summarised recent guidlines of European society of cardiology about preoperative assessment of cardiac patients undergoing non-cardiac surgery

1. Estimation of cardiac risk prior
to noncardiac surgery
D.BASEM ELSAID ENANY
LECTURER OF CARDIOLOGY
AINSHAMS UNIVERSITY

2. PURPOSE OF PREOPERATIVE EVALUATION
-Evaluate patient’s current medical status
-Provide clinical risk profile
-Provide recommendations for management in the perioperative period
-Not to give “cardiac clearance”
-Alter or cancel the planned procedure
-Recommend revascularization if outcome would be altered
-Currently high-quality evidence suggests that coronary revascularization
before major noncardiac surgery is of limited or no benefit in stable patients;
however, this cannot be generalized to patients with left main or severe triple
vessel disease because of the absence of data in these groups.
-Importantly, the risk of thrombosis after PCI is high and the hypercoagulable
perioperative state increases the probability of this occurring.
= Indiscriminate and extensive preoperative cardiac testing is an ineffective
way of using health care funds and can lead to more unwarranted and risky
procedures. In addition to the inappropriate expenditure of resources,
unnecessary testing could cause harm to the patient by delaying surgery.

3. --Three elements must be assessed to determine the
risk of cardiac events:
Patient specific clinical variables
Exercise capacity
Surgery-specific risk

4. --The American College of Cardiology National Database
Library defines recent MI as greater than seven days but
≤30 days.
.

5. Minor predictors:
Minor risk factors are recognized markers for cardiovascular
disease that have not been definitively proven to independently
increase perioperative risk and were not included in the
recommendations for treatment by the ACC/AHA perioperative
guidelines:
-Advanced age (greater than 70 years of age)
-Abnormal ECG (left ventricular hypertrophy, left bundle
branch block, ST-T wave abnormalities)
-Rhythm other than sinus (such as atrial fibrillation)
-Uncontrolled systolic hypertension
(The presence of more than one of these may lead to a higher
suspicion of coronary artery disease.)

6. Surgical factors that influence cardiac risk:
-Related to the urgency, invasiveness, type, and duration of
the procedure, as well as the change in body core
temperature, blood loss, and fluid shifts.
-Every operation elicits a stress response initiated by
tissue injury  mediated by neuro-endocrine factors, and
may induce sympathovagal imbalance.
-Fluid shifts in the peri-operative period add to the surgical
stress increases myocardial oxygen demand.
-Surgery also causes alterations in the balance between
prothrombotic and fibrinolytic factors, potentially resulting
in increased coronary thrombogenicity.

8. =In general, endoscopic and endovascular techniques speed recovery,
decrease hospital stay, and reduce the rate of complications.
However, randomized clinical trials comparing laparoscopic with
open techniques exclude older, sicker, and ’urgent’ patients, and
results from an expert-based randomized trial (laparoscopic vs.open
cholecystectomy) have shown no significant differences in conversion
rate, pain, complications, length of hospital stay, or re-admissions.
-Increased intra-abdominal pressure, pneumoperitoneum and
Trendelenburg position increased mean arterial pressure, central
venous pressure, mean pulmonary artery, pulmonary capillary wedge
pressure, and systemic vascular resistance impairing cardiac
function cardiac risk in patients with heart failure
is not reduced in patients undergoing laparoscopy, and both
should be evaluated in the sameway.

9. =Although it is a less-extensive intervention,
infrainguinal revascularization entails a cardiac risk
similar to—or even higher than—that of aortic
procedures. This can be explained by the higher
incidence of diabetes, renal dysfunction, IHD, and
advanced age in this patient group.

10. =Endovascular AAA repair (EVAR) has been
associated with lower operative mortality and
morbidity than open repair but this advantage reduces
with time, due to more frequent graft-related
complications and re-interventions in patients who
underwent EVAR, resulting in similar long-term AAA-related
mortality and total mortality.

11. =A meta-analysis of studies, comparing open surgical with
percutaneous transluminal methods for the treatment of
femoropopliteal arterial disease, showed that bypass surgery is
associated with higher 30-day morbidity and lower technical failure
than endovascular treatment, with no differences in 30-day mortality;
however, there were higher amputation-free and overall survival rates
in the bypass group at 4 years.
Therefore, multiple factors must be taken into consideration when
deciding which type of procedure serves the patient best.
-An endovascular-first approach may be advisable in patients with
significant comorbidity, whereas a bypass procedure may be offered as
a first-line interventional treatment for fit patients with a longer life
expectancy

13. =Carotid artery stenting has appeared as an attractive, less-invasive
alternative to CEA; however, although CAS reduces the rate of
periprocedural myocardial infarction and cranial nerve palsy, the
combined 30-day rate of stroke or death is higher than CEA,
particularly in symptomatic and older patients.
-The benefit of carotid revascularization is particularly high in
patients with recent (<3 months) transient ischaemic attack
(TIA) or stroke and a >60% carotid artery bifurcation stenosis.
-In neurologically asymptomatic patients, carotid revascularization
benefit is questionable, compared with modern medical
therapy, except in patients with a >80% carotid stenosis and an
estimated life expectancy of >5 years

14. History
--Known cardiac disease.
--The assessment of functional ability provides valuable prognostic
information, since patients with good functional status have a lower risk of
complications.
Functional status can be expressed in metabolic equivalents (1 MET is defined
as 3.5 mL O2 uptake/kg per min, which is the resting oxygen uptake in a
sitting position).
Perioperative cardiac and long-term risk is increased in patients unable to
meet a 4-MET demand during most normal daily activities:
*Can take care of self, such as eat, dress or use the toilet (1 MET)
*Can walk up a flight of steps or a hill (4 METs)
*Can do heavy work around the house such as scrubbing floors or lifting or
moving heavy furniture (between 4 and 10 METs)
*Can participate in strenuous sports such as swimming, singles tennis,
football, basketball, and skiing (>10 METs)
-- However, the presence of PAD may be an important limitation to
assessment of functional capacity since such patients often cannot exercise
because of claudication.

15. Notably, when functional capacity is high, the
prognosis is excellent, even in the presence of stable
IHD or risk factors; otherwise, when functional
capacity is poor or unknown, the presence and number
of risk factors in relation to the risk of surgery will
determine pre-operative risk stratification and peri-operative
management.

16. Physical examination
--Blood pressure measurements in both arms
--Analysis of carotid artery and jugular venous pulsations for the
quality of the pulse contour and the presence of bruits
--Auscultation of the lungs
--Precordial palpation and auscultation
--Abdominal palpation
--Examination of the extremities for edema and vascular
integrity.
--Important findings include evidence of HF or a murmur
suspicious for aortic stenosis (AS), since poorly controlled HF
and significant AS increase perioperative risk.
--The presence of Q waves or significant ST segment elevation or
depression have been associated with an increased incidence of
perioperative cardiac complications.

18. -Each of the six risk factors was assigned one point.
Patients with none, one, or two risk factor(s) were
assigned to RCRI classes I, II, and III, respectively,
and patients with three or more risk factors were
considered class IV.
-The risk associated with each class was 0.4%, 1%, 7%,
and 11% for patients in classes I, II, III, and IV,
respectively.

19. -However, developed years ago and many changes have since occurred
in the treatment of IHD and in the anaesthetic, operative and peri-operative
management of non-cardiac surgical patients.

Gupta preoperative risk
-However, some peri-operative cardiac complications such as
pulmonary oedema and complete heart block, were not considered. By
contrast, the Lee index allows estimation of the risk of peri-operative
pulmonary oedema and of complete heart block, in addition to death
and myocardial Infarction
=Risk models do not dictate management decisions but should be
regarded as one piece of the puzzle to be evaluated, in concert
with the more traditional information

21. American Society of Anesthesiologists (ASA)

23. Biomarkers
Based on the existing data, assessment of serum
biomarkers for patients undergoing non-cardiac
surgery cannot be proposed for routine use, but may
be considered in high-risk patients (METs ≤4 or with a
revised cardiac risk index value >1 for vascular surgery
and >2 for non-vascular surgery).

25. Non-invasive testing

26. -Pre-operative LV systolic
dysfunction, moderate-to-severe
mitral
regurgitation, and
increased aortic valve
gradients are associated
with major cardiac events.
-The limited predictive
value of LV function
assessment for peri-operative
outcome may be
related to the failure to
detect severe underlying
IHD.

27. Exercise testing
--Exercise ECG testing is usually the preferred stress test since exercise tolerance is an
important predictor of outcome that appears to be more important than the ECG
response.
--Exercise ECG testing is usually performed with perfusion imaging or
echocardiography since imaging can better identify high-risk features that would
warrant referral for angiography (eg, reversible large anterior wall defect, multiple
reversible defects, ischemia occurring at a low heart rate, extensive stress-induced wall
motion abnormalities, transient ischemic dilatation).
--In addition, concurrent imaging is essential if the resting ECG has abnormalities that
can interfere with the detection of ischemia during exercise stress. These include
preexcitation (Wolff-Parkinson-White) syndrome, a paced ventricular rhythm, more
than 1 mm of ST depression at rest, complete left bundle branch block, and patients
taking digoxin or with ECG criteria for left ventricular hypertrophy, even if they have
less than 1 mm of baseline ST depression.
--Pharmacologic stress testing is preferred in patients with abdominal aortic
aneurysms ≥6.0 cm in diameter or aneurysms that are symptomatic. It is appropriate
to control hypertension prior to stress testing in patients with aneurysms.

28. --Dipyridamole-thallium imaging is usually preferred in patients with known
cardiac arrhythmias, since dobutamine can induce atrial or ventricular
arrhythmias.
--Dobutamine echocardiography is preferred in patients with bronchospastic
lung disease and in those with severe carotid stenosis, because dipyridamole
can induce bronchospasm and a decrease in blood pressure. It is also
preferred when information about left ventricular function or valvular heart
disease is desired. Dobutamine appears to be safe in patients with abdominal
aortic aneurysms. {patients with ≥5 segments involved had more cardiac
events than those with limited stress-induced ischemia }
--DSE has some limitations: it should not, for example, be used in patients
with severe arrhythmias, significant hypertension, large thrombus-laden
aortic aneurysms, or hypotension.
--DSE has a high negative predictive value and a negative test is associated
with a very low incidence of cardiac events in patients undergoing surgery;
however, the positive predictive value is relatively low (between 25% and
45%)

29. -The onset of a myocardial ischaemic response at low
exercise workloads is associated with a significantly
increased risk of peri-operative and long-term cardiac
events. In contrast, the onset of myocardial ischaemia
at high workloads is associated with only a minor risk
increase, but higher than a totally normal test.
-Reversible ischaemia in <20% of the LV myocardium
did not alter the likelihood of peri-operative cardiac
events, compared with those without ischaemia*.

30. EXERCISE STRESS TESTING
Mean sensitivity for Dx of CAD 68%
Mean specificity 77%
Sensitivity for 3-vessel dis. 86%
Negative predictive value 93%

33. **Patients with ACTIVE cardiac conditions (eg, unstable
coronary syndromes, decompensated heart failure, significant
arrhythmias, or severe valvular stenosis) not undergoing
emergency surgery should first be managed according to
ACC/AHA guidelines:
**Patients without active cardiac symptoms undergoing low risk
surgery OR those with good functional capacity (MET level ≥4)
require no preoperative testing aside from an ECG.
**Patients with poor or unknown functional capacity, or
potential cardiac symptoms who are scheduled to undergo
intermediate risk or vascular surgery are managed according to
the number of clinical risk factors.

34. IHD
**The main indications for noninvasive testing in asymptomatic patients are
estimated high risk (≥3 revised cardiac index criteria) or intermediate risk (1
to 2 revised cardiac index criteria) plus poor or indeterminate functional
status, a history consistent with coronary disease, or high-risk surgery
**2007 ACC/AHA guidelines (not changed in the 2009 focused update) and
the 2009 ESC/ESA guidelines on perioperative cardiovascular evaluation and
care for noncardiac surgery, which recommend coronary revascularization for
symptomatic patients with:
(1) high-risk unstable angina or non-ST-elevation MI
(2) acute ST-elevation MI
(3) angina and left main or three-vessel disease
(4) angina and two-vessel disease if this includes proximal LAD stenosis as
well as LV dysfunction or ischemia on stress testing
**Angiography is only warranted in a small number of asymptomatic patients
undergoing noncardiac surgery (2 to 11 percent in series following the
ACC/AHA and ESC/ESA algorithms).

36. Revascularization
-Control of myocardial ischaemia before surgery is recommended
whenever non-cardiac surgery can be safely delayed. There is,
however, no indication for routinely searching for the presence of
myocardial (silent) ischaemia before non-cardiac surgery.
-Coronary pathology underlying fatal peri-operative myocardial
infarctions revealed that two-thirds of the patients had significant
left-main or three-vessel disease Most of the patients did not
exhibit plaque fissuring and only one-third had an intracoronary
thrombussubstantial proportion of fatal peri-operative myocardial
infarctions may have resulted from low-flow, high-demand ischaemia,
owing to the stress of the operation in the presence of fixed coronary
artery stenoses and therefore amenable to revascularization.

37. -CASS:
protective effect of previous coronary revascularization was more
pronounced in patients with triple-vessel CAD and/or depressed LV
function, as well as in those undergoing highrisk surgery, and lasted
for at least six years; however, the study was performed at a time when
medical therapy did not meet current
standards.
-Covering 3949 patients enrolled in 10 studies between the years 1996
and 2006 (nine observational and the CARP randomized trial), a
meta-analysis that addressed the value of pre-operative coronary
revascularization before non-cardiac surgery revealed no significant
difference between coronary revascularization andmedical
management groups, in terms of post-operative mortality and
myocardial infarction There were no long-term outcome benefits
associated with prophylactic coronary revascularization

41. Recent PCI
--2007 ACC/AHA guideline (not changed in the 2009 focused update) suggested the
following approach in patients who require PCI and need subsequent surgery:
*If the bleeding risk of surgery is low, stenting may be performed and dual antiplatelet
therapy continued.
*If the bleeding risk of surgery is not low, balloon angioplasty is suggested for surgery
needed in 14 to 29 days {Delay surgery for at least one week to permit healing of vessel
injury at the balloon treatment site }, bare metal stenting for surgery needed in 30 to
365 days (ESC 2014 minimumof 4weeks and ideally for up to 3 months ), and drug-eluting
stenting for surgery needed after 365 days(ESC 2014 routine extension of
DAPT beyond 6 months is no longer recommended in new generations)
*Balloon angioplasty — <14 days: delay surgery; >14 days: proceed with aspirin
Bare metal stent: <30 to 45 days: delay surgery; >30 to 45 days: proceed with aspirin
Drug eluting stent: <365 days: delay surgery; >365 days: proceed with aspirin

42. ESC/ESA 2014
In summary, it is recommended that DAPT be
administered for at least 1 month after BMS
implantation in stable CAD, for 6 months after new-generation
DES implantation, and for up to 1 year in
patients after ACS, irrespective of revascularization
strategy.
Importantly, a minimum of 1 (BMS) to 3 (new-generation
DES) months of DAPT might be acceptable,
independently of the acuteness of coronary disease, in
cases when surgery cannot be delayed for a longer
period

43. PCI+urgent surgery
--Platelet P2Y12 receptor blocker should be discontinued for as brief a period
as possible while aspirin therapy continues uninterrupted.
--The concept of bridging a gap in platelet P2Y12 receptor blocker therapy
using an intravenous glycoprotein IIb/IIIa inhibitor such as tirofiban is under
investigation .
--Some experts are willing to recommend shorter discontinuation periods,
perhaps up to three days before either cardiac or noncardiac surgery, and
for procedures less likely to be associated with major bleeding. On the other
hand, consideration may be given to discontinuing platelet P2Y12 receptor
blocker at least seven days before intracranial surgery, given the potentially
disastrous consequences of intracranial bleeding.
--Platelet P2Y12 receptor blocker therapy should be restarted with a loading
dose of 300 mg as soon as possible after surgery, perhaps even later in the
day, if postoperative bleeding has stopped. Some experts recommend a higher
loading dose of 600 mg to decrease time to effectiveness in the higher risk
postoperative setting.
--Aspirin should be continued during this period if possible and not be
discontinued without confirming absolute necessity.

44. -Use of heparin or short-acting GP2b/3a inhibitors is not routinely
recommended in patients being withdrawn from clopidogrel because of lack
of evidence and concern for rebound platelet hyperactivity, especially in
absence of ASA, with or without clopidogrel treatment.
-For patients with a very high risk of stent thrombosis, bridging therapy
with intravenous, reversible glycoprotein inhibitors, such as eptifibatide or
tirofiban, should be considered, the use of low-molecular-weight heparin
(LMWH) for bridging in these patients should be avoided.
-For patients receiving anti-platelet therapy, who have excessive or life-threatening
peri-operative bleeding, transfusion of platelets is recommended.
- ESC 2014 Guidelines recommend withholding clopidogrel and ticagrelor for
five days and prasugrel for seven days prior to surgery unless there is a high
risk of thrombosis
-In addition, it is suggested that surgery be performed in centers with 24 hour
interventional cardiology coverage . Thrombolysis is not very effective because
stent thrombosis is mainly a platelet-mediated event.

45. ASA
--The use of low-dose aspirin in patients undergoing
non-cardiac surgery should be based on an individual
decision, which depends on the peri-operative
bleeding risk, weighed against the risk of thrombotic
complications.
--For patients undergoing spinal surgery or certain
neurosurgical or ophthalmological operations,
it is recommended that aspirin be discontinued for at
least seven days.

46. Acute MI, high-risk
ACS, or high-risk
cardiac anatomy
Bleeding risk of
surgery
Low
Stent and continued
dual-antiplatelet
therapy
Not low
Timing of
surgery
14 to 29 days 30 to 365 days > 365 days
Balloon
angioplasty
Bare-metal
stent
Drug-eluting
stent

48. Valvular heart disease
--Echocardiography should be performed in order to
assess its severity and consequences esp in cardiac
murmur.
--In the presence of severe VHD, clinical and
echocardiographic evaluation be performed and, if
necessary, treated before non-cardiac surgery.
--The key issues:
to assess the severity of VHD, the symptoms and their
relationship to VHD, and the estimated risks of valvular
intervention and of cardiac complications according to the
type of non-cardiac surgery

49. Significant valvular heart disease: AS
--Percutaneous balloon valvotomy critically ill awaiting
surgery , pregnant symptomatic{risky}
--ACC/AHA guidelines concluded that most asymptomatic
patients with severe AS can undergo urgent noncardiac surgery
at relatively low risk with careful intraoperative and
postoperative management, including monitoring of anesthesia
and careful attention to fluid balance Balloon valvotomy was
not recommended; aortic valve replacement should be
considered if preoperative correction of AS is warranted
----Control heart rate (particularly in MS), to avoid fluid
overload as well as volume depletion and hypotension
(particularly in AS)
--European 2012

51. Mitral stenosis
--Non-cardiac surgery can be performed with relatively
low levels of risk in patients with non-significant
mitral stenosis (valve area> 1.5 cm2) and in
asymptomatic patients with significant mitral stenosis
(valve area <1.5 cm2) and systolic pulmonary artery
pressure <50 mm Hg.
--Control heart rate (particularly in MS), to avoid fluid
overload

52. AR, MR
--Symptomatic patients—and those who are asymptomatic
with severely impaired LVEF (<30%)—are at high risk of
cardiovascular complications, and non-cardiac surgery
should be performed only if necessary
--Secondary mitral regurgitation should undergo
peri-operative evaluation and management according to
the recommendations for LV systolic dysfunction or IHD

53. Mitral stenosis

54. Prosthetic valves
-According to the ACC guidelines, those patients with a bileaflet mechanical
AVR with no risk factors (ie, AF, previous thromboembolism, LV dysfunction,
hypercoagulable conditions, older generation thrombogenic valves,
mechanical tricuspid valves, or more than one mechanical valve) should stop
their warfarin 48 to 72 hrs before the procedure (so the INR falls to 1.5) and
restarted within 24 hrs after the procedure.
Heparin is usually unnecessary.
-In those patients at high risk of thrombosis (defined as those with any
mechanical MV replacement, or a mechanical AVR with any risk factor),
therapeutic doses of IV UFH should be started when the INR falls below 2.0
(typically 48 hrs before surgery), stopped 4 to 6 hrs before the procedure,
restarted as early after surgery as bleeding stability allows, and continued
until the INR is again therapeutic with warfarin therapy.
-Certain underlying conditions such as previous bacterial endocarditis are
associated with a relatively high risk of IE (ie, previous endocarditis,
mechanical valve replacement, congenital heart disease with shunt and
transplant valvulopathy).

55. Vitamin K antagonists
- (INR) is ≤1.5, surgery can be performed safely
-Patients with a high risk of thrombo-embolism—for example, patients with:
† AF with a CHA2DS2-VASc score of ≥4] or
† mechanical prosthetic heart valves, newly inserted biological prosthetic
heart valves, or
† mitral valvular repair (within the past 3 months) or
† recent venous thrombo-embolism (within 3 months) or
† thrombophilia
 needbridging therapy with unfractionated heparin (UFH) or therapeutic-dose
LMWH
--It is recommended that VKAtreatment be stopped 3–5 days before
surgery (depending on the type of VKA),with daily INR measurements, until
≤1.5 is reached, and thatLMWHor UFH therapy be started one day after
discontinuation of VKA—or later, as soon as the INR is <2.0.
-UFH is resumed after surgery until the INR is within the therapeutic range
-In patients undergoing surgery with a low risk of serious bleeding, such as
cataract- or minor skin surgery, no change in oral anticoagulation therapy is
needed; however, it is wise to keep INR levels in the lower therapeutic range.

56. NOACs
-The overall recommendation is to stop NOACs for 2–
3 times their respective biological half-lives prior to
surgery in surgical interventions with ‘normal’
bleeding risk, and 4–5 times the biological half-lives
before surgery in surgical interventions with high
bleeding risk.
-Because of the fast ‘on’-effect of NOACs (in
comparison with VKAs), resumption of treatment after
surgery should be delayed for 1–2 (in some cases 3–5)
days, until post-surgical bleeding tendency is
diminished.

57. AC+Emergency surgery
VKA:
-(2.5–5.0 mg) intravenous or oral vitamin K is recommended.
-The effect of vitamin K on INR will first be apparent after 6–12 hours.
-If more immediate reversal of the anticoagulant effect of VKAs is needed, treatment with fresh-frozen
plasma or prothrombin complex concentrate (PCC), is recommended, in addition to
low-dose intravenous or oral vitamin K.
Heparin:
-1 mg of protamine sulphate will usually neutralise at least 100 international units of mucous
heparin or 80 units of lung heparin. The dose of protamine sulphate should be reduced if more
than 15 minutes have elapsed since intravenous injection.
-For example, if 30-60 minutes have elapsed since heparin was injected intravenously, 0.5-0.75 mg
protamine sulphate per 100 units of mucous heparin is recommended. If two hours or more have
elapsed, 0.25-0.375 mg per 100 units of mucous heparin should be administered.
-If the patient is receiving an intravenous infusion of heparin, the infusion should be stopped and
25-50 mg of protamine sulphate given by slow intravenous injection.
-If heparin was administered subcutaneously, 1 mg protamine sulphate should be given per 100
units of mucous heparin – 25-50 mg by slow intravenous injection and the balance by intravenous
infusion over 8-16 hours.

58. LMWH:
-In patients who are receiving LMWHs, the
anticoagulant effect may be reversed within eight
hours of the last dose because of the short half-life. If
immediate reversal is required, intravenous protamine
sulphate can be used, but anti-Xa activity is never
completely neutralized (maximum 50%).
(Protamine sulphate should be administered by slow
intravenous injection over a period of ten minutes. Not
more than 50 mg of protamine sulphate should be
given in any one dose.)

63. Decompensated heart failure
--A reduced LVEF of ≤35% was found to be a strong predictor of post-operative
cardiac events
--Echocardiography is not routinely indicated for assessing left ventricular
systolic function in clinically stable patients.
--Echocardiography is reasonable in patients with symptoms or signs of new
or worsening HF, evaluation of inferior vena cava diameter for the
determination of volume status and right atrial pressure.
--Asking patients about the distance they can walk and number of stairs they
can climb can help stratify risk.
--The cause of new or newly decompensated heart failure HF identified by
preoperative history and physical examination should be evaluated before
major elective surgery.
--Signs of HF at the time of surgery probably confer greater risk than a history
of prior HF that is compensated at the time of the preoperative examination.
-- In the absence of new or active myocardial ischemia, postoperative
pulmonary edema does not affect long-term prognosis.

64. --The best assessment of a patient’s overall functional
capacity is achieved by performing a cardiopulmonary
exercise test (CPX/ CPET). Both the cardiac and
pulmonary reserve and their interaction can then be
evaluated.
--An anaerobic threshold of <11 mL O2/kg/min has
been used as a marker of increased risk
……
Still waiting accumulation of data

66. --Decompensated HF should be optimally treated before major elective
surgery, euvolemic before elective surgery, with stable blood pressure and
optimal end-organ perfusion.. Postponement of surgery may be appropriate
until this is accomplished.
--Routine initiation of perioperative beta blocker therapy is of unproven
benefit and associated with potential harm. There is some evidence
supporting benefit in patients at particularly high risk (eg, revised Goldman
cardiac risk index ≥3); HF is one risk factor in this model. In such patients,
beta blocker therapy should optimally be initiated weeks or more before
surgery.
--The routine use of perioperative invasive monitoring is not recommended.
Such monitoring may be considered in unstable patients with HF requiring
immediate surgery.
--Patients found to have postoperative HF should be evaluated for new or
unstable myocardial ischemia. If there is no evidence for new or active
ischemia, pulmonary edema should be initially managed with diuretics.

67. -Consider the possibility of giving the medications via
nasogastric tube or bioequivalent intravenous dose.
-Regarding patients with LV-assist devices, who are
scheduled for non-cardiac surgery, they should be
evaluated pre-operatively by the centre responsible for
implantation and follow-up
--HF-PEF:
Adequate peri-operative monitoring, attention to
volume status, control of afterload, and adequate
diuretic treatment

70. Arrhythmias
--Ventricular arrhythmias, including ventricular premature beats (VPBs) and
ventricular tachycardia (VT) are particularly common in high-risk patients.
--Monomorphic VT may result from myocardial scarring, and polymorphic
VT is a common result of acute myocardial ischaemia.
--Pre-operative detection of these arrhythmias should therefore lead to
evaluation including methods such as echocardiography, coronary
angiography (with revascularization) and, in selected cases, invasive
electrophysiological study, as appropriate.
--Treatment steps for VPBs include identifying and correcting the reversible
causes (e.g. hypoxia, hypokalemia and hypomagnesaemia).
There is no evidence that VPBs or non-sustained VTs alone are associated
with aworse prognosis or that suppressive therapy is beneficial.
--Sustained monomorphic VT with haemodynamic compromise must be
treated promptly with electric cardioversion. Intravenous amiodarone can be
used for initial treatment of patients with stable sustained monomorphic VT,
to prevent recurrences

71. --Beta-blockers are useful in patients with recurrent sustained polymorphic VT,
especially if ischaemia is suspected or cannot be excluded.
--Amiodarone is reasonable for patients with recurrent sustained polymorphic VT in
the absence of long QT syndrome.
--Torsades de pointes (TdP) :
-Withdrawal of any offending drugs and correction of electrolyte abnormalities are
recommended.
-Management with magnesium sulphate should be considered for patients with TdP
and long QT syndrome.
-Beta-blockade, combined with temporary pacing, is suggested in patients with TdP
and sinus bradycardia.
-Isoproterenol is recommended in patients with recurrent, pause-dependent TdP, who
do not have congenital long QT syndrome.
--If the diagnosis is unclear, wide-QRS tachycardia should be presumed to be VT until
proven otherwise.
--Calcium channel blockers, such as verapamil and diltiazem, should not be used in
patients to terminate wide-QRS-complex tachycardia of unknown origin

72. SVT, AF
--While initiating specific drug therapy, possible aggravating factors such as
respiratory failure or electrolyte imbalance should also be corrected
--No medication is recommended to suppress supraventricular premature beats
--Vagal manoeuvres may terminate SVT in some cases; they usually respond well to
treatment with adenosine.
--In cases with incessant or commonly recurring SVT, beta-blockers, calcium channel
blockers, or amiodarone treatment can be used.
--In rare cases (and taking into account the urgency and nature of planned surgery),
pre-operative catheter ablation of the arrhythmia substrate may be considered, e.g. for
patients with Wolff-Parkinson- White syndrome and pre-excited AF.
--The objective in managing peri-operative AF is usually ventricular rate control
beta-blockers and calcium channel blockers (verapamil, diltiazem) are the drugs of
choice
--Amiodarone can be used as a first-line drug in patients with heart failure, since
digoxin is frequently ineffective in high adrenergic states such as surgery.
--Beta-blockers have been shown to accelerate the conversion of AF to sinus rhythm
in the intensive care unit (ICU) after non-cardiac surgery.
--Anticoagulation must be based on the individual clinical situation.

74. Peri-operative bradyarrhythmias
--Usually respond well to short term pharmacological
therapy; temporary cardiac pacing is rarely required.
--Pre-operative establishment of temporary or
permanent cardiac pacing may be appropriate for
patients with complete heart block or symptomatic
asystolic episodes.
--Asymptomatic bifascicular block, with or without
first-degree atrioventricular block, is not an indication
for temporary pacing; however, the availability of an
external pacemaker is appropriate.

75. Peri-operative management of patients with
pacemaker/implantable cardioverter defibrillator
--The use of unipolar electrocautery represents a significant risk, as the electrical
stimulus from electrocautery may inhibit ’demand’ pacemakers, or may reprogram the
pacemaker.
--These problems can be avoided or minimized by
*using bipolar electrocautery
*correct positioning the ground plate for the electrical circuit.
*Keeping the electrocautery device away from the pacemaker
*giving only brief bursts
*using the lowest possible amplitude.
*The pacemaker should be set in an asynchronous or non-sensing mode in
patients who are pacemaker-dependent. This is most easily done in
the operating room by placing a magnet on the skin over the pacemaker.
*Patients whose underlying rhythm is unreliable should have pacemaker interrogation
after surgery, to ensure appropriate programming and sensing-pacing thresholds.
--The defibrillator function of an ICD can be temporarily deactivated by placing a
magnet on the skin over the ICD. While the device is deactivated, an external
defibrillator should be immediately available

76. Congenital heart disease
--When the defect is simple, the circulation
physiologically normal and the patient well
compensated, the risk may be quite low
--However, complicated patients with congenital heart
disease should only undergo non-cardiac surgery after
thorough evaluation by a multidisciplinary team in a
specialized centre.
--Prophylaxis for endocarditis should be initiated
according to the ESC Guidelines on congenital
heart disease and infective endocarditis

77. Beta blockers
--Possible mechanisms for such a benefit include a reduction in myocardial oxygen
demand, as postoperative stress and high catecholamine levels can lead to adverse
cardiac events, an increase in myocardial oxygen delivery due to prolongation of
coronary diastolic filling time, prevention of fatal ventricular arrhythmias, and
protection against plaque rupture in the setting of increased sympathetic activity.
--Given the results of POISE and the subsequent meta-analysis, the evidence does not
support the initiation of prophylactic perioperative beta blocker therapy in most
patients undergoing noncardiac surgery (RCRI ≤2). While beta blockers appear to
decrease the risk of perioperative MI, the observed increases in the rate of stroke
(hypotension), and possibly in the rate total mortality, more than nullified this benefit
in POISE. A majority of the myocardial infarctions will be asymptomatic, but a few will
result in serious complications in the perioperative period. In contrast, most of the
strokes will be seriously disabling or incapacitating.
--POISE does not exclude benefit in high-risk patients (RCRI ≥3), but such patients
comprised only 2 percent.
Similarly, POISE does not exclude benefit of beta blockers in patients with evidence of
significant ischemia by stress tests who do not undergo preoperative coronary
revascularization, in patients undergoing high-risk vascular surgery nor in those
receiving lower doses of perioperative beta blockers.
--It is suggested to start beta blockers at least one and preferably four weeks before
surgery may lessen the chance that they will cause or contribute to hypotension in
the perioperative period, taper carefully postoperative.

78. ACCF/AHA
— The 2009 ACCF/AHA focused update (of the 2007 ACC/AHA guideline
update on perioperative beta blocker therapy for noncardiac surgery) on
perioperative beta blockade made the following recommendations:
-A strong recommendation to continue in patients previously on these agents.
-A weak recommendation in patients undergoing vascular or intermediate-risk
surgery who have coronary artery disease (CAD) OR more than one
clinical risk factor
-A very weak recommendation in patients undergoing vascular surgery who
have a single clinical risk factor in the absence of CAD or in those who have no
clinical risk factors
-For those patients in whom a beta blocker should is started, the process
should begin days to weeks before elective surgery and the dose should be
carefully titrated. A heart rate of 60 to 80 beats per minute (in the absence of
hypotension) in the perioperative period was thought reasonable.

79. ESC/ESA
— The 2009 ESC/ESA guidelines for pre-operative risk assessment and perioperative
cardiac management in non-cardiac surgery made the following recommendations
regarding perioperative beta blocker use:
Beta blockers should be given in all patients undergoing high-risk surgery, have
ischemic heart disease (recommended), or have myocardial ischemia on pre-operative
testing, and considered in patients undergoing intermediate-risk surgery or those
undergoing low-risk surgery AND with risk factors. Continuation of beta blocker
therapy was also considered useful in patients previously treated
Treatment should be initiated between 30 and 7 days before surgery
The preferred initial drugs and doses were bisoprolol 2.5 mg or metoprolol succinate
50 mg daily. Adjustment before surgery should achieve a resting heart rate between 60
to 70 beats/min with a systolic blood pressure greater than 100 mmHg.
--Postoperative tachycardia should firstly lead to treatment of the underlying cause—
for example, hypovolaemia, pain, blood loss, or infection—rather than simply
increasing the beta-blocker dose.

80. ESC/ESA 2014

81. Statins
-- Patients with coronary disease or a coronary equivalent (diabetes
mellitus, symptomatic carotid artery disease, peripheral artery
disease, abdominal aortic aneurysm, chronic kidney disease, or
multiple risk factors that confer a 10-year risk of CHD greater than 20
percent) should receive therapy with a statin unless it is not tolerated.
--For patients on statin therapy undergoing urgent or emergent major
vascular surgery  continuing such therapy.
--For patients not on statin therapy undergoing urgent or emergent
major vascular surgery initiating therapy before surgery, if possible.
--Over the long-term statin therapy be titrated to recommended
goals.
--Statins with a long half-life (e.g. atorvastatin) or extended release
formulations (e.g. lovastatin) may be favoured to bridge the period
immediately after surgery when oral intake is not feasible.

82. Intravenous nitroglycerin
--Intravenous nitroglycerin can reverse intraoperative
myocardial ischemia. However, a small randomized trial
questioned the effectiveness of prophylactic nitroglycerin
in reducing perioperative ischemia .
Furthermore, the decrease in preload induced by
nitroglycerin may outweigh its benefits.
--The use of nitroglycerin must also be considered in
conjunction with the type of anesthetics to be used, since
some agents can mimic the venodilating and arterial
dilating effects of nitroglycerin.
**Transdermal nitroglycerin should not be given
intraoperatively due to uneven absorption

84. CCB
--Although heart rate-reducing calcium channel
blockers are not indicated in patients with heart failure
and systolic dysfunction, the continuation or
introduction of heart rate-reducing calcium channel
blockers may be considered in patients who do not
tolerate beta-blockers.
--Additionally, calcium channel blockers should be
continued during non-cardiac surgery in patients with
vasospastic angina.
--The use of short-acting dihydropyridines—
in particular, nifedipine capsules—should be avoided.

85. Alpha2 receptor agonists
--alpha2 receptor agonists should not be administered
to patients undergoing non-cardiac surgery.
(clonidine increased the risk of clinically important
hypotension and non-fatal cardiac arrest*)

86. Diuretics
--Diuretic treatment—if necessary to control heart failure—
should be continued to the day of surgery and resumed orally
when possible. In the peri-operative period, volume status in
patients with heart failure should be monitored carefully
and optimized by loop diuretics or fluids.
--Any electrolyte disturbance—especially hypokalaemia
and hypomagnesaemia—should be corrected in due time before
surgery. Acute pre-operative repletion in asymptomatic patients
may be associated with more risks than benefits; thus, minor
asymptomatic electrolyte disturbances should not delay acute
surgery.

87. SUMMARY AND RECOMMENDATIONS
The process of estimating and reducing the risk of perioperative
cardiac events (eg, cardiac death and nonfatal MI), includes the
following four components:
--Defining the urgency of surgery. For instance, risk assessment may
not alter the management of patients who need emergency surgery.
--Initial risk assessment:
*Does the patient have a high-risk condition that is considered a major
predictor of risk in the ACC/AHA guidelines?
* What is the surgery-specific risk of the planned operation?
*What is the patient-specific risk?
--Refinement of initial risk assessment with noninvasive testing in
selected patients.
--Efforts to reduce risk in high-risk patients (eg, beta blockers,
revascularization).

93. General features
**These approaches all have the following general features that apply
only to patients in different risk categories undergoing nonemergent
surgery:
--Patients at low risk generally require no further evaluation before
surgery.
--Patients at high risk (eg, those with signs or symptoms of severe or
unstable coronary disease) often undergo coronary arteriography to
see if any correctable lesions are present.
--Patients at intermediate risk : noninvasive testing can be used to
identify the risk category of an individual patient. Noninvasive testing
has a negative predictive value of almost 100 percent for perioperative
death or nonfatal MI but a positive predictive value of less than 20
percent (eg, 98 and 18 percent, respectively in a review of five studies
of dipyridamole-thallium imaging)

94. Peri-operative monitoring
ECG
--Continuous ECG monitoring is recommended for all patients undergoing anaesthesia
--The duration of ST-segment changes correlates positively with the incidence of peri-operative
myocardial infarction; therefore, when ST-segment changes occur, the
clinician should assume that myocardial ischaemia is present if the patient has a
history of pre-existing cardiac disease (Both ST-segment changes and regional wall
motion abnormalities can be present in the absence of acute ischaemia.)
--Although V5 has for many years been regarded as the best choice for the detection of
intra-operative ischaemia, one study found that V4 was more sensitive and appropriate
than V5 for detecting prolonged post-operative ischaemia and infarction
--combining leads V4 and V5 increased the sensitivity to 90%.When the
leads II, V4 andV5were used simultaneously, the sensitivity was greater
than 95%.
--12-lead ECG monitoring is recommended especially in high-risk patients, although
correct positioning of 12 leads is not feasible in high abdominal and thoracic surgery

95. Transoesophageal echocardiography
--TOE is recommended if acute and severe
haemodynamic instability or life-threatening
abnormalities develop during or after surgery

96. --There appears to be no benefit and possible harm from perioperative
use of pulmonary artery catheters (PAC). It has been concluded that
no subgroups have been defined for which PAC provides more benefit
than harm (PE).
--In terms of postoperative monitoring, it has been suggested that a
single postoperative ECG and troponin concentration should be
measured in patients with established coronary heart disease or
peripheral artery disease and in those at higher risk (eg, diabetes,
cerebrovascular disease). Measurements should be repeated if cardiac
symptoms occur or in the setting of hemodynamic instability.
--High risk (high-risk surgery with one or more additional risk factors
of the revised cardiac risk score) obtaining troponin at 6 to 12 hours
and days 1, 2, and 3 after surgery.
--Data are limited on the management of asymptomatic ischemia in
an attempt to prevent cardiac complications. At the least, more careful
monitoring is warranted.

97. -Oxidative stress (a major
cause of macrovascular
disease) is triggered by
swings in blood glucose,
more than by sustained
and persistent
hyperglycaemia
-reduction in mortality in
those whose blood glucose
control was less strict
[7.8–10 mmol/L (140–180
mg/dL)] than in those in
whom it was tightly
controlled [4.5–6 mmol/L
(81–108 mg/dL)], as well as
fewer incidents of severe
hypoglycaemia.

98. Perioperative myocardial infarction
--The 2007 Joint Task Force of the European Society of Cardiology, American College of Cardiology Foundation,
the American Heart Association, and the World Health Federation (ESC/ACCF/AHA/WHF) defined acute MI as a
clinical event consequent to the death of cardiac myocytes (myocardial necrosis) that is caused by ischemia (but
not other etiologies such as myocarditis or trauma).
-Mechanism:
(i) a mismatch in the supply–demand ratio of blood flow, due to a coronary artery stenosis that may become flow-limiting
by peri-operative haemodynamic fluctuations
(ii) stress-induced rupture of a vulnerable atherosclerotic plaque in combination with vascular inflammation and
altered vasomotion
--In the setting of noncardiac surgery, MI has occurred if there is a typical rise and/or gradual fall (troponin) or
more rapid rise and fall (CK-MB) of biochemical markers of myocardial necrosis after surgery in conjunction with
ischemic symptoms or new or presumably new pathologic Q waves or changes of ischemia on the ECG.
--Troponin is the preferred biomarker as CK-MB is less sensitive and less specific in perioperative patients.
--Both short- and long-term survival are decreased in patients who have sustained a perioperative MI.
--While less sensitive and less validated than troponin testing, obtain a 12-lead electrocardiogram in the
perioperative period for the following patients:
All patients with symptoms of myocardial ischemia.
All patients with risk factors for perioperative MI (baseline and daily for two, and possibly, three days).

99. Management
--Statin and beta-blocker therapies should be initiated unless contraindicated.
--Antithrombotic therapy, including oral antiplatelet therapy and intravenous
anticoagulant and antiplatelet therapy are used in many patients with
spontaneous myocardial infarction, which is often due to a plaque-rupture
event. However, in patients who have undergone surgery recently, the risk of
bleeding with these agents may be significantly increased. In addition, many
of these patients have suffered an MI due to abnormalities in supply-demand
balance. It is unclear that these patients need the aggressive antithrombotic
therapy and early intervention that patients with plaque rupture require. The
decision to start one or more of them should be made only after careful
consideration of the risks and benefits.
--Monitoring in an intensive care unit for at least 24 hours is advised,
particularly if the diagnosis is made within the first 24 hours of surgery.
--An echocardiogram should be obtained in most patients.
--Further risk stratification for the extent of coronary artery disease should be
performed when the patient’s clinical condition allows.

100. Obesity
**A 2009 American Heart Association (AHA) scientific
advisory on obesity noted an association with cardiac and
pulmonary diseases, which may negatively affect the
outcome of surgery:
-Heart failure and myocardial steatosis.
-Sleep apnea with or without pulmonary hypertension,
deep vein thrombosis, and pulmonary embolism.
**The estimation of risk is more difficult in obese patients
due to the uncertain significance of certain components
of the history (dyspnea) and physical examination (lower-extremity
edema). The generally poor exercise capacity of
the obese further complicates risk assessment.

101. Renal disease
--Impaired renal function is associated with a significantly increased risk of CVD and is an independent
risk factor for adverse post-operative cardiovascular outcomes
--(eGFR) should be calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI)
formula

102. Contrast-induced AKI (CI-AKI)
--Defined as a rise of serum creatinine of 44 mmol/L (0.5 mg/dL) or a 25% relative rise
from baseline at 48 hours (or 5–10% at 12 hours) following contrast administration.
--in up to 15% of patients with chronic renal dysfunction who are undergoing
radiographic procedures
--Although most cases of CI-AKI are self-limiting, with renal function returning to
normal within 7 days of the procedure, these patients occasionally (in 0.5–12% of
cases) develop overt renal failure, associated with increased morbidity and mortality.
--The pathogenesis of CI-AKI is multifactorial, and is thought to include a decrease in
glomerular filtration and renal hypoperfusion, together with renal medullary
ischaemia, direct tubular toxicity via reactive oxygen species, and direct cellular
toxicity from the contrast agent.
--A range of strategies has been proposed to prevent CI-AKI, including minimizing the
volume of contrast medium administered, use of less-nephrotoxic contrast agents,
provision of prophylactic renal-replacement therapy, patient hydration, and use of
pharmacological agents to counteract the nephrotoxicity of contrast agents
--The relationship between the volume of contrast agent administered
and the development of CI-AKI is well known, and exceeding the maximum contrast
dose (contrast volume/eGFR) is strongly associated with the development of CI-AKI

103. --The use of low osmolar contrast media (LOCM) or iso-osmolar contrast media
(IOCM) is recommended in patients with mild, moderate, or severe CKD
--Although renal-replacement therapy has a favourable effect, in terms of reducing CI-AKI
in patients with stage 4 or 5 CKD, haemodialysis has been found to be non-beneficial
(and potentially harmful) for the prevention of CI-AKI in those with baseline
CKD stage ≤3.
--Normal saline or isotonic sodium bicarbonate (1.26%)may be used and peripherally
administered, with the advantage that it requires only one hour of pre-treatment
--N-acetyl cysteine may be considered for prophylaxis of CI-AKI, given its low cost and
toxicity profile; however, the evidence for its benefit remains inconclusive
--A number of small studies undertaking alkalinization of urine using a range of agents
(bicarbonate, sodium/potassium citrate, acetazolamide) have shown a reduction in the
incidence of contrast-induced nephropathy
--Recent information suggesting the use of high-dose statins in preventing CI-AKI is
promising
--diuretics are therefore not recommended for the prevention or treatment
of AKI.(no evidence)

106. Cerebrovascular disease
-Low incidence of peri-operative stroke (0.1%).
-Mainly ischaemic and cardioembolic and AF is often the underlying leading
condition withdrawal of anticoagulation and the hypercoagulable state related to
surgery
-Additional aetiologies include atheroembolism, originating from the aorta or the
supra-aortic vessels, and local atherothrombosis in the presence of intracranial
smallvessel disease.
-Hypoperfusion—related to peri-operative arterial hypotension and/or severe stenosis
of the cervicocranial vessels—is an unusual cause of peri-operative stroke
-Rarely, peri-operative stroke may be due to air, fat, or paradoxical embolisms.
-The occurrence of this adverse event was associated with a 700% increase in peri-operative
mortality, corresponding to an absolute risk increase exceeding 20%.
-Multivariate analysis identified age, history of myocardial infarction within 6 months
prior to surgery, acute renal failure, history of stroke, history of TIA, dialysis,
hypertension, chronic obstructive pulmonary disease (COPD), and current tobacco use
as independent predictors of perioperative stroke, while high body mass index was
found to be Protective

107. -Antiplatelet/anticoagulant treatments should be continued whenever
possible throughout the peri-operative period. Alternatively, the
period of drug withdrawal should be kept as short as possible while
weighting thrombo-embolic and haemorrhagic risks
-Adequate selection of the anaesthetic technique (regional vs.
neuraxial vs. general anaesthesia), prevention and treatment of AF,
euglycaemic control (avoiding both hyperglycaemia and
hypoglycaemia), as well as meticulous peri-operative blood pressure
control, may all contribute to reducing the risk of peri-operative
stroke.
--Permanent changes in mental status may occur following non-cardiac
surgery, including spatio-temporal disorientation, memory
loss, hallucinations, anxiety or depression. The underlying
mechanisms, often elusive, may include surgery-induced systemic
inflammation and cerebral hypoperfusion.

108. Peripheral artery disease
--It is not recommended to routinely perform exercise
or imaging test to detect cardiac ischaemia inPAD
patients without clinical symptoms, unless the patient
has more than two of the clinical risk factors
--All patients with PAD should be treated with statins
and platelet inhibitors according to guidelines. Blood
pressure control and lifestyle measures should be
attended to

109. -mean pulmonary arterial
pressure >25 mm Hg at rest, as
assessed by right heart
catheterization
-even IV or inhalation if not oral

110. -pre-operative initiation of
appropriate positive airway pressure
therapy, and planning of peri-operative
techniques
(anaesthetic and surgical) and post-operative
positive airway pressure
management

111. -increase
association with
CAD, PAD

112. Anaesthesia
--Preoperative risk assessment and pre-operative
optimization of cardiac disease should be performed as
a team exercise

113. Pre-operatively and post-operatively,
patientswhocouldmost benefit
fromBNPor high-sensitivity
troponin
measurements are those with
METs ≤4 or with a revised
cardiac risk
index value >1 for vascular
surgery and >2 for non-vascular
surgery.

114. -take care of bleeding
risk with antiplatelets,
anticoagulants

115. Thank you

116. DECREASE-V pilot study
— A separate question is whether revascularization is of
value in patients at somewhat higher risk than in CARP.
This issue was addressed in 101 patients who had ≥3 risk
factors and had extensive stress-induced ischemia on
noninvasive testing in the DECREASE-V Pilot Study, which
showed no benefit from preoperative coronary
revascularization at 30 days, one year, or during a median
follow-up of 2.8 years [16,17]. However, the study was
underpowered and the revascularization group had more
diabetes, angina, and prior strokes than the medical
therapy group. Further study is needed in higher risk
subgroups

117. CARP trial
— The Coronary Artery Revascularization Prophylaxis (CARP) trial was a randomized comparison of preoperative revascularization
(with either PCI or CABG) and medical therapy in patients with stable coronary disease undergoing major vascular surgery [14]. Of
5859 patients scheduled for vascular operations, 1190 were considered to be at increased cardiac risk (based upon clinical factors
and/or stress testing) and had no other exclusions to participation (urgent vascular surgery or severe coexisting illness). These patients
underwent coronary angiography; an additional 680 patients were excluded because of left main coronary disease, severe left
ventricular dysfunction (LVEF ≤20 percent), severe aortic stenosis, or coronary anatomy not suitable for revascularization.
The remaining 510 patients (representing only 9 percent of the original study candidates) were randomly assigned to preoperative
revascularization or medical management. Forty-nine percent of patients had a revised cardiac risk index ≥2 and 13 percent had a
score ≥3 (table 2). Two-thirds of the study subjects had either one- or two-vessel disease. Of those assigned to revascularization, 41
percent underwent CABG and 59 percent underwent PCI (based upon clinician preference). Subsequent vascular surgery was
performed for either abdominal aortic aneurysm (33 percent) or lower extremity arterial disease (67 percent).
The trial was designed to have sufficient power to examine long-term mortality, but not to provide a definitive analysis of perioperative
events. The following outcomes were observed:
Postoperative MI by cardiac enzymes occurred with comparable frequency in patients assigned to revascularization and those assigned
to medical therapy (11.6 versus 14.3 percent).
There were no differences between the revascularization and medical arms in left ventricular ejection fraction at three months (54
versus 55 percent).
At a median of 2.7 years, the primary end point (all-cause mortality) was not significantly different in the revascularization and medical
therapy groups (22 versus 23 percent, relative risk 0.98, 95% CI 0.70-1.37).
The CARP trial was not designed to evaluate the best approach to screening or to decide who should undergo angiography. The study
was also not large enough to provide a conclusive analysis of the potential benefit of revascularization in high-risk subgroups, such as
those with a large stress-induced defect on radionuclide myocardial perfusion imaging or those with three vessel disease plus left
ventricular dysfunction. However, a post-hoc, subset analysis did not show any significant lowering in the risk of death and nonfatal MI
from preoperative revascularization in any risk groups, including the highest risk subsets [15].