (class IIa, LOE: B) and in patients with at least one risk factor (class IIb, LOE: B). Preoperative and postoperative resting 12-lead electrocardiograms are not indicated in asymptomatic patients undergoing low-risk surgery (class III, LOE: B).

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Noninvasive evaluation of left ventricular function

Preoperative resting left ventricular function can be evaluated by echocardiography, radionuclide angiography, and contrast ventriculography. It is considered reasonable to perform a preoperative evaluation of left ventricular function in patients with dyspnoea of unknown origin, with current or prior heart failure, and in patients with worsening dyspnoea or other change in clinical status (class IIa, LOE: C). Routine perioperative evaluation of left ventricular function is not recommended (class III, LOE: B).

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Stress testing

Preoperative stress testing is recommended in patients with active cardiac conditions for whom noncardiac surgery is planned and who should be evaluated and treated before surgery (class I, LOE: B) and in patients with three or more clinical risk factors and a poor functional capacity (<4 METs), who require vascular surgery but only if it will change management (class IIa, LOE: B). It may be considered in patients with at least one or two clinical risk factors and a poor functional capacity, who require intermediate-risk or vascular surgery but again only if it will change management (class IIb, LOE: B). Finally, preoperative stress testing is not considered useful in patients undergoing low-risk surgery and for patients with no clinical risk factors undergoing intermediate-risk surgery (class III, LOE: C).

In patients who cannot exercise, two alternative techniques can be used to assess the importance of the coronary artery disease. One technique is to increase myocardial oxygen demand mainly by increasing heart rate (by pacing or dobutamine) and the other is to induce a hyperaemic response by pharmacological vasodilators such as dipyridamole or adenosine. The most commonly used imaging techniques include echocardiography and radionuclide myocardial perfusion imaging methods. Although most currently applied tests have a satisfying sensitivity and specificity, a recent meta-analysis indicated that dobutamine stress echocardiography seemed to have a positive trend towards better diagnostic performance, especially in situations of valvular or left ventricular dysfunction [9]. Another application of these techniques is to evaluate in patients with coronary artery disease the extent of viable myocardium, hence to identify those patients who may benefit from revascularization [10].

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Preoperative treatment


The potential benefits of preoperative coronary revascularization remain a point of debate. Recent studies [11,12] indicate that only a selected patient population may benefit from such intervention. Basically, the prevailing evidence suggests that the indications for preoperative coronary revascularization are in fact identical to those in the nonoperative setting. The recommendations of the ACC/AHA 2007 guidelines on this issue are as follows. Coronary revascularization is considered useful in patients with stable angina who have significant left main coronary artery disease, three-vessel disease, and two-vessel disease with a significant stenosis of the proximal left anterior descending coronary artery and either an ejection fraction less than 50% or demonstrable ischaemia on noninvasive testing (class I, LOE: A). It is also recommended in patients with unstable angina, non-ST-segment elevation myocardial infarction, and those with acute ST-segment elevation myocardial infarction (class I, LOE: A). The usefulness of preoperative coronary revascularization is not well established in high-risk ischaemic patients (such as in the presence of an abnormal stress echocardiograph with at least five segments of regional wall motion abnormalities; class IIb, LOE: C) and in low-risk ischaemic patients with an abnormal dobutamine stress echocardiography (one to four segments; class IIb, LOE: B). Finally, prophylactic coronary revascularization is not recommended in patients with stable coronary artery disease (class III, LOE: B) (Table 1).

Table 1

Table 1

Once the decision for preoperative coronary revascularization has been taken, a choice should be made between surgery and a percutaneous coronary intervention. A recent study on patients receiving multivessel coronary artery revascularization as prophylaxis for elective vascular surgery [13] indicated that patients having coronary surgery had fewer myocardial infarctions after the vascular surgery than those who had a percutaneous coronary intervention. This difference between groups was attributed to a more complete revascularization.

Percutaneous coronary revascularization with the use of stents represents another issue. Stents have been introduced to reduce the incidence of restenosis. To prevent early in-stent thrombosis, all patients receiving a coronary stent are prescribed dual antiplatelet therapy, the duration of which depends on the type of stent used. Recently, data have indicated that especially in drug-eluting stents, late in-stent thrombosis may occur related to the interruption of antiplatelet therapy [14]. Approximately 5% of patients who had coronary stenting require some form of noncardiac surgery within 1 year after stenting [15]. As antiplatelet therapy may increase the risk of perioperative bleeding, these drugs are usually discontinued at the time of surgery. It has been recognized for some time that such action may have disastrous consequences for the surgical patient [16] and therefore specific guidelines have been developed for the management of such patients (Fig. 2) [17,18]. With respect to potential preoperative revascularization by percutaneous coronary angioplasty, a strategy of balloon angioplasty or bare-metal stent placement followed by 4–6 weeks of dual-antiplatelet therapy is recommended (class IIa, LOE: B). In patients who have received drug-eluting coronary stents and who need an urgent surgical procedure, necessitating the discontinuation of thienopyridine therapy, it is suggested to continue aspirin therapy and restart the thienopyridine as soon as possible (class IIa, LOE: C). Elective noncardiac surgery is not recommended within 4–6 weeks of bare-metal coronary stent implantation or within 12 months of drug-eluting coronary stent implantation in patients in whom thienopyridine therapy, or the dual therapy, aspirin–thienopyridine, will need to be discontinued perioperatively (class III, LOE: B). Finally, elective noncardiac surgery is also not recommended within 4 weeks of balloon angioplasty (class III, LOE: B).

Fig. 2

Fig. 2

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Valve repair

With regard to the indications of valvular repair before noncardiac surgery, only limited data are available, which did not allow for the definition of recommendations. On the basis of clinical experience, it seems logical to have those patients, with valvular disease that is severe enough to constitute an indication for surgical correction, treated before the noncardiac surgery. It has been suggested that a less invasive approach using balloon valvuloplasty might constitute an intermediate step in reducing the operative risk of noncardiac surgery in these patients [19], but there are to date no controlled studies on this subject.

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Perioperative management

Medical therapy

In recent years, a growing number of studies have indicated that optimization of perioperative medical therapy may result in an improvement in postoperative outcome. The most efficient drugs in this regard are the β-blocking agents and the statins.

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Although numerous studies have demonstrated an improved outcome in patients under perioperative β-blocking therapy, this has not consistently been confirmed in other studies (reviewed in ref. [20]). Poldermans et al. [21] demonstrated that further cardiac testing could safely be omitted in intermediate-risk patients, as long as β-blockers were prescribed and titrated to achieve a tight heart rate. The safety of perioperative β-blockade has recently been questioned with the publication of the results of the Peri-Operative Ischemic Evaluation (POISE) trial [22]. This study showed a beneficial effect of a high-dose metoprolol controlled-release therapy on the risk of perioperative myocardial infarction, but this was at the cost of an increased risk of stroke and overall mortality. It was indicated, however, that, in particular, the initiation time and dose of β-blocker therapy, tight dose adjustments for heart rate control, and a correct estimation of the underlying cardiac risk of the individual patient are important factors that may determine the effectiveness of the therapy [23,24].

The ACC/AHA 2007 guidelines recommend to continue β-blocking therapy in patients who are already on β-blocking medication (class I, LOE: C). β-Blockers should also be given to patients undergoing vascular surgery who are at high cardiac risk because of the presence of ischaemia on preoperative testing (class I, LOE: B). β-Blockers are probably recommended for vascular surgery patients in whom preoperative assessment has indicated the presence of coronary heart disease and for patients undergoing intermediate-risk or high-risk surgery in the presence of high cardiac risk (more than one clinical risk factor; class IIa, LOE: B). The benefit of β-blocking therapy is uncertain in patients with only a single risk factor undergoing intermediate-risk or high-risk surgery (class IIB, LOE: C) and in high-risk surgery patients with no clinical risk factors and not on β-blocking therapy (class IIb, LOE: C). Finally, β-blockers should not be given to patients with absolute contraindications to such therapy.

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Statins were initially prescribed because their lipid-lowering properties seem highly effective in the secondary prevention of cardiac events [25]. However, statins also have other beneficial properties on atherosclerotic vascular disease, which are known as its pleiotropic effects [26]. These effects include plaque stabilization, oxidative stress reduction, and a decreased vascular inflammation. Different trials on coronary artery disease patients have shown a beneficial effect of statin therapy on outcome (reviewed in refs [20,24]). More recently, these positive effects have also been observed in major noncardiac surgery with a significant reduction in postoperative cardiovascular morbidity and mortality [27–32].

The ACC/AHA guidelines recommend statins to be continued for all patients scheduled for noncardiac surgery and currently taking this medication (class I, LOE: B). For patients with or without clinical risk factors undergoing vascular surgery, statins are considered reasonable (class IIa, LOE: B). For patients with at least one clinical risk factor scheduled for intermediate-risk surgery, statin therapy can be considered (class IIb, LOE: C).

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Acetylsalicylic acid has a key role in the primary and secondary prevention of cardiovascular disease and it is commonly used, in association with clopidogrel, for the prevention of coronary stent thrombosis. Its potential beneficial effect in the perioperative period of noncardiac surgery is less well established. Concerns with regard to perioperative bleeding complications have been a frequent reason to interrupt this therapy. In a recent meta-analysis, it was shown that although acetylsalicylic acid increased the risk of bleeding complications, this did not lead to higher severity levels of bleeding complications [33]. It was suggested that acetylsalicylic acid should be discontinued only if it may cause bleeding risks with increased mortality or if sequels are similar to the expected cardiovascular risks of acetylsalicylic acid withdrawal. A recent meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50 279 patients at risk for coronary artery disease [34] demonstrated that acetylsalicylic acid nonadherence or withdrawal was associated with a three-fold higher risk of major cardiac events.

α2-Agonists have been shown to reduce perioperative mortality and myocardial infarction during vascular and other major noncardiac surgery [35,36]. It is recommended that α2-agonists for perioperative control of hypertension may be considered for surgical patients with known coronary artery disease or at least one clinical risk factor (class IIb, LOE: B). They should not be given to patients with contraindications to this medication (class III, LOE: C).

The potential beneficial effects of perioperative calcium channel blocker therapy remain to be established. A meta-analysis of 11 studies involving 1007 patients showed a reduction in myocardial ischaemia and supraventricular tachycardia with calcium channel blockers and a trend towards reduced death and myocardial infarction. These effects were mainly observed with diltiazem, whereas dihydropiridines and verapamil did not decrease the incidence of myocardial ischaemia [37].

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Perioperative monitoring

ST-segment monitoring

The occurrence of perioperative ST-segment changes has been associated with cardiac morbidity and mortality also in patients undergoing noncardiac surgery. Intraoperative and postoperative ST-segment monitoring with computerized ST-segment analysis is considered useful for patients with known coronary artery disease or those undergoing vascular surgery (class IIa, LOE: B). It may also be considered in patients with one or more risk factors for coronary artery disease (class IIb, LOE: B).

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Pulmonary artery catheter

Perioperative use of a pulmonary artery catheter remains a controversial issue. Although significant information can be obtained from its use, no differences have been observed in survival or cardiovascular morbidity compared with standard care in patients who underwent major noncardiac surgery [38]. Pulmonary artery catheters are considered to be reasonable in patients at risk for major haemodynamic disturbances. However, it is emphasized that such a decision must be based on careful weighing of the patient's disease, the surgical risk, and the individual experience in use of this catheter (class IIb, LOE: B). The decision to place a pulmonary artery catheter should carefully take into account the potential complications associated with its use [39].

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Transoesophageal echocardiography

The use of transoesophageal echocardiography has gained wide acceptance in the setting of cardiac surgery. However, to date there is no sufficient evidence to support its routine use as a diagnostic monitor or to guide therapy during noncardiac surgery. The emergency use of intraoperative or perioperative transoesophageal echocardiography, however, is considered reasonable in order to determine the cause of an acute life-threatening haemodynamic abnormality (class IIa, LOE: C).

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Blood glucose concentration

The impact of a tight blood glucose concentration on perioperative morbidity and mortality has been the subject of several recent studies. It was suggested that control of blood glucose concentrations to less than 150 mg dl−1 in the perioperative period may improve outcome and minimize the risk of severe hypoglycaemia in anaesthetized patients [40,41]. The American College of Endocrinology recommends that preprandial glucose should be less than 110 mg dl−1, maximal glucose should not exceed 180 mg dl−1, and, in the intensive care unit, blood glucose concentration should be controlled to less than 110 mg dl−1 [42].

The ACC/AHA guidelines recommend perioperative control of blood glucose concentrations in patients with diabetes mellitus or acute hyperglycaemia who are at high risk for myocardial ischaemia or who are undergoing vascular and major noncardiac surgery with planned admission in the intensive care unit (class IIa, LOE: B). On the contrary, the usefulness of a strict perioperative blood glucose control is uncertain in patients with diabetes mellitus or acute hyperglycaemia undergoing noncardiac surgery but without planned admission in the intensive care unit (class IIb, LOE: C).

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Anaesthetic management

Neuraxial techniques can result in sympathetic blockade and cause a decrease in preload and afterload. Although initially some randomized controlled trials have suggested that the use of neuraxial techniques might have beneficial effects on outcome, these data have not been unequivocally confirmed in more recent studies on larger patient populations. The use of thoracic epidural analgesia in coronary artery bypass surgery was associated with fewer pulmonary complications but did not decrease the incidence of myocardial infarction or overall mortality [43]. A randomized trial on 1021 patients compared the effects on outcome of general anaesthesia with opioid analgesia to combined general and epidural anaesthesia and analgesia in intraabdominal aortic, gastric, biliary, and colon surgery. There were no overall differences in death or major complications. However, in the subgroup of patients undergoing aortic surgery, the incidence of myocardial infarction was lower [44]. The Multicentre Australian Study of Epidural Anaesthesia randomized 915 patients undergoing major intraabdominal surgery to either general or combined general and epidural anaesthesia and analgesia. Although there was a modestly improved pulmonary outcome in the patients allocated to the epidural group, no differences were observed in the incidence of death or cardiovascular events between both groups, not even in the patients who underwent aortic surgery [45]. In a recent meta-analysis on the subject, including a large number of noncardiac surgery patients, Liu and Wu [46] concluded that, to date, there is insufficient evidence to confirm (or deny) that postoperative analgesic techniques affect major postoperative morbidity and mortality.

In recent years, increasing evidence has indicated that volatile anaesthetic agents may have cardioprotective properties. In the setting of coronary artery surgery, the use of these drugs was shown to be associated with a better preservation of postoperative myocardial function and less evidence of postoperative myocardial damage (reviewed in ref. [47]). As far as noncardiac surgery is concerned, there are no randomized trials that have compared the effects of different anaesthetic agents on outcome. Recently, a retrospective analysis has been performed on data of a phase II study that compared the Na+/H+ exchanger type I inhibitor zoniporide with placebo on the occurrence of cardiac events in 784 high-risk patients scheduled for urgent or elective major arterial vascular surgery. Type of anaesthesia was retrospectively retrieved from the database and patients were subdivided into two groups: inhalational vs. noninhalational anaesthetic regimen. The incidence of postoperative cardiac events did not differ between the two groups and maximum postoperative troponin I levels were similar in both groups in the total population and in the patients undergoing peripheral arterial surgery. In patients undergoing aortic surgery, the incidence of elevated troponin levels higher than 1.5 and 4 ng ml−1 tended to be lower in the inhalational vs. the noninhalational group in aortic surgery (28 vs. 18% and 30 vs. 20%, respectively), but this difference did not reach statistical significance. The authors suggested that potential beneficial effects on the extent of postoperative myocardial damage in high-risk patients undergoing arterial surgery will probably be more apparent in abdominal aortic surgery than in peripheral vascular surgery and that further sufficiently powered studies using a standardized protocol were necessary to definitively address this question [48]. The ACC/AHA guidelines give a class IIa, LOE: B recommendation for the use of volatile anaesthetic agents during noncardiac surgery in haemodynamically stable patients at risk for myocardial ischaemia.

Other measures to be taken in the perioperative period that may help to improve outcome include maintenance of normothermia [49] and adequate perioperative pain management.

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Postoperative surveillance

Postoperative myocardial ischaemia is a strong predictor of perioperative cardiac morbidity. As its occurrence is not necessarily accompanied by pain, it may remain untreated until overt symptoms of cardiac failure occur. A perioperative myocardial infarction has been associated with a 30–50% perioperative mortality and reduced long-term survival [50,51]. Therefore, accurate diagnosis is essential.

Perioperative myocardial infarction can be documented by assessing clinical symptoms, serial electrocardiograms, cardiac-specific biomarkers, comparative ventriculographic studies, and radioisotopic or magnetic resonance studies. Measurements of troponin T or I have been shown to indicate myocardial damage with smaller amounts of injury [52]. However, the studies with regard to the predictive value of elevated cardiac troponin levels for long-term outcome show variable results with some studies indicating a close association with intermediate and long-term cardiovascular morbidity and mortality [53–55], whereas others are less straightforward [56].

Currently, there seem to be no clear-cut standard criteria for the diagnosis of perioperative myocardial infarction in patients undergoing noncardiac surgery. Although the use of sets of criteria [57], reflecting the unique features of perioperative myocardial infarction, may improve the diagnosis, a routine cardiac-specific troponin measurement is not recommended. The 2007 ACC/AHA guidelines recommend postoperative troponin measurement in patients with electrocardiographic changes or chest pain typical of the acute coronary syndrome (class I, LOE: C); its use is not well established in patients who are clinically stable and have undergone vascular and intermediate-risk surgery (class IIb, LOE: C) and is not recommended in asymptomatic stable patients who have undergone low-risk surgery (class III, LOE: C). Recently, assessment of pro-B-type natriuretic peptide has been gaining interest as a predictor of adverse events and outcome after noncardiac surgery [58,59].

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Patients undergoing noncardiac surgery are at risk of major perioperative cardiac events. Recognition of this risk may greatly influence outcome after such surgery and over the years guidelines have been developed for better care of these patients. However, adherence to such guidelines may critically depend on the convenience of its use in clinical practice. Recently, Hoeks et al. [60] determined the adherence to the 2002 ACC/AHA guidelines [61] and reported disappointing results. There seemed to be poor agreement between these guidelines and daily clinical practice. Only 21% of patients underwent noninvasive testing when recommended. In addition, patients who did not have additional testing despite recommendations received as little cardiac management as did those patients in the low-risk population. This implies that, despite the existence of well defined guidelines, high-risk patients do not get the perioperative management they need. This study poses a number of interesting questions. Are the guidelines too complex to be followed or are patients treated with β-blockers, statins and antiplatelet drugs considered to be already maximally protected, so that further testing is not considered necessary [62]? Although this remains an open question, it has to be acknowledged that the 2007 ACC/AHA guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery are substantially simpler with fewer intermediate steps in the decision tree than the 2002 guidelines.

In general, preoperative testing should allow optimal preparation of the patient for the period of surgery in order to improve the perioperative outcome. This implies risk stratification and optimal preparation. However, it should always be remembered that the use of noninvasive and certainly invasive additional testing should be limited to those instances in which the results of these tests will indeed change patient management.

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Text of the refresher course on the subject held at the Euroanaesthesia 2009 meeting in Milan (Italy).

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cardiac patient; noncardiac surgery; preoperative assessment

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