Advertisement
Mayo Clinic Proceedings Home

Preoperative Assessment of Cardiac Patients Undergoing Noncardiac Surgical Procedures

      A careful clinical history and physical examination are the most important components of the preoperative assessment of the cardiac patient who is to undergo a noncardiac surgical procedure. From these factors and the nature of the surgical procedure planned, a reasonable estimate of potential cardiac risk can be formulated to guide judicious preoperative testing for further definition of potentially high-risk patients. The potential risks associated with an invasive cardiac procedure or surgical intervention must always be considered along with the potential benefits of such a procedure in an attempt to reduce the cardiac risk of noncardiac operations. Aggressive and conscientious preoperative assessment and perioperative care of the high-risk patient by the concerted efforts of the medical consultant, anesthesiologist, and surgeon may substantially diminish cardiac-related morbidity and mortality during noncardiac surgical procedures.
      Patients with cardiac disease are commonly referred to a general internist or cardiologist for assessment before noncardiac surgical procedures. Guided by a thorough clinical history, physical examination, and selective testing, the physician can provide an estimate of potential cardiac risk for such patients. Identification of the high-risk patient may indicate the need for more comprehensive and effective perioperative management and thus decrease cardiac-related morbidity and mortality during noncardiac surgical procedures.

      EFFECT OF CORONARY ARTERY DISEASE

      In most cardiac patients undergoing noncardiac surgical procedures, the greatest potential risks arise from the presence of coronary artery disease. Pooled data from three large series (a total of 46,425 patients) show the risk of perioperative myocardial infarction to be 0.15% in patients without prior clinical evidence of heart disease.
      • Tarhan S
      • Moffitt EA
      • Taylor WF
      • Giuliani ER
      Myocardial infarction after general anesthesia.
      • Von Knorring J
      Postoperative myocardial infarction: a prospective study in a risk group of surgical patients.
      • Goldman L
      • Caldera DL
      • Southwick FS
      • Nussbaum SR
      • Murray B
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Burke DS
      • Krogstad D
      • Carabello B
      • Slater EE
      Cardiac risk factors and complications in noncardiac surgery.
      In patients who have had a prior myocardial infarction, however, the incidence of reinfarction during a major noncardiac operation has ranged from 2.8 to 17.7% (mean, approximately 6%).
      • Tarhan S
      • Moffitt EA
      • Taylor WF
      • Giuliani ER
      Myocardial infarction after general anesthesia.
      • Von Knorring J
      Postoperative myocardial infarction: a prospective study in a risk group of surgical patients.
      • Goldman L
      • Caldera DL
      • Southwick FS
      • Nussbaum SR
      • Murray B
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Burke DS
      • Krogstad D
      • Carabello B
      • Slater EE
      Cardiac risk factors and complications in noncardiac surgery.
      • Steen PA
      • Tinker JH
      • Tarhan S
      Myocardial reinfarction after anesthesia and surgery.
      The risk of perioperative reinfarction is inversely related to the time interval between the preoperative myocardial infarction and the noncardiac surgical procedure, a curvilinear rather than a linear relationship (Fig. 1). A noncardiac surgical procedure performed within 3 months after a myocardial infarction has been associated with reinfarction rates of 27 to 37%; the corresponding rates have been 11 to 16% between 3 and 6 months after infarction and generally 4 to 5% after 6 months.
      • Tarhan S
      • Moffitt EA
      • Taylor WF
      • Giuliani ER
      Myocardial infarction after general anesthesia.
      • Steen PA
      • Tinker JH
      • Tarhan S
      Myocardial reinfarction after anesthesia and surgery.
      The risk of perioperative reinfarction is not significantly different whether the previous event was a Q-wave or a non-Q-wave myocardial infarction.
      • Goldman L
      • Caldera DL
      • Southwick FS
      • Nussbaum SR
      • Murray B
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Burke DS
      • Krogstad D
      • Carabello B
      • Slater EE
      Cardiac risk factors and complications in noncardiac surgery.
      Figure thumbnail gr1
      Fig. 1Inverse relationship of risk of perioperative myocardial reinfarction during noncardiac surgical procedure and time since prior preoperative myocardial infarction in 843 patients. (Patient data from Tarhan and associates
      • Tarhan S
      • Moffitt EA
      • Taylor WF
      • Giuliani ER
      Myocardial infarction after general anesthesia.
      and Steen and colleagues.
      • Steen PA
      • Tinker JH
      • Tarhan S
      Myocardial reinfarction after anesthesia and surgery.
      )
      Recently, Rao and colleagues
      • Rao TLK
      • Jacobs KH
      • El-Etr AA
      Reinfarction following anesthesia in patients with myocardial infarction.
      demonstrated a significant decrease in reinfarction rates with the implementation of aggressive and comprehensive perioperative patient management guided by invasive hemodynamic monitoring (Fig. 2). The reduction in reinfarction rates was especially prominent in patients whose prior myocardial infarction had occurred less than 6 months before the noncardiac surgical procedure. With this approach, these investigators noted a reinfarction rate of only 5.8% in patients who had had an infarction within 3 months before the noncardiac operation.
      Figure thumbnail gr2
      Fig. 2Effect of aggressive perioperative monitoring on rate of reinfarction in 733 patients with prior myocardial infarction who underwent noncardiac surgical procedures.
      (Data from Rao and co-workers.
      • Rao TLK
      • Jacobs KH
      • El-Etr AA
      Reinfarction following anesthesia in patients with myocardial infarction.
      )
      Despite multiple advances in intraoperative and postoperative care, the mortality from perioperative myocardial infarction remains high, ranging from 32 to 69% (mean, approximately 50%).
      • Tarhan S
      • Moffitt EA
      • Taylor WF
      • Giuliani ER
      Myocardial infarction after general anesthesia.
      • Von Knorring J
      Postoperative myocardial infarction: a prospective study in a risk group of surgical patients.
      • Goldman L
      • Caldera DL
      • Southwick FS
      • Nussbaum SR
      • Murray B
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Burke DS
      • Krogstad D
      • Carabello B
      • Slater EE
      Cardiac risk factors and complications in noncardiac surgery.
      • Steen PA
      • Tinker JH
      • Tarhan S
      Myocardial reinfarction after anesthesia and surgery.
      • Rao TLK
      • Jacobs KH
      • El-Etr AA
      Reinfarction following anesthesia in patients with myocardial infarction.
      The risk of cardiac death from reinfarction less than 6 months after a preoperative myocardial infarction is significantly greater than that observed after 6 months, at which time the risk of death is similar to that in patients with no history of cardiac disease who have a perioperative infarction.
      • Steen PA
      • Tinker JH
      • Tarhan S
      Myocardial reinfarction after anesthesia and surgery.

      PREOPERATIVE CARDIAC RISK INDICES

      The benefit of a multifactorial approach to estimation of cardiac risk for noncardiac surgical procedures was first demonstrated by Goldman and colleagues
      • Goldman L
      • Caldera DL
      • Nussbaum SR
      • Southwick FS
      • Krogstad D
      • Murray B
      • Burke DS
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Carabello B
      • Slater EE
      Multifactorial index of cardiac risk in noncardiac surgical procedures.
      in 1977. Multivariate analysis of 39 variables in 1,001 patients revealed 9 variables that had statistically significant and independent predictive value for perioperative cardiac events. A point score was derived from the multivariate discriminant-function coefficient of each variable to reflect its statistical weight in the analysis. From this point score, a related preoperative cardiac risk index was derived (Table 1).
      Table 1Preoperative Cardiac Risk Index for Noncardiac Surgical Procedures
      Modified from Goldman and associates.
      • Goldman L
      • Caldera DL
      • Nussbaum SR
      • Southwick FS
      • Krogstad D
      • Murray B
      • Burke DS
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Carabello B
      • Slater EE
      Multifactorial index of cardiac risk in noncardiac surgical procedures.
      By permission of the New England Journal of Medicine.
      Variable
      BUN = blood urea nitrogen; JVP = jugular venous pressure; MI = myocardial infarction; VPC = ventricular premature contractions.
      Point score
      History:
       Age >70 yr5
       Preoperative MI within 6 mo10
      Physical examination:
       S3 gallop or increased JVP (>12 cm H2O)11
       Significant valvular aortic stenosis3
      Electrocardiogram:
       Rhythm other than sinus, or atrial ectopy7
       Documentation of >5 VPC/min at any time7
      General medical status:
       PaO2 <60 mm Hg or PaCO2 >50 mm Hg
       K+ <3.0 meq/L or HCO3 <20 meq/L3
       BUN >50 mg/dl or creatinine >3.0 mg/dl
       Chronic liver disease or debilitation
      Operation:
       Intraperitoneal, intrathoracic, or aortic3
       Emergency4
        Total possible points53
      * BUN = blood urea nitrogen; JVP = jugular venous pressure; MI = myocardial infarction; VPC = ventricular premature contractions.
      In the study by Goldman and associates,
      • Goldman L
      • Caldera DL
      • Nussbaum SR
      • Southwick FS
      • Krogstad D
      • Murray B
      • Burke DS
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Carabello B
      • Slater EE
      Multifactorial index of cardiac risk in noncardiac surgical procedures.
      19 postoperative cardiac deaths (1.9%) occurred, and 39 patients (3.9%) had one or more life-threatening cardiac complications (perioperative pulmonary edema, myocardial infarction, or ventricular tachycardia) without cardiac death. The preoperative cardiac risk factor index clearly correlated with subsequent cardiac events: in low-risk patients (class I, 0 to 5 points), only 0.9% had cardiac events; in high-risk patients (class IV, 26 points or more), 78% had a life-threatening cardiac event or cardiac death (Table 2).
      Table 2Perioperative Outcome of Cardiac Patients Undergoing Noncardiac Operations, Stratified by Cardiac Risk Index of Goldman and Associates
      Modified from Goldman and associates.
      • Goldman L
      • Caldera DL
      • Nussbaum SR
      • Southwick FS
      • Krogstad D
      • Murray B
      • Burke DS
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Carabello B
      • Slater EE
      Multifactorial index of cardiac risk in noncardiac surgical procedures.
      By permission of the New England Journal of Medicine.
      Life-threatening complication
      Perioperative myocardial infarction, pulmonary edema, or ventricular tachycardia without cardiac death.
      Cardiac death
      Risk classNo. of patientsTotal pointsNo.%No.%
      I5370–540.710.2
      II3166–1216552
      III13013–25151232
      IV18≥264221056
       Total1,001394192
      * Perioperative myocardial infarction, pulmonary edema, or ventricular tachycardia without cardiac death.
      The cardiac risk index of Goldman and co-workers was evaluated by Zeldin
      • Zeldin RA
      Assessing cardiac risk in patients who undergo noncardiac surgical procedures.
      in a prospective study of 1,140 patients who were older than 40 years of age when they underwent general noncardiac surgical procedures. This study validated the findings of Goldman and associates
      • Goldman L
      • Caldera DL
      • Nussbaum SR
      • Southwick FS
      • Krogstad D
      • Murray B
      • Burke DS
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Carabello B
      • Slater EE
      Multifactorial index of cardiac risk in noncardiac surgical procedures.
      and revealed a clear difference in risk of perioperative events between lower and higher classes. Patients in the two higher risk classes (III and IV) had an almost eightfold higher incidence of life-threatening cardiac events in comparison with patients in classes I and II. The risk of perioperative cardiac death was almost 20 times higher in patients in class III or IV (9.3%) than in those in class I or II (0.5%); nearly half (43%) of all cardiac deaths occurred in patients who were in class IV.
      • Zeldin RA
      Assessing cardiac risk in patients who undergo noncardiac surgical procedures.
      The applicability of the cardiac risk index
      • Goldman L
      • Caldera DL
      • Nussbaum SR
      • Southwick FS
      • Krogstad D
      • Murray B
      • Burke DS
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Carabello B
      • Slater EE
      Multifactorial index of cardiac risk in noncardiac surgical procedures.
      to certain types of surgical procedures has been questioned. Major intrathoracic, upper abdominal, or great vessel surgical procedures have been associated with a higher incidence of postoperative congestive heart failure
      • Goldman L
      • Caldera DL
      • Southwick FS
      • Nussbaum SR
      • Murray B
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Burke DS
      • Krogstad D
      • Carabello B
      • Slater EE
      Cardiac risk factors and complications in noncardiac surgery.
      and a threefold greater incidence of myocardial reinfarction
      • Steen PA
      • Tinker JH
      • Tarhan S
      Myocardial reinfarction after anesthesia and surgery.
      than found with other general surgical procedures. Jeffrey and colleagues
      • Jeffrey CC
      • Kunsman J
      • Cullen DJ
      • Brewster DC
      A prospective evaluation of cardiac risk index.
      examined the utility of the cardiac risk index prospectively in 99 patients undergoing elective abdominal aortoiliac procedures for aneurysmal or occlusive disease. The cardiac risk index did identify patients at high risk for life-threatening events (myocardial infarction, pulmonary edema, and ventricular tachycardia). Patients in the low-risk classes I and II, however, had a 9% incidence of such events, in comparison with 3% observed in the general surgical population studied by Goldman and co-workers.
      • Goldman L
      • Caldera DL
      • Nussbaum SR
      • Southwick FS
      • Krogstad D
      • Murray B
      • Burke DS
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Carabello B
      • Slater EE
      Multifactorial index of cardiac risk in noncardiac surgical procedures.
      The authors concluded that the cardiac risk index was unreliable in separating truly low-risk from high-risk patients undergoing procedures on the abdominal aorta.
      • Jeffrey CC
      • Kunsman J
      • Cullen DJ
      • Brewster DC
      A prospective evaluation of cardiac risk index.
      These findings are consistent with the known close association of coronary artery disease with peripheral vascular disease. Routine coronary angiography before vascular surgical procedures has demonstrated that 59% of patients with clinically suspected ischemic heart disease have severe multivessel or even inoperable coronary artery disease.
      • Taylor PC
      Evaluation and surgical management of patients with severe combined coronary artery disease and peripheral vascular atherosclerosis.
      More importantly, 23% of patients with no prior history suggestive of cardiac disease had similar severe, diffuse coronary artery disease. Patients with symptomatic ischemic heart disease undergoing surgical procedures for aortic aneurysm or carotid or aortoiliac occlusive disease had incidences of severe coronary artery disease of 95%, 71%, and 84%, respectively. Other investigators have noted a strong influence of coronary artery disease on the early
      • Brown OW
      • Hollier LH
      • Pairolero PC
      • Kazmier FJ
      • McCready RA
      Abdominal aortic aneurysm and coronary artery disease: a reassessment.
      and late
      • Hollier LH
      • Plate G
      • O'Brien PC
      • Kazmier FJ
      • Gloviczki P
      • Pairolero PC
      • Cherry KJ
      Late survival after abdominal aortic aneurysm repair: influence of coronary artery disease.
      survival of patients who undergo abdominal aortic operations, with 70% and 38%, respectively, of all deaths being cardiac-related.
      With the high prevalence of symptomatic and asymptomatic ischemic heart disease in patients undergoing vascular operations, it is not surprising that the cardiac risk index,
      • Goldman L
      • Caldera DL
      • Nussbaum SR
      • Southwick FS
      • Krogstad D
      • Murray B
      • Burke DS
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Carabello B
      • Slater EE
      Multifactorial index of cardiac risk in noncardiac surgical procedures.
      derived from a broad spectrum of general surgical patients, would underestimate perioperative risk for this subgroup of patients. Aortic surgical procedures are associated with a higher risk of prolonged intraoperative hypotension, which has been implicated as a cause of perioperative cardiac complications.
      • Von Knorring J
      Postoperative myocardial infarction: a prospective study in a risk group of surgical patients.
      • Goldman L
      • Caldera DL
      • Southwick FS
      • Nussbaum SR
      • Murray B
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Burke DS
      • Krogstad D
      • Carabello B
      • Slater EE
      Cardiac risk factors and complications in noncardiac surgery.
      • Rao TLK
      • Jacobs KH
      • El-Etr AA
      Reinfarction following anesthesia in patients with myocardial infarction.
      Such procedures are also commonly associated with large shifts of extravascular and intravascular fluids and postoperative hypoxemia due to multifactorial respiratory insufficiency. Cardiac patients with severe occult coronary artery disease, especially those with left ventricular dysfunction, would clearly be at greater risk when subjected to these greater physiologic stresses than would the general postoperative patient. This increased risk may not be fully identified by a cardiac risk index alone.
      To address the importance of the type of surgical procedure in the outcome of noncardiac operations in cardiac patients, Detsky and associates
      • Detsky AS
      • Abrams HB
      • McLaughlin JR
      • Drucker DJ
      • Sasson Z
      • Johnston N
      • Scott JG
      • Forbath N
      • Hilliard JR
      Predicting cardiac complications in patients undergoing non-cardiac surgery.
      • Detsky AS
      • Abrams HB
      • Forbath N
      • Scott JG
      • Hilliard JR
      Cardiac assessment for patients undergoing noncardiac surgery: a multifactorial clinical risk index.
      used a modified cardiac risk index (Table 3) that accounted for the presence and severity of angina pectoris, a feature conspicuously absent from the index of Goldman and colleagues.
      • Goldman L
      • Caldera DL
      • Nussbaum SR
      • Southwick FS
      • Krogstad D
      • Murray B
      • Burke DS
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Carabello B
      • Slater EE
      Multifactorial index of cardiac risk in noncardiac surgical procedures.
      The type of procedure was not regarded as an individual patient risk characteristic but rather as a “pretest probability” of a potential cardiac complication.
      Table 3Multifactorial Cardiac Risk Index of Detsky and Colleagues
      Modified from Detsky and colleagues.
      • Detsky AS
      • Abrams HB
      • McLaughlin JR
      • Drucker DJ
      • Sasson Z
      • Johnston N
      • Scott JG
      • Forbath N
      • Hilliard JR
      Predicting cardiac complications in patients undergoing non-cardiac surgery.
      By permission of the Society of General Internal Medicine.
      Variable
      VPC = ventricular premature contractions.
      Points
      Coronary artery disease
       Myocardial infarction ≤6 mo10
       Myocardial infarction >6 mo5
       Angina (Canadian Cardiovascular Society class)
        Class III10
        Class IV20
       Unstable angina <6 mo10
      Alveolar pulmonary edema
       Within 1 wk10
       Ever5
      Valvular disease
       Suspected critical aortic stenosis20
      Arrhythmia
       Rhythm other than sinus, with or without atrial ectopy5
       Presence of >5 VPC/min at any time5
      Poor general medical status5
      Age >70 yr5
      Emergency surgical procedure10
      * VPC = ventricular premature contractions.
      The modified risk index was assessed
      • Detsky AS
      • Abrams HB
      • McLaughlin JR
      • Drucker DJ
      • Sasson Z
      • Johnston N
      • Scott JG
      • Forbath N
      • Hilliard JR
      Predicting cardiac complications in patients undergoing non-cardiac surgery.
      in 455 patients with prior evidence of coronary, valvular, or myocardial disease, a group of patients with definite potential cardiac risk. The risk classification was done preoperatively, and then the postoperative events were monitored by observers who did not know the preoperative risk index score and did not have direct responsibility for patient care. In these patients undergoing major surgical procedures, 43 perioperative cardiac events occurred: 15 episodes of left ventricular failure, 13 myocardial infarctions, 9 cardiac deaths, and 6 episodes of unstable angina. The likelihood ratios of a cardiac event were 0.42 for class I (0 to 15 points), 3.58 for class II (16 to 30 points), and 14.93 for class III (more than 30 points).
      With the “pretest probability” determined by the cardiac complication rate for each major type of operation, Detsky and co-workers
      • Detsky AS
      • Abrams HB
      • McLaughlin JR
      • Drucker DJ
      • Sasson Z
      • Johnston N
      • Scott JG
      • Forbath N
      • Hilliard JR
      Predicting cardiac complications in patients undergoing non-cardiac surgery.
      used bayesian analysis to determine the probability of a cardiac event for each risk score stratum, and hence the posttest (or post-risk score index) probability. These values permit a graphic representation of probabilities of a perioperative cardiac event (Fig. 3). Incremental risk was clearly greater for increasing risk classification and surgical procedures associated with higher complication rates. For example, for patients undergoing a surgical procedure with an estimated 10% complication rate, 5%, 25%, and 65% probabilities of a cardiac event could be anticipated for modified index classes I, II, and III, respectively. The analysis endpoints used by Detsky and associates
      • Detsky AS
      • Abrams HB
      • McLaughlin JR
      • Drucker DJ
      • Sasson Z
      • Johnston N
      • Scott JG
      • Forbath N
      • Hilliard JR
      Predicting cardiac complications in patients undergoing non-cardiac surgery.
      included “soft” events such as unstable angina and left ventricular failure, which could enhance the predictive value of preoperative risk factors in assessing coronary artery disease. Overall, the results were similar to prior applications of the original cardiac risk index.
      • Goldman L
      • Caldera DL
      • Nussbaum SR
      • Southwick FS
      • Krogstad D
      • Murray B
      • Burke DS
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Carabello B
      • Slater EE
      Multifactorial index of cardiac risk in noncardiac surgical procedures.
      • Zeldin RA
      Assessing cardiac risk in patients who undergo noncardiac surgical procedures.
      The modified cardiac risk index must still be validated prospectively.
      Figure thumbnail gr3
      Fig. 3Bayesian analysis of perioperative cardiac risk during noncardiac surgical procedures as stratified by the modified cardiac risk index. See text for further discussion.
      (Data from Detsky and associates.
      • Detsky AS
      • Abrams HB
      • McLaughlin JR
      • Drucker DJ
      • Sasson Z
      • Johnston N
      • Scott JG
      • Forbath N
      • Hilliard JR
      Predicting cardiac complications in patients undergoing non-cardiac surgery.
      • Detsky AS
      • Abrams HB
      • Forbath N
      • Scott JG
      • Hilliard JR
      Cardiac assessment for patients undergoing noncardiac surgery: a multifactorial clinical risk index.
      )
      Several important considerations about the potential utility of preoperative cardiac risk indices should be noted. A low risk score index does not exclude a patient from perioperative cardiac risk but rather indicates a low probability of a cardiac event. In an estimation of cardiac risk, the magnitude of the surgical procedure, the surgical and anesthetic expertise in one's own institution, and the referral patient population must be considered. One also must not ignore confounding clinical problems and events that considerably influence individual patient management. Such individual problems may occur so uncommonly that they have no predictive power in the statistical analysis of larger studies and hence fail to appear as a factor in a derived cardiac risk index. For example, the rare event of preoperative out-of-hospital cardiac arrest would represent potentially a very high risk for a noncardiac surgical procedure but appears in no reported cardiac risk index.
      • Goldman L
      • Caldera DL
      • Nussbaum SR
      • Southwick FS
      • Krogstad D
      • Murray B
      • Burke DS
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Carabello B
      • Slater EE
      Multifactorial index of cardiac risk in noncardiac surgical procedures.
      • Detsky AS
      • Abrams HB
      • McLaughlin JR
      • Drucker DJ
      • Sasson Z
      • Johnston N
      • Scott JG
      • Forbath N
      • Hilliard JR
      Predicting cardiac complications in patients undergoing non-cardiac surgery.
      Another limitation of preoperative cardiac risk indices is the nature of the methods used to assess left ventricular function. Quantitative measures of left ventricular function have been shown to be the most important prognostic indicators of survival in patients who have coronary artery disease.
      • Mock MB
      • Ringqvist I
      • Fisher LD
      • Davis KB
      • Chaitman BR
      • Kouchoukos NT
      • Kaiser GC
      • Alderman E
      • Ryan TJ
      • Russell Jr, RO
      • Mullin S
      • Fray D
      • Killip III, T
      • participants in the Coronary Artery Surgery Study
      Survival of medically treated patients in the Coronary Artery Surgery Study (CASS) Registry.
      • The Multicenter Postinfarction Research Group
      Risk stratification and survival after myocardial infarction.
      Clinical evidence of left ventricular dysfunction, such as jugular venous distention, a third heart sound, pulmonary edema, and frequent ventricular ectopic beats, has been shown to be predictive of the occurrence of cardiac events during noncardiac operations,
      • Goldman L
      • Caldera DL
      • Southwick FS
      • Nussbaum SR
      • Murray B
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Burke DS
      • Krogstad D
      • Carabello B
      • Slater EE
      Cardiac risk factors and complications in noncardiac surgery.
      • Goldman L
      • Caldera DL
      • Nussbaum SR
      • Southwick FS
      • Krogstad D
      • Murray B
      • Burke DS
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Carabello B
      • Slater EE
      Multifactorial index of cardiac risk in noncardiac surgical procedures.
      • Zeldin RA
      Assessing cardiac risk in patients who undergo noncardiac surgical procedures.
      • Detsky AS
      • Abrams HB
      • McLaughlin JR
      • Drucker DJ
      • Sasson Z
      • Johnston N
      • Scott JG
      • Forbath N
      • Hilliard JR
      Predicting cardiac complications in patients undergoing non-cardiac surgery.
      but these factors remain indirect and imperfect estimates of left ventricular function.
      Foster and colleagues
      • Foster ED
      • Davis KB
      • Carpenter JA
      • Abele S
      • Fray D
      • Principal investigators of CASS and their associates
      Risk of noncardiac operation in patients with defined coronary disease: the Coronary Artery Surgery Study (CASS) Registry experience.
      studied the influence of coronary artery disease and left ventricular function, as defined by angiography, in patients undergoing noncardiac surgical procedures. This study analyzed the outcome of 1,600 major noncardiac surgical procedures performed between 1978 and 1981 on patients (mean age, approximately 58 years) in the Coronary Artery Surgery Study (CASS) Registry. General abdominal (cholecystectomy in 40%), urologic, orthopedic, and gynecologic procedures accounted for 81% of the operations; a vascular or thoracic procedure was done in 13%. In this study, 13 (0.8%) cardiac-related deaths, 21 (1.3%) episodes of congestive heart failure, and 10 (0.6%) perioperative myocardial infarctions occurred. Univariate analysis revealed that multiple signs and symptoms of severe left ventricular dysfunction were related to operative outcome, as was the angiographic left ventricular wall motion score (sum of five segments; scored 1 = normal to 6 = aneurysmal). Left ventricular ejection fraction was not analyzed in this study. Multivariate analysis revealed that only dyspnea on exertion and left ventricular wall motion score were independently predictive of both cardiac-related morbidity and mortality. A preoperative history of myocardial infarction was not an independent predictor of cardiac outcome, an implication that it is the degree of left ventricular dysfunction, not just a history of infarction (which may indicate a mild or even dubious event), that is most important.
      That study
      • Foster ED
      • Davis KB
      • Carpenter JA
      • Abele S
      • Fray D
      • Principal investigators of CASS and their associates
      Risk of noncardiac operation in patients with defined coronary disease: the Coronary Artery Surgery Study (CASS) Registry experience.
      also showed that noncardiac operative mortality was significantly decreased in patients who had undergone a prior coronary artery bypass operation (0.9%) in comparison with those who had not (2.4%) and was similar to that in patients without severe coronary artery disease evident on angiography (0.5%). This analysis, however, did not include the operative mortality associated with the coronary artery bypass procedure itself (2.3% overall for CASS Registry patients).
      • Foster ED
      • Davis KB
      • Carpenter JA
      • Abele S
      • Fray D
      • Principal investigators of CASS and their associates
      Risk of noncardiac operation in patients with defined coronary disease: the Coronary Artery Surgery Study (CASS) Registry experience.
      No statistically significant difference was noted in postoperative nonfatal cardiac complications such as heart failure or myocardial infarction in patients who had or had not undergone a prior coronary bypass operation. Moreover, the number of coronary arteries diseased did not influence perioperative morbidity or mortality.

      PREOPERATIVE ASSESSMENT OF CARDIOVASCULAR FUNCTION

      The cardiovascular functional status of a patient is most often estimated on the basis of a thorough clinical history. Preoperative exercise stress testing is an additional objective means of functional assessment before a noncardiac surgical procedure.
      • Cutler BS
      • Wheeler HB
      • Paraskos JA
      • Cardullo PA
      Applicability and interpretation of electrocardiographic stress testing in patients with peripheral vascular disease.
      • Gerson MC
      • Hurst JM
      • Hertzberg VS
      • Doogan PA
      • Cochran MB
      • Lim SP
      • McCall N
      • Adolph RJ
      Cardiac prognosis in noncardiac geriatric surgery.
      • Carliner NH
      • Fisher ML
      • Plotnick GD
      • Garbart H
      • Rapoport A
      • Kelemen MH
      • Moran GW
      • Gadacz T
      • Peters RW
      Routine preoperative exercise testing in patients undergoing major noncardiac surgery.
      Results of exercise testing are dependent on the pretest probability of ischemic heart disease in the patient population studied. This factor will be influenced not only by the patient's clinical manifestations but also by the surgical procedure planned—;that is, patients referred for vascular operations have a high frequency of coexisting coronary artery disease.
      • Taylor PC
      Evaluation and surgical management of patients with severe combined coronary artery disease and peripheral vascular atherosclerosis.
      In a series of 130 patients undergoing treadmill or arm ergometric electrocardiographic stress testing before vascular surgical procedures, Cutler and colleagues
      • Cutler BS
      • Wheeler HB
      • Paraskos JA
      • Cardullo PA
      Applicability and interpretation of electrocardiographic stress testing in patients with peripheral vascular disease.
      found an impressive correlation between exercise-induced ischemia and subsequent cardiac events. Of patients exercising to more than 75% of their maximal predicted heart rate, those with normal findings on an exercise electrocardiogram had no cardiac mortality or postoperative myocardial infarction. Those patients with an ischemic electrocardiographic response had a 4.3% incidence of nonfatal myocardial infarction. A high-risk group was identified in those patients who exercised to less than a 75% maximal predicted heart rate and had ischemic electrocardiographic changes. In this subgroup, the incidence of perioperative infarction was 25.9% (with 71% mortality) and overall cardiac mortality was 18.5%.
      Carliner and associates
      • Carliner NH
      • Fisher ML
      • Plotnick GD
      • Garbart H
      • Rapoport A
      • Kelemen MH
      • Moran GW
      • Gadacz T
      • Peters RW
      Routine preoperative exercise testing in patients undergoing major noncardiac surgery.
      studied similar exercise electrocardiographic testing prospectively in 200 patients (mean age, 59 years) undergoing various surgical procedures (52% abdominal, 34% vascular, and 14% thoracic). Postoperative cardiac death, myocardial infarction, and suspected myocardial ischemia or injury occurred more frequently in patients with an abnormal preoperative exercise electrocardiogram (27%) than in those without (14%) and more frequently in those patients exercising to less than 5 METs (21%) than in those exercising to a higher workload (12%). Because of the small number of primary events (three cardiac deaths and three myocardial infarctions), the statistical power for identifying predictors of events was limited in this study. By multivariate analysis, only an abnormal preoperative resting electrocardiogram (left ventricular hypertrophy, ST-T wave abnormalities, left bundle-branch block, or Q-wave myocardial infarction) was found to be an independent predictor of cardiac events.
      In 100 patients 65 years of age or older (mean age, 73 years) undergoing exercise radionuclide angiography before elective major abdominal, aortic, or thoracic surgical procedures, Gerson and associates
      • Gerson MC
      • Hurst JM
      • Hertzberg VS
      • Doogan PA
      • Cochran MB
      • Lim SP
      • McCall N
      • Adolph RJ
      Cardiac prognosis in noncardiac geriatric surgery.
      found that only a resting left ventricular regional wall motion abnormality and the inability to exercise for 2 minutes to a heart rate of more than 99 beats/min were independently predictive of a cardiac event. The presence of one or more variables of the Goldman risk index
      • Goldman L
      • Caldera DL
      • Nussbaum SR
      • Southwick FS
      • Krogstad D
      • Murray B
      • Burke DS
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Carabello B
      • Slater EE
      Multifactorial index of cardiac risk in noncardiac surgical procedures.
      also was a significant univariate predictor, as was an ejection fraction of less than 50%. In the absence of a “Goldman indicator,”
      • Goldman L
      • Caldera DL
      • Nussbaum SR
      • Southwick FS
      • Krogstad D
      • Murray B
      • Burke DS
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Carabello B
      • Slater EE
      Multifactorial index of cardiac risk in noncardiac surgical procedures.
      the inability to exercise was associated with a 19.4% incidence of perioperative cardiac events in comparison with a 1.5% incidence in patients able to exercise. Prospective analysis of an additional 55 patients revealed that only the inability to exercise for 2 minutes to a heart rate of more than 99 beats/min independently predicted perioperative cardiac events (cardiac death, myocardial infarction, left ventricular failure, or ventricular tachycardia) with a sensitivity of 80% and a specificity of 53%.
      • Gerson MC
      • Hurst JM
      • Hertzberg VS
      • Doogan PA
      • Cochran MB
      • Lim SP
      • McCall N
      • Adolph RJ
      Cardiac prognosis in noncardiac geriatric surgery.
      Similar findings were noted in 148 patients undergoing symptom-limited exercise radionuclide angiography before peripheral vascular surgical procedures at the Mayo Clinic.
      • Kopecky SL
      • Gibbons RJ
      • Hollier LH
      Preoperative supine exercise radionuclide angiogram predicts perioperative cardiovascular events in vascular surgery (abstract).
      All 11 perioperative cardiac events (5 deaths, 5 myocardial infarctions, and 1 cardiac arrest) occurred in patients unable to exercise to more than a relatively low workload of 400 kg-m/min (4.5 METs for a 70-kg patient). Cardiac events did not correlate with exercise-induced changes in left ventricular ejection fraction or regional function. Contrary to prior observations in patients undergoing similar surgical procedures,
      • Pasternack PF
      • Imparato AM
      • Riles TS
      • Baumann FG
      • Bear G
      • Lamparello PJ
      • Benjamin D
      • Sanger J
      • Kramer E
      The value of the radionuclide angiogram in the prediction of perioperative myocardial infarction in patients undergoing lower extremity revascularization procedures.
      perioperative myocardial infarction was not found to correlate with resting left ventricular ejection fraction.
      The primary limitation of both the clinical history and the exercise stress testing in assessment of cardiovascular function is the patient's inability to undergo adequate physical exertion. This restriction may be due to peripheral vascular, orthopedic, or neurologic disease, the nature of the preoperative illness, advanced age, general deconditioning and debilitation, or some combination of these factors. Such limited exercise performance, in turn, substantially decreases the sensitivity of stress testing and hence its potential prognostic value.
      In patients unable to exercise adequately, intravenous dipyridamole-thallium imaging has been found to be an alternative means of stress testing.
      • Boucher CA
      • Brewster DC
      • Darling RC
      • Okada RD
      • Strauss HW
      • Pohost GM
      Determination of cardiac risk by dipyridamole-thallium imaging before peripheral vascular surgery.
      • Leppo J
      • Plaja J
      • Gionet M
      • Tumolo J
      • Paraskos JA
      • Cutler BS
      Noninvasive evaluation of cardiac risk before elective vascular surgery.
      • Eagle KA
      • Singer DE
      • Brewster DC
      • Darling RC
      • Mulley AG
      • Boucher CA
      Dipyridamole-thallium scanning in patients undergoing vascular surgery: optimizing preoperative evaluation of cardiac risk.
      In this technique, intravenous administration of dipyridamole causes coronary artery vasodilatation, which results in increased blood flow to the myocardium supplied by nonstenotic vessels but limited perfusion in regions supplied by stenotic vessels with diminished flow reserve. This heterogeneity of blood flow is reflected in heterogeneous uptake of thallium, which produces a reversible redistribution defect on the immediate images that resolves on delayed images.
      A preliminary study
      • Boucher CA
      • Brewster DC
      • Darling RC
      • Okada RD
      • Strauss HW
      • Pohost GM
      Determination of cardiac risk by dipyridamole-thallium imaging before peripheral vascular surgery.
      of 48 patients undergoing peripheral vascular operations found that, of 16 patients with preoperative dipyridamole-induced thallium redistribution defects, 8 (50%) subsequently had a perioperative cardiac event (death, infarction, or unstable angina). No cardiac events were noted in patients with normal findings on dipyridamole scans or in the 12 patients with only persistent defects (prior myocardial infarction). Clinically evident cardiac symptoms were not predictive of subsequent complications, although the study did not include patients considered at high risk by the criteria of Goldman and co-workers.
      • Goldman L
      • Caldera DL
      • Nussbaum SR
      • Southwick FS
      • Krogstad D
      • Murray B
      • Burke DS
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Carabello B
      • Slater EE
      Multifactorial index of cardiac risk in noncardiac surgical procedures.
      The authors concluded that a reversible defect on dipyridamole-thallium imaging identified a high cardiac risk for vascular surgical procedures and advocated further evaluation of this subgroup by coronary angiography in anticipation of possible coronary revascularization.
      • Boucher CA
      • Brewster DC
      • Darling RC
      • Okada RD
      • Strauss HW
      • Pohost GM
      Determination of cardiac risk by dipyridamole-thallium imaging before peripheral vascular surgery.
      Leppo and associates
      • Leppo J
      • Plaja J
      • Gionet M
      • Tumolo J
      • Paraskos JA
      • Cutler BS
      Noninvasive evaluation of cardiac risk before elective vascular surgery.
      studied the results of dipyridamole-thallium imaging in 100 patients before aortic or peripheral vascular surgical procedures. The presence of dipyridamole-induced thallium redistribution was associated with a 33% rate of cardiac events (myocardial infarction or death) in comparison with a 2% rate in those with no redistribution. Dipyridamole-thallium imaging was highly sensitive (93%) in predicting perioperative myocardial infarction or death in patients undergoing a vascular operation if a redistribution defect was present. The positive predictive value, however, was low (33%), as was the specificity (62%). A scan without a redistribution defect was reassuring because the negative predictive value was very high (98%). If diabetes was present or the ST-segment depression was precipitated by dipyridamole-thallium stress, regression analysis showed that the probability of a perioperative event increased to approximately 60%, 30 times the risk observed in patients without a thallium redistribution defect. The number of redistribution defects and dipyridamole-induced ST-segment depressions had only univariate predictive value for cardiac events.
      In another study in which dipyridamole-thallium imaging was used before vascular surgical procedures, Eagle and colleagues
      • Eagle KA
      • Singer DE
      • Brewster DC
      • Darling RC
      • Mulley AG
      • Boucher CA
      Dipyridamole-thallium scanning in patients undergoing vascular surgery: optimizing preoperative evaluation of cardiac risk.
      also noted the predictive value of a redistribution defect and found that the location and number of thallium redistribution defects added little to the risk analysis. Demonstration of a thallium redistribution defect in the presence of one or more clinical risk factors (angina, prior myocardial infarction, congestive heart failure, electrocardiographic Q waves, or diabetes) was associated with a considerably higher incidence of perioperative cardiac complications (44%) in comparison with patients without such clinical risk factors (0%). Because of this observation, these investigators advocated dipyridamole-thallium imaging before vascular operations only in patients with one or more of the aforementioned clinical risk factors.

      APPROACH TO ASSESSMENT AND MANAGEMENT

      Obtaining a thorough cardiovascular history is vital in the preoperative evaluation for noncardiac surgical procedures, and its findings are corroborated by the cardiovascular physical examination, chest roentgenogram, and electrocardiogram. Close attention should be paid to the presence, severity, and pattern of angina pectoris and also to the efficacy and appropriateness of the current medical program. A history and chronology of prior myocardial infarction (or infarctions) should be elicited, as should symptoms suggestive of left ventricular dysfunction.
      As demonstrated in several studies involving exercise stress testing,
      • Cutler BS
      • Wheeler HB
      • Paraskos JA
      • Cardullo PA
      Applicability and interpretation of electrocardiographic stress testing in patients with peripheral vascular disease.
      • Gerson MC
      • Hurst JM
      • Hertzberg VS
      • Doogan PA
      • Cochran MB
      • Lim SP
      • McCall N
      • Adolph RJ
      Cardiac prognosis in noncardiac geriatric surgery.
      • Kopecky SL
      • Gibbons RJ
      • Hollier LH
      Preoperative supine exercise radionuclide angiogram predicts perioperative cardiovascular events in vascular surgery (abstract).
      the functional limitation of a patient with ischemic heart disease has the most significant implications for cardiac risk in noncardiac surgical procedures. Exercise stress testing is noninvasive and widely available but should be used selectively. Patients not suspected clinically of having ischemic heart disease should not undergo routine stress testing before general noncardiac operations.
      In general, if patients with chronic stable angina are able to perform activities of daily living—;for example, housework or walking briskly on level ground without symptoms—;such patients will probably tolerate the stress of most noncardiac surgical procedures.
      • Goldman L
      Assessment and management of the cardiac patient before, during, and after noncardiac surgery.
      Such patients would experience angina only with unusual exertion or stress and would be classified in New York Heart Association functional class II. This group of patients would not routinely require preoperative stress testing; however, the authors believe that patients about to undergo major intrathoracic, upper abdominal, or vascular surgical procedures (especially if they have diabetes or ischemic left ventricular dysfunction) should be strongly considered for preoperative stress testing. In contrast, patients with significant symptomatic limitation (New York Heart Association functional class III or IV) or progressive or accelerating symptoms of angina should undergo coronary angiography.
      If the patient's functional limitation from ischemic heart disease is not clear on the basis of the history, then exercise stress testing, if possible, is indicated. Even if minimal anginal symptoms are present, stress testing should be undertaken before a major upper abdominal, intrathoracic, or, especially, peripheral vascular surgical procedure if the patient has (1) had a definite prior myocardial infarction (on the basis of the history or electrocardiography), (2) symptomatic left ventricular dysfunction, or (3) diabetes mellitus. Previous studies
      • Cutler BS
      • Wheeler HB
      • Paraskos JA
      • Cardullo PA
      Applicability and interpretation of electrocardiographic stress testing in patients with peripheral vascular disease.
      • Gerson MC
      • Hurst JM
      • Hertzberg VS
      • Doogan PA
      • Cochran MB
      • Lim SP
      • McCall N
      • Adolph RJ
      Cardiac prognosis in noncardiac geriatric surgery.
      • Carliner NH
      • Fisher ML
      • Plotnick GD
      • Garbart H
      • Rapoport A
      • Kelemen MH
      • Moran GW
      • Gadacz T
      • Peters RW
      Routine preoperative exercise testing in patients undergoing major noncardiac surgery.
      • Kopecky SL
      • Gibbons RJ
      • Hollier LH
      Preoperative supine exercise radionuclide angiogram predicts perioperative cardiovascular events in vascular surgery (abstract).
      are in agreement that, if adequate exercise capacity (5 to 6 METs) is demonstrated on exercise testing, the cardiac risk during noncardiac surgical procedures, including peripheral vascular operations, is low. Coronary angiography should be performed if the patient is unable to exercise to an adequate workload because of ischemic symptoms or demonstrates other signs of an early positive high-risk stress test. In such a situation, coronary revascularization probably is warranted.
      If a patient with a history of angina, prior infarction, congestive heart failure, or diabetes is unable to exercise to an adequate workload for any noncardiac reason, we recommend dipyridamole-thallium scanning if a major intrathoracic, upper abdominal, or peripheral vascular operation is planned. The absence of a dipyridamole-induced reversible thallium defect has a high negative predictive value and indicates very low risk for a noncardiac surgical procedure. The detection of any definite reversible thallium defect is associated with approximately a 20 to 33% risk of perioperative myocardial infarction or cardiac death.
      • Boucher CA
      • Brewster DC
      • Darling RC
      • Okada RD
      • Strauss HW
      • Pohost GM
      Determination of cardiac risk by dipyridamole-thallium imaging before peripheral vascular surgery.
      • Leppo J
      • Plaja J
      • Gionet M
      • Tumolo J
      • Paraskos JA
      • Cutler BS
      Noninvasive evaluation of cardiac risk before elective vascular surgery.
      • Eagle KA
      • Singer DE
      • Brewster DC
      • Darling RC
      • Mulley AG
      • Boucher CA
      Dipyridamole-thallium scanning in patients undergoing vascular surgery: optimizing preoperative evaluation of cardiac risk.
      As directed by clinical judgment, coronary angiography should be strongly considered for further preoperative evaluation in anticipation of coronary revascularization by either percutaneous transluminal coronary angioplasty or a coronary artery bypass operation (depending on the angiographic findings).
      In an attempt to decrease cardiac mortality and morbidity from coronary artery disease, some investigators have recommended routine coronary angiography
      • Hertzer NR
      • Young JR
      • Kramer JR
      • Phillips DF
      • deWolfe VG
      • Ruschhaupt III, WF
      • Beven EG
      Routine coronary angiography prior to elective aortic reconstruction: results of selective myocardial revascularization in patients with peripheral vascular disease.
      and coronary artery bypass operations, as indicated in patients undergoing peripheral vascular
      • Hertzer NR
      • Young JR
      • Kramer JR
      • Phillips DF
      • deWolfe VG
      • Ruschhaupt III, WF
      • Beven EG
      Routine coronary angiography prior to elective aortic reconstruction: results of selective myocardial revascularization in patients with peripheral vascular disease.
      • DeBakey ME
      • Lawrie GM
      Combined coronary artery and peripheral vascular disease: recognition and treatment (editorial).
      • Hertzer NR
      Fatal myocardial infarction following lower extremity revascularization: two hundred seventy-three patients followed six to eleven postoperative years.
      and carotid
      • Ennix Jr, CL
      • Lawrie GM
      • Morris Jr, GC
      • Crawford ES
      • Howell JF
      • Reardon MJ
      • Weatherford SC
      Improved results of carotid endarterectomy in patients with symptomatic coronary disease: an analysis of 1,546 consecutive carotid operations.
      surgical procedures. A coronary artery bypass operation before a noncardiac surgical procedure, including thoracic or vascular procedures, has been suggested to decrease perioperative cardiac mortality significantly, to 0% to 1.1%
      • Foster ED
      • Davis KB
      • Carpenter JA
      • Abele S
      • Fray D
      • Principal investigators of CASS and their associates
      Risk of noncardiac operation in patients with defined coronary disease: the Coronary Artery Surgery Study (CASS) Registry experience.
      • Crawford ES
      • Morris Jr, GC
      • Howell JF
      • Flynn WF
      • Moorhead DT
      Operative risk in patients with previous coronary artery bypass.
      • Mahar LJ
      • Steen PA
      • Tinker JH
      • Vlietstra RE
      • Smith HC
      • Pluth JR
      Perioperative myocardial infarction in patients with coronary artery disease with and without aorta-coronary artery bypass grafts.
      in comparison with a cardiac mortality of 2.4% in patients with similar coronary artery disease treated medically.
      • Foster ED
      • Davis KB
      • Carpenter JA
      • Abele S
      • Fray D
      • Principal investigators of CASS and their associates
      Risk of noncardiac operation in patients with defined coronary disease: the Coronary Artery Surgery Study (CASS) Registry experience.
      The potential risks and benefits of coronary revascularization before major noncardiac surgical procedures must be considered carefully. In a CASS report,
      • Kennedy JW
      • Kaiser GC
      • Fisher LD
      • Fritz JK
      • Myers W
      • Mudd JG
      • Ryan TJ
      Clinical and angiographic predictors of operative mortality from the Collaborative Study in Coronary Artery Surgery (CASS).
      the overall operative mortality for coronary artery bypass procedures was 2.3%. This mortality increased to 2.9% for all patients with a left ventricular ejection fraction less than 50% and to 7.9% in all patients older than 70 years of age. Mortality rates for coronary artery bypass operations are likely to be higher in some institutions. Recent multicenter experience with percutaneous transluminal coronary angioplasty has demonstrated an overall mortality of 1.0% (2.8% when triple-vessel disease is present), a 4.3% incidence of nonfatal infarction, and a need for emergency coronary artery bypass operation in 3.4% of patients.
      • Detre K
      • Holubkov R
      • Kelsey S
      • Cowley M
      • Kent K
      • Williams D
      • Myler R
      • Faxon D
      • Holmes Jr, D
      • Bourassa M
      • Block P
      • Gosselin A
      • Bentivoglio L
      • Leatherman L
      • Dorros G
      • King III, S
      • Galichia J
      • Al-Bassam M
      • Leon M
      • Robertson T
      • Passamani E
      • co-investigators of the National Heart, Lung, and Blood Institute's Percutaneous Transluminal Coronary Angioplasty Registry
      Percutaneous transluminal coronary angioplasty in 1985–1986 and 1977–1981: the National Heart, Lung, and Blood Institute Registry.
      No trial examining the risks and benefits of percutaneous transluminal coronary angioplasty before noncardiac surgical procedures has been reported to date.
      The benefits of the coronary revascularization procedures must be carefully weighed against the potential risks (which may be higher) in the endeavor to decrease cardiac mortality and morbidity associated with major noncardiac surgical procedures. The presence of cardiac risk index factors, severity of ischemic symptoms, functional limitation, presence and degree of left ventricular dysfunction, age, medical therapeutic options, and general medical condition all are important factors that affect the individual patient's preoperative management. As demonstrated by numerous studies, the method of anesthesia (general versus spinal) and the specific type of anesthetic agent administered do not contribute substantially to the perioperative cardiac risk.
      • Tarhan S
      • Moffitt EA
      • Taylor WF
      • Giuliani ER
      Myocardial infarction after general anesthesia.
      • Von Knorring J
      Postoperative myocardial infarction: a prospective study in a risk group of surgical patients.
      • Goldman L
      • Caldera DL
      • Southwick FS
      • Nussbaum SR
      • Murray B
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Burke DS
      • Krogstad D
      • Carabello B
      • Slater EE
      Cardiac risk factors and complications in noncardiac surgery.
      • Steen PA
      • Tinker JH
      • Tarhan S
      Myocardial reinfarction after anesthesia and surgery.
      • Rao TLK
      • Jacobs KH
      • El-Etr AA
      Reinfarction following anesthesia in patients with myocardial infarction.
      • Goldman L
      • Caldera DL
      • Nussbaum SR
      • Southwick FS
      • Krogstad D
      • Murray B
      • Burke DS
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Carabello B
      • Slater EE
      Multifactorial index of cardiac risk in noncardiac surgical procedures.
      • Zeldin RA
      Assessing cardiac risk in patients who undergo noncardiac surgical procedures.
      Patients with prior myocardial infarction should undergo careful assessment for symptoms and signs of congestive heart failure or functional limitation; if present, noninvasive assessment of left ventricular function with radionuclide angiography or two-dimensional echocardiography is often warranted. A similar approach would be reasonable in patients with nonischemic dilated cardiomyopathy or hemodynamically significant valvular aortic or mitral regurgitation, in whom important left ventricular dysfunction may also occur.
      If congestive heart failure is present, every effort should be made to optimize medical therapy preoperatively, and dehydration and hypotension from overly aggressive diuretic and vasodilator therapy, respectively, should be avoided. In patients with clinical evidence of congestive heart failure and confirmation of severe left ventricular dysfunction, intraoperative hemodynamic monitoring by pulmonary artery catheterization is indicated, especially for major intrathoracic, upper abdominal, or aortoiliac surgical procedures. By continuous monitoring of left ventricular filling (wedge) pressure and other hemodynamic variables, therapy with fluids, inotropic agents, nitroglycerin, and other vasodilators can be optimally guided. Benefits of such monitoring could continue well into the postoperative period,
      • Rao TLK
      • Jacobs KH
      • El-Etr AA
      Reinfarction following anesthesia in patients with myocardial infarction.
      when major mobilization of extravascular fluid could precipitate pulmonary edema in patients with severe left ventricular dysfunction.
      Assessment of pulmonary capillary wedge pressure has been shown to be more sensitive than electrocardiographic monitoring in the detection of intraoperative myocardial ischemia.
      • Kaplan JA
      • Wells PH
      Early diagnosis of myocardial ischemia using the pulmonary arterial catheter.
      Aggressive use of hemodynamic monitoring with meticulous postoperative cardiopulmonary care in patients with a prior myocardial infarction, especially if it occurred within 6 months before the noncardiac surgical procedure (Fig. 2), has been shown to decrease the overall incidence of perioperative reinfarction significantly (7.7% to 1.9%) and also to decrease the mortality from reinfarction itself (57% to 36%) in one nonrandomized series of patients.
      • Rao TLK
      • Jacobs KH
      • El-Etr AA
      Reinfarction following anesthesia in patients with myocardial infarction.
      Because approximately 50% of all patients who have postoperative myocardial infarction have no typical symptoms of ischemia,
      • Goldman L
      • Caldera DL
      • Southwick FS
      • Nussbaum SR
      • Murray B
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Burke DS
      • Krogstad D
      • Carabello B
      • Slater EE
      Cardiac risk factors and complications in noncardiac surgery.
      • Goldman L
      • Caldera DL
      • Nussbaum SR
      • Southwick FS
      • Krogstad D
      • Murray B
      • Burke DS
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Carabello B
      • Slater EE
      Multifactorial index of cardiac risk in noncardiac surgical procedures.
      • Foster ED
      • Davis KB
      • Carpenter JA
      • Abele S
      • Fray D
      • Principal investigators of CASS and their associates
      Risk of noncardiac operation in patients with defined coronary disease: the Coronary Artery Surgery Study (CASS) Registry experience.
      close monitoring by serial myocardial enzyme determinations, electrocardiography, and even invasive hemodynamic studies
      • Rao TLK
      • Jacobs KH
      • El-Etr AA
      Reinfarction following anesthesia in patients with myocardial infarction.
      has been advocated in potentially high-risk patients.
      Intraoperative hemodynamic monitoring should be considered
      • Wells PH
      • Kaplan JA
      Optimal management of patients with ischemic heart disease for noncardiac surgery by complementary anesthesiologist and cardiologist interaction.
      • Goldman L
      Cardiac risks and complications of noncardiac surgery.
      during major noncardiac operations in patients with the following: (1) high-risk ischemic heart disease not amenable to revascularization techniques, (2) myocardial infarction within 6 months preoperatively, (3) clinically significant left ventricular failure from any cause, (4) severe aortic or mitral stenosis, (5) surgical treatment of aortic aneurysm, or (6) emergency or relatively urgent surgical procedures in which optimization of cardiac status is not possible. By use of invasive monitoring for guidance, perioperative hemodynamics may be optimized with the use of intravenous vasodilator, inotropic, or β-adrenergic antagonist therapy as indicated for the individual patient, although no randomized, controlled trial has been performed to substantiate decreased cardiovascular morbidity and mortality during noncardiac surgical procedures with this approach. The low risk associated with invasive hemodynamic monitoring by experienced operators again should be balanced against the potential benefits.
      Other cardiovascular issues should be evaluated before noncardiac surgical procedures. The patient's medication program for hypertension, ischemic heart disease, arrhythmia, or congestive heart failure should be carefully examined for efficacy and appropriateness. In general, cardiovascular medications should be continued up to the time of operation and resumed as soon as possible postoperatively, even by using nasogastric tube administration. Initial concerns about precipitation of hypotension and bradyarrhythmia during general anesthesia because of use of β-adrenergic antagonist therapy are unfounded; such therapy should be continued uninterrupted insofar as possible, especially in patients with ischemic heart disease in whom acute withdrawal may precipitate rebound myocardial ischemia.
      • Goldman L
      Cardiac risks and complications of noncardiac surgery.
      Likewise, antihypertensive medication should remain as continuous as possible. Significant perioperative hypertension will occur in approximately 25% of hypertensive patients; it seems to be unrelated to preoperative control and frequently occurs in patients undergoing repair of abdominal aortic aneurysm and other peripheral vascular surgical procedures, including carotid endarterectomy.
      • Goldman L
      • Caldera DL
      Risks of general anesthesia and elective operation in the hypertensive patient.
      Perioperative hypertension can be controlled readily and safely with intravenous administration of β-adrenergic antagonists, particularly with continuous infusion of the ultrashort-acting agent esmolol.
      • Reves JG
      • Flezzani P
      Perioperative use of esmolol.
      Both supraventricular and especially ventricular arrhythmias may reflect underlying myocardial or valvular disease and have been independently associated with increased perioperative cardiac risk.
      • Goldman L
      • Caldera DL
      • Southwick FS
      • Nussbaum SR
      • Murray B
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Burke DS
      • Krogstad D
      • Carabello B
      • Slater EE
      Cardiac risk factors and complications in noncardiac surgery.
      • Goldman L
      • Caldera DL
      • Nussbaum SR
      • Southwick FS
      • Krogstad D
      • Murray B
      • Burke DS
      • O'Malley TA
      • Goroll AH
      • Caplan CH
      • Nolan J
      • Carabello B
      • Slater EE
      Multifactorial index of cardiac risk in noncardiac surgical procedures.
      Hence, the preoperative anti-arrhythmia therapy should be maintained throughout the perioperative period. Prophylactic infusion of lidocaine should be considered for the suppression of complex ventricular ectopic beats only in the patient with a history of ventricular arrhythmia that causes symptoms or cardiac arrest.
      • Goldman L
      Assessment and management of the cardiac patient before, during, and after noncardiac surgery.
      Asymptomatic conduction system disease such as bundle-branch block or bifascicular or even trifascicular block does not presage advanced or complete heart block during noncardiac surgical procedures.
      • Pastore JO
      • Yurchak PM
      • Janis KM
      • Murphy JD
      • Zir LM
      The risk of advanced heart block in surgical patients with right bundle branch block and left axis deviation.
      In general, prophylactic pacing is reserved for only those patients in whom permanent cardiac pacing is clearly indicated.

      Frye RL, Collins JJ, DeSanctis RW, Dodge HT, Dreifus LS, Fisch C, Gettes LS, Gillette PC, Parsonnet V, Reeves TJ, Weinberg SL: Guidelines for permanent cardiac pacemaker implantation, May 1984: a report of the Joint American College of Cardiology/American Heart Association Task Force on Assessment of Cardiovascular Procedures (Subcommittee on Pacemaker Implantation). Circulation 70:331A-339A, 1984

      Severe valvular heart disease should be evident on physical examination. The cause and severity of valvular disease can be clarified by two-dimensional and Doppler echocardiography and, in certain cases, cardiac catheterization. In general, patients with symptomatic severe aortic or mitral stenosis should be considered candidates for surgical correction or valvuloplasty
      • Rahimtoola SH
      Catheter balloon valvuloplasty of aortic and mitral stenosis in adults: 1987.
      (if surgical correction is not a reasonable option) before major noncardiac operations. Medical therapy guided by careful intraoperative hemodynamic monitoring should be adequate for asymptomatic patients with severe aortic or mitral stenosis.
      • Goldman L
      Cardiac risks and complications of noncardiac surgery.
      Recent experience at the Mayo Clinic has shown that selected patients with symptomatic, severe aortic stenosis can undergo noncardiac surgical procedures with current anesthetic techniques without prohibitive cardiac-related mortality and morbidity.
      • O'Keefe JH
      • Shub C
      • Rettke SR
      Can patients with severe aortic stenosis safely undergo noncardiac surgery? (abstract).
      The approach to patients with mechanical valvular prostheses who require long-term anticoagulation is variable. In one study, discontinuation of oral anticoagulant therapy 1 to 3 days preoperatively with resumption approximately 2 days (range, 1 to 7 days) postoperatively was associated with a 13% incidence of bleeding complications but no thromboembolic events.
      • Tinker JH
      • Tarhan S
      Discontinuing anticoagulant therapy in surgical patients with cardiac valve prostheses: observations in 180 operations.
      Other investigators
      • Katholi RE
      • Nolan SP
      • McGuire LB
      The management of anticoagulation during noncardiac operations in patients with prosthetic heart valves: a prospective study.
      used a similar method for aortic prostheses but achieved additional anticoagulation with infusion of full-dose heparin until 6 hours preoperatively and resumption of this regimen 12 to 24 hours postoperatively for patients with mechanical prostheses in the mitral position; no thromboembolic events and a rate of bleeding complications similar to that previously mentioned were noted with this approach.
      Prophylaxis against bacterial endocarditis should be administered according to the recommendations of the American Heart Association.
      • Shulman ST
      • Amren DP
      • Bisno AL
      • Dajani AS
      • Durack DT
      • Gerber MA
      • Kaplan EL
      • Millard HD
      • Sanders WE
      • Schwartz RH
      • Watanakunakorn C
      Prevention of bacterial endocarditis: a statement for health professionals by the Committee on Rheumatic Fever and Infective Endocarditis of the Council on Cardiovascular Disease in the Young.
      In general, patients with hypertrophic obstructive cardiomyopathy tolerate major noncardiac surgical procedures without increased cardiac-related mortality or life-threatening ventricular arrhythmia.
      • Thompson RC
      • Liberthson RR
      • Lowenstein E
      Perioperative anesthetic risk of noncardiac surgery in hypertrophic obstructive cardiomyopathy.
      Conditions that may exacerbate the dynamic left ventricular outflow tract obstruction, such as hypovolemia or peripheral vasodilatation, should be avoided in patients with this disorder.

      REFERENCES

        • Tarhan S
        • Moffitt EA
        • Taylor WF
        • Giuliani ER
        Myocardial infarction after general anesthesia.
        JAMA. 1972; 220: 1451-1454
        • Von Knorring J
        Postoperative myocardial infarction: a prospective study in a risk group of surgical patients.
        Surgery. 1981; 90: 55-60
        • Goldman L
        • Caldera DL
        • Southwick FS
        • Nussbaum SR
        • Murray B
        • O'Malley TA
        • Goroll AH
        • Caplan CH
        • Nolan J
        • Burke DS
        • Krogstad D
        • Carabello B
        • Slater EE
        Cardiac risk factors and complications in noncardiac surgery.
        Medicine. 1978; 57: 357-370
        • Steen PA
        • Tinker JH
        • Tarhan S
        Myocardial reinfarction after anesthesia and surgery.
        JAMA. 1978; 239: 2566-2570
        • Rao TLK
        • Jacobs KH
        • El-Etr AA
        Reinfarction following anesthesia in patients with myocardial infarction.
        Anesthesiology. 1983; 59: 499-505
        • Goldman L
        • Caldera DL
        • Nussbaum SR
        • Southwick FS
        • Krogstad D
        • Murray B
        • Burke DS
        • O'Malley TA
        • Goroll AH
        • Caplan CH
        • Nolan J
        • Carabello B
        • Slater EE
        Multifactorial index of cardiac risk in noncardiac surgical procedures.
        N Engl J Med. 1977; 297: 845-850
        • Zeldin RA
        Assessing cardiac risk in patients who undergo noncardiac surgical procedures.
        Can J Surg. 1984; 27: 402-404
        • Jeffrey CC
        • Kunsman J
        • Cullen DJ
        • Brewster DC
        A prospective evaluation of cardiac risk index.
        Anesthesiology. 1983; 58: 462-464
        • Taylor PC
        Evaluation and surgical management of patients with severe combined coronary artery disease and peripheral vascular atherosclerosis.
        Cleve Clin Q. 1981; 48: 172-173
        • Brown OW
        • Hollier LH
        • Pairolero PC
        • Kazmier FJ
        • McCready RA
        Abdominal aortic aneurysm and coronary artery disease: a reassessment.
        Arch Surg. 1981; 116: 1484-1487
        • Hollier LH
        • Plate G
        • O'Brien PC
        • Kazmier FJ
        • Gloviczki P
        • Pairolero PC
        • Cherry KJ
        Late survival after abdominal aortic aneurysm repair: influence of coronary artery disease.
        J Vasc Surg. 1984; 1: 290-297
        • Detsky AS
        • Abrams HB
        • McLaughlin JR
        • Drucker DJ
        • Sasson Z
        • Johnston N
        • Scott JG
        • Forbath N
        • Hilliard JR
        Predicting cardiac complications in patients undergoing non-cardiac surgery.
        J Gen Intern Med. 1986; 1: 211-219
        • Detsky AS
        • Abrams HB
        • Forbath N
        • Scott JG
        • Hilliard JR
        Cardiac assessment for patients undergoing noncardiac surgery: a multifactorial clinical risk index.
        Arch Intern Med. 1986; 146: 2131-2134
        • Mock MB
        • Ringqvist I
        • Fisher LD
        • Davis KB
        • Chaitman BR
        • Kouchoukos NT
        • Kaiser GC
        • Alderman E
        • Ryan TJ
        • Russell Jr, RO
        • Mullin S
        • Fray D
        • Killip III, T
        • participants in the Coronary Artery Surgery Study
        Survival of medically treated patients in the Coronary Artery Surgery Study (CASS) Registry.
        Circulation. 1982; 66: 562-568
        • The Multicenter Postinfarction Research Group
        Risk stratification and survival after myocardial infarction.
        N Engl J Med. 1983; 309: 331-336
        • Foster ED
        • Davis KB
        • Carpenter JA
        • Abele S
        • Fray D
        • Principal investigators of CASS and their associates
        Risk of noncardiac operation in patients with defined coronary disease: the Coronary Artery Surgery Study (CASS) Registry experience.
        Ann Thorac Surg. 1986; 41: 42-49
        • Cutler BS
        • Wheeler HB
        • Paraskos JA
        • Cardullo PA
        Applicability and interpretation of electrocardiographic stress testing in patients with peripheral vascular disease.
        Am J Surg. 1981; 141: 501-506
        • Gerson MC
        • Hurst JM
        • Hertzberg VS
        • Doogan PA
        • Cochran MB
        • Lim SP
        • McCall N
        • Adolph RJ
        Cardiac prognosis in noncardiac geriatric surgery.
        Ann Intern Med. 1985; 103: 832-837
        • Carliner NH
        • Fisher ML
        • Plotnick GD
        • Garbart H
        • Rapoport A
        • Kelemen MH
        • Moran GW
        • Gadacz T
        • Peters RW
        Routine preoperative exercise testing in patients undergoing major noncardiac surgery.
        Am J Cardiol. 1985; 56: 51-58
        • Kopecky SL
        • Gibbons RJ
        • Hollier LH
        Preoperative supine exercise radionuclide angiogram predicts perioperative cardiovascular events in vascular surgery (abstract).
        J Am Coll Cardiol. 1986; 7: 226A
        • Pasternack PF
        • Imparato AM
        • Riles TS
        • Baumann FG
        • Bear G
        • Lamparello PJ
        • Benjamin D
        • Sanger J
        • Kramer E
        The value of the radionuclide angiogram in the prediction of perioperative myocardial infarction in patients undergoing lower extremity revascularization procedures.
        Circulation. 1985; 72: II13-II17
        • Boucher CA
        • Brewster DC
        • Darling RC
        • Okada RD
        • Strauss HW
        • Pohost GM
        Determination of cardiac risk by dipyridamole-thallium imaging before peripheral vascular surgery.
        N Engl J Med. 1985; 312: 389-394
        • Leppo J
        • Plaja J
        • Gionet M
        • Tumolo J
        • Paraskos JA
        • Cutler BS
        Noninvasive evaluation of cardiac risk before elective vascular surgery.
        J Am Coll Cardiol. 1987; 9: 269-276
        • Eagle KA
        • Singer DE
        • Brewster DC
        • Darling RC
        • Mulley AG
        • Boucher CA
        Dipyridamole-thallium scanning in patients undergoing vascular surgery: optimizing preoperative evaluation of cardiac risk.
        JAMA. 1987; 257: 2185-2189
        • Goldman L
        Assessment and management of the cardiac patient before, during, and after noncardiac surgery.
        in: Parmley WW Chatterjee K Cardiology. Vol 2. JB Lippincott Company, Philadelphia1988: 1-15 (Chapter 73)
        • Hertzer NR
        • Young JR
        • Kramer JR
        • Phillips DF
        • deWolfe VG
        • Ruschhaupt III, WF
        • Beven EG
        Routine coronary angiography prior to elective aortic reconstruction: results of selective myocardial revascularization in patients with peripheral vascular disease.
        Arch Surg. 1979; 114: 1336-1343
        • DeBakey ME
        • Lawrie GM
        Combined coronary artery and peripheral vascular disease: recognition and treatment (editorial).
        J Vasc Surg. 1984; 1: 605-607
        • Hertzer NR
        Fatal myocardial infarction following lower extremity revascularization: two hundred seventy-three patients followed six to eleven postoperative years.
        Ann Surg. 1981; 193: 492-498
        • Ennix Jr, CL
        • Lawrie GM
        • Morris Jr, GC
        • Crawford ES
        • Howell JF
        • Reardon MJ
        • Weatherford SC
        Improved results of carotid endarterectomy in patients with symptomatic coronary disease: an analysis of 1,546 consecutive carotid operations.
        Stroke. 1979; 10: 122-125
        • Crawford ES
        • Morris Jr, GC
        • Howell JF
        • Flynn WF
        • Moorhead DT
        Operative risk in patients with previous coronary artery bypass.
        Ann Thorac Surg. 1978; 26: 215-220
        • Mahar LJ
        • Steen PA
        • Tinker JH
        • Vlietstra RE
        • Smith HC
        • Pluth JR
        Perioperative myocardial infarction in patients with coronary artery disease with and without aorta-coronary artery bypass grafts.
        J Thorac Cardiovasc Surg. 1978; 76: 533-537
        • Kennedy JW
        • Kaiser GC
        • Fisher LD
        • Fritz JK
        • Myers W
        • Mudd JG
        • Ryan TJ
        Clinical and angiographic predictors of operative mortality from the Collaborative Study in Coronary Artery Surgery (CASS).
        Circulation. 1981; 63: 793-801
        • Detre K
        • Holubkov R
        • Kelsey S
        • Cowley M
        • Kent K
        • Williams D
        • Myler R
        • Faxon D
        • Holmes Jr, D
        • Bourassa M
        • Block P
        • Gosselin A
        • Bentivoglio L
        • Leatherman L
        • Dorros G
        • King III, S
        • Galichia J
        • Al-Bassam M
        • Leon M
        • Robertson T
        • Passamani E
        • co-investigators of the National Heart, Lung, and Blood Institute's Percutaneous Transluminal Coronary Angioplasty Registry
        Percutaneous transluminal coronary angioplasty in 1985–1986 and 1977–1981: the National Heart, Lung, and Blood Institute Registry.
        N Engl J Med. 1988; 318: 265-270
        • Kaplan JA
        • Wells PH
        Early diagnosis of myocardial ischemia using the pulmonary arterial catheter.
        Anesth Analg. 1981; 60: 789-793
        • Wells PH
        • Kaplan JA
        Optimal management of patients with ischemic heart disease for noncardiac surgery by complementary anesthesiologist and cardiologist interaction.
        Am Heart J. 1981; 102: 1029-1037
        • Goldman L
        Cardiac risks and complications of noncardiac surgery.
        Ann Intern Med. 1983; 98: 504-513
        • Goldman L
        • Caldera DL
        Risks of general anesthesia and elective operation in the hypertensive patient.
        Anesthesiology. 1979; 50: 285-292
        • Reves JG
        • Flezzani P
        Perioperative use of esmolol.
        Am J Cardiol. 1985; 56: 57F-60F
        • Pastore JO
        • Yurchak PM
        • Janis KM
        • Murphy JD
        • Zir LM
        The risk of advanced heart block in surgical patients with right bundle branch block and left axis deviation.
        Circulation. 1978; 57: 677-680
      1. Frye RL, Collins JJ, DeSanctis RW, Dodge HT, Dreifus LS, Fisch C, Gettes LS, Gillette PC, Parsonnet V, Reeves TJ, Weinberg SL: Guidelines for permanent cardiac pacemaker implantation, May 1984: a report of the Joint American College of Cardiology/American Heart Association Task Force on Assessment of Cardiovascular Procedures (Subcommittee on Pacemaker Implantation). Circulation 70:331A-339A, 1984

        • Rahimtoola SH
        Catheter balloon valvuloplasty of aortic and mitral stenosis in adults: 1987.
        Circulation. 1987; 75: 895-901
        • O'Keefe JH
        • Shub C
        • Rettke SR
        Can patients with severe aortic stenosis safely undergo noncardiac surgery? (abstract).
        Circulation. 1988; 78: II-132
        • Tinker JH
        • Tarhan S
        Discontinuing anticoagulant therapy in surgical patients with cardiac valve prostheses: observations in 180 operations.
        JAMA. 1978; 239: 738-739
        • Katholi RE
        • Nolan SP
        • McGuire LB
        The management of anticoagulation during noncardiac operations in patients with prosthetic heart valves: a prospective study.
        Am Heart J. 1978; 96: 163-165
        • Shulman ST
        • Amren DP
        • Bisno AL
        • Dajani AS
        • Durack DT
        • Gerber MA
        • Kaplan EL
        • Millard HD
        • Sanders WE
        • Schwartz RH
        • Watanakunakorn C
        Prevention of bacterial endocarditis: a statement for health professionals by the Committee on Rheumatic Fever and Infective Endocarditis of the Council on Cardiovascular Disease in the Young.
        Circulation. 1984; 70: 1123A-1127A
        • Thompson RC
        • Liberthson RR
        • Lowenstein E
        Perioperative anesthetic risk of noncardiac surgery in hypertrophic obstructive cardiomyopathy.
        JAMA. 1985; 254: 2419-2421