Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk

THIS IS THE FIRST OF 2 ARTICLES EVALUATING cardiac events in patients undergoing noncardiac surgery. In this article, we review the magnitude of the problem, the pathophysiology of these events, approaches to risk assessment and communication of risk. The number of patients undergoing noncardiac surgery worldwide is growing, and annually 500 000 to 900 000 of these patients experience perioperative cardiac death, nonfatal myocardial infarction (MI) or nonfatal cardiac arrest. Although the evidence is limited, a substantial proportion of fatal perioperative MIs may not share the same pathophysiology as nonoperative MIs. A clearer understanding of the pathophysiology is needed to direct future research evaluating prophylactic, acute and long-term interventions. Researchers have developed tools to facilitate the estimation of perioperative cardiac risk. Studies suggest that the Lee index is the most accurate generic perioperative cardiac risk index. The limitations of the studies evaluating the ability of noninvasive cardiac tests to predict perioperative cardiac risk reveals considerable uncertainty as to the role of these popular tests. Similarly, there is uncertainty as to the predictive accuracy of the American College of Cardiology / American Heart Association algorithm for cardiac risk assessment. Patients are likely to benefit from improved estimation and communication of cardiac risk because the majority of noncardiac surgeries are elective and accurate risk estimation is important to allow informed patient and physician decision-making.

[1]  D. Bell,et al.  AANA Journal course: Update for nurse anesthetists--Part 4--preoperative cardiac evaluation. , 2004, AANA journal.

[2]  D. Cuthbertson,et al.  Critical Appraisal of Cardiac Risk Stratification Before Elective Vascular Surgery , 2003, Vascular and endovascular surgery.

[3]  R. McLeod,et al.  The National Veterans Administration Surgical Risk Study: risk adjustment for the comparative assessment of the quality of surgical care. , 1995, Journal of the American College of Surgeons.

[4]  J. Bienvenu,et al.  Cytokine and hormonal changes after cholecystectomy. Effect of ibuprofen pretreatment. , 1996, Annals of surgery.

[5]  J. Marty,et al.  Guidelines for perioperative cardiac evaluation from the American College of Cardiology/American Heart Association task force are effective for stratifying cardiac risk before aortic surgery. , 2000, Journal of vascular surgery.

[6]  K. Eagle,et al.  Implementation of the ACC/AHA Guidelines for Preoperative Cardiac Risk Assessment in a General Medicine Preoperative Clinic: Improving Efficiency and Preserving Outcomes , 2004, Cardiology.

[7]  D. Sinapius Beziehungen zwischen Koronarthrombosen und Myokardinfarkten , 1972 .

[8]  E F Cook,et al.  Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. , 1999, Circulation.

[9]  M. Breslow,et al.  The Effects of Different Anesthetic Regimens on Fibrinolysis and the Development of Postoperative Arterial Thrombosis , 1993, Anesthesiology.

[10]  J. Gold,et al.  Long-term prognosis after peri-operative cardiac complications. , 1994, Journal of clinical epidemiology.

[11]  W. Krupski Update on perioperative evaluation and management of cardiac disease in vascular surgery patients. , 2002, Journal of vascular surgery.

[12]  H. Kehlet,et al.  Prediction of cardiac risk in non-cardiac surgery. , 1987, European heart journal.

[13]  I. Chapman Relationships of recent coronary artery occlusion and acute myocardial infarction. , 1968, Journal of the Mount Sinai Hospital, New York.

[14]  M. Davies,et al.  Pathology of acute myocardial infarction with particular reference to occlusive coronary thrombi. , 1976, British heart journal.

[15]  E. Braunwald Personal reflections on efforts to reduce ischemic myocardial damage. , 2002, Cardiovascular research.

[16]  J. Norton,et al.  Responses of the hypothalamic-pituitary-adrenal and renin-angiotensin axes and the sympathetic system during controlled surgical and anesthetic stress. , 1987, The Journal of clinical endocrinology and metabolism.

[17]  J J Bax,et al.  A meta-analysis comparing the prognostic accuracy of six diagnostic tests for predicting perioperative cardiac risk in patients undergoing major vascular surgery , 2003, Heart.

[18]  R. Smallridge,et al.  Hormonal responses to graded surgical stress. , 1987, Archives of internal medicine.

[19]  G. Dedoussis,et al.  Abnormal cytokine serum levels correlate with impaired cellular immune responses after surgery. , 1994, Clinical immunology and immunopathology.

[20]  P. Giannoudis,et al.  C-reactive protein in patients who had operative fracture treatment. , 2004, Clinical orthopaedics and related research.

[21]  D. Mangano Peri-operative cardiovascular morbidity: new developments , 1999 .

[22]  A. Gelb,et al.  Myocardial Infarction after Noncardiac Surgery , 1998, Anesthesiology.

[23]  A. Delabays,et al.  Preoperative evaluation of patients with, or at risk of, coronary artery disease undergoing non-cardiac surgery. , 2002, British journal of anaesthesia.

[24]  G. Guyatt,et al.  Clinical Prediction Rules , 2004 .

[25]  E. Antman,et al.  ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery—Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluati , 2002, Circulation.

[26]  D. Sinapius [Relationship between coronary-artery thrombosis and myocardial infarction]. , 1972, Deutsche medizinische Wochenschrift.

[27]  L. Fleisher,et al.  Relationship between postoperative anemia and cardiac morbidity in high‐risk vascular patients in the intensive care unit , 1993, Critical care medicine.

[28]  H. Priebe Triggers of perioperative myocardial ischaemia and infarction. , 2004, British journal of anaesthesia.

[29]  G. Guyatt,et al.  Users' guides to the medical literature. , 1993, JAMA.

[30]  C Weissman,et al.  Myocardial infarction after vascular surgery: the role of prolonged stress-induced, ST depression-type ischemia. , 2001, Journal of the American College of Cardiology.

[31]  L. Fleisher,et al.  The Catecholamine, Cortisol, and Hemodynamic Responses to Mild Perioperative Hypothermia: A Randomized Clinical Trial , 1995, Anesthesiology.

[32]  W. Flinn,et al.  Antithrombin III deficiency as a reflection of dynamic protein metabolism in patients undergoing vascular reconstruction. , 1984, Journal of vascular surgery.

[33]  F. McAlister,et al.  Assessment and reporting of perioperative cardiac risk by canadian general internists , 2002, Journal of General Internal Medicine.

[34]  J B Atkinson,et al.  Pathology of fatal perioperative myocardial infarction: implications regarding pathophysiology and prevention. , 1996, International journal of cardiology.

[35]  Mylan C. Cohen,et al.  Histological analysis of coronary artery lesions in fatal postoperative myocardial infarction. , 1999, Cardiovascular pathology : the official journal of the Society for Cardiovascular Pathology.

[36]  T. Rao,et al.  Angina and Other Risk Factors in Patients With Cardiac Diseases Undergoing Noncardiac Operations , 1990, Anesthesia and analgesia.

[37]  Belinda Young,et al.  Association between cardiac and noncardiac complications in patients undergoing noncardiac surgery: outcomes and effects on length of stay. , 2003, The American journal of medicine.

[38]  D. Schroeder,et al.  Predictors of Survival following Cardiac Arrest in Patients Undergoing Noncardiac Surgery: A Study of 518,294 Patients at a Tertiary Referral Center , 2003, Anesthesiology.

[39]  W. Browner,et al.  Long-term cardiac prognosis following noncardiac surgery. The Study of Perioperative Ischemia Research Group. , 1992, JAMA.

[40]  G. Landesberg The pathophysiology of perioperative myocardial infarction: facts and perspectives. , 2003, Journal of cardiothoracic and vascular anesthesia.

[41]  K Gilbert,et al.  Prospective Evaluation of Cardiac Risk Indices for Patients Undergoing Noncardiac Surgery , 2000, Annals of Internal Medicine.

[42]  W. Fraser,et al.  Response of serum interleukin-6 in patients undergoing elective surgery of varying severity. , 1990, Clinical science.

[43]  J. Gold,et al.  Surveillance for postoperative myocardial infarction after noncardiac operations. , 1988, Surgery, gynecology & obstetrics.

[44]  W. Pearce,et al.  Sequential changes in coagulation and platelet function following femorotibial bypass. , 1984, Journal of vascular surgery.

[45]  M. Müllner,et al.  C-reactive protein and mortality in patients with acute aortic disease , 2002, Intensive Care Medicine.

[46]  W. Browner,et al.  Association of Perioperative Myocardial Ischemia with Cardiac Morbidity and Mortality in Men Undergoing Noncardiac Surgery , 1990 .

[47]  W. Shoemaker,et al.  Tissue oxygen debt as a determinant of lethal and nonlethal postoperative organ failure. , 1988, Critical care medicine.

[48]  H. Kehlet,et al.  Effect of patient-controlled analgesia on plasma catecholamine, cortisol and glucose concentrations after cholecystectomy. , 1988, British journal of anaesthesia.

[49]  V. Fuster,et al.  Coronary plaque disruption. , 1995, Circulation.

[50]  S. Hollenberg Preoperative cardiac risk assessment. , 1999, Chest.

[51]  L. Hirsch Competing interests: none declared. , 2006 .

[52]  C. Ashton,et al.  The Incidence of Perioperative Myocardial Infarction in Men Undergoing Noncardiac Surgery , 1993, Annals of Internal Medicine.

[53]  Allan S. Detsky,et al.  Predicting cardiac complications in patients undergoing non-cardiac surgery , 1986, Journal of General Internal Medicine.

[54]  P. Ridker,et al.  Inflammatory bio‐markers and cardiovascular risk prediction , 2002, Journal of internal medicine.

[55]  J. Torrie,et al.  Safety assessment of postoperative pain management by an acute pain service , 1993, Pain.

[56]  C. Weissman The Metabolic Response to Stress: An Overview and Update , 1990, Anesthesiology.

[57]  L. Fleisher,et al.  Postoperative myocardial ischemia: etiology of cardiac morbidity or manifestation of underlying disease? , 1995, Journal of clinical anesthesia.

[58]  M. Breslow,et al.  Determinants of Catecholamine and Cortisol Responses to Lower Extremity Revascularization , 1993, Anesthesiology.

[59]  E. Falk Plaque rupture with severe pre-existing stenosis precipitating coronary thrombosis. Characteristics of coronary atherosclerotic plaques underlying fatal occlusive thrombi. , 1983, British heart journal.

[60]  G. Gresham,et al.  Atherosclerosis and coronary heart-disease. , 1960, Lancet.

[61]  Gries,et al.  Perioperative catecholamine changes in cardiac risk patients , 1999, European journal of clinical investigation.

[62]  G. Heudebert,et al.  Adverse cardiac events after surgery: assessing risk in a veteran population. , 2001, Journal of general internal medicine.

[63]  J. Verheijen,et al.  The postoperative fibrinolytic shutdown: a rapidly reverting acute phase pattern for the fast-acting inhibitor of tissue-type plasminogen activator after trauma. , 1985, Scandinavian journal of clinical and laboratory investigation.

[64]  D. Liepert,et al.  IMPROVED HEMODYNAMIC AND RENAL FUNCTION WITH CLONIDINE IN CORONARY ARTERY BYPASS GRAFTING , 1990 .

[65]  S. Gottlieb,et al.  Unintentional Hypothermia Is Associated with Postoperative Myocardial Ischemia , 1993, Anesthesiology.

[66]  A. Mahdy,et al.  Differential modulation of interleukin-6 and interleukin-10 by diclofenac in patients undergoing major surgery. , 2002, British journal of anaesthesia.

[67]  M. Breslow,et al.  Catecholamine and cortisol responses to lower extremity revascularization: correlation with outcome variables. Perioperative Ischemia Randomized Anesthesia Trial Study Group. , 1995, Critical care medicine.

[68]  S. Ellis,et al.  Angiographic correlates of cardiac death and myocardial infarction complicating major nonthoracic vascular surgery. , 1996, The American journal of cardiology.

[69]  M. Meade,et al.  Semiquantitative dipyridamole myocardial stress perfusion imaging for cardiac risk assessment before noncardiac vascular surgery: a meta-analysis. , 2002, Journal of vascular surgery.

[70]  H. Sox,et al.  Clinical prediction rules. Applications and methodological standards. , 1985, The New England journal of medicine.

[71]  L. Way,et al.  Long-term cardiac prognosis following noncardiac surgery , 1992 .

[72]  M. Sekiguchi,et al.  Coronary thrombosis in pathogenesis of acute myocardial infarction. Histopathological study of coronary arteries in 108 necropsied cases using serial section. , 1978, British heart journal.

[73]  L Goldman,et al.  Multifactorial index of cardiac risk in noncardiac surgical procedures. , 1977, The New England journal of medicine.

[74]  P. Rehak,et al.  Perioperative myocardial cell injury: the relationship between troponin T and cortisol. , 2000, Journal of clinical anesthesia.