Professional Documents
Culture Documents
Major non-cardiac surgery is associated with an incidence of modifying intra- and postoperative patient care, preopera-
perioperative cardiac death of 0.5–1.5%, and of major cardio- tive cardiac management is hoped to improve overall peri-
vascular complications (non-fatal cardiac arrest, non-fatal operative outcome. The immediate aims of preoperative
myocardial infarction, heart failure, clinically relevant cardiac management are: (i) identification of patients with
arrhythmias, and stroke) of 2.0– 3.5%. Underlying cardiovas- potentially life-threatening cardiac disease that requires
cular disease significantly contributes to perioperative mor- preoperative assessment and treatment by a cardiologist;
bidity and mortality.1 Depending on the type of surgery (ii) identification of the most appropriate testing and avoid-
and patient age, the prevalence of various cardiovascular ance of unnecessary testing (an important aspect because
diseases in patients undergoing non-cardiac surgery ranges non-invasive and invasive testing are not only associated
from ,5% to 70%, being highest in patients older than with patient discomfort and financial burden, but also
70 yr undergoing major vascular surgery.1 with morbidity and mortality related to the test procedure,
Preoperative cardiovascular management is an essential false test results, and postponement of required surgery);
component of overall perioperative cardiovascular care. It and (iii) identification and implementation of most appro-
involves preoperative detection and management of cardio- priate medical (e.g. initiation, continuation, or optimization
vascular disease, and prediction of both short- and long- of cardiovascular medication) and interventional cardiovas-
term cardiovascular risk. It thereby not only affects anaes- cular treatment strategies (e.g. preoperative coronary
thetic perioperative management (e.g. choice of anaes- revascularization or cardiac valve replacement). The ulti-
thetic drug and method, type of monitoring, postoperative mate goal of preoperative cardiovascular management is
care) but also surgical decision-making (e.g. postponement, to improve overall patient outcome. This requires individua-
modification, and cancellation of surgical procedure). By lized management.
& The Author [2011]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
For Permissions, please email: journals.permissions@oup.com
BJA Priebe
Preoperative assessment
Table 1 Classes of recommendations1
Active cardiac conditions, a high-risk surgical procedure, and
poor exercise tolerance are the strongest independent pre- Classes Definitions
dictors of adverse perioperative cardiac outcome. I Evidence and/or general agreement that a given
treatment or procedure is beneficial, useful, and
effective
Active cardiac conditions II Conflicting evidence and/or a divergence of opinion
Active/unstable cardiac conditions [unstable angina pectoris, about the usefulness/efficacy of the given treatment or
acute heart failure, significant cardiac arrhythmias, sympto- procedure
matic valvular heart disease (VHD), and recent myocardial IIa Weight of evidence/opinion is in favour of usefulness/
efficacy
infarction with residual myocardial ischaemia] are associated
IIb Usefulness/efficacy is less well established by evidence/
with very poor perioperative outcome. They thus need to be
opinion
identified and, if present, evaluated and treated by a cardiol-
III Evidence or general agreement that the given
ogist according to respective national or international guide- treatment or procedure is not useful/effective, and in
lines. Subsequent management (delay, modification, or some cases may be harmful
cancellation of planned procedure) will depend on test
results and response to treatment.
84
Preoperative cardiac management BJA
Table 3 Cardiac risk stratification (combined incidence of cardiac death and non-fatal myocardial infarction within 30 days of surgery) according
to surgical risk. *These procedures do not generally require further preoperative cardiac testing. On the basis of guidelines published by the
European Society of Cardiology (ESC)1
85
BJA Priebe
resting oxygen uptake. Depending on the resting oxygen con- If performed and interpreted appropriately, CPET provides
sumption, 4 METs may reflect very different oxygen uptakes. a wealth of additional information beyond standard cardiac
Without knowing the individual’s resting oxygen consump- stress tests which can potentially assist in the perioperative
tion and gas exchange characteristics, and without control- management of complex cardiovascular and pulmonary
ling for height and speed of climbing and walking, it is disease.24 25 However, CPET requires complex equipment
impossible to know whether an individual remains below or and highly trained personnel for correctly performing the
above their anaerobic threshold (AT) at those given activities. test and interpreting the results; it is not feasible in the
Thus, applying an average oxygen consumption value to immobile patient, the individual positive predictive values
each individual irrespective of body composition and age of VO2 peak and AT remain to be determined, and identifi-
must be expected to lower the predictive value. In addition, cation of the AT is not always straightforward. The results
assessment relies on patient reporting and may thus not of the DASI questionnaire, the ISWT, and the cycle CPET do
necessarily reflect the individual’s true functional capacity. not necessarily agree. Although a significant correlation
However, assessment of functional capacity by the DASI between measured oxygen consumption and both ISWT
questionnaire or MET can be helpful when formal exercise and DASI has been reported, and although both ISWT and
testing is not possible (e.g. in emergency cases, in immobile DASI were satisfactory predictors of VO2 peak .15 ml O2
or non-cooperative patients, and in patients with pain). kg21 min21 and AT .11 ml O2 kg21 min21, patients with
unsatisfactory questionnaire scores or shuttle walk test
results may have satisfactory CPET results.17 Overall,
Incremental shuttle walk test however, the CPET provided more robust information than
The incremental shuttle walk test (ISWT) is widely used for did Duke’s score and shuttle testing. It remains to be seen
the assessment of cardiopulmonary reserve. It has the whether such relatively objective information modifies peri-
patient walk up and down a usually 10 m course (shuttle) operative management in a way which improves periopera-
at a speed dictated by an audio signal, with the walking tive outcome.
86
Preoperative cardiac management BJA
Table 5 Cardiac risk factors (modified after ref. 1) Table 6 Recommendations for preoperative resting
electrocardiogram and echocardiography (modified after ref. 1)
History of angina pectoris
History of myocardial infarction Recommendations Class Level of
History of heart failure evidence
reproduce all of the factors of the RCRI as independent pre- Recommended: for patients with severe I C
valvular heart disease
dictors of outcome, and identified additional pre- and intra-
Should be considered: for left ventricular IIa C
operative independent predictors of outcome (e.g. age.68 assessment in patients undergoing
yr, BMI .30 kg m – 2, hypertension, duration of surgery high-risk surgery
≥3.8 h, red blood cell transfusion ≥1 unit).3 If validated,
87
BJA Priebe
88
Preoperative cardiac management BJA
ischaemic events. As 30% of patients (66 of 216) undergoing
coronary angiography underwent preoperative percutaneous Table 9 Recommendations for coronary revascularization
(modified after ref. 1). STEMI, ST-segment elevation myocardial
coronary intervention (PCI) because of one or more coronary
infarction (MI); NSTEMI, non-ST-segment elevation MI; LAD, left
artery stenosis .75%, it is possible that the improved anterior descending; LV, left ventricular. Class of recommendation
outcome was, again, due to preoperative coronary revascu- and level of evidence in parentheses)
larization. In this study, preoperative angiography and coron-
ary revascularization were seemingly associated with benefit Patients with acute coronary syndrome
in some circumstances (i.e. asymptomatic patients under- All patients with STEMI (I,A)
going intermediate-risk vascular surgery) where the ESC Patients with NSTEMI at high risk (elevated serum troponin
concentration and ST-segment depression at baseline, ongoing
management algorithm (see below) clearly does not rec-
symptoms, high thrombotic risk, advanced age, diabetes
ommend such interventions. mellitus) (I,A)
However, the limiting factor of this study is that coronary Patients with stable angina pectoris or silent ischaemia and . . .
angiography was used as the primary and only means of Left main coronary artery stenosis .50% (I,A)
detecting coronary artery disease. It is thus possible that Any proximal LAD coronary artery stenosis .50% (I,A)
outcome in the patients not undergoing preoperative angio- 2- or 3-vessel coronary artery disease with impaired LV function
graphy was worse because they were not adequately (I,B)
assessed for clinically relevant coronary artery disease. It is Documented LV ischaemic area .10% (I,B)
likely that several of the control patients had poor or Single remaining patent vessel with .50% stenosis and
unknown functional capacity and ≥3 cardiac risk factors. If impaired LV function (I,C)
these had been managed according to the ESC algorithm Patients with persistent signs of extensive ischaemia or a high
(see below), they would have undergone additional pre- cardiac risk undergoing high-risk vascular surgery (IIb, B)
operative non-invasive cardiac testing. The results of such
testing might have affected subsequent management in a
89
BJA Priebe
Patient or surgery-specific factors dictate the strategy, and do not allow further
cardiac testing or treatment. The consultant provides recommendations on
Step 1 Urgent surgery Yes
perioperative medical management, surveillance for cardiac events, and
continuation of chronic cardiovascular medication
No
Treatment options should be discussed in a multidisciplinary team, involving all
perioperative physicians because interventions might have implications on
Step 2 One of active or unstable Yes
anaesthetic and surgical care. For instance, in the presence of unstable angina, if
cardiac conditions the planned surgical procedure can be delayed, patients can proceed for coronary
artery intervention with the initiation of dual antiplatelet therapy; if delay is
No impossible, surgery is performed as planned under optimal medical therapy
The consultant can identify risk factors and provide recommendations for
Step 3 Risk of surgical procedure† Low postoperative care with regard to life style and medical therapy according to
European Society of Cardiology (ESC) guidelines to improve long-term outcome
Intermediate or high
≤ 4 METs
• Preoperative statin therapy and a titrated low-dose β-blocker regimen
appear appropriate
Intermediate • Preoperative therapy with angiotensin inhibitors is recommended in patients
Step 5 Risk of surgical procedure†
risk with systolic left ventricular dysfunction
• A preoperative baseline electrocardiogram is recommended in patients with
≥ 1 cardiac risk factor(s) to monitor changes during the perioperative period
High risk
Step 7 Consideration of non-invasive testing. Non-invasive testing can also be considered before any surgical procedure for
patient counselling, change of perioperative management in relation to type of surgery, and anaesthetic technique
Fig 1 Algorithm for preoperative cardiac risk assessment and management. Modified after the ESC algorithm for preoperative cardiac risk
assessment and management.1 MET, metabolic equivalent task. †See Table 3 for risk of surgical procedure. #See Table 4 for assessment of
functional capacity. See Table 5 for cardiac risk factors.
patient is able to generate .4 METs in daily life (as indicated cardiac risk assessment’,1 this is not the case with the follow-
by confirmatory answers to the respective questions), peri- ing steps because they are based on the RCRI, a population-
operative prognosis is usually good (independent of a derived risk index with poor discriminative power. Despite
history of cardiac disease) and surgery can be performed this limitation, it is used in the decision-making for sub-
as planned without additional cardiac testing. In patients sequent non-invasive cardiac testing. If such testing would
with documented coronary artery disease or cardiac risk reliably discriminate between low and high risk, the poor dis-
factors, preoperative initiation of statin therapy and a titrated criminative power of the RCRI would not be of a major
low-dose b-blocker regimen can be considered. concern. However, as mentioned above, the positive predic-
tive values of cardiac stress tests are also uniformly very
Step 5: re-assessment of surgical risk low. The ESC algorithm states that in patients with up to
As patients with reduced functional reserve carry an two clinical cardiac risk factors (Table 5), surgery can be per-
increased perioperative cardiac risk, re-assessment of the formed as planned after optimization of cardiovascular
cardiac risk of the surgical procedure is recommended medication.
in patients with unknown or a functional capacity of
≤4 METs. Such patients may undergo intermediate-risk Step 7: consideration of non-invasive testing
surgery without additional cardiac testing. In this case, Because of the uniformly low positive predictive values of
optimal cardiovascular medication should be assured and cardiac stress test, cardiac stress testing is strongly rec-
a baseline ECG obtained in patients with cardiac risk ommended only in patients with ≥3 clinical risk factors
factors. If high-risk surgery is planned, cardiac risk factors undergoing high-risk surgery (i.e. open aortic surgery or
need to be assessed. open lower extremity arterial surgery) (Table 7).
Step 6: assessment of cardiac risk factors Step 8: interpretation of stress test results
Whereas the first four steps of the management algorithm If cardiac stress testing shows no or only mild
meet the objective of the ESC guidelines for ‘individualized stress-inducible myocardial ischaemia, the ESC guidelines
90
Preoperative cardiac management BJA
do not make additional invasive testing mandatory, but rec- emphasis must be placed on optimal perioperative medical
ommend to start therapy with statins and titrated low-dose therapy in high-risk patients. Pharmacological stabilization
b-blockers (Fig. 2). Patients with extensive stress-inducible of coronary plaques (by statins, aspirin, b-blockers, and ACE
myocardial ischaemia present a challenge. On the one inhibitors) is probably more effective in reducing periopera-
hand, even optimal medical treatment will not necessarily tive cardiac morbidity and mortality than increasing myocar-
provide sufficient cardioprotection. On the other hand, preo- dial oxygen delivery by coronary revascularization.
perative prophylactic coronary revascularization usually does Preoperative optimization of cardiovascular medication is
not improve perioperative outcome in this patient popu- certainly one of the most important, if not the most impor-
lation. Under these circumstances, a highly individualized tant aspect of preoperative cardiac management.61 62
approach is required. The very high cardiac risk of the
planned surgical procedure needs to be balanced against
the possible harms of not performing surgery (e.g. risk of
b-Blockers
rupture of an abdominal aneurysm). If there is an indication As a consequence of the results of the POISE study,63 the
for coronary revascularization, the angiographic findings, focused update on perioperative b-blockade by the ACC
patient preference, and the anticipated time interval and AHA18 64 list only one class I indication for perioperative
between coronary revascularization and surgery will influ- b-blocker therapy: continuation of b-blockers in patients
ence the method of coronary revascularization (Fig. 2). undergoing surgery who are receiving b-blockers for
treatment of conditions with ACC/AHA class I guideline indi-
cations (level of evidence: C). In contrast, the ESC guidelines1
Pharmacological management list three class I indications for perioperative b-blocker
When considering the pathophysiology of coronary artery therapy: (i) patients with known coronary artery disease or
disease,28 54 55 the proven cardioprotective efficacy of myocardial ischaemia on preoperative stress testing (level
optimal medical therapy in patients with clinically relevant of evidence: B); (ii) patients undergoing high-risk surgery
coronary artery disease and the questionable additional (level of evidence: B); and (iii) patients previously treated
benefit of additional coronary revascularization in secondary with b-blockers for coronary artery disease, arrhythmias, or
cardiac prevention,51 56 – 59 the morbidity and mortality hypertension (level of evidence: C). The third class I indi-
associated with coronary artery revascularization,45 the lack cation is identical with that of the ACC/AHA. However, the
of proven benefit of a prophylactic preoperative coronary other two class I indications are not supported by findings
revascularization,39 – 41 52 and the increased perioperative of the POISE study. Both guidelines emphasize early start
risk of patients with coronary artery stents,53 60 great and dose titration of b-blockers. The ACC/AHA guidelines18
91
BJA Priebe
64
recommend that treatment be started days to weeks Patients may be receiving ACE inhibitors or ARBs to primarily
before surgery, aiming at a heart rate of 60–80 beats treat hypertension or LV systolic dysfunction (e.g. after myo-
min21 while avoiding hypotension. The ESC guidelines1 rec- cardial infarction). Taking into account the high risk associ-
ommend that treatment be started optimally between 30 ated with decompensation of LV function, in cardiovascular
days and at least 1 week before surgery, aiming at a heart stable patients taking ACE inhibitors or ARBs for treatment
rate of 60–70 beats min21 and a systolic arterial pressure of LV dysfunction, the medication should be continued
.100 mm Hg. It remains to be seen whether these rec- when undergoing high-risk surgery (I, C), and continuation
ommendations can be fulfilled in daily clinical practice. should be considered when undergoing low- or
The importance of strict heart rate control as an indepen- intermediate-risk surgery (IIa, C).1 In patients taking the
dent predictor of outcome remains open to debate. A medication for treatment of hypertension, transient discon-
thorough search for causes of tachycardia other than myo- tinuation should be considered (IIb, C). All of these rec-
cardial ischaemia must be conducted before an elevated ommendations are based on low level evidence, reflecting
heart rate is symptomatically treated with b-blockers. Per- lack of scientifically solid data.
sistent perioperative tachycardia may well be due to hypovo-
laemia, pain, anxiety, anaemia, hypothermia, infection, Antiplatelet therapy
latent heart failure, or pulmonary embolism. In such situ-
Aspirin
ations, heart rate control by b-blockers could endanger
lives. Especially, anaemic patients may not be tolerating Discontinuation of aspirin may be responsible for 15% of all
aggressive, heart rate-controlled perioperative b-blocker recurrent acute coronary syndromes in patients with docu-
therapy.65 – 67 mented stabile coronary artery disease.86 87 Thus, aspirin
taken for secondary cardiac prevention should, in general,
Statins not be discontinued.88 Perioperatively, aspirin should only
be discontinued if the expected risk of bleeding and its poss-
92
Preoperative cardiac management BJA
If surgery cannot be postponed, at least aspirin should be 3 Kheterpal S, O’Reilly M, Englesbe M, et al. Pre-operative and
continued whenever possible. intra-operative predictors of cardiac adverse events after
general, vascular, and urological surgery. Anesthesiology 2009;
110: 58– 66
Conclusion
4 Monin J-L, Lancellotti P, Monchi M, et al. Risk score for predicting
Although preoperative cardiac management has improved outcome in patients with asymptomatic aortic stenosis. Circula-
during the past decades, we are not yet in the situation tion 2009; 120: 69–75
where we can accurately predict individual perioperative 5 Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valve
risk.104 There are several reasons for that. First, the individ- implantation for aortic stenosis in patients who cannot
ual stress response (e.g. cardiovascular and endocrine) to a undergo surgery. N Engl J Med 2010; 363: 1597– 607
given stressor (e.g. a given surgical procedure, haematocrit 6 Tamburino C, Capodanno D, Ramando A, et al. Incidence and
predictors of early and late mortality after transcatheter aortic
value) and the individual interactions between pharmaco-
valve implantation in 663 patients with severe aortic stenosis.
logical intervention (e.g. antiplatelet and cardiovascular Circulation 2011; 123: 299– 308
medication) and intra- and postoperative risk factors (e.g. 7 Buellesfeld L, Windecker S. Transcatheter aortic valve implan-
anaemia, hypercoagulability, hypovolaemia, inflammatory tation: the evidence is catching up with reality. Eur Heart J
response, and cardiovascular depression) are highly 2011; 32: 133–7
variable. 8 Eltchaninoff H, Prat A, Gilard M, et al. Transcatheter aortic valve
Secondly, and probably more important, preoperative implantation: early results of the FRANCE (FRench Aortic
cardiac management is only one aspect of overall periopera- National CoreValve and Edwards) registry. Eur Heart J 2011;
tive care. There are numerous intra- and postoperative 32: 191– 7
factors (e.g. haemodynamic, endocrine, metabolic, and 9 Zahn R, Gerckens U, Grube E, et al. Transcatheter aortic valve
implantation: first results from a multi-centre real-world regis-
inflammatory responses; surgical care issues; duration of
try. Eur Heart J 2011; 32: 198– 204
surgery; hypovolaemia; hypothermia; anaemia; thromboem-
10 Older P, Smith R, Courtney P, Hone R. Pre-operative evaluation of
93
BJA Priebe
20 Singh SJ, Morgan MD, Hardman AE, Rowe C, Bardsley PA. 37 Choi J-H, Cho DK, Song Y-B, et al. Pre-operative NT-proBNP and
Comparison of oxygen uptake during a conventional treadmill CRP predict peri-operative major cardiovascular events in non-
test and the shuttle walking test in chronic airflow limitation. cardiac surgery. Heart 2010; 96: 56 –62
Eur Respir J 1994; 7: 2016–20 38 Bolliger D, Seeberger MD, Filipovic M. Pre-operative cardiac risk
21 Onorati P, Antonucci R, Valli G, et al. Non-invasive evaluation of assessment in noncardiac surgery: are natriuretic peptides the
gas exchange during a shuttle walking test vs. a 6-min walking magic bullet? J Am Coll Cardiol 2009; 54: 1607–8
test to assess exercise tolerance in COPD patients. Eur J Appl 39 McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascular-
Physiol 2003; 89: 331–6 ization before elective major vascular surgery. N Engl J Med
22 Win T, Jackson A, Groves AM, Sharples LD, Charman SC, 2004; 351: 2795–804
Laroche CM. A comparison of shuttle walk with measured 40 Poldermans D, Schouten O, Vidakovic R, et al. A clinical random-
peak oxygen consumption in patients with operable lung ized trial to evaluate the safety of a noninvasive approach
cancer. Thorax 2006; 61: 57– 60 in high-risk patients undergoing major vascular surgery:
23 Older P, Smith R. Experience with the pre-operative invasive the DECREASE-V Pilot Study. J Am Coll Cardiol 2007; 49: 1763– 9
measurement of haemodynamic, respiratory and renal function 41 Schouten O, van Kuijk J-P, Flu W-J, et al. Long-term outcome of
in 100 elderly patients scheduled for major abdominal surgery. prophylactic coronary revascularization in cardiac
Anaesth Intensive Care 1988; 16: 395– 8 high-risk patients undergoing major vascular surgery (from
24 Balady GJ, Arena R, Sietsema K, et al. Clinician’s guide to cardi- the randomized DECREASE-V pilot study). Am J Cardiol 2009;
opulmonary exercise testing in adults. A scientific statement 103: 897– 901
from the American Heart Association. Circulation 2010; 122: 42 Monaco M, Stassano P, Di Tommaso L, et al. Systematic strategy
191– 225 of prophylactic coronary angiography improves long-term
25 Arena R, Sietsema KE. Cardiopulmonary exercise testing in the outcome after major vascular surgery in medium- to high-risk
clinical evaluation of patients with heart and lung disease. Circu- patients: a prospective, randomized study. J Am Coll Cardiol
lation 2011; 123: 668– 80 2009; 54: 989– 96
26 Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and 43 Landesberg G, Mosseri M. Prophylactic pre-operative coronary
prospective validation of a simple index for prediction of revascularization: is the phoenix awakening? J Am Coll Cardiol
94
Preoperative cardiac management BJA
53 Howard-Alpe GM, de Bono J, Hudsmith L, Orr WP, Foex P, 75 Kapoor AS, Kanji H, Buckingham J, Devereaux PJ, McAlister FA.
Sear JW. Coronary artery stents and non-cardiac surgery. Br J Strength of evidence for peri-operative use of statins to reduce
Anaesth 2007; 98: 560–74 cardiovascular risk: systematic review of controlled studies. Br
54 Libby P, Theroux P. Pathophysiology of coronary artery disease. Med J 2006; 333: 1149–56
Circulation 2005; 111: 3481– 8 76 Biccard BM. A peri-operative statin update for non-cardiac
55 Levin R. Plaque vulnerability: pathologic form and patient fate. surgery. Part II: Statin therapy for vascular surgery and peri-
J Am Coll Cardiol 2010; 55: 133– 4 operative statin trial design. Anaesthesia 2008; 63: 162–71
56 Diamond GA, Kaul S. COURAGE under fire: on the management 77 Schouten O, Boersma E, Hoeks SE, et al. Fluvastatin and peri-
of stable coronary disease. J Am Coll Cardiol 2007; 50: 1604– 9 operative events in patients undergoing vascular surgery.
57 Hochman JS, Steg PG. Does preventive PCI work? N Engl J Med N Engl J Med 2009; 361: 980–9
2007; 356: 1572–4 78 Le Manach Y, Godet G, Coriat P, et al. The impact of postopera-
58 O’Rourke RA. Optimal medical therapy is a proven option for tive discontinuation or continuation of chronic statin therapy
chronic stable angina. J Am Coll Cardiol 2008; 52: 905–7 on cardiac outcome after major vascular surgery. Anesth
Analg 2007; 104: 1326–33
59 Peterson ED, Rumsfeld JS. Finding the courage to reconsider
medical therapy for stable angina. N Engl J Med 2008; 359: 79 Schouten O, Hoeks SE, Welten GMJM, et al. Effect of statin with-
751– 3 drawal on frequency of cardiac events after vascular surgery.
Am J Cardiol 2007; 100: 316–20
60 Spahn DR, Howell SJ, Delabays A, Chassot P-G. Coronary stents
and peri-operative anti-platelet regimen: dilemma of bleeding 80 Kersten JR, Fleisher LA. Statins. The next advance in cardiopro-
and stent thrombosis. Br J Anaesth 2006; 96: 675–7 tection? Anesthesiology 2006; 105: 1079– 80
61 Flu WJ, Hoeks SE, van Kuijk JP, Bax JJ, Poldermans D. Treatment 81 Feldman LS, Broman DJ. Peri-operative statins: more than
recommendations to prevent myocardial ischemia and infarc- lipid-lowering? Cleveland Clin J Med 2008; 75: 654– 62
tion in patients undergoing vascular surgery. Curr Treat 82 Poldermans D. Statins and noncardiac surgery: current evidence
Options Cardiovasc Med 2009; 11: 33– 44 and practical considerations. Cleveland Clin J Med 2009; 76
62 Voûte MT, Winkel TA, Poldermans D. Optimal medical manage- (Suppl 4): S79 –83
ment around the time of surgery. Heart 2010; 96: 1842–8 83 Briguori C, Visconti G, Focaccio A, et al. Novel approaches for pre-
95
BJA Priebe
93 Eisenstein EL, Anstrom KJ, Kong DF, et al. Clopidogrel use and 99 Casterella PJ, Tcheng JE. Review of the 2005 American College of
long-term clinical outcomes after drug-eluting stent implan- Cardiology, American Heart Association, and Society for Cardio-
tation. J Am Med Assoc 2007; 297: 159– 68 vascular Interventions guidelines for adjunctive pharmacologic
94 Ho PM, Peterson ED, Wang L, et al. Incidence of death and acute therapy during percutaneous coronary interventions: practical
myocardial infarction associated with stopping clopidogrel after implications, new clinical data, and recommended guideline
acute coronary syndrome. J Am Med Assoc 2008; 299: 532–9 revisions. Am Heart J 2008; 155: 781–90
95 Silber S, Albertsson P, Avilès FF, et al. Guidelines for percuta- 100 Riddell JW, Chiche L, Plaud B, Hamon M. Coronary stents and
neous coronary interventions: the Task Force for Percutaneous noncardiac surgery. Circulation 2007; 116: e378– 82
Coronary Interventions of the European Society of Cardiology. 101 Practice alert for the peri-operative management of patients
Eur Heart J 2005; 26: 804– 47 with coronary artery stents: a report by the American Society
96 Bassand JP, Hamm CW, Ardissino D, et al. Guidelines for the of Anesthesiologists Committee on Standards and Practice Par-
diagnosis and treatment of non-ST-segment elevation acute ameters. Anesthesiology 2009; 110: 22 –3
coronary syndromes. Eur Heart J 2007; 28: 1598– 660 102 Schouten O, van Domburg RT, Bax JJ, et al. Noncardiac surgery
97 Van de Werf F, Bax J, Betriu A, et al. Management of acute myo- after coronary stenting: early surgery and interruption of anti-
cardial infarction in patients presenting with persistent platelet therapy are associated with an increase in major
ST-segment elevation: the Task Force on the management of adverse cardiac events. J Am Coll Cardiol 2007; 49: 122–4
ST-segment elevation acute myocardial infarction of the Euro- 103 Rabbitts JA, Nuttall GA, Brown MJ, et al. Cardiac risk of noncar-
pean Society of Cardiology. Eur Heart J 2008; 29: 2909– 45 diac surgery after percutaneous coronary intervention with
98 Grines CL, Bonow RO, Casey DE, et al. Prevention of premature drug-eluting stents. Anesthesiology 2008; 109: 596– 604
discontinuation of dual antiplatelet therapy in patients with cor- 104 Reilly CS. Can we accurately assess an individual’s peri-operative
onary artery stents. A science advisory from the American Heart risk? Br J Anaesth 2008; 101: 747–9
Association, American College of Cardiology, Society for Cardio- 105 Kehlet H, Mythen M. Why is the surgical high-risk patient still at
vascular Angiography and Interventions, American College of risk? Br J Anaesth 2011; 106: 289–91
Surgeons, and American Dental Association, with represen- 106 Grocott MPW, Pearse RM. Prognostic studies of peri-operative
tation from the American College of Physicians. Circulation risk: robust methodology is needed. Br J Anaesth 2010; 105:
96