Preoperative cardiac assessment for patients with infrarenal abdominal aortic aneurysms: a survey of current practice by vascular surgeons in New South Wales and Australian Capital Territory.
BACKGROUND
The reported mortality rate following open elective repair of abdominal aortic aneurysm (AAA) varies between 0 and 12%. Much of the mortality and major morbidity is caused by cardiac events. The evidence regarding best practice for cardiac assessment and optimization of this patient group is unclear. The aim of the present study was to evaluate current practice of cardiac risk factor assessment by vascular surgeons in New South Wales (NSW) and Australian Capital Territory (ACT) for patients undergoing open elective repair of infrarenal AAA.


METHODS
A postal questionnaire was sent to 46 surgeons in NSW and ACT identified as expressing a principal or major interest in vascular surgery. If no response was received within 3 weeks, a second questionnaire was sent and if no response was received after the second mailing, a telephone survey of non-responders was conducted. Data were collated regarding the importance of risk factors elicited by clinical history, preoperative investigation, referral for cardiological opinion, use of perioperative beta-blockade and the timing of aortic surgery in relation to coronary artery revascularization and acute myocardial infarction.


RESULTS
The overall response rate was 87% (40/46) and the median (range) response time was 14 (4-109) days. Only 22 of 40 and 23 of 40 surgeons consider diabetes mellitus or renal impairment, respectively, to be important when assessing cardiac risk and 34 of 40 surgeons do not employ a validated risk index in preoperative assessment. Sixteen of 40 surgeons refer all patients needing AAA repair to a cardiologist, while 24 of 40 would initiate cardiac investigations themselves (either stress electrocardiography, scintigraphy or echocardiography). Seventeen surgeons always or usually commenced perioperative beta-blockade with wide variations in the commencement (1 to > 28 days preoperatively) and duration (< 1 week to > 28 days postoperatively) of treatment. The timing of AAA repair following coronary revascularization ranged from < 1 week to 6 months and delay in surgical repair of AAA following myocardial infarction ranged from < 1 week to > 6 months.


CONCLUSIONS
Preoperative assessment of cardiac risk in patients for repair of AAA lacks consensus among vascular surgeons in NSW and ACT. The diversity of clinical practice may rest with the paucity of prospective trials published in the medical literature or the influence of local institutional facilities.
Wong
Shen
S
Department of Vascular Surgery, The Royal North Shore Hospital, St Leonards, New South Wales, Australia.
Appleberg
Michael
M
Neale
Michael L
ML
Fisher
Charles M
CM
Lewis
David R
DR
D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D001315:Australia / Q000453:epidemiology; D006331:Heart Diseases / Q000453:epidemiology*; D006801:Humans; D009517:New South Wales / Q000453:epidemiology; D011300:Preoperative Care / Q000379:methods*; D011364:Professional Practice; D012307:Risk Factors; D011795:Surveys and Questionnaires; D014656:Vascular Surgical Procedures / Q000401:mortality*