ANESTHESIA FOR THE CARDIAC PATIENT 0889-8537/97 $0.00 + .

20

PREOPERATIVE ASSESSMENT OF
PATIENTS WITH CARDIAC
DISEASE UNDERGOING
NONCARDIAC SURGERY
Tuula S. 0. Kurki, MD

In the aging population cardiac disease plays a major role as a risk factor
among patients undergoing noncardiac surgery. More than 1 million patients
with known coronary artery disease (CAD) undergo noncardiac surgery in the
United States on an annual basis.3O There are 3 million additional noncardiac
surgical patients who have risk factors for CAD, and approximately 4 million
other patients who are greater than 65 years of age (who are at increased risk of
cardiac morbidity). Annually about 50,000 out of 25 million patients undergoing
noncardiac surgery have perioperative myocardial infarction (MI) (0.2%). Pa-
tients with known CAD have a 1.1%perioperative incidence of MI in noncardiac
surgery. The mortality following perioperative MI has been reported as 26% to
70%.30 Thus, it is important to identify those patients who have increased risk
of perioperative cardiac morbidity and mortality to correct conditions that might
positively alter outcome. It is controversial whether preoperative interventions,
such as drug therapy or myocardial revascularization, are beneficial.
The main goals of the preoperative assessment of the cardiac patient for
noncardiac surgery are risk stratification and the potential reduction of this
risk by various interventions. These interventions may incIude modifying drug
therapy or the surgical approach, more intensive intraoperative monitoring,
anesthetic techniques, and possible myocardial revascularization. A proper pre-
operative assessment entails the collection of information about the patients
medical history and physical condition, the ordering and interpretation of appro-
priate tests, education of the patient and family members, selection of preanes-
thetic medication, and obtaining informed consent4

From The Mount Sinai Medical Center, New York, New York

ANESTHESIOLOGY CLINICS OF NORTH AMERICA

-
~ ~ ~ ~~~~~~

VOLUME 15 * NUMBER 1 MARCH 1997 1

2 KURKI

ASSESSMENT OF PREOPERATIVE RISK

General Classification

Several cardiac risk stratification models are available. The American Society
of Anesthesiologists (ASA) classification of physical status2 has five different
categories and has been widely applied to surgical patients.2,l9 Patients with
asymptomatic cardiac disease are assigned to ASA class 11; if they have angina
controlled by the treatment, they belong to class 111. Patients with unstable
angina belong to class IV, and patients with acute MI with cardiogenic shock
belong to class V. The predictive value of this classification regimen, however,
is limited.

Functional Classifications

The New York Heart Associations functional classification5 (Table 1) of

limited exercise tolerance is as follows:
Class 1 refers to patients who are symptomatic only with strenuous exercise
Class 2 are symptomatic with moderate exercise
Class 3 are symptomatic with limited exercise (climbing one flight of stairs
or walking one or two blocks)
Class 4 patients have symptoms at rest and with any activity
The Canadian Cardiovascular Society Functional classification of angina
pectoris (CCVSA) is similar to the New York Heart Association classification
(Table l).7

General Risk Scores

Goldman et all4,l5 developed multifactorial clinical risk indices for patients

undergoing noncardiac surgery by identifying risk factors that predicted periop-
erative cardiac complications or death. The patients were assigned to four risk
classes based on the risk points (Table 2): class I, 0-5 points; class II,6-12 points;
class 111, 13-25 points; and class IV, over 25 points. The risk of perioperative

TABLE 1. NEW YORK HEART ASSOCIATION AND CANADIAN CARDIOVASCULAR

SOCIETY FUNCTIONAL CLASSIFICATION OF ANGINA
NYHA5 CCVSA
Class 1 No symptoms with ordinary Class I Ordinary physical activity
physical activity does not cause angina
Class 2 Symptoms with ordinary Class II Slight limitation with
activity; slight limitation of ordinary activity
activity
Class 3 Symptoms with less than Class 111 Marked limitations of
ordinary activity; marked ordinary activity
limitation of activity
Class 4 Symptoms with any physical Class IV Inability to carry on any
activity or even at rest physical activity without
discomfort
 PATIENTS WITH CARDIAC DISEASE UNDERGOING NONCARDIAC SURGERY 3

TABLE 2. GOLDMANS AND DETSKYSMULTIFACTORIAL CARDIAU RISK INDICES

FOR NONCARDIAC SURGERY
Goldman Detsky
Variable Score Variable Score
Age 270 years 5 Age >70 years 5
Myocardial infarction <c6 10 Myocardial infarction <6 10
months months
ECG: nonsinus rhythm or 7 Myocardial infarction >6 5
PVCs months
>5 PVCs anytime 7 Unstable angina <3 months 10
53 gallop or JVD 11 Alveolar pulmonary edema <1 10
week
Aortic stenosis 3 Pulmonary edema ever in past 5
Emergency operation 4 Sinus rhythm and PACs 5
Intrathoracic, intraperitoneal,or 3 Nonsinus rhythm or PVCs 5
aortic operation
Poor general status 3 CCVSA class 111 10
CCVSA class IV 20
Critical aortic stenosis 20
Emergency operation 10
Poor general status 5
Total possible score 53 Total possible score 120

PVCs = premature ventricular contractions: JVD = jugular venous distention; APCs = atrial
premature contractions; CCVSA = Canadian Cardiovascular Society Angina Classification.

cardiac complications ranged from less than 1%in class I to approximately 78%
in class IV; the risk factors are summarized in Table 2. Detsky et a19 modified
the original Goldman multifactorial index by adding more variables (Canadian
Cardiovascular Society angina class: unstable angina, and history of pulmonary
edema). A high score in either risk index was predictive of a poor postoperative
outcome; however, they were not as accurate in predicting cardiac morbidity in
low-risk patients (Goldman class I and II).11,34Lette et alZ8found that neither
risk index predicted adverse outcomes in low-risk patients.

Cardiac Surgical Indices

There are several risk indices available for patients undergoing cardiac
surgery. These are more complex than the manual indices described previously.
Parsonnet,% Hannan,s and HigginsZ0have developed a risk index that uses
logistic regression models to stratify patients morbidity and mortality risk. The
Parsonnet model has been widely used. EdwardsO has developed a risk index
that is based on the Bayesian approach. There is also a simple, manual, 7-factor
index available for individual cardiac patients,= Table 3 shows the patient risk
factors that are common to these five studies. Many of the risk factors are similar
for patients undergoing noncardiac surgery.Z1,26 In the future there may be risk
stratification systems for predicting morbidity and mortality that are applicable
to both cardiac and noncardiac patients.

CLINICAL EVALUATION
Clinical history and physical examination are the basis of the preoperative
assessment, but additional testing is required depending on the patients under-
4 KURKI

TABLE 3. PREOPERATIVE RISK FACTORS FOR POSTOPERATIVE MORBIDITY/

MORTALITY IN OPEN HEART SURGERY: COMPARISON OF 5 DIFFERENT STUDIES
Parsonnet
Edwards et allo Hannan et all* Higgins et alZo Kurki, KatajaZ5 et al"

Cardiogenic EF% <20 Emergency Cerebrovascular Catastrophic

shock disease state
Preoperative Disasters Renal failure Diabetes Age >80 years
IABP
MI <21 days Prior OHS Prior OHS Emergency Prior OHS
Prior CABG Renal failure LV dysfunction Arrhythmias Emergency
IV nitrates CHF Mitral Previous MI Renal failure
insufficiency
Emergency Previous MI Age >70 years EF% <49 Rare
circumstances
Left main Female Diabetes Age >70 years Mitral
disease insufficiency
Female Diabetes Weight <65 kg Renal failure Aortic stenosis
Pulmonary Obesity Anemia Pulmonary Valve surgery
disease disease

OHS = open heart surgery; IABP = intra-aortic balloon pump; MI = myocardial infarction; EF =
left ventricular ejection fraction; LV = left ventricular.

lying diseases and the planned procedure. A complicating factor in this process
is the trend toward more day-of-admission and outpatient surgery. Patients who
are categorized as ASA class I11 or IV that are scheduled to undergo day-of-
admission or ambulatory surgery are especially problematic for the anesthesiolo-
gist. The anesthesiologist should have all of the pertinent preoperative data in
advance of the operative procedure. Automated questionnaires are available to
obtain the patients' medical history in a standardized These have been
shown to be similar in quality to general preoperative physician-derived health
status measures.42These preoperative questionnaires may assist in the develop-
ment of a preoperative diagnostic testing strategy and intraoperative plan.
The physician evaluating a cardiac patient must find answers to these basic
questions:
Is this patient at increased risk for perioperative morbidity and mortality?
What further diagnostic work-up is necessary?
What should be done preoperatively to minimize the risk of adverse events?
Should the surgery be altered, postponed, or canceled?

PREOPERATIVE DEMOGRAPHIC PREDICTORS OF

CARDIAC MORBIDITY

Age
Age is one of the risk factors for cardiac morbidity. Aging is associated
with CAD, diabetes mellitus, peripheral vascular disease, and arterial hyperten-
sion. Age may not be an important independent risk factor, but its association
with other disease processes makes it a useful univariate predictor of cardiac
risk. Elderly patients with a reduced level of activity are more difficult to
evaluate because diagnostic criteria for cardiac risk are often exercise-related. In
 PATIENTS WITH CARDIAC DISEASE UNDERGOING NONCARDIAC SURGERY 5

addition, physically active patients have been shown to have less complica-
tions.I3 Patients with incapacitating disease with systemic manifestations are at
very high risk.

Previous MI

The urgency of the surgery, the relative risks and benefits of the procedure,
and the patients cardiac status should be considered carefully when surgery is
planned following a recent MI. Patients with a history of a previous MI (at any
time in the past) have a 5% to 8% greater risk of perioperative reinfarction, and
the reinfarction mortality rate is 36% to 70?0.~O,31 The risk of reinfarction dimin-
ishes within the time since the original MI. MI within 3 months had a rein-
farction rate up to 30%, up to 15% within 3 to 6 months, and MI beyond 6
months had only a 6% reinfarction rate.
Rao and c011eagues~~ showed that the incidence and mortality of myocardial
reinfarction was reduced significantly in a group of patients undergoing surgery
during the latter half of a retrospective study. The authors attributed the im-
provement in outcome to more intensive perioperative monitoring in the op-
erating room and intensive care unit. They determined that only 5.7% of the
patients undergoing noncardiac surgery within 3 months of an MI suffered
perioperative reinfarction; this declined to 2.3% during the 3- to 6-month post-
MI interval. In most of the other studies the reinfarction rates have been higher:
5% to 8% in patients with remote (>6 months) infarction0,35 to 6% to 40% in
those with recent MI (<6 months).
Given this impressive association of recent MI with cardiac risk, it is neces-
sary to generate recommendations for patients presenting for noncardiac sur-
gery. In general, emergency, life-saving surgery should be performed; elective
surgery should be delayed until at least 3 months following the MI. In semi-
urgent cases the patient should have an extensive preoperative evaluation in
consultation with a cardiologist, and the case should proceed with more inten-
sive perioperative monitoring and postoperative care. The patient should be
informed of the increased risk associated with the procedure.

Stable Angina

Patients with stable angina have also been demonstrated to have increased
risk for MI and sudden death in ambulatory surgery. In nonambulatory, noncar-
diac surgery the issue of cardiac risk is controver~ial.~~Exercise tolerance should
be assessed carefully and the NYHA or CCVSA angina classification should be
determined. If the patient is unable to climb one flight of stairs without chest
pain, a diagnostic test (e.g., exercise stress test or dipyridamole-thallium im-
aging) is probably indicated. Some patients have silent (painless) myocardial
ischemia and are at a greater risk for MI than patients with symptomatic
angina. Several large, prospective 39, 43 have provided the consensus
that preoperative and postoperative myocardial ischemia, but not intraoperative
myocardial ischemia, is associated with perioperative cardiac morbidity. A very
large percentage of this perioperative ischemia was silent in nature. Unstable
angina is generally a contraindication for elective noncardiac surgery. Shah et
al showed that 28% of patients with unstable angina had an adverse event
perioperatively.
6 KURKI

Congestive Heart Failure

There are about 2 million patients in the United States with congestive heart
failure. Preoperative congestive heart failure (left ventricular dysfunction) is a
major risk factor for perioperative morbidity. Low left ventricular ejection frac-
tion, low cardiac output, high left ventricular end-diastolic pressure, and echo-
cardiographically measured regional wall motion abnormalities are sensitive
indicators of left ventricular dysfunction. It has been shown that symptomatic
congestive heart failure is a predictor of perioperative pulmonary edema?, l4

Cardiac Arrhythmia

A history of cardiac arrhythmias is associated with an increased likelihood

of postoperative congestive heart failure. Frequent premature ventricular con-
tractions or nonsinus rhythm (atrial fibrillation or atrial flutter) are predictive of
perioperative cardiac morbidity in noncardiac surgery. Complete (third degree)
heart block, left bundle branch block, and second-degree heart block (Mobitz 11)
increase risk in the perioperative period as well.

Hypertension

Hypertension is a major risk factor for CAD. About 60 million people in

the United States have hypertension. Coexisting hypertension increases the risk
of perioperative MI in patients with a previous MI.38Patients with untreated,
uncontrolled hypertension should not be scheduled for elective surgery. Antihy-
pertensive therapy, especially P-blocking agents and Ca-channel blockers,
should always be continued until the operation.

Diabetes Mellitus

Patients with diabetes mellitus, especially type I, have been shown to have
a greater risk for postoperative myocardial ischemia.21Furthermore, diabetic
patients are more likely to have silent ischemia because of altered neural pain
pathways in the heart. Diabetes is also associated with postoperative congestive
heart failure and wound infection^.^^,^ Many diabetic patients also have renal
insufficiency.

Valvular Heart Disease

Patients with aortic stenosis (AS) are at a 14-fold greater risk for postopera-
tive mortality as compared with patients without AS.15 The larger the pressure
gradient across the aortic valve (especially 1100 mm Hg), the greater the risk
for hemodynamic instability. Mitral valve prolapse (MVP) increases the risk of
infective endocarditis, neurologic ischemic episodes, and perioperative atrial,
junctional, and ventricular arrhythmias.2zAntibiotic prophylaxis is indicated in
these patients.8
 PATIENTS WITH CARDIAC DISEASE UNDERGOING NONCARDIAC SURGERY 7

Miscellaneous

Smoking increases the risk of CAD and postoperative respiratory complica-

tions, especially in the patients with chronic obstructive pulmonary disease
(COPD).u Previous coronary artery bypass graft (CABG) surgery or coronary
angioplasty has been shown to lower postoperative MI rate in patients undergo-
ing noncardiac This is a controversial point, however, because the
combined risk of the myocardial revascularization and the noncardiac surgical
procedure is probably equal to the risk of the noncardiac surgery in patients
who have not undergone revascularization.

CARDIAC RISK OF INDIVIDUAL PROCEDURES

Two characteristics of surgery are important: site and urgency. Intrathoracic

and upper abdominal surgery have a higher risk for cardiac morbidity than
peripheral surgical procedures.12Peripheral vascular surgery has been shown to
carry at least the same risk as aortic surgery.24Major vascular surgery carries a
special risk for perioperative morbidity." Abdominal aortic reconstruction in
patients with aortic occlusive disease has one of the highest risks for cardiac
morbidity; these patients have often CAD. Cross-clamping of the aorta is associ-
ated with significant hemodynamic changes. The patients should be evaluated
carefully and their hypertension should be under control." The performance of
emergency surgery increases the risk of perioperative cardiac m0rbidity.4~The
length of the operation is also important. If the surgical procedures last longer
than 2 hours, the risk of perioperative mortality is higher.30

PREOPERATIVE THERAPY

Preoperative therapy of a patient with CAD for noncardiac surgery should

focus on the alleviation of the myocardial ischemia and on treatment of ischemic
damage, especially congestive heart failure and arrhythmias. The important
principles are the optimization of the balance between myocardial oxygen sup-
ply and demand, the prevention of hypercoagulability, and the prevention of
coronary vasospasm.
In the ischemic heart muscle oxygen demand exceeds the oxygen supply.
The hemoglobin level would be optimal in the range of 10 to 12 g/dL to have
optimal oxygen supply for the heart. In patients with valvular heart disease
high Hb levels (increased viscosity) may cause decreases in blood flow through
the stenotic valve orifice. The treatment should increase the oxygen supply by
increasing the coronary blood flow and decrease the oxygen demand by decreas-
ing the heart rate.
The major anti-anginal drugs in use today are the P-adrenergic blocking
drugs, the calcium-channel blocking agents, and nitrates. It is critical to maintain
the P-blocker and other anti-anginal therapy throughout the perioperative pe-
riod to avoid withdrawal effects and to prevent perioperative ischemia. Some
studies have shown that P-blockers are more effective in preventing periopera-
tive myocardial ischemia than calcium-channel blo~kers.3~. 43 The P-blockers have
been shown conclusively to have a myocardial protective effect following MI.4b
Diltiazem (a calcium channel blocker) has an adverse effect upon survival after
MI.16 Myocardial oxygen demand is also increased with hypertension; therefore,
8 KURKI

patients' antihypertensive treatment should be continued throughout the periop-

erative period.
Patients with long-term anticoagulant therapy (for atrial fibrillation, pros-
thetic heart valves, deep vein thrombosis, or prior cerebral embolism) should
discontinue their warfarin (coumadin) therapy 3 to 5 days prior to surgery (if
major surgery). If there is a risk of embolism, heparin should be started intrave-
nously before the operation and discontinued approximately 6 hours prior to
surgery (or reversed using protamine). In emergency situations, the effects of
warfarin may be reversed by intravenous vitamin K (10-25 mg IM or IV slowly).
The effect of vitamin K is evident 12 to 24 hours after parenteral injection.
Ideally, aspirin should be discontinued one week before major operations to
allow recovery of platelet function. The prothrombin time (PT), activated partial
thromboplastin time (PTT), and platelet count are sufficient to guide therapy in
most Patients with congenital or valvular heart disease (AS, MVP,
prolapse, mitral regurgitation, prior endocarditis, prior rheumatic fever) or pros-
thetic heart valves should have antibiotic prophylaxis started before surgery.
The American Heart Association has published suggested regimens for
prophylaxis against bacterial endocarditis! For dental procedures, amoxicillin
3.0 g orally is recommended 1hour before, followed by 1.5 g 6 hours later. The
suggested oral regimen for patients who are allergic to penicillin is erythromycin
1.0 g PO 1 hour before followed by 0.5 g 6 hours later. The recommended
parenteral regimen for high-risk patients is ampicillin 2.0 g IM or IV and
gentamicin 1.5 mg/kg IM or IV 0.5 hours before operation. For the penicillin
allergic patient, the recommended treatment is vancomycin 1.0 g IV slowly over
1 hour, starting 1 hour before operation. In addition, gentamicin 1.5 mg/kg IM
or IV is added if gastrointestinal or genitourinary tracts are involved.

PREOPERATIVE DIAGNOSTIC TESTING

Based on the preoperative evaluation of the patient, preoperative laboratory,

electrocardiographic, radiological, and radionuclide testing is ordered. The tests
are not substitutes for good clinical evaluation. They should only be performed
if their results will influence the perioperative treatment or monitoring. Patients
with cardiac disease should be tested for anemia, renal insufficiency, and diabe-
tes mellitus. Liver function should be tested if the patient has congestive heart
failure (possible venous stasis in liver) or right ventricular dysfunction. Serum
electrolytes should be tested if the patient is receiving diuretic therapy or has
renal disease. Urinalysis should be performed if there is a suspicion of urinary
tract infection or renal disease. In many institutions, however, extensive labora-
tory testing is mandated in all patients.", 32 Chest radiography should be per-
formed in all patients over 60 years of age, although many institutions require
this examination at a lower age threshold. Patients with valvular heart disease
or CAD should have a recent (less than 1 month) chest radiograph. In greater
than 70% of patients cardiomegaly is an indication of low left ventricular ejection
fraction (<4O%), which is a predictor of perioperative cardiac m ~ r b i d i t y . ~
Electrocardiography is routinely recommended for every patient over 35 to
40 years of age before Abnormalities have been shown in 14% to 53%
of all patients. Cardiac patients with angina should have an electrocardiogram
(12-lead) taken preoperatively. Electrocardiographic abnormalities occur preop-
eratively in 40% to 70% of patients with CAD who undergo noncardiac surgery.
ST-segment and T-wave changes (65% to 90%) are most common.3oAmbulatory
electrocardiography (Holter monitoring) may detect silent ischemic episodes in
 PATIENTS WITH CARDIAC DISEASE UNDERGOING NONCARDIAC SURGERY 9

patients with CAD. Twenty percent to 40% of surgical patients with or at risk
for CAD have frequent, silent ischemic episodes during the 48-hour period
before surgery.= This is also one of the less expensive methods of perioperative
risk stratification for patients with CAD.
Exercise electrocardiography (treadmill) testing is advantageous because it
is one of the least invasive methods of detecting significant CAD.27Exercise
treadmill testing increases myocardial workload progressively, thus provoking
ischemia. There are several protocols available for performing the test, but the
most commonly used is the Bruce protocol.22The heart rate and cardiac output
increase during exercise. Contractility and wall tension are determinants of
oxygen consumption, which increases fourfold with maximal exercise. A reduc-
tion in coronary reserve with ischemic heart disease results in myocardial ische-
mia or dy~rhythmias.~~ Electrocardiographic changes in the ST-segment (depres-
sion 2 0.1 mV or elevation 2 0.2 mV 80 seconds after the J-point) are diagnostic
of CAD, and clinical signs of left ventricular dysfunction are also considered
positive findings. The electrocardiographic lead where the ST-segment changes
first appeared should be monitored perioperatively if possible. The perioperative
heart rate and blood pressure should not exceed the values at which ischemic
events occurred during the test. Some patients are not able to perform lower
extremity exercise because of peripheral vascular disease, arthritis, or other
problems with the lower extremities. Those patients may have exercise testing
using arm ergometry.
Radionuclide methods to assess myocardial perfusion and viability may be
used with and without pharmacologic agents or exercise to induce myocardial
ischemia.17 There are different techniques that can be used, including thallium
scintigraphy, technetium (sestamibi or teboroxime) imaging, or radionuclide
ventri~ulography.~, 27 The most commonly used agent in nuclear imaging is
thallium-201 (TL-201). There are two methods of imaging: planar imaging and
the newer SPECT (single-photon emission-computed tomography) technology?
TL-201 is a cyclotron-produced radionuclide with a half-life of 72 hours. It
mimics potassium (K + ) and is taken up by viable myocardial cells.
Thallium can be injected intravenously, and cardiac blood pool activity rises
rapidly and falls more gradually as the thallium is extracted by the tissues.
Approximately 5% of an injected TL-201 dose is distributed to the myocardium.
The myocardium extracts about 80% to 90% of the thallium passing through the
coronary circulation. The time to peak myocardial thallium activity is delayed
in the resting heart compared with the exercise-stressed or pharmacologically
stressed heart. The initial uptake of TL-201 is relatively homogenous in patients
without CAD. Nonviable (scarred) and ischemic myocardium does not take up
TL-201; therefore, a defect is detectable in the imaging. Following the initial
distribution of TL-201, the myocardial TL-201 activity may change with cessation
of exercise-induced or pharmacologically induced myocardial ischemia. Regions
with reversible myocardial ischemia have delayed uptake and regions (distal to
coronary artery stenoses) have a slower clearance than normal regions. TL-201
redistribution, however, can occur only if the tissue is viable. The following
parameters are studied in TL-201 stress imaging: the size of the defect, left
ventricular cavity size, and lung uptake. Several studies have shown that thal-
lium redistribution is predictive of postoperative cardiac morbidity and mortal-
ity when selected patients with intermediate cardiac risk (by Goldman cardiac
risk index criteria) are e~aluated.~, 17, 27, 34 The use of these tests is restricted by
their costs and availability, and their predictive value in consecutive prospective
series of unselected patients with intermediate cardiac risk has not been proven.
PHARMACOLOGIC STRESS TESTS
Not all patients are able to exercise ( e g , those with claudication, abdominal
aortic aneurysm, musculoskeletal or neurological disease). For these patients
there are pharmacologic stress tests that simulate the stress of exercise.6* 29
Dipyridamole and adenosine are coronary vasodilators that may be admin-
istered intravenously in stable patients who are unable to exercise. These agents
are arteriolar vasodilators that are capable of inducing myocardial ischemia in
tissue zones that are dependent on collateral perfusion. The explanation for this
is that myocardial tissue distal to a significantly stenosed coronary artery may
be receiving perfusion via a collateral vessel from a region that is perfused by a
normal coronary artery. This potentially ischemic tissue is maximally vasodi-
lated at resting conditions to preserve the pressure gradient that is supplying
blood through the collateral vessel. Arteriolar vasodilators cause decreased resis-
tance to blood flow through the myocardial tissue that is supplied by the normal
coronary artery (which is normally moderately constricted at resting conditions).
The vasodilation in the normal tissue bed decreases the perfusion pressure
across the collateral vessel and induces myocardial ischemia in the collateral-
dependent zone of myocardium, a coronary steal syndrome. The phenomenon
is reversible when the vasodilators effect on the normal tissue bed subsides
upon withdrawal of the agent. Adenosine has a very short half-life (10 seconds)
and must be administered by infusion. Dipyridamole exerts its action by
blocking cellular reuptake of adenosine. Patients with asthma cannot be tested
with dipyridamole because it is associated with severe bronchoconstriction.4
Dobutamhe is a P-adrenergic agonist that causes an increase in myocardial
oxygen demand by its inotropic and chronotropic effects and induces myocardial
ischemia in patients with CAD. It can be infused as an alternative to dipyridamole,
adenosine, or exercise. Dobutamine has been used as the pharmacological stressor
in stress echocardiography, in which wall motion abnormalities assessed using two-
dimensional echocardiography serve as the indicator of myocardial i~chemia.3~, 37
It is likely that the simple treadmill exercise test will remain the standard
risk stratification test for assessing the likelihood of significant CAD in patients
scheduled for noncardiac surgery. It is relatively inexpensive and has acceptable
sensitivity and specificity. Coronary angiography and possible revascularization
(CABG or angioplasty) is recommended for patients scheduled for major vascu-
lar or abdominal surgery with unstable angina or poor exercise tolerance, or
those patients with intermediate risk factors with abnormal test results (exercise
stress test, ambulatory electrocardiography, dipyridamole or adenosine thallium
imaging, dobutamine stress test or stress echocardiography, e t ~ . ) . 2 ~

IS THE PATIENT READY FOR SURGERY?

Based upon the patient history, clinical evaluation, and test results, a deci-
sion must be made regarding the patients readiness for surgery. In some cases
the operation should be postponed to improve the patients condition. The
operation should be canceled if risks of an adverse cardiac event clearly exceed
the likely benefits of the operation. If the patient has unstable angina or other
manifestations of severe CAD, coronary angiography and angioplasty or coro-
nary artery bypass surgery should be considered prior to the noncardiac surgery.
As an alternative, the surgery could proceed with more intensive perioperative
monitoring. This decision regarding preoperative myocardial revascularization
and the value of intensive perioperative monitoring will remain controversial
for the foreseeable future because of the lack of randomized, prospective studies
addressing this issue (Fig. 1).
 Preoperative evaluation
History and Physicalexamination
r - 1
I Patients Low Risk
c70 years Unstable angina
Stable angina Recent Mi (<6 weeks)
I I
Major
Peripheral surgery Emergency, vascular Peripheralsurgery Emergency surgery Emergency
Ophthaimologic lntraabdominalor Ophthaimologicor Vascular, intraabdominai (minor elective should be
Plasiic surgery, etc. thoracic surgery Plastic surgery

Il-lead ECG, Chest X-ray

Exercisetolerance or CBC, electrolytes
CBC, electrolytes Exercisetolerance Exercise tolerance DPTI, etc. Oipyrldamolethallium or
CBC. electrolytes CBC, electrolytes
i
Normal exercisetolerance Poor exercisetolerance
Anesthesia plans tocallgeneral Normal DPTl Abnormal DPTl Angloplasty or CABG
spinallepidural if Indicated
Postpone major elective

II
Proceedwnh surgery Defer surgery
Monnoring needs lnvaslve monnoring Emergency surgery:
perioperatively Noninvasive BP, lnvasive BP, CVP, NoninvasiveBP,
spoz,EtcOZ spoz. Etc02 SpOZ. EtCO2 anti-anglnaltherapy Refer for CABG?
TEE ifavallable?

icu followup
Postoperative Ambulatory or hemdynamic monitoring ICU followup
resource overnight stay Continue invasive Analgesia Intense analgesia? lnvadve monltoring
allocatlon Analgesia in PACU monnoring overnight in hospltal Antlanginai therapy?
PACU or iCU Intense analaesla?

Figure 1. Suggested algorithm for preoperative assessment of patients with cardiac disease for noncardiac surgery. ECG = electrocardiogram; CBC =
complete blood count; SpO, = digital pulse oximetry; EtCO, = end tidal carbon dioxide; PACU = post anesthesia care unit; ICU = intensive care unit;
BP = blood pressure; CVP = central venous pressure; Al = aortic valve insufficiency; AS = aortic valve stenosis; DPTl = dipyridamole thallium imaging;
CABG = coronary artery bypass graft; PTCA = percutaneous transluminal coronary angioplasty.
t:
12 KURKI

References

1. Abraham S, Coles A, Coley C, et al: Coronary risk of noncardiac surgery. Prog

Cardiovasc Dis 34205, 1991
2. American Society of Anesthesiologists: New classification of physical status. Anesthesi-
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3. Blaustein A: Preoperative and perioperative management of cardiac patients undergo-
ing noncardiac surgery. Cardiol Clin 13:149, 1995
4. Brown K Prognostic value of cardiac imaging in patients with known or suspected
coronary artery disease: Comparison of myocardial perfusion imaging, stress echocar-
diography and positron emission tomography. Am J Cardiol 75:35D, 1995
5. The Criteria Committee of the New York Heart Association: Nomenclature and Criteria
for Diagnosis of Diseases of the Heart and Great Vessels, ed 7. New York, New York
Heart Association/Little, Brown, 1973
6. Cambria PR, Brewster DC, Abbott WM, et a1 The impact of selective use of dipyrida-
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Vasc Surg 15:43, 1992
7. Campeau L Canadian Cardiovascular Society functional classification of angina pecto-
ris [letter]. Circulation 54:522, 1976
8. Dajani AS, Bisno AL, Chung KJ, et al: Prevention of bacterial endocarditis: Recommen-
dations by the American Heart Association. JAMA 2642919, 1990
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FIN00680 Helsinki
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