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Cardiac testing for noncardiac surgery: past, present, and future
Editorial Cardiac Testing for Noncardiac Surgery: Past, Present, and Future John E. Tetzlaff, MD,* Ibrahim Farid, MD† Division of Anesthesiology and Critical Care Medicine, The Cleveland Clinic Foundation, Cleveland, OH
*Director, Center for Anesthesiology Education †Fellow Address correspondence to Dr. Tetzlaff at the Division of Anesthesiology and Critical Care Medicine, E-30, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA. E-mail: [email protected] Received for publication April 11, 2002; revised manuscript accepted for publication May 7, 2002.
The evaluation of risk is a fundamental part of the role of the anesthesiologist in the perioperative period. For elective surgery, this evaluation begins with identification of correctable elements of co-morbidity and appropriate intervention to reduce risk and/or improve outcome. Optimum anesthetic care requires a balance between sensitive detection of risk and cost-effective utilization of expensive resources. The preparation of the patient with known cardiovascular disease for noncardiac surgery is an excellent example of this dilemma. Formal risk-stratification has been a regular part of the daily practice of anesthesiology since the 1960s, with the assignment of an American Society of Anesthesiologists (ASA) physical status classification as a part of every anesthetic administered. Sponsored by the ASA and published by Dripps et al.,1 ASA physical status assignment was designed to predict risk. Subsequent large-scale reviews have shown ASA physical status classifications to correlate with the incidence of major morbidity and mortality,2,3 although not in a manner that lends itself to predicting specific cardiac risk, or guiding cardiac testing for elective surgery. The desire to identify a means to predict perioperative cardiac risk has been driven by the observation that adverse cardiac events correlate with certain kinds of surgery, including carotid artery surgery,4 aortic aneurysm repair,5 and peripheral revascularization procedures.6 Recognizing that vascular surgery was highly associated with adverse cardiac events, Hertzer et al.7 advocated routine cardiac catheterization before vascular surgery, and achieved a very low mortality after major aortic surgery. Subsequent review of this approach revealed normal coronaries in only 8% of more than 1,000 patients scheduled for peripheral vascular surgery, with a significant incidence (14%) with severe correctable coronary artery disease that was not suspected by the clinical history.8 Coronary angiography led to coronary artery bypass graft procedures in 130 patients in this series who subsequently underwent aortic surgery, with less than 1% mortality. Screening with routine cardiac catheterization did not expand from these studies into a general risk prediction strategy due to the cost and morbidity associated with the procedures. Other approaches have included routine screening with exercise stress testing,9 dipyridamole-thallium imaging,6 and dobutamine stress echocardiography.10 Although some data are supportive,11 routine screening ultimately proves less than ideal for preoperative preparation for large populations of patients due to risk, cost, and logistics.12 In an attempt to combine patient factors with surgical issues, Goldman et al.13
Journal of Clinical Anesthesia 14:321–323, 2002 © 2002 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010
0952-8180/02/$–see front matter PII S0952-8180(02)00383-5
Editorial
created a scoring system designed to predict perioperative adverse cardiac events by assigning points based on risk factors. Factors found to correlate with cardiac events included recent myocardial infarction (MI), uncompensated congestive heart failure, and emergency surgery. This scoring system was shown subsequently to be capable of identifying the patients who were at highest risk, but it was not effective in stratifying those patients at lesser risk, and, finally, it was only minimally helpful in guiding preoperative assessment. Isolated observations also have some influence in risk assessment. Although any cardiac event is worthy of prevention, perioperative MI requires particular attention due to the high mortality, even compared with MI that occurs outside the hospital.14 The risk of subsequent surgery after successful coronary artery bypass grafting is greatly reduced,7,8,15 and may approach the risk found in patients without cardiac disease.16 Besides coronary artery disease, other cardiovascular diseases, such as uncontrolled hypertension,17 valvular heart disease,18 cardiomyopathy,19 and asymmetrical septal hypertrophy,20 correlate with increased risk of adverse perioperative cardiac events. Functional status and activity level of the patient correlate with cardiac risk. Those patients with good exercise capacity have low risk,21 whereas sedentary patients have significantly increased risk.22,23 Functional status is relatively easy to determine with the information collected by interviewing the patient and correlates well with maximum oxygen utilization24 and exercise capacity.25 The observation that perioperative myocardial ischemia (POMI) sometimes precipitates MI26 and increases perioperative cardiac risk has led to a variety of pharmacologic interventions designed to reduce POMI. Although nitroglycerin has a clear therapeutic role in the treatment of acute myocardial ischemia, administration before ischemia has not been shown to prevent POMI. Prophylactic use of calcium channel blockers does not decrease POMI27 and, indeed, may increase risk.28 In contrast, -blockers have clearly demonstrated efficacy as protection for patients with cardiac disease who are undergoing noncardiac surgery. This finding has been shown in patients undergoing different surgical procedures,29 vascular patients,30 and orthopedic patients,31 and it may reduce events for up to 2 years after surgery.32 The wealth of new information led to the formation of an unprecedented consensus group, convened to create a uniform approach to presurgical preparation of patients with cardiac disease scheduled for noncardiac surgery. Unique elements of this group were the multidisciplinary structure (internists, cardiologists, surgeons, and anesthesiologists) and the agreement that crossed traditional specialty lines. The resulting guidelines, often referred to as American College of Cardiology/American Heart Association (ACC/AHA) guidelines because of the site of primary publication, have been widely adopted since publication in 1996.33 The guidelines take a step-wise approach to presurgical preparation that includes surgical factors, medical risk factors, and the functional status of the patient, and by the use of an algorithm, arriving at a 322
J. Clin. Anesth., vol. 14, August 2002
uniform application. Surgical and medical risk factors are classified as low, intermediate, or high risk. Functional status is defined by oxygen utilization or metabolic-equivalents and the value specified for low, intermediate, or high activity levels. It specifically states that excellent functional status precludes further cardiac testing for the majority of surgical procedures. Uncontrolled hypertension, valvular heart disease (especially aortic stenosis), and cardiomyopathy are identified as factors that significantly increase risk and indicate functional studies. The role of prophylactic -blockers is acknowledged, and the nonspecific role of anesthetic drugs and the benefit of excellent postoperative analgesia are emphasized. Although obvious, it is specifically stated that abnormal findings must be treated, although the options remain numerous. The choice of functional study is also unspecified. Although the result of widespread use of ACC/AHA guidelines has been a more uniform approach, there is also a perception of increased testing.12 Subsequent evaluation of the results of guidelines use has revealed a few observations. The medical risk assessment may be more sensitive to risk than the surgical issues, although the surgical risk may be more specific.34 The review of Lustik et al.35in this issue of the Journal of Clinical Anesthesia further challenges some of the elements of these guidelines, based on observed limitations of supporting evidence. Many of the studies did not use control groups, whereas others failed to use randomization, introducing investigator bias into the outcome. These authors correctly state that functional studies are designed to identify critical coronary stenosis, even though there is increasing evidence that many perioperative MIs result from coronary arteries with noncritical stenosis. Although interventional procedures and coronary artery bypass grafting reduce the risk of subsequent surgical procedures, many of the reports that identify reduced risk do not take into account the morbidity and mortality of the interventional procedures. Some procedures, such as angioplasty, may convert a stable state into an unstable one, if plaque activation causes unstable angina or if acute restenosis occurs. This is a dynamic issue, because the introduction of stenting has greatly reduced acute reocclusion, and the introduction of potent antiplatelet drugs (e.g., clopidogrel) have almost eliminated plaque activation. So it is once more obvious that a change will occur in our approach to preoperative optimization of patients with cardiac disease for noncardiac surgery. Lustik et al.35 have proposed an alternative to the ACC/AHA guidelines that they believe will reduce testing by focusing on functional status and beta-blockade. The consensus group has reconvened, and there likely will be revision of the ACC/ AHA guidelines this year. It is already clear that we will be increasing the use of beta-blockade,36 and for low and intermediate risk surgery, prophylactic beta-blockade may replace functional testing for some of our patients. Further information about functional status may also influence our choices in the future, as may the use of other classes of drugs, such as angiotensin-converting enzyme inhibitors, to reduce perioperative risk.
Editorial
References 1. Dripps RD, Lamont A, Eckenhoff JE: The role of anesthesia in surgical mortality. JAMA 1961;178:261– 6. 2. Vacanti CJ, vonHouten RJ, Hill RC: A statistical analysis of the relationship of physical status to postoperative mortality in 68,388 cases. Anesth Analg 1970;49:564 – 6. 3. Lewin I, Lerner AG, Green SH, Del Guercio LR, Siegel JH: Physical class and physiologic status in the prediction of operative mortality in the aged sick. Ann Surg 1971;174:217–31. 4. Mackey WC, ODonnell TF Jr, Callow AD: Cardiac risk in patients undergoing carotid endarterectomy: impact on perioperative and long-term mortality. J Vasc Surg 1990;11:226 –34. 5. Roy WL, Edelist G, Gilbert B: Myocardial ischemia during noncardiac surgical procedures in patients with coronary artery disease. Anesthesiology 1979;51:393–7. 6. Younis LT, Aguirre F, Byers S, et al: Perioperative and long-term prognostic value of intravenous dipyridamole thallium scintigraphy in patients with peripheral vascular disease. Am Heart J 1990;119:1287–92. 7. Hertzer NR, Young JR, Kramer JR, et al: Routine coronary angiography prior to elective aortic reconstruction: results of selective myocardial revascularization in patients with peripheral vascular disease. Arch Surg 1979;114:1336 – 44. 8. 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. 9. Cutler BS, Wheeler HB, Paraskos JA, Cardullo PA: Assessment of operative risk with electrocardiographic exercise testing in patients with peripheral vascular disease. Am J Surg 1979; 137:484 – 90. 10. Eichelberger JP, Schwarz KQ, Black ER, Green RM, Ouriel K: Predictive value of dobutamine echocardiography just before noncardiac vascular surgery. Am J Cardiol 1993;72:602–7. 11. Mangano DT, Goldman L: Preoperative assessment of patients with known or suspected coronary disease. N Engl J Med 1995; 333:1750 – 6. 12. Mangano DT: Assessment of the patient with cardiac disease: an anesthesiologist’s paradigm. Anesthesiology 1999;91:1521– 6. 13. Goldman L, Caldera DL, Nussbaum SR, et al: Cardiac risk factors and complications in non-cardiac surgery. Medicine 1978;57:357– 70. 14. Badner NH, Knill RL, Brown JE, Novick TV, Gelb AW: Myocardial infarction after noncardiac surgery. Anesthesiology 1998;88: 572– 8. 15. Edwards WH, Mulherin JL Jr., Walker WE: Vascular reconstructive surgery following myocardial revascularization. Ann Surg 1978;187:653–7. 16. Crawford ES, Morris GC Jr., Howell JF, Flynn WF, Moorhead DT: Operative risk in patients with previous coronary artery bypass. Ann Thoracic Surg 1978;26:215–20. 17. Stone JG, Foex P, Sear JW, Johnson LL, Khambatta HJ, Triner L: Risk of myocardial ischaemia during anaesthesia in treated and untreated hypertensive patients. Br J Anaesth 1988;61:675–9. 18. Reyes VP, Raju BS, Wynne J, et al: Percutaneous balloon valvuloplasty compared with open surgical commissurotomy for mitral stenosis. N Engl J Med 1994;331:961–7. 19. Thompson RC, Liberthson RR, Lowenstein E: Perioperative
20.
21.
22. 23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35. 36.
anesthetic risk of noncardiac surgery in hypertrophic obstructive cardiomyopathy. JAMA 1985;254:2419 –21. Haering JM, Comunale ME, Parker RA, et al: Cardiac risk of noncardiac surgery in patients with asymmetric septal hypertrophy. Anesthesiology 1996;85:254 –9. Nelson CL, Herndon JE, Mark DB, Pryor DB, Califf RM, Hlatky MA: Relation of clinical and angiographic factors to functional capacity as measured by the Duke Activity Status Index. Am J Cardiol 1991;68:973–5. Hertzer NR: Basic data concerning associated coronary disease in peripheral vascular patients. Ann Vasc Surg 1987;1:616 –20. Morris CK, Ueshima K, Kawaguchi T, Hideg A, Froelicher VF: The prognostic value of exercise capacity: a review of the literature. Am Heart J 1991;122:1423–31. Hlatky MA, Boineau RE, Higginbotham MB, et al: A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J Cardiol 1989;64:651– 4. Myers J, Do D, Herbert W, Ribisl P, Froelicher VF: A nomogram to predict exercise capacity from a specific activity questionnaire and clinical data. Am J Cardiol 1994;73:591– 6. Mangano DT, Browner WS, Hollenberg M: Li J, Tateo IM: Long-term cardiac prognosis following noncardiac surgery. The Study of Perioperative Ischemia Group. JAMA 1992;268:233–9. Slogoff S, Keats AS: Does chronic treatment with calcium entry blocking drugs reduce perioperative myocardial ischemia? Anesthesiology 1988;68:676 – 80. Furberg CD, Psaty BM: Calcium antagonists: antagonists or protagonists of mortality in elderly hypertensives? J Am Geriatr Soc 1995;43:1309 –10. Wallace A. Layug B, Tateo I, et al: Prophylactic atenolol reduces postoperative myocardial ischemia. McSPI Research Group. Anesthesiology 1998;88:7–17. 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. Urban MK, Markowitz SM, Gordon MA, Urquhart BL, Kligfield P: Postoperative prophylactic administration of beta-adrenergic blockers in patients at risk for myocardial ischemia. Anesth Analg 2000;90:1257– 61. 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. Eagle KA, Brundage BH, Chaitman BR, et al: Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery. Circulation 1996;93:1278 –317. Ali MJ, Davison P: Pickett W, Ali NS: ACC/AHA guidelines as predictors of postoperative cardiac outcomes. Can J Anaesth 2000;47:10 –9. Lustik SJ, Eichelberger JP, Chhibber AK: Preoperative stress testing: new guidelines. J Clin Anesth 2002:14:375–380. Warltier DC: Beta-adrenergic-blocking drugs: incredibly useful, incredibly underutilized. Anesthesiology 1998;88:2–5.
J. Clin. Anesth., vol. 14, August 2002
323
*Director, Center for Anesthesiology Education †Fellow Address correspondence to Dr. Tetzlaff at the Division of Anesthesiology and Critical Care Medicine, E-30, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA. E-mail: [email protected] Received for publication April 11, 2002; revised manuscript accepted for publication May 7, 2002.
The evaluation of risk is a fundamental part of the role of the anesthesiologist in the perioperative period. For elective surgery, this evaluation begins with identification of correctable elements of co-morbidity and appropriate intervention to reduce risk and/or improve outcome. Optimum anesthetic care requires a balance between sensitive detection of risk and cost-effective utilization of expensive resources. The preparation of the patient with known cardiovascular disease for noncardiac surgery is an excellent example of this dilemma. Formal risk-stratification has been a regular part of the daily practice of anesthesiology since the 1960s, with the assignment of an American Society of Anesthesiologists (ASA) physical status classification as a part of every anesthetic administered. Sponsored by the ASA and published by Dripps et al.,1 ASA physical status assignment was designed to predict risk. Subsequent large-scale reviews have shown ASA physical status classifications to correlate with the incidence of major morbidity and mortality,2,3 although not in a manner that lends itself to predicting specific cardiac risk, or guiding cardiac testing for elective surgery. The desire to identify a means to predict perioperative cardiac risk has been driven by the observation that adverse cardiac events correlate with certain kinds of surgery, including carotid artery surgery,4 aortic aneurysm repair,5 and peripheral revascularization procedures.6 Recognizing that vascular surgery was highly associated with adverse cardiac events, Hertzer et al.7 advocated routine cardiac catheterization before vascular surgery, and achieved a very low mortality after major aortic surgery. Subsequent review of this approach revealed normal coronaries in only 8% of more than 1,000 patients scheduled for peripheral vascular surgery, with a significant incidence (14%) with severe correctable coronary artery disease that was not suspected by the clinical history.8 Coronary angiography led to coronary artery bypass graft procedures in 130 patients in this series who subsequently underwent aortic surgery, with less than 1% mortality. Screening with routine cardiac catheterization did not expand from these studies into a general risk prediction strategy due to the cost and morbidity associated with the procedures. Other approaches have included routine screening with exercise stress testing,9 dipyridamole-thallium imaging,6 and dobutamine stress echocardiography.10 Although some data are supportive,11 routine screening ultimately proves less than ideal for preoperative preparation for large populations of patients due to risk, cost, and logistics.12 In an attempt to combine patient factors with surgical issues, Goldman et al.13
Journal of Clinical Anesthesia 14:321–323, 2002 © 2002 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010
0952-8180/02/$–see front matter PII S0952-8180(02)00383-5
Editorial
created a scoring system designed to predict perioperative adverse cardiac events by assigning points based on risk factors. Factors found to correlate with cardiac events included recent myocardial infarction (MI), uncompensated congestive heart failure, and emergency surgery. This scoring system was shown subsequently to be capable of identifying the patients who were at highest risk, but it was not effective in stratifying those patients at lesser risk, and, finally, it was only minimally helpful in guiding preoperative assessment. Isolated observations also have some influence in risk assessment. Although any cardiac event is worthy of prevention, perioperative MI requires particular attention due to the high mortality, even compared with MI that occurs outside the hospital.14 The risk of subsequent surgery after successful coronary artery bypass grafting is greatly reduced,7,8,15 and may approach the risk found in patients without cardiac disease.16 Besides coronary artery disease, other cardiovascular diseases, such as uncontrolled hypertension,17 valvular heart disease,18 cardiomyopathy,19 and asymmetrical septal hypertrophy,20 correlate with increased risk of adverse perioperative cardiac events. Functional status and activity level of the patient correlate with cardiac risk. Those patients with good exercise capacity have low risk,21 whereas sedentary patients have significantly increased risk.22,23 Functional status is relatively easy to determine with the information collected by interviewing the patient and correlates well with maximum oxygen utilization24 and exercise capacity.25 The observation that perioperative myocardial ischemia (POMI) sometimes precipitates MI26 and increases perioperative cardiac risk has led to a variety of pharmacologic interventions designed to reduce POMI. Although nitroglycerin has a clear therapeutic role in the treatment of acute myocardial ischemia, administration before ischemia has not been shown to prevent POMI. Prophylactic use of calcium channel blockers does not decrease POMI27 and, indeed, may increase risk.28 In contrast, -blockers have clearly demonstrated efficacy as protection for patients with cardiac disease who are undergoing noncardiac surgery. This finding has been shown in patients undergoing different surgical procedures,29 vascular patients,30 and orthopedic patients,31 and it may reduce events for up to 2 years after surgery.32 The wealth of new information led to the formation of an unprecedented consensus group, convened to create a uniform approach to presurgical preparation of patients with cardiac disease scheduled for noncardiac surgery. Unique elements of this group were the multidisciplinary structure (internists, cardiologists, surgeons, and anesthesiologists) and the agreement that crossed traditional specialty lines. The resulting guidelines, often referred to as American College of Cardiology/American Heart Association (ACC/AHA) guidelines because of the site of primary publication, have been widely adopted since publication in 1996.33 The guidelines take a step-wise approach to presurgical preparation that includes surgical factors, medical risk factors, and the functional status of the patient, and by the use of an algorithm, arriving at a 322
J. Clin. Anesth., vol. 14, August 2002
uniform application. Surgical and medical risk factors are classified as low, intermediate, or high risk. Functional status is defined by oxygen utilization or metabolic-equivalents and the value specified for low, intermediate, or high activity levels. It specifically states that excellent functional status precludes further cardiac testing for the majority of surgical procedures. Uncontrolled hypertension, valvular heart disease (especially aortic stenosis), and cardiomyopathy are identified as factors that significantly increase risk and indicate functional studies. The role of prophylactic -blockers is acknowledged, and the nonspecific role of anesthetic drugs and the benefit of excellent postoperative analgesia are emphasized. Although obvious, it is specifically stated that abnormal findings must be treated, although the options remain numerous. The choice of functional study is also unspecified. Although the result of widespread use of ACC/AHA guidelines has been a more uniform approach, there is also a perception of increased testing.12 Subsequent evaluation of the results of guidelines use has revealed a few observations. The medical risk assessment may be more sensitive to risk than the surgical issues, although the surgical risk may be more specific.34 The review of Lustik et al.35in this issue of the Journal of Clinical Anesthesia further challenges some of the elements of these guidelines, based on observed limitations of supporting evidence. Many of the studies did not use control groups, whereas others failed to use randomization, introducing investigator bias into the outcome. These authors correctly state that functional studies are designed to identify critical coronary stenosis, even though there is increasing evidence that many perioperative MIs result from coronary arteries with noncritical stenosis. Although interventional procedures and coronary artery bypass grafting reduce the risk of subsequent surgical procedures, many of the reports that identify reduced risk do not take into account the morbidity and mortality of the interventional procedures. Some procedures, such as angioplasty, may convert a stable state into an unstable one, if plaque activation causes unstable angina or if acute restenosis occurs. This is a dynamic issue, because the introduction of stenting has greatly reduced acute reocclusion, and the introduction of potent antiplatelet drugs (e.g., clopidogrel) have almost eliminated plaque activation. So it is once more obvious that a change will occur in our approach to preoperative optimization of patients with cardiac disease for noncardiac surgery. Lustik et al.35 have proposed an alternative to the ACC/AHA guidelines that they believe will reduce testing by focusing on functional status and beta-blockade. The consensus group has reconvened, and there likely will be revision of the ACC/ AHA guidelines this year. It is already clear that we will be increasing the use of beta-blockade,36 and for low and intermediate risk surgery, prophylactic beta-blockade may replace functional testing for some of our patients. Further information about functional status may also influence our choices in the future, as may the use of other classes of drugs, such as angiotensin-converting enzyme inhibitors, to reduce perioperative risk.
Editorial
References 1. Dripps RD, Lamont A, Eckenhoff JE: The role of anesthesia in surgical mortality. JAMA 1961;178:261– 6. 2. Vacanti CJ, vonHouten RJ, Hill RC: A statistical analysis of the relationship of physical status to postoperative mortality in 68,388 cases. Anesth Analg 1970;49:564 – 6. 3. Lewin I, Lerner AG, Green SH, Del Guercio LR, Siegel JH: Physical class and physiologic status in the prediction of operative mortality in the aged sick. Ann Surg 1971;174:217–31. 4. Mackey WC, ODonnell TF Jr, Callow AD: Cardiac risk in patients undergoing carotid endarterectomy: impact on perioperative and long-term mortality. J Vasc Surg 1990;11:226 –34. 5. Roy WL, Edelist G, Gilbert B: Myocardial ischemia during noncardiac surgical procedures in patients with coronary artery disease. Anesthesiology 1979;51:393–7. 6. Younis LT, Aguirre F, Byers S, et al: Perioperative and long-term prognostic value of intravenous dipyridamole thallium scintigraphy in patients with peripheral vascular disease. Am Heart J 1990;119:1287–92. 7. Hertzer NR, Young JR, Kramer JR, et al: Routine coronary angiography prior to elective aortic reconstruction: results of selective myocardial revascularization in patients with peripheral vascular disease. Arch Surg 1979;114:1336 – 44. 8. 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. 9. Cutler BS, Wheeler HB, Paraskos JA, Cardullo PA: Assessment of operative risk with electrocardiographic exercise testing in patients with peripheral vascular disease. Am J Surg 1979; 137:484 – 90. 10. Eichelberger JP, Schwarz KQ, Black ER, Green RM, Ouriel K: Predictive value of dobutamine echocardiography just before noncardiac vascular surgery. Am J Cardiol 1993;72:602–7. 11. Mangano DT, Goldman L: Preoperative assessment of patients with known or suspected coronary disease. N Engl J Med 1995; 333:1750 – 6. 12. Mangano DT: Assessment of the patient with cardiac disease: an anesthesiologist’s paradigm. Anesthesiology 1999;91:1521– 6. 13. Goldman L, Caldera DL, Nussbaum SR, et al: Cardiac risk factors and complications in non-cardiac surgery. Medicine 1978;57:357– 70. 14. Badner NH, Knill RL, Brown JE, Novick TV, Gelb AW: Myocardial infarction after noncardiac surgery. Anesthesiology 1998;88: 572– 8. 15. Edwards WH, Mulherin JL Jr., Walker WE: Vascular reconstructive surgery following myocardial revascularization. Ann Surg 1978;187:653–7. 16. Crawford ES, Morris GC Jr., Howell JF, Flynn WF, Moorhead DT: Operative risk in patients with previous coronary artery bypass. Ann Thoracic Surg 1978;26:215–20. 17. Stone JG, Foex P, Sear JW, Johnson LL, Khambatta HJ, Triner L: Risk of myocardial ischaemia during anaesthesia in treated and untreated hypertensive patients. Br J Anaesth 1988;61:675–9. 18. Reyes VP, Raju BS, Wynne J, et al: Percutaneous balloon valvuloplasty compared with open surgical commissurotomy for mitral stenosis. N Engl J Med 1994;331:961–7. 19. Thompson RC, Liberthson RR, Lowenstein E: Perioperative
20.
21.
22. 23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35. 36.
anesthetic risk of noncardiac surgery in hypertrophic obstructive cardiomyopathy. JAMA 1985;254:2419 –21. Haering JM, Comunale ME, Parker RA, et al: Cardiac risk of noncardiac surgery in patients with asymmetric septal hypertrophy. Anesthesiology 1996;85:254 –9. Nelson CL, Herndon JE, Mark DB, Pryor DB, Califf RM, Hlatky MA: Relation of clinical and angiographic factors to functional capacity as measured by the Duke Activity Status Index. Am J Cardiol 1991;68:973–5. Hertzer NR: Basic data concerning associated coronary disease in peripheral vascular patients. Ann Vasc Surg 1987;1:616 –20. Morris CK, Ueshima K, Kawaguchi T, Hideg A, Froelicher VF: The prognostic value of exercise capacity: a review of the literature. Am Heart J 1991;122:1423–31. Hlatky MA, Boineau RE, Higginbotham MB, et al: A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J Cardiol 1989;64:651– 4. Myers J, Do D, Herbert W, Ribisl P, Froelicher VF: A nomogram to predict exercise capacity from a specific activity questionnaire and clinical data. Am J Cardiol 1994;73:591– 6. Mangano DT, Browner WS, Hollenberg M: Li J, Tateo IM: Long-term cardiac prognosis following noncardiac surgery. The Study of Perioperative Ischemia Group. JAMA 1992;268:233–9. Slogoff S, Keats AS: Does chronic treatment with calcium entry blocking drugs reduce perioperative myocardial ischemia? Anesthesiology 1988;68:676 – 80. Furberg CD, Psaty BM: Calcium antagonists: antagonists or protagonists of mortality in elderly hypertensives? J Am Geriatr Soc 1995;43:1309 –10. Wallace A. Layug B, Tateo I, et al: Prophylactic atenolol reduces postoperative myocardial ischemia. McSPI Research Group. Anesthesiology 1998;88:7–17. 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. Urban MK, Markowitz SM, Gordon MA, Urquhart BL, Kligfield P: Postoperative prophylactic administration of beta-adrenergic blockers in patients at risk for myocardial ischemia. Anesth Analg 2000;90:1257– 61. 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. Eagle KA, Brundage BH, Chaitman BR, et al: Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery. Circulation 1996;93:1278 –317. Ali MJ, Davison P: Pickett W, Ali NS: ACC/AHA guidelines as predictors of postoperative cardiac outcomes. Can J Anaesth 2000;47:10 –9. Lustik SJ, Eichelberger JP, Chhibber AK: Preoperative stress testing: new guidelines. J Clin Anesth 2002:14:375–380. Warltier DC: Beta-adrenergic-blocking drugs: incredibly useful, incredibly underutilized. Anesthesiology 1998;88:2–5.
J. Clin. Anesth., vol. 14, August 2002
323