Estimation of Cardiac Risk Before Noncardiac Surgery: The Evolution of Cardiac Risk Indices
ABSTRACT Postoperative cardiac complications are among the most feared events in patients undergoing noncardiac surgery. Hospitalists, internists, cardiologists, and anesthesiologists are frequently asked to provide preoperative consultations to assess risk and optimize medical treatment for the patient. Over the years, numerous studies have attempted to define preoperative risk factors in an attempt to risk stratify patients and determine when interventions may be applied to reduce risk. These studies have proposed various risk indices and algorithms based on identification of different risk factors, related to variations in patient populations, types of surgery, definitions of comorbidities, and endpoints studied. This article reviews many of these risk indices, highlighting their findings, utilities, and limitations.
- Anesthesiology 02/1990; 72(1):153-84. DOI:10.1097/00000542-199001000-00025 · 6.17 Impact Factor
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ABSTRACT: In this article, we describe a multifactorial cardiac risk index that can be used to assess patients undergoing noncardiac surgery. The index is a modified version of an index that was previously generated by Goldman and coworkers on a set of 1001 consecutive patients and prospectively validated in our clinical setting (a general medical consultation service in a large teaching hospital) on 455 patients. We present a Bayesian approach to assessing cardiac risks by converting average risks for patients undergoing particular surgical procedures (pretest probabilities) to average risks for patients with each index score (posttest probabilities). A simple nomogram is presented for performing such a calculation.Archives of Internal Medicine 12/1986; 146(11):2131-4. DOI:10.1001/archinte.146.11.2131 · 13.25 Impact Factor
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ABSTRACT: To summarize available evidence on preoperative cardiac risk stratification so that the internist may 1) use clinical and electrocardiographic findings to stratify a patient's perioperative risk for myocardial infarction and death; 2) decide which tests provide useful additional risk-related information; and 3) understand the benefits, risks, and evidence surrounding the decision to undertake coronary revascularization before elective noncardiac surgery. A MEDLINE search and review of the reference lists of identified articles. Sensitivities, specificities, and likelihood ratios for diagnostic tests were calculated, and a quality rating for study methods was applied. Myocardial infarction and mortality were the major outcomes considered, and a quality rating for study methods was applied. Clinical and electrocardiographic findings, organized by multivariate prediction indices, accurately identify patients as having low, intermediate, or high risk for myocardial infarction or death. Pharmacologic stress imaging with thallium or echocardiography probably improves risk stratification for intermediate-risk patients having vascular surgery. These tests have not been shown to be effective prognostic indicators for patients having nonvascular surgery. No studies of angiography for risk prediction have been reported. Decision analyses and retrospective series suggest that the risks incurred by doing coronary angiography and revascularization before elective surgery outweigh the benefits. Prospective, controlled studies of coronary revascularization are lacking. Evidence from a randomized, controlled trial has shown a survival benefit with the perioperative use of beta-blockers in patients at risk for coronary artery disease. Evaluation of all surgical patients by use of clinical indices is recommended. Low-risk patients need no further evaluation before surgery. High-risk patients need optimal management of their high-risk problems, including (if appropriate) beta-blocker use, and may need to have their elective procedures canceled. Intermediate-risk patients probably benefit from further noninvasive stress testing, especially if they are having vascular surgery. Further clinical trials are needed for most areas of concern.Annals of internal medicine 09/1997; 127(4):313-28. DOI:10.7326/0003-4819-127-4-199708150-00012 · 16.10 Impact Factor