title: Preoperative cardiac risk management.
abstract: CAD is present in most patients with peripheral arterial disease and is the leading cause of morbidity and mortality after vascular operations. Clinical risk assessment attempts to identify those patients at low, intermediate, or high cardiac risk for adverse cardiac outcomes. Additional tests add little information to the estimates obtained by clinical scoring in patients at low risk. Patients with high cardiac risk scores are clearly at increased risk of experiencing postoperative complications, but further investigations are needed only if knowledge of the functional severity or degree of myocardial ischemia will alter subsequent management. In general, high-risk patients should proceed to coronary angiography, intensive perioperative monitoring, alteration in the planned operation, or avoidance of surgery altogether if indications are less than compelling. Those patients identified as intermediate risk by clinical scoring benefit most from additional tests. In these patients special studies or even coronary arteriography may be useful if the vascular surgery can be delayed until myocardial revascularization is completed. Practically, preoperative cardiac work-up must also consider the indication for surgery. Patients who have threatened limbs or ruptured aneurysms or are severely symptomatic cannot afford the time involved for obtaining additional tests. Moreover, the question of what to do with the information provided by special studies is problematic in these patients. For example, if significant symptomatic or asymptomatic CAD is present in a patient with a gangrenous foot, what is gained by the delay in lower extremity revascularization required when prophylactic CABG is performed? Reports supporting prophylactic CAD intervention are nonrandomized and uncontrolled. CABG and PTCA should be performed only on the merits of the patient's cardiac symptoms and coronary artery anatomy, not to enhance safety of the proposed vascular procedure, because advances in surgical and anesthetic techniques and intraoperative and postoperative monitoring have resulted in lower morbidity and mortality of elective vascular surgery.
authors.affiliation: Department of Surgery, University of Colorado Health Sciences Center, Denver, USA.
authors.forename: W C
authors.initials: WC
authors.lastname: Krupski
authors.forename: D D
authors.initials: DD
authors.lastname: Bensard
mesh_terms: D001157:Arterial Occlusive Diseases / Q000601:surgery*; D003327:Coronary Disease / Q000175:diagnosis*; D006801:Humans; D011300:Preoperative Care; D012307:Risk Factors; D014656:Vascular Surgical Procedures