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Assessment of cardiac risk before non-cardiac general surgery
  1. Olaf Schouten1,
  2. Jeroen J Bax2,
  3. Don Poldermans3
  1. 1Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
  2. 2Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
  3. 3Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, the Netherlands
  1. Correspondence to:
    Professor Don Poldermans
    Department of Vascular Surgery, Room H 921, Erasmus MC, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands; d.poldermans{at}erasmusmc.nl

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Developments in anaesthetic and surgical techniques—that is, loco-regional anaesthesia and minimally invasive surgery—have improved postoperative cardiac outcome considerably in recent years. For example, patients with a severely reduced left ventricular function used to be at increased risk, but because of the implementation of these new techniques they are now scheduled for surgery at relatively low risk. In other words, the improvement of perioperative care has altered the impact of established cardiac risk factors.

However, as more patients with cardiac co-morbidity survive surgery, long-term cardiac outcome has gained interest. Therefore, the focus of preoperative risk evaluation should also take into consideration the impact of cardiac co-morbidity on long-term survival. After all, patients should live long enough to enjoy the benefits of surgery.

It is estimated that the incidence of cardiac complications after non-cardiac surgical procedures is between 0.5–1.0%.1,2 Annually around 100 million adults undergo some form of non-cardiac surgery. Consequently, approximately 500 000 to 1 000 000 people will suffer from perioperative cardiac complications. Moreover, one out of every four of these patients will die. For the prevention of perioperative cardiac complications it remains of critical importance to identify those at increased risk and treat them accordingly, to improve both perioperative and long-term survival.

This article gives an overview of the current status of preoperative cardiac screening. In a stepwise approach the use and prognostic value of clinical cardiac risk factors, laboratory measurements, non-invasive and invasive coronary testing, and consequently medical and interventional strategies to alter cardiac risk will be discussed (fig 1).

Figure 1

 Nine steps to optimal preoperative cardiac risk evaluation and modification.

STEP 1: IDENTIFICATION OF CLINICAL RISK FACTORS

The first, most simple and least costly step in preoperative cardiac risk stratification is the identification of clinical cardiac risk factors. In the last three decades much attention has focused on the identification of patients at …

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