Perioperative cardiac care of the high-risk non-cardiac patient

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Perioperative cardiac care of the high-risk non-cardiac patient
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PrintISBN-13: 9780199687039 Publishedonline: Mar2015
DOI: 10.1093/med/9780199687039.001.0001 ©EuropeanS ocietyofCardiology
Chapter: Perioperativecardiacca reofthehigh-risknon-cardiacpatient
Author(s): MartinBalik
DOI: 10.1093/med/9780199687039.003.0076
OxfordMedicineOnline
TheESCTextbookofIntensiveandAcuteCardiovascular
Care(2ed.)
EditedbyMarcoTubaro,PascalVranckx,SusannaPrice,andChristiaanVrints
Perioperativecardiaccareofthehigh-risknon-cardiacpatient

Summary

Perioperative cardiac care of the high-risk non-cardiac patient
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Non-cardiacsurgeryconveysacardiacriskrelatedtothestatusofthepatient’s
cardiovascularsystem.Cardiac-relatedriskofsurgerycanbeassessedbyintegratingthe
riskandurgencyoftheprocedurewithcardiovascularriskfac tors,whichincludeage,
ischaemicheartdisease,heartfailure,stroke,diabetesmellitus,chronicobstructive
pulmonarydisease,andrenaldysfunction.Anindividualassessmentcanincludesimple
multivariatescoringsystems,developedwiththeaimofevaluatingcardiacriskpriorto
non-cardiacsurgery.Patientassessmentcanbeextendedforindicatedadditionaltests.
Theindicationsforfurthercardiactestingandtreatmentsarethesameasinthenon-
operativesetting,buttheirtimingisdependentontheurgencyofsurgery,andpatient-
specificandsurgicalriskfactors.Adelayinsurgery,duetotheuseofbothnon-invasive
andinvasivepreoperativetesting,shouldbelimitedtothosecirc umstancesinwhichthe
resultsofsuchtestswillclearlyaffectpatientmanagement.Inhigh-riskpatients,theresult
ofthecardiacassessmenthelpstochooseadequateperioperativemonitoringandto
indicateforanintensivecareunitstayperioperatively.Chronic medicationscanbe
adjusted,accordingtothecurrentknowledgeonperioperativemanagement.Drugswith
thepotentialtoreducetheincidenceofpost-operativecardiaceventsandmortality
includebeta-blockers,statins,andaspirin.Chronicplateletanti-aggregationand
anticoagulationtherapieshavetobeadaptedbyweighingtheriskofbleedingagainstthe
riskofthromboticcomplications.
Summary[link]
Definitionofthehigh-risksurgic alpatient[link]
Riskscoringsystems[link]
Typeofprocedure[link]
Typesofanaesthesia,painmanagement,andassociatedcardiovascularrisk[link]
Impactoftheorganizationofperioperativecare[link]
Pathophysiologyofperioperativemyocardialischaemia[link]
Non-invasivepreoperativetesting[link]
Electrocardiography[link]
Stresstesting[link]
Myocardialperfusionimaging[link]
Echocardiographyanddobutaminestressechoc ardiography[link]
Natriureticpeptidesandcardiactroponins[link]
Coronarycomputedtomographyangiography[link]
Invasivepreoperativetesting[link]
Indicationsforcoronaryangiography[link]
Percutaneoustransluminalcoronaryangioplasty,bare-metalstents,drug-eluting
stents[link]
Preoperativesurgicalcoronaryrevasculariz ation[link]
Contents

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Perioperativemonitoring:electrocardiography,echocardiography,pulmonaryartery
catheter,temperaturecontrol[link]
Specific[link]
Heartfailure[link]
Hypertension[link]
Perioperativearrhythmias,pacemaker,andimplantabledefibrillator[link]
Chronic valvulardiseaseandnon-cardiacsurgery[link]
Pulmonarydisease[link]
Pulmonaryhypertension[link]
Renaldisease[link]
Cerebrovasculardisease[link]
Diabetesmellitus[link]
Perioperativemedicalmanagement[link]
β-blockersandivabradine
α2-agonists
Calciumchannelblockers[link]
Angiotensin-convertingenzymeinhibitors[link]
Plateletanti-aggregationtherapy[link]
Warfarinandnovelanticoagulants[link]
Statins[link]
Conclusion[link]
Personalperspective[link]
Furtherreading[link]
Definitionofthehigh-risksurgicalpatient
Risksco ringsystems
Severalscoringsystemstoassesstheriskofperioperativecardiaceventshavebeeninuse
overthelast50years.Amongthem,themostcitedistheLeeRevisedCardiacRiskIndex
(RCRI)Stratific ationSystem[1]whichidentifiessixindependentpredic torsassoc iatedwith
cardiacmorbidityandnon-cardiacsurgery(see Table76.1).Theseare:high-risksurgery
(e.g.intraperitoneal,intrathoracic,suprainguinalvascular),historyofischaemicheartdisease
(historyofmyocardialinfarction(MI),angina,orapositiveexercisetest,exc ludingprevious
revascularization),historyofcongestiveheartfailure,historyofcerebrovasculardisease,
preoperativetreatmentwithinsulin,andapreoperativeserumcreatinineabove177
micromoles/L.TheoverallriskofcardiaceventsdefinedasMI,cardiacarrest,pulmonary
oedema,orcompleteheartblockisstratifiedintofourlevels,inwhichtheriskfactorsranged
from0to3,ormore.Theresultingscoregivesfourclassesofrisk(see Table76.1).The
RCRIperformedwellindistinguishinglow-tohigh-riskpatientsforalltypesofnon-cardiac
surgerybutwaslessacc urateinvascularnon-cardiacsurgerypatients[2].RCRIalsodoes
notpredictall-causemortalitywell,becauseitdoesnotcapturetheriskfactorsfornon-
cardiaccausesofperioperativemortality.Laterstudies[3,4]havefoundahigherrateof
cardiaceventsatthesameRCRI,comparedtotheLeepaper[1].Thereasonscouldbethat

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theoriginalRCRIstudydidnotincludeemergencysurgerypatients,patientshadlowerillness
severity,theCK-MBfractionwasused,ratherthanthemoresensitivetroponins,andthe
originalRCRIriskpredictiondidnottakeintoacc ountthemortality[1].Theperformanceofthe
Leeindexcanbeimprovedbyaddingageandamoredetaileddescriptionofthetypeof
surgery[5](see Table76.2).Themultivariatelogisticregressionanalysisaimedat
determiningtheriskfac torsassociatedwithintraoperative/post-operativeMIorcardiacarrest
[6]foundthetypeofsurgery,thedependentfunctionalstatus,abnormalcreatinine,the
AmericanSocietyofAnesthesiologistsclass,andincreasedageaspredictors.Thedeveloped
riskmodelhadahigherpredictiveaccuracythanRCRI,andaneasy-to-useonlinecalculator
wasdeveloped[7].Besidesdevelopingnewcardiacriskmodels,thereisalsoanapproachto
recalibratetheriskindextospecifichigh-risksubgroupssuchaslungresectionorvascular
surgery[8].Anarrayofsurgery-specificperioperativeriskcalculatorsandorgan
complication-spec ificriskcalculatorscanbeassessedonline[7].Therearetwofocusedrisk
calc ulatorsforvascularsurgery,oneforopenaorticprocedures,oneforinfrainguinalbypass
surgery,oneforbariatric surgery,andoneforbowelresectionaftermesentericischaemia.
Table76.1CalculationoftheRevisedCardiac RiskIndex
Predictor Points
High-risksurgery 1
Ischaemicheartdisease 1
Congestiveheartfailure 1
Cerebrovasculardisease 1
Insulintreatment 1
Renalinsufficiency(plasmacreatinine>177
micromoles/L)
1
Totalsco re(points) Ratesofcardiac
complications(%)
0 0.4
1 0.9
2 6.6
3or>3 11.0

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Table76.2Surgicalrisk estimate(modifiedfromBoersmaetal.)
Lowrisk(<1%) Intermediaterisk(1–5%) Highrisk(>5%)
◆Breast
◆Dental
◆Endocrine
◆Eye
◆Gynaecology
◆Reconstructlve
◆Orthopaedic—
minor(knee
surgery)
◆Urological—minor
◆Abdominal
◆Carotid
◆Peripheralarterialangioplasty
◆Endovascularaneurysmrepair
◆Headandnecksurgery
◆Neurological/orthopaedic—
major(hipandspinesurgery)
◆Pulmonaryrenal/liver
transplant
◆Urological—major
◆Aorticandmajor
vasc ularsurgery
◆Peripheral
vasc ularsurgery
RiskofMIandcardiac deathwithin30daysaftersurgery.
Typeofpro cedure
TheEuropeanguidelines[9]payattentiontothetypesofsurgicalproceduresassociatedwith
variousrisklevels(see Table76.2).Surgic alprocedurescanbedividedintohigh-risk(i.e.
emergencyandvascularprocedures),intermediate-risk,andlow-riskprocedures[9].Their
estimated30-daycardiaceventratesare5%,1–5%,and1%,respectively(see Table
76.2).Vascularsurgerypatientsareauniquesubgroupofnon-cardiacsurgerypatients,as
theirprevalenceofcoronaryarterydisease(CAD)isdisproportionatelyhigherthanthatinthe
othergroups.Animportantfactortoconsideristheurgencyanddurationofthesurgical
procedure.Laparoscopicprocedureswithlesstissuetrauma,andshorterintestinalparalysis
andpost-operativehospitalcarerequirespecialattention.Pneumoperitoneumincreasesthe
intra-abdominalpressure,reducesthevenousreturn,andinc reasestheSVR.Therefore,the
proceduremaybedemandingforthecardiovascularsystem,andpatientsshouldundergo
similarevaluationasforopenabdominalsurgery.
Besidesmultivariatescoringsystems,thepatient’shistoryandclinic alpresentationmustbe
adequatelyassessed.ACC/AHAsuggestsastepwiseapproachtoperioperativecardiac
assessment[10]whichevaluatestheurgencyoftheprocedure,thepresenceofserious
cardiacconditions(see Table76.3),andthepatient’sfunctionalcapacityandcombines
thesewiththedeterminationoftheriskofsurgery(see Table76.2).Urgencyitselfcarries
anincreasedperioperativerisk.Forinstance,thecompositemortalityrateforelectiverepairof
abdominalaorticaneurysmsissignificantlylower(3.5%)thanthatforrupturedaneurysms
(42%)[11].Thepresenceofoneormoreofseriousc ardiacconditions(see Table76.3)
impliesamajorclinic alriskandmayleadtothedelayorcancellationofsurgery,unlessthe
surgeryisemergent.Forexample,itappearsreasonabletowait4–6weeksafteranMIto
performelectivesurgery.Ifthepatienthasnothadarecentexercisetest,thefunctionalstatus
canusuallybeestimatedfromtheabilitytoperformtheactivitiesofdailyliving.Perioperative
a
a

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cardiovasculareventsaremorecommoninpatientswhoreportedaninabilitytowalkfour
blocksorclimbtwoflightsofstairs[12].
Table76.3Activecardiac conditionsforwhichthepatientshouldundergoevaluationand
treatmentbeforenon-cardiacsurgery(class1,levelofevidence:B)
Co ndition Examples
Unstablecoronary
syndromes
Unstableorsevereangina(CCSclassIIIorIV)†
RecentMI‡
DecompensatedHF(NYHA
functionalc lassIV:
worseningornew-onsetHF)
Significantarrhythmias High-gradeAVblockMobitzII,third-degreeAVblock,AV
heartblock
Symptomaticventriculararrhythmias,supraventricular
arrhythmias(includingAF)withuncontrolledventricular
rate(HR>100beats/minatrest)
Symptomaticbradycardia
Newlyrecogniz edVT
Severevalvulardisease SevereAS(meanpressuregradient>40mmHg,AVA
<1.0cm ,orsymptomatic)
SymptomaticMS(progressivedyspnoeaonexertion,
exertionalpresyncope,orHF)
†Mayinclude‘stable’anginainpatientswhoareunusuallysedentary.
‡TheAmericanCollegeofCardiologyNationalDatabaseLibrarydefinesrecentMlas>7
days,but≤1month(within30days).
AF,atrialfibrillation;AS,aorticstenosis;AV,atrioventric ular;AVA,aorticvalvearea;CCS,
CanadianCardiovasc ularSociety;HF,heartfailure;HR,heartrate;Ml,myoc ardial
infarction;MS,mitralstenosis;NYHA,NewYorkHeartAssociation;VT,ventricular
tachycardia.
FleisherLA,BeckmanJA,BrownKA,etal.2009ACCF/AHAFocusedUpdateonPerioperative
BetaBloc kadeIncorporatedIntotheACC/AHA2007GuidelinesonPerioperative
Cardiovasc ularEvaluationandCareforNoncardiacSurgeryJACC2009,54(22):e13–118.
ReproducedwithpermissionfromElsevier
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Typesofanaesthesia,painmanagement,andassociatedcardio vascularrisk
Thequalityofcurrentanaesthetictechniques(eithergeneralorregional)allowslong-lasting
procedureswithlittlec ardiovasc ularrisk.Theriskassociatedwithvarioustypesof
anaesthesiaisreportedtoberelativelysmall[13–15]andismorerelatedtothepresenceof
clinicalcomorbidities.Concerninggeneralanaesthesia,thereareadvantagesofwell-titratable
moderninhalationalanaesthetic sandmodernopioidstoprovideadequateanalgesiaandto
reduceperioperativestress[16,17].Neuraxialbloc kades(epiduralorsubarachnoid)were
showntoimprovepost-operativeanalgesiaandpulmonaryoutcome,toshortentheintensive
careunit(ICU)stay,andtoreducethromboembolic complications[18–21].Qualityofpain
controlisessentialfortheeliminationofunwantedtachycardiaandhypertension.Patient-
controlledanalgesia(PCA)isthepreferredwayofpost-operativepainmanagementinmany
departments[22,23].
Impacto ftheorganizationofperioperativecare
Theimportantfac tortoconsideralsoistheorganizationofperioperativecarewhenevaluating
asurgery-specific risk.Analysisofpatientsundergoingabdominalaorticsurgeryshowedthat
mortalityvariedbetween0and66% ,basedonseveralfactors,includingthepresenceor
absenceofdailyroundsofanICUspecialist.Theabsenceofintensivistcareleadstoan
increasedriskofcardiacarrest,acuterenalfailure,sepsis,andreintubation[24].
Pathophysiologyofperioperativemyocardialischaemia
PerioperativemyocardialischaemiaistheresultofanimbalancebetweenmyocardialO
demand(VO )andmyocardialO supply(DO ).Therearetwodistinctivemechanisms,
leadingtoperioperativemyocardialischaemia[25].Morefrequentisamechanismrelatedto
themyocardialO supply–demandimbalance.Factorsthatinc reaseVO aretachycardia,loss
oftemperaturewithshivering,inflammation,sepsis,andcatecholamines.DO maybelimitedin
hypoxaemia,anaemia,andfluidshiftsoftenassociatedwithbloodloss[26].Thesecondtype
ismorerelatedtoCADandthebalancebetweenprothrombotic andfibrinolyticfactorsoften
relatedtoinflammationandtheextentofsurgicaltissueinjurywhichpotentiates
hypercoagulability.Plateletsplayanimportantroleinthedevelopmentofc oronarythrombosis,
andtheiractivitymaybestimulatedbyasurgicalevent.ThemajorityofMIsocc urredin
arterieswithhigh-gradestenosis,asshownpriortomajorvascularsurgery[27].
PathophysiologyshowsplaqueruptureinabouthalfofallperioperativeMIs[28],andacute
coronarythrombosisinone-third[29].Thedefinitionandc riteriaofperioperativeMIcanbe
foundelsewhere(see ChapterX).Perioperativemyocardialischaemiaisanindependent
riskfactorforsubsequentMIwithinthenext6months[30].
Non-invasivepreoperativetesting
Testingshouldprovideinformationthatsubstantiallyaddstotheinformationalreadyprovided
andshouldnotleadtoharmfuldelaysandfutileutilizationofresources.
Electrocardiography
Thepreoperative12-leadelec troc ardiogram(ECG)containsimportantprognosticinformation
2
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inrelationtomorbidityandmortality[31].A12-leadECGisrecommendedforallpatients
undergoingsurgery[9].Thepresence,magnitude,andextentofQwavesprovideacrude
estimateoftheleftventric le(LV)systolicfunction.HorizontalordownslopingST-segment
depressionandLVhypertrophyinpatientswithCADareallassoc iatedwithperioperativerisk.
Leftbundlebranchblock(LBBB)isassociatedwithworselong-termprognosis[32].
Stresstesting
Stresstestingisrecommendedinhigh-risksurgerypatientswiththreeandmoreclinical
factors,aslistedin Table76.1,andpoorfunctionalcapacity.Thetestingshouldhavea
potentialimpactonpatientmanagement.Stresstestingmaybeconsideredalsoinhigh-risk
surgerypatientswithtwoclinicalfactorsandpoorfunctionalcapacity.Again,suchtesting
shouldchangemanagement[9,10].ThepurposeistoraisethemyocardialVO toalevel
wheredemandoutweighssupply,leadingtoisc haemicc hangesontheECG.Asurvey
demonstratedthatstresstestingmayreducethemeanhospitalstayand1-yearmortalitywhen
appliedinhigh-orintermediate-riskpatients.Incontrast,itwasassociatedwithharmand
increasedexpensesinlow-riskpatients[33].
Theexercisestresstestinghasveryoftenlimitations,duetoparallelmedicalissuessuchas
claudication.Patientsarenotabletoreachthetargetheartrate;thusthesensitivityand
specificityoftheexamarelowered[34].
Myocardialperfusionimaging
MPIovercomestheproblemofpatientac tiveparticipation.MPIisusuallypreferredinpatients
withknowncardiacarrhythmias,sincedobutamine(seenextsection)caninducebothatrialor
ventriculararrhythmias.Avasodilatingagent,suchasadenosineordipyridamole,parallelsthe
effectsofexerciseonthecoronaryvascularbed.Aradionuclide,suchasthallium-201,is
added,andapositivetestisrepresentedbyareasofinitialfillingdefects,withlaterfilling
duringredistributionoftheradionuclide.Besidesthesideeffects,suchassystemic
vasodilatationandadenosine-relatedeffectsontheconductionsystemandbronchi,thetest
doesnotprovideenoughcorrelationbetweenitspositivityandperioperativecardiac events
[35].Anotheroptionisacombinationofdipyridamoleandtec hnetium-99msestamibi
radiotracerwhichdoesnotdifferentiatepatientswithachanceforperioperativecardiac
events;however,itmaypredictanincreasedriskoflatecardiacevents[36].
Echocardiographyanddobutaminestressechocardiography
Restechocardiographyshouldbeconsideredinpatientsundergoinghigh-risksurgeryand/or
inpatientswithmurmurordyspnoea,ortoevaluateforpossiblepulmonaryhypertension.Itis
notrecommendedinasymptomaticpatients[9,37].Anabnormalechocardiogramwithany
degreeofsystolicdysfunction,moderatetosevereLVhypertrophy,moderatetosevereMR,or
anaorticgradientof20mmHgorgreatershowedasensitivityof80%,aspecific ityof52%,a
positivepredictivevalueof12%,andaratherhighnegativepredictivevalueof97%,interms
ofadversecardiaceventduringnon-cardiacsurgery[38].
ComparedtoMPI,dobutaminestressechocardiography(DSE)ispreferredinpatientswith
asthmaandinthosewithseverecarotidstenosis,becausedipyridamolecaninduce
bronchospasmandadecreaseinbloodpressure.DSEalsooffersinformationonthe
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ventricularfunctionandvalvularheartdisease.ComparingradionuclidetestingwithDSEhas
notrevealedsignificantdifferencesinsensitivityandspecificity.Thenegativepredictivevalue
ofbothdipyridamole–thalliumnuclearimagingandDSEishigh;however,thepositive
predic tivevalueofDSEwasreportedtobehigher,particularlyinhigh-riskpatients[39,40].
ThePerioperativeIschaemicEvaluation(POISE)trial[4]andtheDutchEchocardiographic
CardiacRiskEvaluationApplyingStressEchocardiography-2(DECREASE-2)trial[41]limit
radionuclideimagingtothosecontraindic atedtodobutamine.Themeta-analysisofBeattie[42]
demonstratedthatDSEhadbetternegativepredictivecharacteristicsthanradionuclide
imagingwiththallium.ApositiveDSEresultwastwicemorepredictivethanapositivethallium
scan[42].
Natriureticpeptidesandcardiactropo nins
cTnTandcTnIhavehighertissuespecificitythanothercardiacbiomarkers[43].Theirrolein
thediagnosisofMIisdescribedelsewhere(see ChapterX).Theprognosticsignific anceof
evensmallelevationsintroponins,inrelationtoMI,hasbeenconfirmedinclinicaltrials[44,
45].High-sensitivitytroponinswillfurtherenhancetheassessmentofmyocardialdamagein
riskgroupofpatients.Theirroleseemstobeparticularlyintheirhighnegativepredictive
abilitytoruleoutMIwithasingleblooddraw[46–48].Allavailabledataemphasizethatthe
diagnosisofmyocardialischaemiashouldnotbemadesolelyonthebasisofbiomarkers.
Brainnatriureticpeptide(BNP)andNT-proBNPareproducedincardiacmyocytes,inresponse
toincreasesinfillingpressures,i.e.myocardialwallstress.Thismayoc curindependentlyof
thepresenceofmyoc ardialischaemia[49].Ofimportanceistheirnegativepredictivevaluein
excludingelevatedend-diastolic pressuresandheartfailureindyspnoeicpatients[50–52].
PreoperativeBNPandNT-proBNPlevelshaveadditionalprognosticvalueformortalityand
cardiaceventsaftermajornon-cardiacvascularsurgery[53–56].Theclinic alpresentation
anddifferentialdiagnosisintheevaluationofpositivefindingsareveryimportant.Besides
heartfailure,thelevelsofNPsriseinsepsis,septicshock,burns,acuterespiratorydistress
syndrome(ARDS),lungembolism,pulmonaryhypertension,chronicobstructivepulmonary
disease(COPD),asthma,lungtumours,obesity,andrenalinsufficiency.Inparticular,renal
failureandsepsismaybeassociatedwithelevatedlevelsofNPswhichmaymake
interpretationinrelationtohaemodynamicparametersdifficult[57–59].
Co ronarycomputedtomographyangiography
Thenon-invasivemethodofcardiaccomputedtomographyangiography(CCTA)recently
showedahighnegativepredictivevalueforthedetectionofcoronarydiseaseandahigher
sensitivityforCADthanstandardmethods[60].ThemainindicationsforCCTAarestable
symptomsconsistentwithCADanduninterpretableECGorstresstesting,asuspected
coronaryanomalyorfistula,andinpreparationtonon-coronarycardiacsurgery[61].Another
trialdemonstratedoutcomessimilartocontrols,butwithincreasedamountoftesting,radiation
exposure,andnocostreduction[62].Thedisadvantagewiththisnon-invasivetestisaneed
forslowingtheheartratetothetargetrangeof60–65beats/minwhichisnotfeasibleincertain
patients,e.g.valvularregurgitationsorheartfailure[63].CoronaryarteryCa depositsare
assoc iatedwithariskofcardiacischaemia.Electronbeamcomputedtomography(EBCT)has
anunclearimpactinpreoperativetestingandhasanassociatedburdenofhighradiation
exposure[64].
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Invasivepreoperativetesting
Theriskofnon-cardiacsurgerymustsupersedethecombinedriskofbothcoronary
angiographyandsubsequentrevascularizationprocedure.
Indicationsforcoronaryangio graphy
Invasivecardiac evaluationwithcoronaryangiographyisindicatedsimilarlyasinnon-surgical
setting.Coronaryangiographyisnotrecommendedforriskstratificationinpatientsundergoing
non-cardiacsurgery[10].
Percutaneoustransluminalcoronaryangioplasty,bare-metalstents,drug-eluting
stents
Preoperativepercutaneouscoronaryintervention(PCI)didnotreducetheratesofpost-
operativecoronaryevent[65],andacomparisonofPCIwithcoronaryarterybypassgraft
(CABG)ontheriskofsubsequentnon-cardiacsurgery[66]hasnotshownsignificantly
differentratesofMIanddeath.CurrentknowledgesuggeststhatPCIbeforenon-cardiac
surgeryisofnovalueinpreventingperioperativecardiacevents,exceptinthosepatientsin
whomPCIisindependentlyindicatedforanACS.Afterballoonangioplasty,adelayofnon-
cardiacsurgeryissuggestedfor2–4weekstoallowforhealingofthevesselinjury(see
Figure76.1).Arterialrecoiloracutethrombosisatthesiteofballoonangioplastymayoccur
typicallywithinhourstodaysafterthePCI.Incontrast,>8weeks’delayincreasesthechance
ofrestenosisattheangioplastysiteandtheoreticallyincreasesthechanceofperioperative
ischaemia.Eventualstentimplantationbringsariskofthrombosisandembolizationrelatedto
itstype,length,sizeofthefinallumen,thepresenceofdissection,andimportantlytothetime
betweenstentimplantationandnon-cardiac surgery[9,10].Therecommendationssuggestat
least4–6weeks,andideally3months,betweenstentimplantationandnon-cardiacsurgery
(see Figure76.1).Thisshouldenablestentre-endothelializationunderDAPT[67].The
presenceofDESmaydelayendothelialization,implyingalongerperiodofDAPT[68],ideally
upto12monthsbeforeelectivesurgicalprocedure[9,10](see Figure76.1).Ifsurgery
cannotbedelayed,thenBMSand/orballoonangioplastyshouldbeperformed,ideallywith
continuingaspirinthroughouttheperioperativeperiod[69].Thesituationmayimprove,
possiblyevenforperioperativepatients,withthesecond-generationDESwhichhavereported
asignificantlylowerratesofstentthrombosis[70].Theissueofbiodegradabledrug-eluting
coronarystentswasaddressedinstudiesshowingeitherfailuretoeliminateneointimal
hyperplasia[71]orsimilarratesofmajoradversec ardiacevents;however,itdemonstrateda
significantlylowerriskofverylatestentthrombosis,whencomparedtothedurablepolymer
DES[72].

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Figure76.1
Recommendationsfortimingofnon-cardiacsurgeryafterPCI.PCI,percutaneouscoronary
intervention.
Guidelinesforpre-operativecardiac riskassessmentandperioperativecardiacmanagement
innon-cardiacsurgery:TheTaskForceforPreoperativeCardiac RiskAssessmentand
PerioperativeCardiac ManagementinNon-c ardiacSurgeryoftheEuropeanSocietyof
Cardiology(ESC)andendorsedbytheEuropeanSocietyofAnaesthesiology,Poldermansetal.
EuropeanHeartJournal,reproducedwithpermissionfromOxfordUniversityPress.
Preoperativesurgicalcoronaryrevascularization
PreoperativecoronaryrevascularizationwasaddressedbyCoronaryArteryRevascularization
Prophylaxis(CARP)trial[73],withtheendpointoflong-termmortalityinpatientsbeforemajor
electivevascularsurgery.The2.7years’mortality,aswellastherateofpost-operativeMIsor
daysinhospital,wasnotsignific antlyreducedintherevasculariz ationgroup(22%vs23%in
controls).TheDECREASE-Vpilotstudy[74]didnotfindadifferencebetweenthe30-dayand
1-yearall-causemortality,non-fatalMI,andpost-operativetroponinelevationsbetweenthe
revascularizationandmedicaltherapypatients.Thisstudyiscurrentlyunderscrutinyfor
suspecteddatafabrication[75].
Perioperativemonitoring:electrocardiography,echocardiography,
pulmonaryarterycatheter,temperaturecontrol
PerioperativeST-segmentautomatedtrendingmonitorswerefoundtohaveanacceptable
sensitivityandspecificity,partic ularlyifSTchangesaredetectedinleadsV4,V5,andII[76,
77].However,ifasingleleadisusedformonitoring,thereisanincreasedriskofmissingan
ischaemicepisode,comparedtotheuseofleadcombinations.ST-segmentmonitoringis
limitedinpatientswithintraventricularconductiondefects(e.g.LBBB)andventric ular-paced
rhythms.ThedurationofST-segmentchangesindicativeofmyocardialischaemiawasfoundto
beanindependentpredic torofperioperativecardiaceventsinhigh-risknon-cardiacsurgery
patients.ST-segmentdepressionof>30minperepisodeor>2hours’cumulativeduration
havebeenshowntopredictworselong-termsurvivalinhigh-riskpatients[78,79].
Preoperativeechocardiographymaysignificantlyhelptostratifycardiovascularrisk,
particularlyifindicatedinsymptomaticpatients.Besidesacomplete,non-invasive
haemodynamicassessment,leftventric ularejectionfraction(LVEF)of<35%hadasensitivity
of50%andaspecificityof91%forthepredictionofperioperativenon-fatalMIorcardiac
death[38,80].Echocardiographyalsofacilitatesthemanagementofhaemodynamicinstability
duringoraftersurgery.Themainadvantageofechocardiographyovercontinuousmonitors,
likeprematureatrialcontractions(PAC),isamorecomprehensiveevaluationofthecardiac
structureandfunction.Informationisquicklyavailableontheregionalorglobalcontractility,
preload,diastolicdysfunction,afterload,rightheart,valvedisorders,peric ardialdisease,aortic
pathology,andcardiacoutput.Whenintegratedwithbasiclungultrasonography,itprovides
dataonthepleuralspaceandlungpathology.Asaroutine,itisfaster,non-invasive,and
cheaper,comparedtocontinuousmonitoringwith,forexample,PACs.Theroleof
echocardiographyintheperioperativesettingisgrowingwithknowledgeofthemodality

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amonganaesthetistsandintensivists[81–85].
Continuousinvasivewaysofmonitoring,likePACs,didnotdemonstratemajorbenefit
assoc iatedwithnon-cardiacsurgery[86,87].Theircontributionliesinthecontinuityof
monitoring,particularlyinhigh-riskpatientsselectedbyintermittentmethods,i.e.
echocardiography.ContinuousmeasurementofPAPmayguidetherapyinpatientswith
pulmonaryhypertensionandrightheartimpairment,orinvalvulardisorders.Theassessment
ofstrokevolumeandcardiacoutputiscomparabletonon-invasiveDopplermeasurements
andmaybeinferiorinseveretricuspidregurgitation[88].Suggestedmonitoringofstatic
pressureparametershavebeenchallengedbyfunctionalhaemodynamicassessmentby
Dopplerechoc ardiography[89].
HypothermiainducesshiveringandpotentiallycausesanimbalancebetweenthesystemicO
deliveryandconsumption.Non-cardiacsurgerypatientsexposedtotemperaturesof<35°C
showedanincreasedriskofmyocardialischaemia[90].Activewarmingwithheatedinfusions
andforcedaircirculationiswarranted,dependingonthecharacterandlengthofthe
procedure.
Specific
Heartfailure
Heartfailurepatientspresentingfornon-cardiacsurgerypresentwith2–4-foldhighermortality
thancontrols[91].Withtheroutineavailabilityofnatriureticpeptide(NP)assays[49]andtheir
negativepredictivevaluetoexcludeelevatedend-diastolicpressures[50,51],itmaybe
possibletoimprovethepreoperativeriskassessment.Theprevalenceofheartfailurewitha
preservedejectionfraction(EF)hasincreasedovera15-yearperiod,representingnowalmost
50%ofcases[92].Thesamepercentageofpatientsundergoingcardiacornon-cardiac
surgeryhasechocardiographicallydemonstrablediastolicfunctionabnormalities.Besidesthe
prognosticimpactoftheLVsystolic function,thepresenceofdiastolicdysfunctionprovidesan
incrementalprognostic value.Itisrelatedtoall-causemorbidityandmortality,congestive
heartfailure,andpost-operativelengthofstay[93].Theprognosisofapatientisalsorelated
totherightventricle(RV)functionwhic hisinfluencedbymechanicalventilation[94]andfluid
changes.Acompromisedrightheartisverysensitivetoanincreaseoftheafterload
(mechanicalventilation,lungorpleuralpathology)andtochangesofthepreload(bloodloss
orvasodilatation,volumeoverload)[95].
Echocardiographyhasbeenevaluatedwithanegativepredictivevalueof97%topredict
heartfailurerelatedtoperioperativecomplications[38].Specialattentionshouldbegivento
thepatient’svolumestatus,sinceestimationoftheintravascularvolumeisoneofthekey
issuesofpatientstabilizationinperioperativecare.Ameta-analysis[96]revealedthat
physiciansinintensivecareestimatethepreloadcorrectlyonlyin56%;however,onlythreeof
the29studies(685patients)usedechocardiography.Itispossiblethattheapplic ationofaset
ofechocardiographicparameters,includingheart–lunginteractions,mayhelptoguide
correctlyvolumetherapyinperioperativeheartfailurepatient[97].Heartfailuremaydevelop
eitherimmediatelyaftersurgery(duetomyocardialisc haemia,arrhythmia,rapidfluidshift),
hourslater(duetothemobiliz ationoffluidwithrestorationofthevasculartone),ordayslater
(duetothirdspacefluidreabsorption).Regionalanaesthetictechniquesaresometimes
2

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preferredinheartfailurepatientswithregardtosmoothanalgesia,theavoidanceof
mechanicalventilation,andearlierpatientmobiliz ation.However,neuraxialblockadesoften
requiresomeextrafluidloadingwhichhastobemobilizedwithrestorationofthevasculartone
hoursaftertheoperation.Thismaycausefluidoverloadinganddecompensationofchronic
heartfailure.TheperioperativecontinuingofACE-Is,β-blockers,statins,andaspirinis
independentlyreportedasreducingin-hospitalmortalityofpatientswithLVdysfunctionwho
areundergoingmajorvascularsurgery[98].
Hypertension
Antihypertensivetherapyistobecontinueduntilthemorningofsurgery,andthemedication
shouldberestartedassoonaspossibleinthepost-operativecourse.Inparticular,β-blockers
andclonidineshouldnotbeceasedpriortosurgery,becauseoftheriskofreboundeffect.
HypertensionisoftenassociatedwithCAD;thus,avoidingperioperativehaemodynamic
instabilityisapriorityinthepreventionofmajorcardiovascularcomplications[99,100].There
isnoevidencethatpostponingsurgeryinhypertensionofgrade1or2,inordertooptimize
therapy,wouldimproveoutc ome.However,ingrade3hypertension(systolicbloodpressure
over180mmHgordiastolicbloodpressureover110mmHg),thepotentialbenefitofoptimizing
theantihypertensivemedicationshouldbeweighedagainsttherisksofdelayingthesurgical
procedure[101,102].
Perioperativearrhythmias,pacemaker,andimplantabledefibrillato r
Bothsupraventricularandventriculararrhythmiasmaybeassociatedwithacoronaryeventin
theperioperativeperiod[103].Besidesmyoc ardialischaemia,otherpossiblecausesinclude
fluidshifts,particularlyinpatientswithventriculardysfunction,ionandmetabolic
derangements,drugtoxicity,temperatureshifts,anaemia,andhypoxia.Treatmentof
arrhythmiasconsistsoftreatingtheprimarycause,i.e.correctionofhypokalaemia,
hypomagnesaemia,andhypovolaemiawithreductionofadoseofinotropesand
vasopressors.Electricalcardioversionisindicatedinsupraventricularorventricular
arrhythmiasinhaemodynamicallycompromisedpatients.Thedetailedtherapyofvarious
arrhythmiasisdescribedelsewhere(see SectionVIII).Perioperativearrhythmiasimplic ate
theavoidanceofchronicβ-blockadecessationand/orconsiderationofaperioperativeβ-
blocker[104,105].InpatientswithanEFof≤35%,ahistoryofheartfailure,andnon-sustained
ventriculartachycardia(NSVT)intheperioperativeperiod,evaluationbyan
electrophysiologistmaybeindicatedforpotentialbenefitfromimplantablecardioverter
defibrillator(ICD)therapyfortheprimarypreventionofsuddencardiacdeath(SCD)[106,
107].ThemostfrequentarrhythmiaisAF,withtheage-relatedprevalenceincreasingto5–15%
at80years[108,109].AFisassociatedwithincreasedratesofdeath,stroke,andother
thromboembolicevents,heartfailure,reducedexercisecapacity,andLVdysfunction.Patients
withAFaremoresensibletoperioperativechangesinthepreload.Associatedthromboembolic
risk[110,111]requiresadjustingofthedosageoforalanticoagulantsortheperioperative
transitionfromoralanticoagulantstobridgingtherapywithLMWHorUFH,accordingtothe
bleedingriskoftheprocedure.
Perioperativebradyarrhythmiasusuallyrespondwelltoshort-termIVpharmacotherapy,and
non-invasivetransc utaneousortransoesophagealpacing.Theindicationsforpercutaneous
temporarypacingarethesameasforpermanentpacemakers(see ChapterX).

Perioperative cardiac care of the high-risk non-cardiac patient
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Asymptomaticbifascicularblock,withorwithoutfirst-degreeAVbloc k,isnotanindicationfor
transvenouspacing[112].Pac emaker-dependentpatientsshouldavoidunipolar
electrocautery,andthepacemakershouldbesetinanasynchronousornon-sensingmode
(VOOorDOO)byplacingamagnetoverthedevic eduringsurgery.Ifunipolarelectrocautery
isunavoidable,thenthegroundplatefortheelectric alcircuitshouldbepositionedawayfrom
thegenerator;thedeviceshouldbesettothelowestpossibleamplitude,andthecautery
shouldavoidareasclosetothepacemakeror/andalongthepacinglead[10].TheICDshould
haveitsarrhythmiaalgorithmsturnedoffduringsurgerytopreventunwantedshocksdueto
spurioussignalsthatthedevicemayinterpretasVTorVF.Anapplicationofmagnetmayonly
switchoffthecardioverterfunction.Thetemporaryprogrammingtoasynchronnousmodehas
tobedoneseparately[10,113].
Chronicvalvulardiseaseandnon-cardiacsurgery
Patientswithknownorsuspectedvalvulardiseaseshouldbediagnosedwith
echocardiographyduringtheelectiveoremergencypreoperativeassessment.Patientswith
valvulardiseaseoraftervalvularreplacementshouldhavetheiranticoagulationtherapy
modified.Mostoften,oralanticoagulantsareceased,withtemporarybridgingof
anticoagulationwithlowmolecularweightheparin(LMWH)orUFH.ProphylaxisforIEshouldbe
startedpriortotheprocedure,acc ordingtocurrentguidelines[114].
Inparticular,severeASwithanaorticvalvearea(AVA)of≤1cm oranAVAindexof≤0.6
cm c arriesasignific antriskofperioperativeheartfailure[115,116].Thesepatientsshouldbe
consideredforvalvesurgery,balloonvalvuloplasty,ortranscatheteraorticvalveimplantation
(TAVI)beforeplannedhigh-risknon-cardiacsurgery[117,118].Metic ulousmonitoring
includesrepeatedechoc ardiography.Theaimistoprovideanidealpreload,maintainthe
coronaryperfusion,andavoidsignificanttachycardiaorrapidarrhythmiaswithshorteningof
theventriculardiastolicfillingtime.Thismayresultinlowcardiacoutputsyndromewhichmay
bealsocausedbybradycardiaduetoaratherconstantstrokevolumeinvalvestenosis.
MSbecomessignificantwithamitralvalveareaof≤1.5cm andpulmonaryarterysystolic
pressureof≥50mmHg,particularlyinsymptomaticpatients.Beforeplannedhigh-risksurgery,
percutaneousmitralcommissurotomyorcardiacsurgerymightbeconsidered[119].Theaims
ofhaemodynamicmonitoringaresimilartothoseinAS,duetoaconstantstrokevolume,i.e.
optimizationofthepreload,andavoidanceoftachycardia,rapidarrhythmia,orsignificant
bradycardia.
Significantaorticandmitralvalveregurgitationsdonotincreasetheperioperativeriskin
asymptomaticpatients.WithimpairmentofLVsystolicfunction,itisadvisabletoavoidnon-
cardiacsurgery[119].Theessentialsofmetic uloushaemodynamicmonitoringare
optimizationofthepreload,avoidanceofbradycardia,andthepharmacologicalreductionof
theafterloadinordertoreducethevalvularregurgitationfraction.
Pulmonarydisease
Pulmonarydiseases(COPD,inparticular)increasetheriskofpost-operativeinfectiouslung
complicationswithastayinintensivecare.Thecausativemec hanismisthedevelopmentof
atelectasisundergeneralanaesthesiaand/orduringpost-operativepainmanagement,
particularlyafterthoracicorabdominalsurgery.Theinvolvementofregionalanaesthesia
2
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reducespulmonarycomplicationsandallowsformoreconvenientpost-operativepain
management[19].Corpulmonalewithrightheartfailureisadirectcomplic ationofsevere
COPD.However,COPDisalsoassociatedwithanincreasedriskofCAD.Patientswitha
reducedforcedexpiratoryvolumein1s(FEV )hada75%increasedriskofcardiovascular
mortality,comparedwiththosewithanormalFEV [120].Concerningperioperative
medications,therearenospecialcontraindicationstotheuseofcardioselectiveβ-blockersor
statinsinCOPDpatients[121,122].
Pulmonaryhypertension
Pulmonaryhypertension(PH)(i.e.restingmeanpulmonaryarterialpressure(PAP)≥25mmHg)
canbedividedaspre-capillaryandpost-capillary;thelattercanbedividedfurtherinto
passiveandreactive,accordingtothetranspulmonarygradient.Mostfrequentamongthe
populationisPHassociatedwithleftheartdisease(78.7%),followedbylungdiseases,
hypoxia,hypercarbia(9.7%),pulmonaryarterialhypertension(PAH)(4.2%),chronic
thromboembolicpulmonarydisease(0.6%),anduncertaincauses(6.8%).Besidesthe
treatmentoftheassociatedpathology(LVfunction,valvedisease,lungandpleuralpathology,
etc.),theperioperativemanagementofPHrequiresjudicioustitrationofthepreloadwithregard
totheRVfunctionandPAP.Ifrepeatedechocardiographyisnotsufficient,thenPACand
continuousmonitoringisindicatedinmoderate-andhigh-risknon-cardiacsurgery.Specific
drugtherapyisnotwithheldandincludescalciumchannelblockers(CCBs)(diltiazem,
nifedipine)invasoreactivePAH,prostanoids,endothelinreceptorantagonists,and
phosphodiesteraseinhibitors(sildenafil)[123].IncasesofRVfailure,theinotropicsupportwith
dobutamineormilrinonemaybeinitiated,andadministrationoftemporaryinhaled
epoprostenolornitricoxide(NO)mayberequired.Haemodynamicinstabilitysometimes
requiresthetemporarycessationofsildenafilandsystemicprostanoids,duetovasodilatation
andtheriskofhypotension.PatientsbenefitfromcentralizationinPHcentreswherecardiac
andnon-cardiacsurgeryareperformedbyspecializ edteams[124].
Renaldisease
Deteriorationofkidneyfunctionisanindependentriskfactorforadverseperioperativecardiac
events.Mildincreasesofplasmacreatinineareassociatedwithanincreaseinmortalityin
cardiovascularsurgery[1,125].Theperioperativedevelopmentofrenaldysfunctionduring
electiveaorticsurgeryisastrongmortalitypredictor,withareported12.6%mortalityat30
days[126].Thepresenceofdiabeticnephropathyisassoc iatedstronglywithCADand
perioperativecardiac risk[10].Therelativelylowsensitivityofplasmac reatinineforestimating
theglomerularfiltrationrate(GFR)decreasemaybeimprovedbyusingplasmac ystatinC
[127,128].Anotheravailablebiomarkerisneutrophilgelatinase-associatedlipocalin(NGAL)
whic hispreferablytakenintheurine,becauseofsignificantinfluencesofsystemic
inflammationuponplasmalevels[129–131].Arenoprotectiveapproachwhic himproves
mortalityandmorbidityofperioperativepatientsundergoingnon-cardiacsurgeryhasbeen
beststudiedinpatientswithcontrast-inducednephropathy(CIN).TheprevalenceofCIN
amongintensivecarepatientsreaches11.5%withtypic almultifactorialaetiology[132].
Variousnephroprotectivestrategiesweresuggestedwhichareapplicableperioperativelyin
non-cardiacsurgerypatients.Theconsensusappearstobeestablishedinadequatevolume
loading,post-proceduralcontrastfiltration/dialysis,andinfusionofbicarbonate.Lesseffectis
expectedfromIVNACand/oraminophylline[133,134].
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Cerebrovasculardisease
Cerebrovasculardiseasecarriesaperioperativeriskofstroke,particularlyinelderlypatients.
Potentialstrokemechanismsinc ludehypoperfusion(globalorfocal),thromboembolism
(cardiac,fromaorticarchatherosclerosis,orparadoxicalduetoforamenovale),and
haematologicalmechanisms.Medicalmeasurestopreventstrokeincludecontrolof
hypertensionanddiabetes,andcontinuingofantiplateletagentsoranticoagulantsinpatients
withlowriskofbleeding.Oralanticoagulantsindentalprocedures,cataractsurgery,
endoscopic procedures,andsuperficialexcisionsmaysignificantlyreducetheriskof
perioperativeanddelayed-onsetstroke,comparedtobridgingtherapywithheparins[135].
Besidescardiacsurgery,withariskbetween2%and10%,carotidandperipheralvascular
surgerycarriesahigherriskof1–5%,comparedtoariskof0.08–0.07%ingeneralsurgery
[136–138].Headandnecksurgerycarriesarelativelyhighriskof4.8%,duetothe
involvementofneckvesselsandtracheostomy.Perioperativemortalityincasesofstroke
complicationsisremarkablyhigh(18–26%)[139].
Symptomaticextrac ranialcarotidstenosiscarriesasignific antriskofperioperativestroke
(8.5%)incardiacsurgerypatients.Symptomatic vertebrobasilarstenosisisassoc iatedwitha
6%riskofperioperativestroke,regardlessofthetypeofsurgery.Beforeundergoinggeneral
orcardiacsurgery,symptomaticpatientswith>70%ofextracranialcarotidstenosisshould
undergocarotidendarterectomy(CEA)orcarotidangioplastyandstenting(CAS).Forpatients
withsymptomaticintrac ranialstenoses,itisrecommendedtodelaysurgeryforatleast1
month,toaggressivelytreattheneurovasculardisease,andpossiblytoallowtimefor
collateralvesselformation.Thestrokeriskrelatedtointracranialstentingislikelytoexceed
theperioperativestrokeriskfornon-cardiacsurgery.Patientswithasymptomaticextracranial
orintracraniallargearterystenosisdonotrequireCEAorCASbeforesurgery,becausethe
risksassoc iatedwithCEAorCASarehigherthantheperioperativestrokerisk[140].
Fewdatacanbefoundonthetimingofsurgeryafterstroke.Recoveryofalteredcerebral
autoregulationafterstrokeisprobablywithin2weeks,andacerebralinfarctundergoesa
seriesofchangeswhichmakesitpotentiallyvulnerableforaboutamonth.Thus,itis
recommendedtoleaveaboutamonthtoelapsebetweenanischaemicstrokeandsurgery.
Theuseofclopidogrelafterstentingrequiresabout1weekofcessationbeforeplanned
surgerytoavoidhaemorrhagic complications.Itisrecommendedtocontinueaspirinasa
preventionofvasculareventsthroughouttheperioperativeperiod[140].
Diabetesmellitus
Diabetesstronglyinfluencesthecardiovascularsystemandpromotesatherosclerosis,
endothelialdysfunction,theactivationofplatelets,andpro-inflammatorycytokines.Surgical
stress,togetherwithhaemodynamicalterations,furtherenhancestheprothrombotic state.This
mayleadtoinstabilityofpre-existingcoronaryplaques,thrombusformation,vesselocclusion,
andMI.Assessmentoftherenalfunctioniswarranted,sincediabeticnephropathyisstrongly
assoc iatedwithCADandperioperativecardiacrisk[10].
Inadequateinsulineffectandhyperglycaemia,evenintheabsenc eofdiabetes
perioperatively,showeda2–4-foldincreaseintheriskofmyocardialischaemia,troponin
release,and30-dayandlong-termcardiac events[141,142].Thetightglucosec ontrol
between5.0and5.6mmol/Lwithintensiveinsulintherapydemonstratedmajorclinicalbenefits

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forsurgicalICUpatients,comparedtopatientswhohad8.3–8.9mmol/L[143].Morbidityinthe
medicalICUpatientsundertightglucosec ontrolwasimproved,exceptinasubgrouprequiring
criticalcarefor≥3days[144].However,trialssupportingtightglucosecontrolwithinsulin
werequestionedbytheNICE-SUGARstudy[145].Theprimaryendpointofdeathby90days
afterrandomizationandratesofhypoglycaemiawereincreasedwithintensiveglucosecontrol
(27.5%),comparedto(24.9%)conventionalcontrols.Patientsundergoingnon-cardiacsurgery
undertightcontrolofbloodglucoseconcentrationsdemonstrateddecreasedmorbidityand
mortality[146].Therisksofstroke,MI,anddeathwereincreased3–4-foldbypreoperative
hyperglycaemiainpatientsundergoingCEA[147].Itseemsadvisabletotargetalevelof6.0–
8.0mmol/Lperioperatively,aimingforthepreventionofhyperglycaemia[9].
Perioperativemedicalmanagement
β-blockersandivabradine
Theprimaryissueswiththeadministrationofperioperativeβ-blockersaretheassessmentof
riskindicatingpotentialbenefit,thetimeofinitiation,doseadjustments,andthemonitoringof
therapy[148].Perioperativebisoprololreducedtheriskofcardiaceventsinintermediate-risk
patients[99].However,theeffectwasnotseeninhigh-riskpatientswithacumulationofrisk
factorsandsignificantwallmotionabnormalitiesonechocardiography.TheDECREASEtrial
[39]demonstratedthebenefitsofbisoprolol,andareview[149]confirmedthebeneficialeffect
ofperioperativeβ-blockersonischaemiccardiaceventsandcardiacdeathinthenon-cardiac
surgerypatients.Ameta-analysis[150]included22existingtrialswith2437includedpatients
andfoundsignificantbenefitsonlyforacompositeoutcomeofcardiovascularmortality,non-
fatalMI,andnon-fatalcardiacarrest.Themeta-analysisnotedarelativeriskofhaemodynamic
instability,i.e.bradycardiaandhypotension.
TheDiabeticPostoperativeMortalityandMorbidity(DIPOM)trialdidnotdemonstratea
significantlyreducedriskofdeathandcardiaccomplic ationswithmetoprolol[151].The
MetoprololafterVascularSurgery(MaVS)trialdemostratednodifferenceincardiacmortality,
non-fatalMI,ornewcongestiveheartfailurebetweengroupson5-dayperioperative
metoprololtherapyandcontrols[152].ThePOISEtrial[4]included8351patientsand
demonstrateda17%decreaseinthecompositeendpointdefinedasdeath,MI,ornon-fatal
cardiacarrestat30days.However,the30%decreaseinnon-fatalMIwaspartiallyoffsetbya
33%increaseintotalmortalityanda2-foldincreaseinstroke.ThestudiesDECREASE-IV[153]
andDECREASE-V[74]wererecentlyputunderscrutinyforsuspecteddatafabrication[75].A
recentmeta-analysis[154],excludingtheDECREASEstudies,foundthatβ-blockersresultedin
a27%increasedmortalityrisk.CurrentEuropeanandAmericanguidelinesonthe
perioperativeuseofβ-blockerssuggestthatβ-blockersshouldnotbewithdrawninpatients
withestablishedtherapyforhypertension,heartfailure,ischaemic heartdisease,or
arrhythmias.Theyarerecommendedinpatientswhohaveknownischaemicheartdiseaseor
myocardialischaemia,accordingtopreoperativestresstesting,andinpatientsscheduledfor
risk-relatedsurgery.Basedonthenewfindings,thedrugsshouldnotbegivenasroutine,and
theiradministrationrequirestitration,accordingtohaemodynamicmonitoringandthepatient’s
stability.β-blockersarenotc ontraindicatedinpatientswithclaudication,andcardioselective
agentsarenotcontraindicatedinCOPD[5,10,99].Titratablenovelagents,likeesmolol,may
coverperioperativeindicationsinunstablepatients[155–157].

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IvabradineisaspecificinhibitoroftheIfc hannelofthesinoatrialnode.Itreducesheartrate,
independentlyofthebloodpressureormyoc ardialcontractility.Inarandomizedtrial,both
ivabradineandmetoprololsuccinatereducedtheincidenceofischaemiaandMIsignificantly,
whencomparedwithplacebo[158].Thesefindingsneedtobeconfirmedbyfuturestudiesin
theperioperativesetting,becauseivabradinemightbeconsideredforpatientswitha
contraindicationtoβ-blockers.Similarly,patientswithreducedheartfunctionand
downregulationofβ-receptorsmightbenefitfromperioperativeadministrationofivabradine.
α2-agonists
α2-agonistsreducethesympatheticoutflowandmyocardialO consumption.Clonidineand
dexmedetomidinehavemultipleapplications,particularlyinreducingtherequirementsfor
opioids,inloweringbloodpressure,andinthetreatmentofalcohol,nic otine,anddrug
withdrawal.Clonidinealsoactslikeananti-ischaemicagentandwasfoundtoreducethe
incidenceofmyocardialischaemiainpatientsundergoingsurgery[159],aswellastoreduce
post-operativelong-termmortality[160].Areview[149]confirmedtheeffectsofclonidineon
loweringtheincidenceofmyocardialischaemiaandriskofcardiacdeath.Perioperative
clonidineappearstobeasecond-lineagenttooralβ-blockers,becauseithaslowerriskof
bronchospasminasthmatics,isnotc ontraindicatedinhigh-degreeheartblock,andcomesin
atranscutaneousformthatcanbeusedinpatientswhoarenottakingoralmedications.
Chronic clonidinemedicationshouldnotbeabruptlyceasedbeforesurgerytoavoidrebound
hypertension[161].
Calciumchannelblockers
Diltiazemandverapamillowertheheartratewhichmakesthemsuitablemedicationsto
influencethemyocardialO demand,particularlyinpatientswithanintolerancetoβ-blockers.
Ameta-analysisinnon-cardiacsurgery[162]showedthatCCBssignificantlyreduced
ischaemiaandSVT;however,thebeneficialimpactwasfoundonlyonacompositeendpointof
MIand/ordeath.Theothermajorsubgroupistheperipherallyactingdihydropyridineswithno
influenceonheartrate.Theirapplic ationinaorticsurgerypatientsresultedinanincreasein
mortality[163]whichmightbeappliedtotheeventualuseofc urrentcalc iumchannel-blocking
antihypertensiveswithalonghalf-life,largevolumeofdistribution,highproteinbinding,and
irregularresorptionthroughthesmallintestineafterabdominalaorticsurgery.Itis
recommendedthatCCBsshouldbecontinuedduringnon-cardiacsurgeryinhypertensive
patients,andparticularlyinpatientswithPrinzmetalanginapectoris.Heartrate-reducingCCBs
(e.g.diltiaz em)maybeconsideredbeforenon-cardiacsurgeryinpatientswhohave
contraindicationstoβ-blockers.TheroutineuseofCCBstoreducetheriskofperioperative
cardiovascularcomplic ationsisnotrec ommended[9].
Angiotensin-convertingenzymeinhibito rs
Angiotensin-convertingenzymeinhibitors(ACE-Is)anddirectARBsareindicatedforthe
treatmentofheartfailureandhypertension.Theirusecarriesariskofseverehypotension
underanaesthesia,inparticularwhencombinedwithconcomitantβ-blocker.Theriskof
hypotensionisashighwithACE-IsaswithARBs.TransientdiscontinuationofACE-Isbefore
non-cardiacsurgeryinhypertensivepatientsshouldbeconsidered.Diastolicdysfunctionisa
risingcauseofheartfailure,reachingupto50%ofallpatientspresentingwithheartfailureto
ICUs[164].PerioperativetreatmentwithACE-Ismighthavebeneficialeffec tsonpost-operative
2
2

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outc omeincardiacsurgery[165].InpatientswithLVsystolicdysfunction,itisrecommended
tocontinueACE-Isduringtheperioperativeperiod,underclosemonitoring[9].The
renoprotectiveeffectsarequestionablewithfluidshiftsduringsurgery,becauseelevated
angiotensinactivityisneededtomaintaintheglomerularfiltrationfraction[166].
Plateletanti-aggregationtherapy
Aspirinwasshowntoreduceperioperativevascularevents,includingstroke,withno
significantimpactonmortality[167,168].Ameta-analysis[169]showedthattheriskof
bleedingcomplicationsiselevatedby1.5timeswithaspirin;however,theseverityofbleeding
issimilartothatofcontrols,withpossibleexceptionsinneurosurgeryandprostatectomy.The
withdrawalofaspirinbringsa3-foldhigherriskofanadversecardiacevent[170].Therefore,
themedicationcanbeomittedonlyifthebleedingriskoutweighsthepotentialcardiacbenefit.
Clopidogrelanddualanti-aggregationincreasesignific antlythebleedingcomplicationsand
requirementsforplateletandpackedcelltransfusions,ifnotstoppedearlierthan5daysbefore
cardiacsurgery[171,172].Thesedatacanbealsoappliedtopatientsindicatedfornon-
cardiacsurgery.Forpatientsonaspirin,clopidogrel,ordualanti-aggregationtherapyandwith
lifethreateningbleeding,i.e.withanindicationforemergencysurgery,thetransfusionof
plateletsshouldbeconsideredtogetherwithotherhaemostaticmeasures.
Warfarinandnovelanticoagulants
Patientsundergoingnon-cardiacsurgerysometimestakeoralantic oagulantsthatinterferewith
thesynthesisofvitaminK-dependentc oagulationfactors,orneworalanticoagulants(NOACs)
inhibitingdirectlythrombin(e.g.dabigatran)orfactorXa(e.g.rivaroxaban,apixaban,
edoxaban,betrixaban).Anindicationforthesedrugsismorefrequentintheelderly
population,withregardtotheprevalenceofchronicAF,valvularprostheses,DVT,andPE.
Concerningoralanticoagulants,forpatientswhorequireminimallyinvasiveprocedures
(dental,superficialsurgery),therecommendationistobrieflyreducetheINRtothelowor
subtherapeuticrange(i.e.INR<1.5)andresumethenormaldoseoforalanticoagulation
immediatelyaftertheprocedure[173].Forpatientswithhighbleedingriskinplannedsurgery,
itmaybenecessarytocompletelydiscontinuethetherapyfor4–5daysbeforetheprocedure
andtobridgetheanticoagulationeitherwithLMWHorUFHtwicedaily,duetoaparallelriskof
thromboembolism[9,10].Forpatientswithlowerthromboembolic risk,bridgingwithLMWHor
UFHisusuallyindicatedoncedaily.Incasesofemergencysurgeryorableedingcomplication,
theoralanticoagulantscanbereversedwithprothrombincomplexconcentrate(PCC).The
timingofsurgeryandthedegreeofanticoagulation(i.e.thelevelofINR)areimportant,asthe
lessurgentconditionsandlowerINRcasescanbereversedwithfreshfrozenplasmaand
vitaminK[174,175].
TheNOACssofartestedinclinicaltrialshaveallshownnon-inferioritytowarfarinalso
demonstratingbettersafetyparametersinpatientswithoutrenalimpairment.NOACshavea
significantlyshortereliminationhalf-life(5–17hours)whichenablessurgicalinterventionswith
transientstoppingofthetherapyandnobridgingwithheparins.NOACscanberestartedas
soonaseffectivehaemostasishasbeenachieved.Specialattentionisrequiredforpatients
withrenalfailureandDTItherapy(e.g.dabigatran),because80%ofitsexcretionrouteis
renal.Similarly,renalandhepaticimpairmentmaycauseanprolongationoftheelimination
half-lifeofthedirectfactorXainhibitors(e.g.rivaroxaban).Ithasbeenrecommendedthat,

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beforeminorsurgicalproc edures,oneortwodosesbeskippedjustbeforesurgery,provided
thatthecreatinineclearanceis>50mL/min.Inthesettingofmajorsurgery,ithasbeen
recommendedtoskip3–4dosesoftheseagents.Thesetimeperiodsshouldbeextendedin
thesettingoftheelderlyoranimpairedrenalfunction[176,177].Incasesofemergency,with
notimetowaitforweaningoftheanticoagulationeffects,theprioritiesaretheadministrationof
non-specific prohaemostaticagentssuchasPCCsoractivatedfactorVII,theeliminationof
NOACswithdialysisincasesofdabigatran,andtheadministrationofac tivatedcharcoal,
togetherwithanosmoticlaxative,ifwithin2hoursofNOACingestion[177,178].Dialysisis
unlikelytohelpindirectfactorXainhibitors,duetohigherplasmaproteinbinding,while
vigorousdiuresistopotentiatetheirrenalclearancemayhavearoleinseverebleeding[176,
177].
Statins
Theeffectsofstatinsincludeinflammatorymodulation,theinhibitionofneovascularization,and
atheroscleroticplaquestabilizationviatheinhibitionofthrombogenic,proliferative,and
leucocyteadhesiveproperties[179].Administeringstatinsthroughouttheperioperativeperiod
wasassociatedwithasignificantreductionofperioperativemortalityandperioperativeratesof
MI[180,181].Temporarilydiscontinuingstatinmedication(upto24hours)appearstobesafe
[182].Withgrowingillnessseverity,thenaturaldecreaseofapoproteins,whic harenecessary
toconveycholesterolinthesolubleformtotissues,leadstoadecreaseofLDLand
cholesterollevels.Arecentstudyonseverelyseptic patientsdidnotshowbenefitinnewly
indicatedstatinusersbutshowedprovenbenefitonmortalityandIL-6levelsinprevioususers
ofatorvastatin[183].Inpatientsundergoingvascularsurgery,perioperativefluvastatin
therapy,initiated1monthbeforesurgery,wasassociatedwithanimprovementinpost-
operativecardiacoutcome[184].
Conclusion
Thepreparationofahigh-riskpatienttosafelyundergonon-cardiacsurgerydependsonclose
cooperationbetweenanaesthesiologists,surgeons,andcardiologists.Thedemographic
developmentinEuropesuggestsanincreaseinthenumberofelderlypatientsundergoing
surgicalproceduresinthecomingyears[185].Theincreasingnumberofelderlypatients
conveysmorecomorbidities,i.e.hypertension,ischaemicheartdisease,diabetes,andrenal
dysfunction[186,187].Theimpactofageisobviouswithmortalityofeventualcomplications
ofsurgeryintheelderly[5].Formanypatients,non-cardiac surgeryrepresentstheirfirst
opportunitytoreceiveanappropriateassessmentofbothshort-andlong-termcardiac risks.
Basedonperioperativeobservations,patientsmaybedirectedtofurthercardiologyfollow-up
whic hmaysubsequentlyimprovetheirlong-termmorbidityandmortality.
Costvsbenefitratioofamedicalconsultationaspartofthepreoperativeevaluationmaybe
considered.Inthemajorityofpreoperativecardiologyconsultations(40%),nofurther
recommendationswereexpressed;onlyin3.4%ofconsultationsdidacardiologistidentifya
newfinding[188].Afteradjustingforillnessseverity,theperioperativemedicalconsultation
hadnosignificantimpactonglycaemiccontrol,β-blockerexposure,ortheprophylaxisfor
venousthromboembolism(VTE).Itsignificantlyincreasedtheamountofpreoperativetesting,
theamountofpharmacologicalinterventions,hospitalcosts,lengthsofstay,and30-dayand

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1-yearmortality[189,190].Apossiblesolutiontotheseconcernsistheincreaseofthe
anaesthesiainvolvementandconsultation.Amatchedpairanalysisdemonstratedthat
anaesthesiaconsultationreducedthemeanhospitalstaybuthadnoeffecton30-dayor1-
yearmortality.Furthertrialsarewarrantedtoinvestigatethecost-effectivenessofwidespread
anaesthesiaconsultationinpreparationformajornon-cardiacsurgery,includingthe
involvementofaspecializ edpre-anaesthesiaclinic[191,192].
Personalperspective
Newerdrugs,roboticandlaparoscopicprocedures,andthequalityofcurrentanaesthetic
techniquespermitlong-lastingprocedures,withoutaneedforomissionofchronic
medicationsorarequirementfortheirtemporaryreplacement.Theelectivepatientsenter
thepre-anaesthesiaclinic,andtheemergencypatientsaremanagedwithnodelayby
skilledanaesthetistswithregardtotheirknowledgeofdiagnosticandtherapeutic
measuresoftenadoptedfromacutecardiology.Thepreoperativecardiologyconsultations
arelimitedtothosefewwithanidentifiednewdiagnosis.Basedonperioperative
observations,patientsmaybedirectedtofurthercardiologyfollow-upwhichmay
subsequentlyimprovetheirlong-termmorbidityandmortality.
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Medi cine Onli ne for personal use (for detai ls see Pri vacy Policy). Subscriber: Oxford University Press - Main Accnt; date: 16
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