Preoperative Cardiac Risk Assessment
An Updated Approach
Lina Romero, MD; Christian de Virgilio, MD
Hypothesis We provide an updated algorithm for approaching preoperative
cardiac risk assessment in patients undergoing noncardiac surgery.
Design A National Library of Medicine PubMed literature search was
performed dating back to 1985 using the keywords "preoperative cardiac
risk for noncardiac surgery." This search was restricted to English
language articles involving human subjects.
Results Patient-specific and operation-specific cardiac risk can be
determined clinically. Patients with major cardiac risk factors have a high
incidence of perioperative cardiac complications, whereas the risk is less than
3% for low-risk patients. For intermediate-risk patients, no prospective
randomized studies demonstrate the efficacy of noninvasive stress testing
(dipyridamole thallium or dobutamine echocardiography) or of subsequent
coronary revascularization for preventing perioperative cardiac complications.
Recent studies demonstrate that perioperative -blockade
significantly reduces the adverse cardiac event rate in intermediate-risk
patients.
Conclusions Most patients with high cardiac risk should proceed with coronary
angiography. Patients with low cardiac risk can proceed to surgery without
noninvasive testing. For intermediate-risk patients, consideration may be given
to further stress testing prior to surgery; however, in most patients,
proceeding to surgery with perioperative -blockade
is an acceptable alternative.
Arch Surg. 2001;136:1370-1376
CARDIOVASCULAR disease is a major public health
concern affecting 25% of Americans and is the number one killer in the United States,
Canada, Europe, and Japan.1 One third of
noncardiac surgical patients may harbor coronary artery disease (CAD), a
significant cause of perioperative morbidity and mortality after noncardiac
surgery.2 In a series of
1000 patients undergoing coronary angiography prior to peripheral vascular
surgery, 25% of patients were found to have surgically correctable CAD.3 Thus, the importance
of performing cardiac risk assessment prior to surgery to identify high-risk
patients in whom adverse cardiac events may be prevented becomes clear. In most
patients, however, an extensive cardiac workup is unnecessary and costly and
delays definitive patient care. The purpose of this article is to provide a
general framework for approaching cardiac risk assessment in patients
undergoing noncardiac surgery. Risk assessment needs to be individualized and
should be based on the urgency of the operation, the type of procedure planned
(operation-specific risk), and the patient's clinical risk factors
(patient-specific risk). We will discuss the rationale and guidelines for
preoperative cardiac risk assessment, describe various risk-scoring systems and
available noninvasive tests, and propose an updated treatment algorithm.
Cardiac complications are the leading cause of
perioperative morbidity and mortality following noncardiac surgery. These
complications are defined as unstable angina or myocardial ischemia, myocardial
infarction (MI), dysrhythmias, congestive heart failure (CHF), and cardiac
death. The likelihood of developing a perioperative cardiac event is related to
the urgency and magnitude of the procedure and the degree of hemodynamic stress
experienced by the patient. Intraoperative myocardial ischemia is often noted
as ST segment changes in the lateral leads on an electrocardiogram (ECG) or as
segmental wall motion abnormalities on transesophageal echocardiography. Postoperative
ischemia is often silent and typically begins between postoperative days 3 and
5. Perioperative ischemic changes are precipitated by factors that increase
myocardial oxygen demand such as tachycardia, hypertension, anemia, stress, or
the discontinuation of -blockers.4
Based on the previous factors, operations have
been classified as low, intermediate, or high risk (Table 1).
High-risk operations carry a perioperative adverse cardiac event or death rate
of 5% or greater. These include major emergent operations, especially in
elderly patients, aortic and lower-extremity vascular surgery, and anticipated
prolonged procedures with expected fluid shifts or high estimated blood loss.
Intermediate-risk operations are reported to carry a cardiac risk of less than
5%. These include carotid endarterectomy, uncomplicated head and neck
procedures, and intraperitoneal, intrathoracic, orthopedic, and prostate
surgery. For low-risk procedures such as endoscopy, superficial procedures,
cataract surgery, and breast surgery, the associated cardiac risk is reported
to be less than 1%.4 Thus, with respect to
surgery-specific risk, a detailed cardiac assessment should focus on patients
undergoing high-risk operations. In most instances, these operations are major
vascular in nature because patients undergoing emergency surgery do not have
time for an in-depth assessment. Selected patients undergoing intermediate- or
low-risk operations may warrant careful evaluation based on patient-specific
risk factors.
In addition to the proposed operation, patients'
clinical markers of cardiac disease are important in assessing cardiac risk.
Major predictors of cardiac risk include recent MI, unstable or severe angina,5 decompensated CHF,
significant dysrhythmias, and severe valvular disease (Table 2).
Reports from the 1960s and 1970s demonstrated that a prior MI within 3 months
of surgery increased the perioperative rate of reinfarction to 30%. If the MI
was within 3 to 6 months of surgery, the reinfarction rate was 15%; if the MI
occurred more than 6 months prior to surgery, the reinfarction rate was 6%.6 Recently, however, Rao
et al7 have shown that
although a history of MI does increase the risk of reinfarction, the overall
rate is only 1.9%, and only 5.7% for an MI within 3 months of surgery. Patients
with symptomatic aortic stenosis manifested by angina, syncope, or heart
failure often experience severe perioperative CHF, shock, and even sudden death
after undergoing noncardiac surgery.8
Another way of assessing patient-specific risk
is to determine functional capacity. Functional capacity is an important
predictor of future cardiac events.9 The metabolic
equivalent is a standardized way of measuring functional capacity. An
assessment of the patient's functional capacity has been shown to correlate
with the maximum uptake on treadmill tests and reliably predicts future cardiac
events.10 Patients with
poor functional capacity (ie, an inability to walk up a flight of stairs or to
climb a hill) are at an increased cardiac perioperative and long-term risk.11
In recent decades, several classification
systems have been developed to assess cardiac risk. The Dripps index of the
American Society of Anesthesiologists (ASA) is used to predict cardiac death within
48 hours of surgery.12 Patients are divided
into 5 classes of physical status according to cardiac history, with ASA 1
being a normal, healthy patient and ASA 5 being a moribund patient.
Perioperative mortality rates range from 0% for ASA 1 to 9.4% for ASA 5.
However, the ASA classification system has limited utility; it is very
subjective and has not been uniformly reproducible. The Goldman Cardiac Risk
Index and the Detsky index are multifactorial approaches to risk assessment
that were developed to overcome the limitations of the ASA classification
system.7, 13 Unfortunately these
systems are cumbersome to use and lack general applicability; their findings
have been supported or refuted by an equal number of studies.14-18
Because most procedures with high cardiac risk
are vascular in nature, Eagle et al19 identified risk
factors specific for these patients (Table 3).
Multivariate analysis revealed 6 clinical factors that were predictive of
adverse perioperative cardiac events: age older than 70 years, history of MI or
Q waves on an ECG, diabetes mellitus, angina, CHF, and ventricular ectopy
requiring therapy. Adverse cardiac event rates were 3.1%, 15.5%, and 50% for
patients with 0, 1 or 2, and 3 or more risk factors, respectively, according to
Eagle and colleagues. Several studies by de Virgilio et al20-22 have confirmed the
utility of these risk factors as predictors of adverse perioperative cardiac
events in patients undergoing major vascular surgery. In patients undergoing
abdominal aortic aneurysm (AAA) repair, they noted a 20% adverse event rate in
patients with 2 or more risk factors vs no cardiac events in patients with 1 or
no risk factors.22 However, the risk
factors developed by Eagle and colleagues do not account for the severity of
the angina, the length of time since the last MI, or whether the CHF is
decompensated.
Lee et al23 prospectively
produced the Revised Cardiac Risk Index stratification system in an attempt to
simplify the Goldman index. They identified 6 independent predictors of cardiac
complications in patients undergoing noncardiac surgery: high-risk surgery
(intraperitoneal, intrathoracic, or suprainguinal vascular procedures), history
of ischemic heart disease, history of CHF, history of cerebrovascular disease,
preoperative treatment with insulin, and a preoperative serum creatinine level
greater than 2.0 mg/dL (>177 µmol/L). Rates of major cardiac complications
(including MI, CHF, ventricular fibrillation, primary cardiac arrest, and
complete heart block) with 0, 1, 2, or 3 or more of these risk factors were
0.5%, 1.3%, 4%, and 9%, respectively.
Exercise ECG Stress Testing
Exercise stress testing in ambulatory patients provides a good estimate of
functional capacity and can detect myocardial ischemia. The sensitivity of
exercise stress testing for detecting obstructive CAD depends on the severity
of the stenosis, the extent of disease, and the clinical history. Gianrossi et
al24 performed a
meta-analysis of 147 consecutive studies involving 24 074 patients who
underwent both exercise stress testing and coronary angiography. The mean
sensitivity of an exercise ECG for multivessel CAD was 81% (range, 40%-100%)
with a mean specificity of 66% (range, 17%-100%). Sensitivity has been shown to
decrease in patients who cannot reach maximum levels of exercise. This is a
major limitation of the exercise ECG in vascular patients; 50% of these
patients are unable to reach maximum exercise levels. The specificity of
exercise ECG is poor in the presence of ST segment/T wave abnormalities on a
resting ECG or with the use of digoxin.25, 26 Other limitations of
the exercise ECG are that the results are difficult to interpret in the
presence of left bundle branch block, the extent of myocardial ischemia cannot
be determined, and it provides no information on left ventricular function.27 In patients who cannot
exercise, stress testing can be performed by chemical means using either
dobutamine, dipyridamole thallium, or adenosine.
Dipyridamole Thallium Stress
Test
The utility of dipyridamole thallium scintigraphy (DTHAL) as a predictor of
perioperative adverse cardiac events has been studied extensively.19, 28-37 Early reports
found a strong correlation between redistribution on DTHAL and perioperative
adverse cardiac events.19, 28-31 Cutler and Leppo28 prospectively studied
116 patients undergoing aortic surgery. They found that all postoperative MIs
and deaths occurred in the patients with redistribution on DTHAL. Eagle and
colleagues reported retrospectively that DTHAL results were best used when
combined with clinical risk factors. Patients with 1 or 2 risk factors and
redistribution on DTHAL had a 29% cardiac event rate, vs 3.2% for those without
redistribution.19
More recent reports question the value of DTHAL
as a preoperative cardiac screening device.32-37 In a study of 457
vascular patients undergoing AAA repair, Baron et al33 demonstrated that a
history of documented CAD and an age of 65 years or older were better
predictors of adverse cardiac events than perfusion imaging. The lack of
correlation between abnormal DTHAL and adverse cardiac events was confirmed in
2 retrospective studies by de Virgilio et al21, 32 and a prospective
blinded study by Mangano et al.34 More recently, a
prospective blinded study by de Virgilio et al37 confirmed a lack of
association between reversible defects on DTHAL and adverse cardiac events in
82 patients undergoing elective vascular surgery. Unlike the previous studies, this
prospective study excluded low-risk patients (ie, those with no risk factors
according to the classification by Eagle and colleagues). The adverse cardiac
event rate was 13.8% for patients with a reversible defect vs 9.8% for those
without (P = .70). The adverse
event rate in patients with 2 or more reversible defects was 12.5%, vs 11.1% in
patients with fewer than 2 reversible defects. The sensitivity of DTHAL with 2
or more reversible defects was only 11%, with a specificity of 90%. The
positive and negative predictive values were 12.5% and 89%, respectively.
Because at least 7 studies in the literature demonstrate no correlation between
DTHAL and perioperative adverse cardiac events, we currently do not recommend
DTHAL as a screening tool prior to vascular surgery.
Dobutamine Stress
Echocardiography
Dobutamine stress echocardiography is another noninvasive test used to detect
hemodynamically significant CAD.38-43 The development of
new wall motion abnormalities (NWMAs) following dobutamine administration is
considered an indication of significant CAD.44-47 Unfortunately,
there are few prospective blinded studies available on dobutamine
echocardiography as a preoperative test. Davila-Roman et al44 reported a 20%
adverse event rate in patients with NWMAs in a retrospective study of 98
patients undergoing elective vascular surgery. There were no cardiac events in
patients with normal stress test results. In a retrospective study of 81
patients undergoing AAA repair, Langan et al45 noted no
perioperative cardiac complications in the 56 patients with normal findings on
an echocardiogram. Of the 25 patients with NMWAs, 9 had their noncardiac
surgery deferred. Of these, 4 underwent a preoperative coronary artery bypass
graft (CABG), 1 of whom died of a stroke and 1 of a ruptured AAA. Sixteen
patients with NWMAs proceeded to surgery without a CABG, 3 (19%) of whom
experienced a postoperative MI. Lalka et al46 reported a 29%
cardiac event rate after aortic surgery in patients with NMWAs vs a 4.6% event
rate in patients with normal study results. In one prospective blinded study of
75 patients undergoing major vascular surgery, the sensitivity and negative
predictive value of NWMAs on the echocardiogram were 100%, but the positive
predictive value was only 19%.47 Of note, 21% of
patients had an adverse reaction to the dobutamine infusion. In the largest
retrospective study to date, the Dutch Echocardiographic Cardiac Risk
Evaluation Applying Stress Echocardiography Study Group found that the adverse
event rate was 10.6% in patients with 3 or more cardiac risk factors who had 5
or more segments of NWMAs, vs a 2% adverse event rate in patients without
NWMAs.48 This 10.6%
cardiac event rate occurred despite the use of -blockade.
Four patients with severe NWMAs who were excluded from the study underwent a
CABG, and 2 of them died as a result of this operation. The authors suggest
that coronary angiography should be considered in patients with multiple
cardiac risk factors and a positive stress echocardiogram result.
Resting Left Ventricular
Function
Left ventricular systolic or diastolic dysfunction in the perioperative period
has been shown to be a good predictor of postoperative CHF and of death in
critically ill patients.4 Several retrospective
and prospective studies have demonstrated that a decreased preoperative
ejection fraction is associated with increased perioperative morbidity and
mortality.49-54 However, in
a more recent study, McCann and Wolfe55 found no significant
difference in perioperative mortality or cumulative life-table survival rates
between patients with a normal and low left ventricular ejection fraction.
Coronary Angiography
Most physicians would agree that preoperative coronary angiography should be
performed in patients with overt cardiac symptoms such as severe or unstable
angina.5 In the absence
of severe symptoms, the indications for angiography are controversial and must
be individualized. Coronary angiography with possible revascularization should
be considered for patients undergoing elective high-risk operations (particularly
aortic surgery) who have a positive stress test result and multiple cardiac
risk factors.
Preoperative Coronary
Revascularization
To date, no prospective randomized studies show a lower perioperative cardiac
event rate in patients undergoing cardiac evaluation and a prophylactic
preoperative CABG. Retrospective studies, however, do demonstrate a decreased
perioperative cardiac event rate and an improved 5-year survival rate in
patients with a preoperative CABG.56-59 In 1000
consecutive patients undergoing preoperative coronary arteriography, Hertzer60 and colleagues found
that 251 patients had severe correctable CAD. Of these, 216 patients underwent
a CABG, with a 5.5% mortality rate. There was an additional 0.9% mortality rate
due to AAA rupture after the CABG. The overall mortality rate was 3.9% for
patients undergoing AAA repair and 2.4% for lower extremity revascularization.
The late mortality rate was the same for patients undergoing a preoperative
CABG as those without clinically evident CAD. Follow-up from the Coronary
Artery Surgery Study revealed a 0.9% mortality rate after noncardiac surgery in
patients who had previously undergone a CABG, vs a 2.3% mortality rate for
medically treated patients with CAD.61 In patients
undergoing high-risk surgery (abdominal, thoracic, or head and neck surgery), a
prior CABG reduced the postoperative MI rate from 2.7% to 0.8% (P = .002) and the mortality rate from 3.3%
to 1.7% (P = .03), compared with
patients treated medically. However, there was no benefit to undergoing a CABG
prior to a low-risk procedure. Patients with severe angina and/or multivessel
disease were found to benefit the most.62
Although a CABG does appear to afford myocardial
protection during subsequent surgery, one must factor in the risk of the
intervention, the consequences of delaying definitive care of the vascular
disorder (eg, ruptured AAA or limb loss), and the cost. Coronary arteriography
has a 0.3% risk of mortality. A coronary artery bypass graft carries an
operative mortality rate of 3% overall, and closer to 5% in patients with
peripheral vascular disease. Thus, the strategy of coronary angiography with a
possible CABG reduces overall mortality only when the estimated mortality rate
of the proposed operation is substantially higher than 5%.63 Even then, mortality
would be reduced at the expense of greater morbidity and higher cost. Bry et al64 estimated that the
costs of cardiac screening and intervention were $392 253 per life saved
and $181 039 per MI prevented.
In recent years, several authors have
recommended against prophylactic coronary revascularization prior to vascular
surgery. Massie et al65 noted that any
benefit from invasive cardiac evaluation was offset by several deaths and MIs
that complicated this evaluation. Seeger et al36 reported that stress
thallium imaging confirmed a high incidence of CAD in aortic surgery patients
but that prophylactic cardiac intervention did not lower operative or long-term
mortality rates. Taylor et al66 limited cardiac
evaluation to patients with severe symptomatic CAD (unstable angina, severe
CHF, or uncontrolled dysrrhythmias), which represented only 5.8% of their
subjects. Of these, only 0.5% had a prophylactic CABG. Despite the paucity of
cardiac evaluation and intervention, the perioperative MI rate for the overall
group was just 3.9%, with no deaths in patients undergoing elective vascular
surgery. This morbidity and mortality rate is no different from that of studies
using routine cardiac screening. Our vascular group espouses a similar
selective approach for the cardiac assessment of patients undergoing elective
aortic surgery.67
Medical Therapy
Several studies have analyzed the role of -blockers
in reducing the rate of perioperative myocardial ischemia, infarction, and death.
Stone et al68 reported a 28%
frequency of ST segment depression in patients treated with a placebo vs a 2%
rate in patients treated with oral -blockade.
Similarly, Pasternack et al69 reported an 18% MI
rate in controls vs a 3% perioperative MI rate in patients treated with oral
metoprolol immediately following the operation and with intravenous metoprolol
during AAA repair. Mangano et al70 noted that with the
use of atenolol, the postoperative mortality rate was reduced from 14% to 3%
during the first year and from 21% to 10% the second year after noncardiac
surgery. The study by Poldermans et al71 demonstrated that the
30-day complication rate in patients with NWMAs who were given perioperative -blockade was
similar to that in patients without NWMAs. More recently, in a follow-up
retrospective review, they confirmed the benefit of -blockade in intermediate-risk patients. However, -blockade failed to lower the cardiac event rate in patients
with very high risk (3 clinical risk factors
and 5 NWMAs).48
Every patient undergoing nonemergent surgery
should undergo cardiac risk assessment (Figure 1).
This assessment may be limited to a careful history and physical examination.
The first goal is to identify the patient with high cardiac risk. For patients
with unstable angina, acute MI, symptomatic aortic stenosis, or decompensated
CHF, the operation poses an inordinate cardiac risk and should be postponed if
the condition is not immediately life threatening. In most instances these
patients should proceed to coronary angiography if surgery is being
contemplated. If no severe cardiac symptoms are present, the number of cardiac
risk factors should be determined. If the cardiac history is positive, it is
important to establish whether the cardiac disease is active, its severity, and
whether coronary revascularization has been performed. If a patient has a
cardiac history but has undergone coronary revascularization within the last 5
years and is now symptom free, such a patient has a low cardiac risk and can
proceed to surgery.
If the patient has 1 or no cardiac risk factors,
the operation will carry a low predicted risk and can be performed without
further cardiac testing. This applies to both low- and high-risk surgery
(aortic and major vascular). Perioperative -blockade
should be used in most patients with at least 1 cardiac risk factor. On the
other hand, if the patient has multiple cardiac risk factors, one should consider
the type of operation to be performed. If the proposed operation is low or
moderate risk, the patient can proceed to surgery without additional testing.
If the patient with multiple cardiac risk factors is about to undergo a
high-risk operation, the urgency of that operation must be considered. If the
patient has limb-threatening ischemia or a very large or symptomatic
nonruptured AAA, further cardiac testing should probably be omitted. For these
patients, one can change the proposed operation to a less stressful procedure
or consider perioperative -blockade. In a
purely elective case (eg, an aortobifemoral bypass in a patient with
claudication), dobutamine stress echocardiography should be considered. If the
results of the stress echocardiogram are normal, one can proceed with surgery.
If the echocardiogram shows NWMAs, the number of segments should be determined.
If there are 5 or more segments of NWMAs, there are 4 options: cancel the
surgery, modify the operation (axillofemoral bypass instead of aortobifemoral
bypass), proceed with surgery using -blockade,
or perform coronary angiography. The decision of which option to choose must be
individualized based on the indications for surgery, age, expected life span,
and the estimated risk of coronary intervention.
In summary, adverse cardiac events remain a
significant source of morbidity and mortality after noncardiac surgery. In a
small subgroup of patients, major predictors of cardiac risk will be identified
during a clinical evaluation. In these patients, coronary angiography will
likely be necessary. With intermediate-risk patients, the urgency and type of
surgical procedure should be taken into account; however, the use of
noninvasive cardiac stress testing should be restricted. As we enter the new
millennium, enthusiasm for aggressive cardiac evaluation has been tempered by
studies that question the predictive value of these techniques. Cardiac testing
may be a double-edged sword. Although it can identify significant CAD, it adds
expense and delays definitive treatment. Stress test results may call for
invasive cardiac procedures that can lead to the very same cardiac
complications they are designed to prevent. We recommend that stress testing be
considered only for the small group of patients who are undergoing elective
high-risk surgery and have multiple cardiac risk factors, and then only if
there are no risks to delaying the operation and if coronary revascularization
has a low mortality rate at one's particular institution. In the vast majority
of patients, advances in perioperative medical and anesthetic treatment,
including the use of -blockade, have led
to acceptably low rates of cardiac complications, rendering cardiac stress
testing unnecessary.
Author/Article Information
From the Department of Surgery, Harbor UCLA Medical Center, Torrance, Calif.
Corresponding author and reprints: Christian de Virgilio, MD, Harbor UCLA
Medical Center, Department of Surgery, 1000 W Carson St, Torrance, CA 90509.
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Edward E.
Rylander, M.D.
Diplomat American
Board of Family Practice.
Diplomat American
Board of Palliative Medicine.