Assessing Cardiac Risk in Vascular Surgical Patients: Current Status

Abstract

The prevalence of coronary arterial disease in vascular patients is now well appreciated. Several vascular surgical series from the 1960s indicated problems with both perioperative myocardial infarction (MI) and late cardiac death. 1,2 At the Cleveland Clinic from 1969 through 1978 MI accounted for 50% to 60% of operative deaths following aortic surgery 3 In addition, several longitudinal studies of patients with vascular disease have documented a high percentage of late deaths resulting from cardiac causes.4-6 Many vascular surgical series during the 1980s have specifically addressed postoperative MI and cardiac death (Table 1). Presently in the United States at least 50,000 patients annually sustain a perioperative MI, leading to more than 20,000 deaths.35Postoperative MI may be associated with a 50% mortality.36 From 60% to 90% of postoperative MIs occur in the first 3 days after surgery; the remainder generally occur between the fourth and sixth postoperative days.37,3s Approximately 50% of patients with postoperative MIs present without pain but with other clinical indicators for infarction: arrhythmias, hypertension, hypotension, or altered mental status .37 Ischemic ST-T segment changes are sometimes difficult to distinguish from other ECG changes, so creatine kinase isoenzymes are frequently used to confirm postoperative MI.39 Postoperative elevation of the MB isoenzyme > 5 % of the total creatine kinase value is consistent with the occurrence of an acute MI. Charlson et al., 40 however, have emphasized that there is currently no consensus on the definition for postoperative MI, including a lack of uniformity for the method of creatine kinase isoenzyme measurement.Clinically apparent postoperative (within 30 days) MI associated with vascular surgery has an incidence of 2% to 8% (Table 1). Careful prospective evaluation with serial ECGs and analysis of myocardial enzymes, however, increases the overall incidence to 10% to 17% ~8,21,25,31 1 Leppo et al. 31 performed serial examinations for 2 to 3 days and defined MI as typical ECG changes in association with elevation of the creatine kinase MB isoenzyme fraction. They found an incidence of perioperative MI of 17%. Other prospective studies have included some MIs diagnosed only on the basis of elevation of the MB isoenzyme level.18,21,25 Although the incidence of postoperative MI in these studies was relatively high (10% to 16%), the mortality rate of postoperative MI was only 14%. This may either reflect improvement in the management of postoperative MI or more likely demonstrates a lesser significance of clinically inapparent but chemically present MI. In fact, using MB isoenzyme elevation as the sole criterion for diagnosis of at NANYANG TECH UNIV LIBRARY on June 5, 2016 pvs.sagepub.com Downloaded from

Late survival after perioperative myocardial infarction complicating vascular surgery

“…The role of CABG in improving overall survival for elderly vascular patients with multiple risk factors, however, remains controversial. 1,6,[23][24][25] Elderly patients undergoing vascular surgery with elevated serum creatinine levels and left ventricular dysfunction have a reported mortality rate with CABG that exceeds 25%. 26 Certainly the 40% perioperative mortality rate associated with subsequent CABG in patients with nonfatal PMI clearly did not favorably influence their overall survival rates.…”

Early Results of Combined and Staged Coronary Bypass and Carotid Endarterectomy in Advanced Age Patients in Single Centre

“…Berens et al l reported that stroke was seen by rate of 10.9% in >65 years old patients with >80% carotid arterial stenosis [ 10 ]. The frequency of perioperative myocardial enfarction in patients underwent isolated CEA has been determined in range of 1.5% to 5% [ 11 ]. CEA is recommended in patients with symptomatic carotid disease undergoing CABG due to coronary artery disease, but it is not well determined which procedure including staged or combined CEA plus CABG should be performed in current literature.…”

Cardiac risk stratification in patients undergoing endoluminal graft repair of abdominal aortic aneurysm: a single-institution experience with 365 patients

“…11 Coronary artery disease is the most prominent risk factor, accounting for up to 60% of periop-erative deaths. 7,8,[12][13][14] This proportionately high cardiac morbidity can be explained by several factors. Angiographic studies have shown that 60% of patients with AAA have severe coronary artery disease.…”