Preoperative Cardiac Evaluation for Noncardiac Surgery: A Critical ...

abstract
• Objective: To review preoperative cardiac risk stratification
and management in patients undergoing
noncardiac surgery.
• Methods: Review of the literature, with a focus on
the 2007 American College of Cardiology/American
Heart Association guidelines and landmark papers.
• Results: The updated guidelines emphasize preoperative
clinical risk stratification and deemphasize
routine preoperative cardiac testing in patients with
known or suspected coronary disease. Most patients
without active cardiovascular conditions who are
not at very high risk can proceed to surgery without
further testing. Use of preoperative noninvasive testing
is warranted in selected very high-risk patients
and/or if the results will change patient management.
β-Blocker therapy is reasonable in higher-risk patients.
However, the updated guidelines do not include
data from the POISE trial, the results of which
call into question the routine initiation of prophylactic
preoperative β blockade. There is ongoing research
concerning preoperative statin therapy, which appears
to be beneficial, especially in vascular surgery
patients. A notable change in the guidelines reflects
recent evidence that intermediate-risk patients might
not benefit from prophylactic preoperative revascularization.
• Conclusion: An individualized multidisciplinary approach
and risk-benefit discussion with each patient
is the most prudent path to ensuring success.
Each year, 100 million adults worldwide undergo noncardiac
surgery, with approximately 30 million of
these surgeries performed in the United States [1–3].
An increasing proportion of surgical patients are elderly
and have concomitant cardiac disease. Despite advances
in medical therapy and subsequent improvements in event
rates, cardiovascular complications remain a major area
of surgical morbidity and mortality. As a result, innumerable
studies have addressed the topic of cardiovascular risk
stratification and management.
clinical review
Preoperative Cardiac Evaluation for Noncardiac
Surgery: A Critical Review
Bizath S. Taqui, MD, Keith McNellis, MD, Kathleen Coppola, MD, Himani Shishodia, MD, Brian Wolfe, MD,
Guiliana DeFrancesch, MD, Mary G. van den Berg-Wolf, MD, Lawrence I. Kaplan, MD, and Darilyn V. Moyer, MD
Since 1996, several organizations have convened expert
panels to develop evidence­based guidelines. However, gaps
and inconsistencies in the available data have led to differing
recommendations. The 2 most commonly cited guidelines,
from the American College of Physicians [4] and the American
College of Cardiology/American Heart Association
(ACC/AHA) [5], differed considerably when originally published
in the late 1990s. Most recently, the ACC/AHA published
a revised version of their guidelines [6]. Although the
2007 ACC/AHA update is currently the reference standard,
it has been and continues to be an impetus for debate. Thus,
more than half a century after perioperative myocardial
infarction (MI) was first identified as an entity, the optimal
strategy for predicting and preventing surgery­associated
cardiovascular complications remains controversial.
This paper will examine current areas of consensus and
controversy within the field of perioperative cardiovascular
evaluation with a focus on the updated ACC/AHA guidelines
and a review of landmark papers.
incidence and Pathophysiology of cardiac
complications
The incidence of perioperative MI depends on patient risk
factors as well as the risk associated with surgery. It also depends
on the universal definition of MI, which has recently
been broadened [7]. Based on the available literature, the
incidence of perioperative MI in low­risk patients undergoing
noncardiac surgery is 1% to 3% [8], but the incidence in
higher­risk patients is up to 38% in some studies [9]. The
variability is also related to the intensity of perioperative
medical management as well as the sensitivity and specificity
of the diagnostic modalities. At this time, there are no
standard diagnostic criteria for perioperative MI [10]. Furthermore,
since most perioperative MI are silent, the true incidence
may be underestimated. Finally, incidence estimates
may include data that are outdated due to the continuous
advances in management of cardiac patients.
From the Department of Medicine, Temple University School of Medicine, Philadelphia,
PA.
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PreoPerative cardiac evaluation
Table 1. Revised Cardiac Risk Index
Lee Variables
1 High-risk type of surgery
2 Ischemic heart disease (includes any of the following: history
of myocardial infarction; history of positive exercise test;
current complaint of chest pain that is considered to be
secondary to myocardial ischemia; use of nitrate therapy;
electrocardiography with pathologic Q waves)
3 Congestive heart failure
4 History of cerebrovascular disease
5 Preoperative treatment with insulin
6 Preoperative serum creatinine > 2.0 mg/dL
No. of
Variables
Risk of Major Postoperative
Cardiac Complication
0 0.4%
1 0.9%
2 7.0%
≥ 3 11.0% High risk
Adapted from reference 19.
Most perioperative MIs fall into the non–ST­segment
elevation MI category [11]. Risk is highest during the first
3 postoperative days. Perioperative MIs are caused by
prolonged myocardial ischemia or plaque rupture and coronary
thrombosis. Myocardial ischemia is caused by supply/
demand mismatches. Increased demand may result from
catecholamine surges that are triggered by the stress and
pain associated with surgery. Hypoxia and decreased supply
may occur in association with anesthesia, hypotension,
and bleeding. Furthermore, surgery is a proinflammatory,
hypercoagulable state, which may lead to plaque fissure and
thrombosis, respectively. The precise mechanisms of perioperative
ischemia and infarction are still unclear and being
investigated. However, perioperative MI has been shown to
be an independent risk factor for cardiovascular death and
nonfatal MI during the 6 months following surgery [12].
clinical risk Stratification: Patient risk Factors
Since the publication of Goldman’s cardiac risk index [13],
several authors have attempted to modify the original model
[14–18]. In a prospective study of 4315 patients older than
50 years undergoing elective surgery, Lee et al [19] developed
the Revised Cardiac Risk Index (RCRI) (Table 1), which uses
6 independent variables to predict risk of a major cardiac
complication. Rates of major cardiac complications with 0, 1,
2, and 3 or more of these factors were 0.5%, 1.3%, 4%, and 9%,
respectively, in the derivation cohort and 0.4%, 0.9%, 7%, and
11% in the validation cohort. Lee et al [19] noted that the model
might not be as useful in patients at very low risk (length of
stay < 2 days) or in those undergoing emergency surgeries.
Table 2. Active Cardiac Conditions for Which the Patient
Should Undergo Evaluation and Treatment Before
Noncardiac Surgery
Condition Examples
Unstable coronary
syndromes
Decompensated HF
(NYHA functional
class IV; worsening
or new-onset HF)
Unstable or severe angina*
Recent MI
Significant arrhythmias High-grade atrioventricular block
Mobitz II atrioventricular block
3rd-degree atrioventricular heart block
Symptomatic ventricular arrhythmias
Supraventricular arrhythmias (including
atrial fibrillation) with uncontrolled ventricular
rate (HR > 100 bpm at rest)
Symptomatic bradycardia
Newly recognized ventricular tachycardia
Severe valvular
disease
Severe aortic stenosis
Symptomatic mitral stenosis
HF = heart failure; HR = heart rate; MI = myocardial infarction;
NYHA = New York Heart Association. (Adapted from reference 6.)
*May include “stable” angina in patients who are unusually sedentary.
The Lee model is the only index to be derived during modern
times and has the major advantage of reflecting current practices
in anesthesia, medicine, and surgery. The Lee index was
validated by Boersma et al [20] in their retrospective analysis
of over 100,000 patients and is currently the preferred tool for
preoperative cardiac risk stratification.
The current ACC/AHA guideline have designated the
variables from the Lee index (all but high­risk surgery) as
“clinical risk factors;” these replace the old “intermediate risk
factors” category. Also in the current guidelines, patients in
the “highest” clinical risk category are now designated as
those with “active cardiac conditions” (Table 2). These active
cardiac conditions include unstable coronary conditions, decompensated
heart failure, significant arrhythmias, and severe
valvular disease. Their presence precludes the performance
of nonemergent surgery until the conditions are stabilized.
The “lowest” risk category of clinical predictors do not independently
predict adverse cardiac outcomes, and these minor
predictors remain unchanged from the earlier guidelines.
The ACC/AHA committee also identifies functional status
as an important predictor of cardiac risk. This is based on
evidence that suggests a correlation between an individual’s
ability to perform certain tasks and maximal oxygen uptake
by treadmill testing. There are also a few observational
studies linking functional capacity with perioperative outcomes.
However, the incorporation of functional status into
the ACC/AHA evaluation and care algorithm (Figure 1) has
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Step 1
Step 2
Step 3
Step 4
Vascular
surgery
Step 5
Need for emergency
noncardiac surgery?
NO
Active cardiac
conditions
NO
Low-risk surgery
NO
Functional capacity ≥ 4
METs without symptoms
3 or more clinical
risk factors
Consider testing if it will
change management †
No or unknown
Intermediaterisk
surgery
YES
YES
YES
sparked controversy. Critics of this strategy cite that people
with poor functional status are a heterogeneous group and
that there are insufficient prospective data that further testing
in such a group would improve perioperative outcomes.
Critics also doubt if functional status adds any incremental
predictive power to the RCRI.
Finally, the ACC/AHA committee comments on diseasespecific
risk, such as that associated with coronary artery
disease (CAD), congestive heart failure (CHF), hypertension,
valvular heart disease, arrhythmias, cardiomyopathy, pulmonary
vascular disease, and congenital heart disease. CAD
and CHF have been identified as independent predictors of
perioperative cardiac complications in several studies and
are topics we focus on herein. There is little information regarding
the impact of cardiomyopathy, pulmonary vascular
disease, and congenital heart disease on perioperative outcomes.
Hypertension with emphasis on risks and benefits
Operating room
Evaluate and treat per
ACC/AHA guidelines
Vascular
surgery
Proceed with
planned surgery
Proceed with planned surgery with HR control †
or consider noninvasive testing if it will change management
clinical review
Perioperative surveillance
and postoperative risk
stratification and risk factor
management
Consider operating room
Proceed with
planned surgery*
Proceed with
planned surgery
Figure 1. Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular
disease, or cardiac risk factors for patients aged 50 years or older. HR = heart rate. *Noninvasive testing may be considered
before surgery in specific patients with risk factors if it will change management. † Consider perioperative β blockade for populations
in which this has been shown to reduce cardiac morbidity/mortality. (Adapted from reference 6.)
of β and angiotensin blockade, valvular heart disease with
emphasis on aortic stenosis, and arrhythmias with emphasis
on atrial fibrillation are important topics in perioperative
management. However, an extensive review of the literature
concerning these areas is beyond the scope of this article.
clinical risk Stratification: Surgery-Specific risk
In his work with the Multicenter Study of Perioperative
Ischemia Research Group (www.iref.org), Mangano [21]
determined that cardiac complications were 2 to 5 times
more likely to occur with emergency surgery procedures
than with elective operations. Goldman and Detsky [13,16]
also identified emergency surgery as high risk. Detsky et
al also looked at surgery­specific risk. At their institution,
intraperitoneal, intrathoracic, and vascular surgeries had the
highest probability of being associated with a cardiac event;
these are the “high­risk” surgeries Lee et al [19] incorporated
www.turner-white.com Vol. 16, No. 6 June 2009 JCOM 273
YES
1 or 2 clinical
risk factors
Intermediaterisk
surgery
No clinical
risk factors

PreoPerative cardiac evaluation
Table 3. Cardiac Risk* Stratification for Noncardiac
Surgical Procedures
Risk Stratification Procedure Examples
Vascular (reported cardiac
risk often > 5%)
Intermediate (reported
cardiac risk generally
1%–5%)
Low (reported cardiac
risk generally < 1%)
Adapted from reference 6.
Aortic and other major vascular surgery
Peripheral vascular surgery
Intraperitoneal and intrathoracic surgery
Carotid endarterectomy
Head and neck surgery
Orthopedic surgery
Prostate surgery
Endoscopic procedures
Superficial procedure
Cataract surgery
Breast surgery
Ambulatory surgery
*Risk of cardiac death and nonfatal myocardial infarction.
into their index. These data, confirmed in other studies,
reflect the duration and large fluid shifts associated with
these procedures. Furthermore, cardiac complication rates
for vascular surgery may be due to the high concurrence of
CAD. Thus, the highest­risk noncardiac operation is aortic
aneurysm repair, which incorporates all of these problems.
The ACC/AHA committee performed an extensive review
of surgery­specific risk and identified 3 categories of
procedures (Table 3). The low­risk group (< 1% cardiac risk)
includes endoscopic and superficial procedures as well as cataract,
breast, and ambulatory surgeries. The intermediate­risk
group (1%–5% risk) includes a heterogeneous group of procedures
(prostate, orthopedic, head and neck, intraperitoneal
and intrathoracic surgeries, endovascular abdominal aortic
aneurysm repair, and carotid endarterectomy). The highestrisk
group (> 5% risk) is reserved for aortic, peripheral vascular,
and other major vascular surgery. Unlike the Lee index,
the ACC/AHA guidelines assigned highest­risk status only
to certain vascular surgeries. This interpretation of the data is
corroborated by most other studies, including data from the
National Surgical Quality Improvement Project registry data
[22]. One area of controversy surrounding the ACC/AHA review
was the lack of information provided about laparoscopic
procedures compared with open approaches.
Preoperative noninvasive testing
The ACC/AHA guideline recommends use of noninvasive
testing in select patients (Figure 1). Assessment of left ventricular
(LV) function has not been shown to independently
predict perioperative ischemic events. Furthermore, in a
meta­analysis of 8 studies, resting LV ejection fraction less
than 35% had only 50% sensitivity and 91% specificity in
predicting postoperative heart failure. Thus, the ACC/AHA
guidelines do not routinely recommend preoperative evaluation
of LV function.
Exercise stress testing has a limited role in preoperative
risk stratification because more than 50% of patients fail to
reach heart rates greater than 75% of their age predicted
maximum. Also, many patients have disease that limits
their ability to walk effectively. Exercise stress testing is also
of limited utility in patients with baseline electrocardiogram
abnormalities such as left bundle branch block, left
ventricular hypertrophy with strain patterns, or ST segment
deviations. Thus, pharmacologic stress testing has become
the primary modality for patients requiring preoperative
risk stratification. Pharmacologic stress testing can be done
using nuclear imaging (dipyridamole or adenosine thallium)
or echocardiography (dobutamine echocardiography).
Dipyridamole and adenosine are relatively contraindicated
in patients with bronchospasm or critical carotid occlusive
disease. Dobutamine should be avoided in patients with
serious arrhythmias, severe hypertension or hypotension,
and critical aortic stenosis.
A few conclusions can be made regarding the data on
noninvasive testing for preoperative coronary risk stratification.
First, the data should be interpreted with caution
for several reasons. The majority of the studies used weak
methods (retrospective design, lack of blinding, selection
bias, confounding). Most studies reported low perioperative
event rates. Meta­analyses of the different studies were limited
by significant between­study heterogeneity. The majority
of the studies involved vascular surgery patients.
Second, in pooled analyses comparing different diagnostic
modalities [23], all of the tests demonstrated very high negative
predictive values (at least 95%). However, the positive
predictive values of the tests were much lower (at most 20%).
Overall, there was comparable accuracy between myocardial
perfusion imaging and dobutamine echocardiography [24].
Perfusion imaging may be more sensitive for detecting ischemia,
but dobutamine echocardiography tended to have a
higher specificity and positive predictive value [25,26].
Third, preoperative stress testing may be more useful
if cardiac risk is quantified to severity of disease using
either number and size of reversible perfusion defects (for
perfusion imaging) or inducible regional wall motion abnormalities
(for stress echocardiography) [27,28]. Some studies
suggested that the heart rate at which ischemia is induced
(ischemic threshold) may also be predictive of adverse perioperative
events [6].
Finally, studies combining clinical risk indexes and noninvasive
testing showed lack of utility of such testing in low­risk
patients. Furthermore, as new data have emerged about preoperative
medical therapy and coronary revascularization,
authorities are advocating against preoperative noninvasive
testing for intermediate­risk patients. Two trials demonstrated
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that in patients at intermediate risk who were treated with optimal
medical therapy (β blockers), preoperative noninvasive
testing, and/or coronary revascularization provided no additional
benefit [29,30]. However, data are lacking for patients at
very high risk for perioperative cardiac complications because
most studies included very few of these patients.
Boersma et al [20] retrospectively evaluated the endpoints
of perioperative cardiac death or nonfatal MI in
vascular surgery patients on β­blocker therapy who had undergone
preoperative dobutamine echocardiography. The
researchers found that low­risk patients had the lowest rate
of cardiac complications (< 1%), regardless of findings on
dobutamine echocardiography. Patients at intermediate or
higher risk had a low rate of complications (< 1.2%) if they
had fewer than 4 segments with new wall motion abnormalities
on dobutamine echocardiography. However, the rate of
cardiac complications was significant (> 5%) in patients with
profoundly abnormal echocardiography, despite being on
β blockade. Pretest clinical probability was calculated using
a score similar to the RCRI.
The ACC/AHA guidelines position on preoperative noninvasive
testing represented a major paradigm shift, with preoperative
noninvasive testing recommended in intermediate­
to higher­risk patients only if “it will change management.”
The strongest recommendation for consideration of testing
is for vascular surgery patients who have poor or unknown
functional capacity and 3 or more clinical risk factors. Patients
who have good functional capacity or no clinical risk factors
can proceed to surgery. For the remaining patients, there is a
choice between medical management and further testing.
Perioperative Medical therapy
β Blockers
Perioperative use of β blockers is another area of controversy.
The evidence supporting the efficacy of perioperative
β­blocker therapy is largely based on 2 randomized controlled
trials (RCTs) published in the late 1990s [31,32]. The trials
were based on the theory that β blockade would improve
supply­demand mismatch associated with surgery. In their
landmark trial, Mangano et al [31] assigned 200 patients undergoing
noncardiac surgery to atenolol (given intravenously
before and immediately after surgery, then orally for the
duration of hospitalization) or placebo. The enrolled patients
had CAD or at least 2 risk factors for CAD (age > 65 years,
hypertension, smoking, serum cholesterol > 6.2 mmol/L, or
diabetes). Although there was no difference in perioperative
MI or death, the atenolol group had significantly fewer
episodes of ischemia detected on Holter monitoring and significantly
lower mortality at 2 years. The principal effect was
demonstrated 6 to 8 months after surgery and maintained
over the entirety of the 2 years. In a major limitation of the
study, the researchers did not control for pre­ or postoperative
clinical review
use of medications. More patients in the atenolol group were
using angiotensin­converting enzyme inhibitors and β blockers
when they were discharged.
The second major RCT (DECREASE), reported by Poldermans
et al [32], randomized 112 patients undergoing
vascular surgery to bisoprolol versus placebo. These patients
had been selected from a larger cohort due to their high
clinical risk and abnormal dobutamine echocardiography
findings. Bisoprolol was started at least 7 days prior to surgery
and continued for 30 days postoperatively. There was a
significantly lower incidence of cardiac death and nonfatal
MI in the bisoprolol group. Of note, the study protocol was
unblinded. Another weakness of the DECREASE study was
its selective inclusion criteria, which may limit generalizability
to a larger cohort of patients.
This issue of inclusion criteria was addressed in 2001
when Boersma et al used regression analysis to identify 7
clinical risk factors that predicted adverse cardiac events
(angina, prior MI, CHF, prior stroke, diabetes, renal failure,
and age > 70 years) and used these criteria to analyze the
1351 consecutive patients initially considered for enrollment
in the Poldermans study. In patients without any risk factors,
there was no benefit from β blockade. In intermediate­risk
patients with up to 3 risk factors, the β­ blocker group had a
lower risk of cardiac complications regardless of stress test
findings. The same benefit occurred in higher­risk patients
with at least 3 risk factors who had 4 or fewer wall motion
abnormalities on dobutamine echocardiography. However,
β blockers did not protect the small group of highest­risk patients
with the most extensive ischemia (≥ 5 wall motion abnormalities).
It should be noted that the study had problems
with respect to randomization techniques and blinding.
In a similar 2005 study, Lindenauer et al [33] used the
RCRI to analyze an administrative database of more than
780,000 patients who had undergone noncardiac surgery.
Again, intermediate­ to higher­risk patients benefited from
perioperative β blockade. However, low­risk patients or those
with diabetes actually seemed to do worse with β blockade.
Limitations of the study include retrospective design, potential
incorrect estimation of the number of patients who actually
received β blockade, lack of data on concomitant medications,
exclusion of patients with CHF and chronic obstructive
pulmonary disease, and inclusion of patients undergoing
urgent or emergent surgery (even though the revised cardiac
index was not derived from this population).
Additional studies of patients undergoing noncardiac surgery
have been less favorable toward β blockers. The POBBLE
[34] and MaVS [35] trials failed to show benefit of β blockade
in low­ or intermediate­risk patients undergoing vascular
surgery. Similarly, in DIPOM [36] there was no benefit from
β blockade for diabetic patients undergoing noncardiac surgery.
In the DIPOM study, patients given β blockade had
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PreoPerative cardiac evaluation
Table 4. Recommendations for Perioperative β-Blocker Therapy Based on Published Randomized Clinical Trials
Surgery
No Clinical
Risk Factors
significantly higher rates of hypotension and bradycardia.
Of note, none of these studies used the protocol suggested
by DECREASE trial. Also, these trials all used metoprolol,
suggesting the possibility of class effect. Class effect was also
suggested by a large database, which favored the use of longacting
over shorter­acting β blockers [37].
The conflicting results between studies resulted in the publication
of several overviews on the topic [38–41]. However, the
reviews used different inclusion criteria and differed in their
conclusions. In addition, the reviews were limited by the small
size and heterogeneous nature of the individual trials. In the
first large RCT of perioperative β blockade, the POISE investigators
[42] randomized 8351 patients, most of whom were at
intermediate risk, to extended­release metoprolol or placebo.
Patients who were already on β blockers were excluded from
the trial. Although the primary composite endpoint (cardiovascular
death, nonfatal MI, and nonfatal cardiac arrest) was
lower at 30 days in the metoprolol group, the benefits were at
a cost. The metoprolol group had a higher mortality rate (most
likely due to sepsis) and higher risk of stroke (possibly due to
increased rates of hypotension and bradycardia). The nature
of the association of sepsis with β­blocker use, and whether
there was causality was unclear. To further support their cautious
attitude toward β blockers, the authors reflected on the
relatively benign outcome in the patients with nonfatal cardiac
events as opposed to the disability that was associated with
nonfatal strokes. Finally, the authors were unable to identify
differences in primary outcome between subgroups that had
been prespecified using the RCRI.
Rather than resolving the controversy surrounding perioperative
beta blockade, the POISE trial may have contributed
to it. The study population included patients with a
high rate of cerebrovascular disease and high rates of urgent
and emergent surgeries. The major criticisms of the study,
however, concern dosing regimen and timing of initiation.
In the POISE study, the starting dose of metoprolol was 2 to
8 times the commonly prescribed dose. Also, the study drug
was started only a few hours prior to surgery. This initiation
time not only interferes with proper titration but may also
underutilize the anti­inflammatory effect of β blockade.
1 or More Clinical
Risk Factors CHD or High Cardiac Risk
Patients Currently
Taking β Blockers
Vascular May be considered Reasonable Patients found to have myocardial ischemia
on preoperative testing: recommended
Patients without ischemia or no previous
test: reasonable
Recommended
Intermediate risk ID May be considered Reasonable Recommended
Low risk ID ID ID Recommended
CHD = coronary heart disease; ID = insufficient data. (Adapted from reference 6.)
This additional mechanism was first proposed to explain
the long­term benefit of perioperative β blockade months
after surgery, which has been demonstrated by several studies,
including the original study by Mangano et al.
Finally, class effect may be important because perioperative
cardioprotection is regulated mainly by B1 adrenoreceptor
blockade. Blocking both B1 and B2 receptors in the presence
of increased adrenaline levels may lead to increased
alpha stimulation and a rise in blood pressure. Bisoprolol has
higher B1 selectivity compared with atenolol and metoprolol,
which might explain why it has performed better in trials.
In summary, there are still several issues that require
clarification regarding the use of perioperative β blockade.
These include choice of β blocker as well as optimal dosage
and timing of initiation and withdrawal. There does appear
to be consensus in optimal heart rate, with most authorities
citing targets of 55 to 65 bpm. Finally, a critical aspect remains
the identification of ideal candidates for perioperative
β blockers based on clinical risk. The revised cardiac risk
index seemed to address this issue until the POISE trial.
Additional risk indices might need to be developed to further
clarify the ideal candidate. The ACC/AHA guidelines
published prior to POISE recommended starting β blockers
in higher­risk patients who also have ischemia on stress
testing (Table 4). However, the only group who received a
class 1A (high level of evidence) indication for perioperative
β blockade was patients already taking β blockers.
Statins
Perioperative use of statins is an emerging area of study.
There is a growing body of evidence that statins improve
endothelial function, decrease vascular inflammation, and
stabilize atherosclerotic plaques. Most data are based on
observational studies [43,44]. In one of the few prospective
trials to date, Durazzo et al [45] assigned 100 patients undergoing
vascular surgery to atorvastatin versus placebo, with
surgery scheduled an average of 30 days after randomization.
There was a significantly lower incidence of cardiac
complications at 6­month follow­up in the statin group. Two
large retrospective studies [46,47] of patients undergoing
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noncardiac surgery demonstrated significant reductions in
mortality associated with perioperative statin use.
Meta­analyses have also shown an overall benefit from
statin use. Hindler et al [48] reported a 44% reduction in
mortality associated with statin use during noncardiac
surgery. The risk reduction was even higher for patients
undergoing vascular surgery. In a recent review of 18 studies,
Kapoor et al [49] also reported a reduction in mortality
in patients receiving perioperative statin therapy. These data
are limited by the retrospective nature of most of the studies
as well as between­study heterogeneity in patient risk as
well as type, dose, and duration of the statins. Further study
is required on potential side effects, including myopathy
and rhabdomyolysis.
Preoperative revascularization
Most of the data regarding benefits of preoperative coronary
revascularization are from retrospective studies. The largest
retrospective review of preoperative coronary artery
bypass grafting (CABG) was conducted by Eagle et al [3].
In this study, patients undergoing lower­risk surgery (urologic,
orthopedic, breast, and skin), had low mortality rates
regardless of whether or not they had preoperative CABG.
However, among patients undergoing thoracic, abdominal,
head/neck, and vascular surgeries, patients who had prior
CABG had lower risk of death and MI in the 30 days after the
noncardiac surgery. The benefit of preoperative CABG was
greatest in patients who had multivessel disease and more
severe angina. Similar benefits of preoperative revascularization
were also demonstrated in the BARI [50] trial as well as
an analysis of Medicare patients conducted by Fleisher et al
[51]. However, a major limitation of these studies is their failure
to incorporate risks of CABG and/or delaying noncardiac
surgery into the equation. As a result, decision analyses were
published to address these risks as well as long­term benefits
of CABG. Most authors recommend that preoperative CABG
should only be performed if it is necessary based on indications
independent of the noncardiac surgery [52,53].
Early studies of preoperative percutaneous coronary intervention
(PCI) were limited by small sample size, retrospective
analysis, lack of adequate comparison groups, and variable
timing between PCI and noncardiac surgery [54–59]. Posner
et al [60] found a benefit from preoperative balloon angioplasty
only if it was performed more than 90 days prior to
noncardiac surgery. After balloon angioplasty, delaying noncardiac
surgery for more than 8 weeks increases the chance of
restenosis. However, at least 2 weeks is required to allow for
vessel healing after angioplasty.
The CARP trial [29] was the first multicenter RCT addressing
the issue of preoperative revascularization. Using
a cohort of 5859 VA patients, McFalls et al [29] randomly assigned
510 vascular surgery patients with stable CAD to ei­
clinical review
ther revascularization or medical therapy. Of note, researchers
excluded patients requiring emergent/urgent surgery as
well as patients with unstable coronary syndromes, at least
50% left main stenosis, LV ejection fraction less than 20%,
or severe aortic stenosis. There was no difference between
groups in death or nonfatal MI at 30 days and 2.7 years
after noncardiac surgery. The CARP trial was criticized for
excluding highest­risk patients.
The DECREASE V pilot study [61] attempted to address
the highest­risk group of patients, who were underrepresented
in the CARP trial. This study randomized 101 highrisk
vascular surgery patients who had extensive ischemia
on noninvasive testing. Most patients had 3­vessel CAD and
nearly half had ejection fractions less than 35%. At 1 month
and 1 year after noncardiac surgery, there was no evidence
of improved outcomes in patients that been randomized to
preoperative revascularization. It should be noted that both
trials were underpowered and will require further confirmation.
In addition, most patients were on β blockade.
Based on the available evidence, the ACC/AHA guideline
position is that routine prophylactic preoperative revascularization
is not indicated in patients with stable CAD.
Management of surgical patients with prior stents is of
particular concern, especially with the advent of drug­eluting
stents. Stenting causes the denudation of arterial endothelial
surface and subsequent risk of thrombosis. This risk of
thrombosis is particularly high for the first several weeks
after the intervention. Although oral antiplatelet therapy
counteracts the risk of thrombosis, perioperative bleeding
associated with these agents has led to postponement of noncardiac
procedures until therapy is completed. Drug­eluting
stents, compared with bare­metal stents, may prolong the reendothelialization
process, causing an even longer delay.
Early retrospective studies of patients with bare­metal
stents [62,63] showed that perioperative complications occur
mainly when the noncardiac surgery occurs within 6 weeks
of the PCI. In these studies, thrombosis increased when antiplatelet
agents were prematurely discontinued. Conversely,
bleeding rates were higher if antiplatelet agents were continued
through surgery. Subsequent studies that included
patients with drug­eluting stents [64,65] revealed higher
rates of cardiac complications in patients that underwent
noncardiac surgery within the time recommended for antiplatelet
therapy compared with those in whom surgery was
delayed. The risk of thrombosis was high even if antiplatelet
therapy was not interrupted.
The optimum time required between PCI with stents
and noncardiac surgery is unknown. Recommendations are
oulined in Figure 2. The ACC/AHA [66] currently recommends
that antiplatelet therapy be continued for 2 weeks
for balloon angioplasty, 4 to 6 weeks for bare­metal stents,
and 1 year for drug­eluting stents but recognizes that this
www.turner-white.com Vol. 16, No. 6 June 2009 JCOM 277

PreoPerative cardiac evaluation
Time
since
PCI
< 14 days
Delay for elective or
nonurgent surgery
Balloon
angioplasty
> 14 days
Proceed to the operating
room with aspirin
Figure 2. Management of patients with previous percutaneous coronary intervention (PCI). (Adapted from reference 6.)
is arbitrary due to lack of high­quality evidence. There is
no evidence that anticoagulants will reduce risk of stent
thrombosis after discontinuation of antiplatelet therapy.
Additional risk factors for thrombosis need to be balanced
against risk of bleeding [67]. If a nonsurgical procedure is
planned prior to PCI, balloon angioplasty and bare­metal
stents should be used instead of drug­eluting stents. However,
at a time where prophylactic preoperative revascularization
is no longer favored, the more common scenario
occurs when the recently stented patients find out that they
need noncardiac surgery.
conclusion
Despite advances in clinical outcomes research over the past
few decades, preoperative cardiac risk assessment and reduction
remains an area of controversy. The most recent update
of the ACC/AHA guidelines places emphasis on modern risk
assessment and medical management techniques rather than
routine and universal noninvasive testing. A notable change
in the guidelines reflects recent evidence that intermediaterisk
patients might not benefit from prophylactic preoperative
revascularization. However, the current studies lack sufficient
power, especially with respect to the highest­risk patients.
Also, the updated guidelines do not include data from the
POISE trial, the results of which call into question the routine
initiation of prophylactic preoperative β blockers. POISE also
questioned whether the RCRI is sufficient for risk stratification.
Future research is needed to identify subgroups of
patients who will benefit from preoperative revascularization
and/or β blockade. The type, dose, and timing of β blockade
need to be clarified, and further trials concerning preoperative
statins are needed. Until then, the ACC/AHA guidelines
should be used as a framework rather than an algorithm. An
individualized multidisciplinary approach and risk­benefit
discussion with each patient is the most prudent path to ensuring
success.
Previous PCI
Bare-metal
stent
Delay for elective or
nonurgent surgery
Corresponding author: Bizath S. Taqui, MD, Section of General Internal
Medicine, Temple University School of Medicine, Jones Hall, 1316 W.
Ontario St., Philadelphia, PA 19140.
Financial disclosures: None.
Drug-eluting
stent
> 30–45 days < 30–45 days < 365 days
> 365 days
Proceed to the operating
room with aspirin
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