La valutazione del rischio in anestesia

Claudio MelloniLibero professionista

Consulente di anestesia per Villa TorriVilla ChiaraPoliambulatorio Gynepro

Bologna

Rischio in anestesia

Limitazioni della lettura

bull Non si parla del rischio tecnicolegato alle attrezzature o alle diverse tecniche di anestesia

bull La lettura egrave piuttosto focalizzata alla valutazione preoperatoriacon excursus nella dinamica operatoria (presunta almenohellip)

bull Ci si riferisce alla chirnoncardiaca

Critical Elements for Risk Stratification in Patients Undergoing Noncardiac Surgery

bull Risk-assessment tool must be accuratebull Predicts perioperative events (positive likelihood ratio 10)bull Predicts absence of perioperative events (negative likelihood

ratio 02)bull Risk-assessment tool must influence outcomebull Identifies subgroups in which surgery should be cancelled or

treatment changedbull Identifies subgroups that do or do not benefit from proven

therapy to reduce riskbull Risk-assessment tool must have a favorable harmsndashbenefit

tradeoff

Cardiac Risk Index in Noncardiac Surgery Criteria Finding

Age (yr) gt70 5

Cardiac status MI within 6 mo 10

Ventricular gallop or jugular venous distention (signs of heart failure)

11

Significant aortic stenosis 3

Arrhythmia other than sinus or premature atrial contractions 7

ge5 premature ventricular contractionsmin 7

General medical condition Po2 lt 60 mm Hg Pco2 gt 50 mm Hg K lt 3 mmolL HCO3 lt20 mmolL BUN gt 50 mgdL serum creatinine gt 3 mgdL elevated AST a chronic liver disorder or bedbound

3

Type of surgery needed Emergency surgery 4Intraperitoneal intrathoracic or aortic surgery 3

Risk is based on the total number of pointsLevel I 0ndash5Level II 6ndash12Level III 13ndash25Level IV gt25

Adapted from Goldman L et al Multifactorial index of cardiac risk in noncardiac surgical procedures New England Journal of Medicine 297845ndash850 1977

Revised cardiac risk index(RCRI) Lee TH Marcantonio ER Mangione CM Thomas EJ Polanczyk CA Cook EF

Sugarbaker DJ Donaldson MC Poss R Ho KK Ludwig LE Pedan A Goldman L Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac

Risk of Major Noncardiac Surgery Circulation 1999 100 1043-1049

bull bull High risk surgerybull ndash intraperitoneal intrathoracic or

suprainguinal vascular proceduresbull bull Ischemic heart diseasebull bull HO CHFbull bull HO Cerebrovascular diseasebull bull Insulin therapy for DMbull bull Preop Crgt20mgdl

bull Circulation 1999 Sep 7100(10)1043-9 Linksbull Derivation and prospective validation of a

simple index for prediction of cardiac risk of major noncardiac surgery

bull Lee TH Marcantonio ER Mangione CM Thomas EJ Polanczyk CA Cook EF Sugarbaker DJ Donaldson MC Poss R Ho KK Ludwig LE Pedan A Goldman L

bull Department of Medicine Brigham and Womens Hospital and Harvard Medical School USA

bull BACKGROUND Cardiac complications are important causes of morbidity after noncardiac surgery The purpose of this prospective cohort study was to develop and validate an index for risk of cardiac complications METHODS AND RESULTS We studied 4315 patients aged gt or = 50 years undergoing elective major noncardiac procedures in a tertiary-care teaching hospital The main outcome measures were major cardiac complications Major cardiac complications occurred in 56 (2) of 2893 patients assigned to the derivation cohort Six independent predictors of complications were identified and included in a Revised Cardiac Risk Index high-risk type of surgery history of ischemic heart disease history of congestive heart failure history of cerebrovascular disease preoperative treatment with insulin and preoperative serum creatinine gt20 mgdL Rates of major cardiac complication with 0 1 2 or gt or = 3 of these factors were 05 13 4 and 9 respectively in the derivation cohort and 04 09 7 and 11 respectively among 1422 patients in the validation cohort Receiver operating characteristic curve analysis in the validation cohort indicated that the diagnostic performance of the Revised Cardiac Risk Index was superior to other published risk-prediction indexes CONCLUSIONS In stable patients undergoing nonurgent major noncardiac surgery this index can identify patients at higher risk for complications This index may be useful for identification of candidates for further risk stratification with noninvasive technologies or other management strategies as well as low-risk patients in whom additional evaluation is unlikely to be helpful

Rischio in anestesia

Limitazioni della lettura

bull Non si parla del rischio tecnicolegato alle attrezzature o alle diverse tecniche di anestesia

bull La lettura egrave piuttosto focalizzata alla valutazione preoperatoriacon excursus nella dinamica operatoria (presunta almenohellip)

bull Ci si riferisce alla chirnoncardiaca

Critical Elements for Risk Stratification in Patients Undergoing Noncardiac Surgery

bull Risk-assessment tool must be accuratebull Predicts perioperative events (positive likelihood ratio 10)bull Predicts absence of perioperative events (negative likelihood

ratio 02)bull Risk-assessment tool must influence outcomebull Identifies subgroups in which surgery should be cancelled or

treatment changedbull Identifies subgroups that do or do not benefit from proven

therapy to reduce riskbull Risk-assessment tool must have a favorable harmsndashbenefit

tradeoff

Cardiac Risk Index in Noncardiac Surgery Criteria Finding

Age (yr) gt70 5

Cardiac status MI within 6 mo 10

Ventricular gallop or jugular venous distention (signs of heart failure)

11

Significant aortic stenosis 3

Arrhythmia other than sinus or premature atrial contractions 7

ge5 premature ventricular contractionsmin 7

General medical condition Po2 lt 60 mm Hg Pco2 gt 50 mm Hg K lt 3 mmolL HCO3 lt20 mmolL BUN gt 50 mgdL serum creatinine gt 3 mgdL elevated AST a chronic liver disorder or bedbound

3

Type of surgery needed Emergency surgery 4Intraperitoneal intrathoracic or aortic surgery 3

Risk is based on the total number of pointsLevel I 0ndash5Level II 6ndash12Level III 13ndash25Level IV gt25

Adapted from Goldman L et al Multifactorial index of cardiac risk in noncardiac surgical procedures New England Journal of Medicine 297845ndash850 1977

Revised cardiac risk index(RCRI) Lee TH Marcantonio ER Mangione CM Thomas EJ Polanczyk CA Cook EF

Sugarbaker DJ Donaldson MC Poss R Ho KK Ludwig LE Pedan A Goldman L Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac

Risk of Major Noncardiac Surgery Circulation 1999 100 1043-1049

bull bull High risk surgerybull ndash intraperitoneal intrathoracic or

suprainguinal vascular proceduresbull bull Ischemic heart diseasebull bull HO CHFbull bull HO Cerebrovascular diseasebull bull Insulin therapy for DMbull bull Preop Crgt20mgdl

bull Circulation 1999 Sep 7100(10)1043-9 Linksbull Derivation and prospective validation of a

simple index for prediction of cardiac risk of major noncardiac surgery

bull Lee TH Marcantonio ER Mangione CM Thomas EJ Polanczyk CA Cook EF Sugarbaker DJ Donaldson MC Poss R Ho KK Ludwig LE Pedan A Goldman L

bull Department of Medicine Brigham and Womens Hospital and Harvard Medical School USA

bull BACKGROUND Cardiac complications are important causes of morbidity after noncardiac surgery The purpose of this prospective cohort study was to develop and validate an index for risk of cardiac complications METHODS AND RESULTS We studied 4315 patients aged gt or = 50 years undergoing elective major noncardiac procedures in a tertiary-care teaching hospital The main outcome measures were major cardiac complications Major cardiac complications occurred in 56 (2) of 2893 patients assigned to the derivation cohort Six independent predictors of complications were identified and included in a Revised Cardiac Risk Index high-risk type of surgery history of ischemic heart disease history of congestive heart failure history of cerebrovascular disease preoperative treatment with insulin and preoperative serum creatinine gt20 mgdL Rates of major cardiac complication with 0 1 2 or gt or = 3 of these factors were 05 13 4 and 9 respectively in the derivation cohort and 04 09 7 and 11 respectively among 1422 patients in the validation cohort Receiver operating characteristic curve analysis in the validation cohort indicated that the diagnostic performance of the Revised Cardiac Risk Index was superior to other published risk-prediction indexes CONCLUSIONS In stable patients undergoing nonurgent major noncardiac surgery this index can identify patients at higher risk for complications This index may be useful for identification of candidates for further risk stratification with noninvasive technologies or other management strategies as well as low-risk patients in whom additional evaluation is unlikely to be helpful

Limitazioni della lettura

bull Non si parla del rischio tecnicolegato alle attrezzature o alle diverse tecniche di anestesia

bull La lettura egrave piuttosto focalizzata alla valutazione preoperatoriacon excursus nella dinamica operatoria (presunta almenohellip)

bull Ci si riferisce alla chirnoncardiaca

Critical Elements for Risk Stratification in Patients Undergoing Noncardiac Surgery

bull Risk-assessment tool must be accuratebull Predicts perioperative events (positive likelihood ratio 10)bull Predicts absence of perioperative events (negative likelihood

ratio 02)bull Risk-assessment tool must influence outcomebull Identifies subgroups in which surgery should be cancelled or

treatment changedbull Identifies subgroups that do or do not benefit from proven

therapy to reduce riskbull Risk-assessment tool must have a favorable harmsndashbenefit

tradeoff

Cardiac Risk Index in Noncardiac Surgery Criteria Finding

Age (yr) gt70 5

Cardiac status MI within 6 mo 10

Ventricular gallop or jugular venous distention (signs of heart failure)

11

Significant aortic stenosis 3

Arrhythmia other than sinus or premature atrial contractions 7

ge5 premature ventricular contractionsmin 7

General medical condition Po2 lt 60 mm Hg Pco2 gt 50 mm Hg K lt 3 mmolL HCO3 lt20 mmolL BUN gt 50 mgdL serum creatinine gt 3 mgdL elevated AST a chronic liver disorder or bedbound

3

Type of surgery needed Emergency surgery 4Intraperitoneal intrathoracic or aortic surgery 3

Risk is based on the total number of pointsLevel I 0ndash5Level II 6ndash12Level III 13ndash25Level IV gt25

Adapted from Goldman L et al Multifactorial index of cardiac risk in noncardiac surgical procedures New England Journal of Medicine 297845ndash850 1977

Revised cardiac risk index(RCRI) Lee TH Marcantonio ER Mangione CM Thomas EJ Polanczyk CA Cook EF

Sugarbaker DJ Donaldson MC Poss R Ho KK Ludwig LE Pedan A Goldman L Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac

Risk of Major Noncardiac Surgery Circulation 1999 100 1043-1049

bull bull High risk surgerybull ndash intraperitoneal intrathoracic or

suprainguinal vascular proceduresbull bull Ischemic heart diseasebull bull HO CHFbull bull HO Cerebrovascular diseasebull bull Insulin therapy for DMbull bull Preop Crgt20mgdl

bull Circulation 1999 Sep 7100(10)1043-9 Linksbull Derivation and prospective validation of a

simple index for prediction of cardiac risk of major noncardiac surgery

bull Lee TH Marcantonio ER Mangione CM Thomas EJ Polanczyk CA Cook EF Sugarbaker DJ Donaldson MC Poss R Ho KK Ludwig LE Pedan A Goldman L

bull Department of Medicine Brigham and Womens Hospital and Harvard Medical School USA

bull BACKGROUND Cardiac complications are important causes of morbidity after noncardiac surgery The purpose of this prospective cohort study was to develop and validate an index for risk of cardiac complications METHODS AND RESULTS We studied 4315 patients aged gt or = 50 years undergoing elective major noncardiac procedures in a tertiary-care teaching hospital The main outcome measures were major cardiac complications Major cardiac complications occurred in 56 (2) of 2893 patients assigned to the derivation cohort Six independent predictors of complications were identified and included in a Revised Cardiac Risk Index high-risk type of surgery history of ischemic heart disease history of congestive heart failure history of cerebrovascular disease preoperative treatment with insulin and preoperative serum creatinine gt20 mgdL Rates of major cardiac complication with 0 1 2 or gt or = 3 of these factors were 05 13 4 and 9 respectively in the derivation cohort and 04 09 7 and 11 respectively among 1422 patients in the validation cohort Receiver operating characteristic curve analysis in the validation cohort indicated that the diagnostic performance of the Revised Cardiac Risk Index was superior to other published risk-prediction indexes CONCLUSIONS In stable patients undergoing nonurgent major noncardiac surgery this index can identify patients at higher risk for complications This index may be useful for identification of candidates for further risk stratification with noninvasive technologies or other management strategies as well as low-risk patients in whom additional evaluation is unlikely to be helpful

Critical Elements for Risk Stratification in Patients Undergoing Noncardiac Surgery

bull Risk-assessment tool must be accuratebull Predicts perioperative events (positive likelihood ratio 10)bull Predicts absence of perioperative events (negative likelihood

ratio 02)bull Risk-assessment tool must influence outcomebull Identifies subgroups in which surgery should be cancelled or

treatment changedbull Identifies subgroups that do or do not benefit from proven

therapy to reduce riskbull Risk-assessment tool must have a favorable harmsndashbenefit

tradeoff

Cardiac Risk Index in Noncardiac Surgery Criteria Finding

Age (yr) gt70 5

Cardiac status MI within 6 mo 10

Ventricular gallop or jugular venous distention (signs of heart failure)

11

Significant aortic stenosis 3

Arrhythmia other than sinus or premature atrial contractions 7

ge5 premature ventricular contractionsmin 7

General medical condition Po2 lt 60 mm Hg Pco2 gt 50 mm Hg K lt 3 mmolL HCO3 lt20 mmolL BUN gt 50 mgdL serum creatinine gt 3 mgdL elevated AST a chronic liver disorder or bedbound

3

Type of surgery needed Emergency surgery 4Intraperitoneal intrathoracic or aortic surgery 3

Risk is based on the total number of pointsLevel I 0ndash5Level II 6ndash12Level III 13ndash25Level IV gt25

Adapted from Goldman L et al Multifactorial index of cardiac risk in noncardiac surgical procedures New England Journal of Medicine 297845ndash850 1977

Revised cardiac risk index(RCRI) Lee TH Marcantonio ER Mangione CM Thomas EJ Polanczyk CA Cook EF

Sugarbaker DJ Donaldson MC Poss R Ho KK Ludwig LE Pedan A Goldman L Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac

Risk of Major Noncardiac Surgery Circulation 1999 100 1043-1049

bull bull High risk surgerybull ndash intraperitoneal intrathoracic or

suprainguinal vascular proceduresbull bull Ischemic heart diseasebull bull HO CHFbull bull HO Cerebrovascular diseasebull bull Insulin therapy for DMbull bull Preop Crgt20mgdl

bull Circulation 1999 Sep 7100(10)1043-9 Linksbull Derivation and prospective validation of a

simple index for prediction of cardiac risk of major noncardiac surgery

bull Lee TH Marcantonio ER Mangione CM Thomas EJ Polanczyk CA Cook EF Sugarbaker DJ Donaldson MC Poss R Ho KK Ludwig LE Pedan A Goldman L

bull Department of Medicine Brigham and Womens Hospital and Harvard Medical School USA

bull BACKGROUND Cardiac complications are important causes of morbidity after noncardiac surgery The purpose of this prospective cohort study was to develop and validate an index for risk of cardiac complications METHODS AND RESULTS We studied 4315 patients aged gt or = 50 years undergoing elective major noncardiac procedures in a tertiary-care teaching hospital The main outcome measures were major cardiac complications Major cardiac complications occurred in 56 (2) of 2893 patients assigned to the derivation cohort Six independent predictors of complications were identified and included in a Revised Cardiac Risk Index high-risk type of surgery history of ischemic heart disease history of congestive heart failure history of cerebrovascular disease preoperative treatment with insulin and preoperative serum creatinine gt20 mgdL Rates of major cardiac complication with 0 1 2 or gt or = 3 of these factors were 05 13 4 and 9 respectively in the derivation cohort and 04 09 7 and 11 respectively among 1422 patients in the validation cohort Receiver operating characteristic curve analysis in the validation cohort indicated that the diagnostic performance of the Revised Cardiac Risk Index was superior to other published risk-prediction indexes CONCLUSIONS In stable patients undergoing nonurgent major noncardiac surgery this index can identify patients at higher risk for complications This index may be useful for identification of candidates for further risk stratification with noninvasive technologies or other management strategies as well as low-risk patients in whom additional evaluation is unlikely to be helpful

Cardiac Risk Index in Noncardiac Surgery Criteria Finding

Age (yr) gt70 5

Cardiac status MI within 6 mo 10

Ventricular gallop or jugular venous distention (signs of heart failure)

11

Significant aortic stenosis 3

Arrhythmia other than sinus or premature atrial contractions 7

ge5 premature ventricular contractionsmin 7

General medical condition Po2 lt 60 mm Hg Pco2 gt 50 mm Hg K lt 3 mmolL HCO3 lt20 mmolL BUN gt 50 mgdL serum creatinine gt 3 mgdL elevated AST a chronic liver disorder or bedbound

3

Type of surgery needed Emergency surgery 4Intraperitoneal intrathoracic or aortic surgery 3

Risk is based on the total number of pointsLevel I 0ndash5Level II 6ndash12Level III 13ndash25Level IV gt25

Adapted from Goldman L et al Multifactorial index of cardiac risk in noncardiac surgical procedures New England Journal of Medicine 297845ndash850 1977

Revised cardiac risk index(RCRI) Lee TH Marcantonio ER Mangione CM Thomas EJ Polanczyk CA Cook EF

Sugarbaker DJ Donaldson MC Poss R Ho KK Ludwig LE Pedan A Goldman L Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac

Risk of Major Noncardiac Surgery Circulation 1999 100 1043-1049

bull bull High risk surgerybull ndash intraperitoneal intrathoracic or

suprainguinal vascular proceduresbull bull Ischemic heart diseasebull bull HO CHFbull bull HO Cerebrovascular diseasebull bull Insulin therapy for DMbull bull Preop Crgt20mgdl

bull Circulation 1999 Sep 7100(10)1043-9 Linksbull Derivation and prospective validation of a

simple index for prediction of cardiac risk of major noncardiac surgery

bull Lee TH Marcantonio ER Mangione CM Thomas EJ Polanczyk CA Cook EF Sugarbaker DJ Donaldson MC Poss R Ho KK Ludwig LE Pedan A Goldman L

bull Department of Medicine Brigham and Womens Hospital and Harvard Medical School USA

bull BACKGROUND Cardiac complications are important causes of morbidity after noncardiac surgery The purpose of this prospective cohort study was to develop and validate an index for risk of cardiac complications METHODS AND RESULTS We studied 4315 patients aged gt or = 50 years undergoing elective major noncardiac procedures in a tertiary-care teaching hospital The main outcome measures were major cardiac complications Major cardiac complications occurred in 56 (2) of 2893 patients assigned to the derivation cohort Six independent predictors of complications were identified and included in a Revised Cardiac Risk Index high-risk type of surgery history of ischemic heart disease history of congestive heart failure history of cerebrovascular disease preoperative treatment with insulin and preoperative serum creatinine gt20 mgdL Rates of major cardiac complication with 0 1 2 or gt or = 3 of these factors were 05 13 4 and 9 respectively in the derivation cohort and 04 09 7 and 11 respectively among 1422 patients in the validation cohort Receiver operating characteristic curve analysis in the validation cohort indicated that the diagnostic performance of the Revised Cardiac Risk Index was superior to other published risk-prediction indexes CONCLUSIONS In stable patients undergoing nonurgent major noncardiac surgery this index can identify patients at higher risk for complications This index may be useful for identification of candidates for further risk stratification with noninvasive technologies or other management strategies as well as low-risk patients in whom additional evaluation is unlikely to be helpful

Revised cardiac risk index(RCRI) Lee TH Marcantonio ER Mangione CM Thomas EJ Polanczyk CA Cook EF

Sugarbaker DJ Donaldson MC Poss R Ho KK Ludwig LE Pedan A Goldman L Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac

Risk of Major Noncardiac Surgery Circulation 1999 100 1043-1049

bull bull High risk surgerybull ndash intraperitoneal intrathoracic or

suprainguinal vascular proceduresbull bull Ischemic heart diseasebull bull HO CHFbull bull HO Cerebrovascular diseasebull bull Insulin therapy for DMbull bull Preop Crgt20mgdl

bull Circulation 1999 Sep 7100(10)1043-9 Linksbull Derivation and prospective validation of a

simple index for prediction of cardiac risk of major noncardiac surgery

bull Lee TH Marcantonio ER Mangione CM Thomas EJ Polanczyk CA Cook EF Sugarbaker DJ Donaldson MC Poss R Ho KK Ludwig LE Pedan A Goldman L

bull Department of Medicine Brigham and Womens Hospital and Harvard Medical School USA

bull BACKGROUND Cardiac complications are important causes of morbidity after noncardiac surgery The purpose of this prospective cohort study was to develop and validate an index for risk of cardiac complications METHODS AND RESULTS We studied 4315 patients aged gt or = 50 years undergoing elective major noncardiac procedures in a tertiary-care teaching hospital The main outcome measures were major cardiac complications Major cardiac complications occurred in 56 (2) of 2893 patients assigned to the derivation cohort Six independent predictors of complications were identified and included in a Revised Cardiac Risk Index high-risk type of surgery history of ischemic heart disease history of congestive heart failure history of cerebrovascular disease preoperative treatment with insulin and preoperative serum creatinine gt20 mgdL Rates of major cardiac complication with 0 1 2 or gt or = 3 of these factors were 05 13 4 and 9 respectively in the derivation cohort and 04 09 7 and 11 respectively among 1422 patients in the validation cohort Receiver operating characteristic curve analysis in the validation cohort indicated that the diagnostic performance of the Revised Cardiac Risk Index was superior to other published risk-prediction indexes CONCLUSIONS In stable patients undergoing nonurgent major noncardiac surgery this index can identify patients at higher risk for complications This index may be useful for identification of candidates for further risk stratification with noninvasive technologies or other management strategies as well as low-risk patients in whom additional evaluation is unlikely to be helpful

bull Circulation 1999 Sep 7100(10)1043-9 Linksbull Derivation and prospective validation of a

simple index for prediction of cardiac risk of major noncardiac surgery

bull Lee TH Marcantonio ER Mangione CM Thomas EJ Polanczyk CA Cook EF Sugarbaker DJ Donaldson MC Poss R Ho KK Ludwig LE Pedan A Goldman L

bull Department of Medicine Brigham and Womens Hospital and Harvard Medical School USA

bull BACKGROUND Cardiac complications are important causes of morbidity after noncardiac surgery The purpose of this prospective cohort study was to develop and validate an index for risk of cardiac complications METHODS AND RESULTS We studied 4315 patients aged gt or = 50 years undergoing elective major noncardiac procedures in a tertiary-care teaching hospital The main outcome measures were major cardiac complications Major cardiac complications occurred in 56 (2) of 2893 patients assigned to the derivation cohort Six independent predictors of complications were identified and included in a Revised Cardiac Risk Index high-risk type of surgery history of ischemic heart disease history of congestive heart failure history of cerebrovascular disease preoperative treatment with insulin and preoperative serum creatinine gt20 mgdL Rates of major cardiac complication with 0 1 2 or gt or = 3 of these factors were 05 13 4 and 9 respectively in the derivation cohort and 04 09 7 and 11 respectively among 1422 patients in the validation cohort Receiver operating characteristic curve analysis in the validation cohort indicated that the diagnostic performance of the Revised Cardiac Risk Index was superior to other published risk-prediction indexes CONCLUSIONS In stable patients undergoing nonurgent major noncardiac surgery this index can identify patients at higher risk for complications This index may be useful for identification of candidates for further risk stratification with noninvasive technologies or other management strategies as well as low-risk patients in whom additional evaluation is unlikely to be helpful

bull Eagle KA Berger PB Calkins H Chaitman BR Ewy GA Fleischmann KE Fleisher LA Froehlich JB Gusberg RJ Leppo JA Ryan T Schlant RC Winters WL Jr Gibbons RJ Antman EM Alpert JSFaxon DP Fuster V Gregoratos G Jacobs AK Hiratzka LF Russell RO Smith SC Jr ACCAHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery---executive summary a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Circulation 2002105 1257-67

bull Importance of Surgical Procedurebull The surgical procedure influences the extent of the preoperative

evaluation required by determining the potential range of changes in perioperative management There is little hard data to define the surgery specific incidence of complications and the rate may be very institution depedendent Eagle et al published data on the incidence of perioperative myocardial infarction and mortality by procedure for patients enrolled in the coronary artery surgery study (CASS)6 Higher risk procedures for which coronary artery bypass grafting reduced the risk of noncardiac surgery compared to medical therapy include major vascular abdominal thoracic and orthopedic surgery Ambulatory procedures denote low risk Vascular surgery represents a unique group of patients in whom there is extensive evidence regarding preoperative testing and perioperative interventions

bull Importance of exercise tolerancebull Exercise tolerance is one of the most important determinants of

perioperative risk and the need for invasive monitoring If a patient can walk a mile without becoming short of breath than the probability of extensive coronary artery disease is small Alternatively if patients become dyspneic associated with chest pain during minimal exertion then the probability of extensive coronary artery disease is high Reilly and colleagues demonstrated that the likelihood of a serious complication occurring was inversely related to the number of blocks that could be walked or flights of stairs that could be climbed7 Exercise tolerance can be assessed with formal treadmill testing or with a questionnaire that assesses activities of daily living

bull Reilly DF McNeely MJ Doerner D Greenberg DL Staiger TO Geist MJ Vedovatti PA Coffey JE Mora MW Johnson TR Guray ED Van Norman GA Fihn SD Self-reported exercise tolerance and the risk of serious perioperative complications Arch Intern Med 1999 159 2185-92

Fleisher LA Beckman JA Brown KA Calkins H Chaikof E Fleischmann KE Freeman WK Froehlich JB Kasper EK Kersten JR Riegel B Robb JF Smith SC Jr Jacobs AK Adams CD Anderson JL Antman EM Faxon DP Fuster V Halperin JL Hiratzka LF Hunt SA Lytle BW Nishimura R Page RL Riegel B

ACCAHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery focused update on perioperative beta-blocker therapy

a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography American Society of Nuclear Cardiology Heart Rhythm Society Society of Cardiovascular Anesthesiologists Society for Cardiovascular Angiography and Interventions and Society for Vascular Medicine and Biology

Circulation 2006 113 2662-74

bull Yang H Raymer K Butler R Parlow J Roberts R The effects of perioperative beta-blockade results of the Metoprolol after Vascular Surgery (MaVS) study a randomized controlled trial Am Heart J 2006 152 983-90

bull Juul AB Wetterslev J Gluud C Kofoed-Enevoldsen A Jensen G Callesen T Norgaard P Fruergaard K Bestle M Vedelsdal R Miran A Jacobsen J Roed J Mortensen MB Jorgensen L Jorgensen J Rovsing ML Petersen PL Pott F Haas M Albret R Nielsen LL Johansson G Stjernholm P Molgaard Y Foss NB Elkjaer J Dehlie B Boysen K Zaric D Munksgaard A Madsen JB Oberg B Khanykin B Blemmer T Yndgaard S Perko G Wang LP Winkel P Hilden J Jensen P Salas N Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery randomised placebo controlled blinded multicentre trial Bmj 2006 332 1482

bull Wallace AW Galindez D Salahieh A Layug EL Lazo EA Haratonik KA Boisvert DM Kardatzke D Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery Anesthesiology 2004 101 284-93

bull Hindler K Shaw AD Samuels J Fulton S Collard CD Riedel B Improved postoperative outcomes associated with preoperative statin therapy Anesthesiology 2006 105 1260-72

Durazzo AE Machado FS Ikeoka DT De Bernoche C Monachini MC Puech-Leao P Caramelli B Reduction in cardiovascular events after vascular surgery with atorvastatin a randomized trial J Vasc Surg 200439 967-75

bull (httpwwwaccorgqualityandscienceclinicaltopictopichtm)

Key wordsbull perioperative riskbull cardiac risk bull noncardiac surgerybull intraoperative riskbull postoperative risk bull risk stratification bull cardiac complication bull cardiac evaluationbull perioperative care bull preoperative evaluationbull preoperative assessmentbull intraoperative complications

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

I marcatori clinici condizioni associate ad alto rischio per complicanze cardiovascolari perioperatorie

bull 1)instabilitagrave coronaricaper esempio un MI recente o una angina instabile o severa

bull 2)Insufficienza cardiaca scompensataNYHA Classe IV o una insufficienza in peggioramento o di nuova insorgenza

bull 3)aritmie significativeblocco AV di alto grado(Mobitz 2BAV 3aritmie ventricolari sintomatichearitmie sopraventricolari con ritmo cardiaco non controllatotachicardia sintomaticatachicardia ventricolare di nuova scoperta

bull 4)malattia valvolare severacioegrave stenosi aortica serrata o stenosi mitralica sintomatica

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

MET equivalenti energetici indice delle possibilitagrave energetiche per varie attivitagrave

bull scaletta dei MET risposta a domande sempliciqualibull sei in grado di avere cura di te stessomangiarebereusare la toilette(MET 1)bull puoi camminare in casa (MET 2) bull puoi camminare 100-200m in piano alla velocitagrave di 3-45 Kmh(Met 3)bull puoi eseguire lavori di casa leggeri come spolverare o lavare i piatti(MET 4)bull puoi salire una rampa di scale o in salitao camminare in piano a 65 Kmh o

correre per una breve distanza(Met 5)bull Puoi fare lavori di casa pesanti come spazzare i pavimenti o sollevare o muovere

mobilio pesante(Met 6-7) bull Puoi partecipare a attivitagrave ricreative leggere come giocare a golfa

bocceballaregiocare a tennis in doppioo lanciare la palla a baseball o calcio(MET 8-9)

bull Puoi partecipare a sport pesanti come il nuototennis in singolocalciopallacanestro o sci(Met 10)

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

La stratificazione chirurgica degli interventi dal punto di vista del rischio cardiaco

bull rischio di MI o morte cardiaca superiore al 5 ndash chirurgia vascolare maggiore(aortica) e quella periferica

bull a rischio intermedio compreso fra 1 e 5

la chirurgia intraperitoneale ed intratoracica

endoarterectomia carotidea

chirurgia della testa e del collo

chirurgia ortopedica maggiore

chir prostatica

bull rischio minoreinferiore allrsquo1 ndash procedure endoscopichendash superficie corporeandash chirurgia per cataratta ndash Chir mammaria

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

bull Importance of Surgical Procedurebull The surgical procedure influences the extent of the preoperative

evaluation required by determining the potential range of changes in perioperative management There is little hard data to define the surgery specific incidence of complications and the rate may be very institution depedendent Eagle et al published data on the incidence of perioperative myocardial infarction and mortality by procedure for patients enrolled in the coronary artery surgery study (CASS)6 Higher risk procedures for which coronary artery bypass grafting reduced the risk of noncardiac surgery compared to medical therapy include major vascular abdominal thoracic and orthopedic surgery Ambulatory procedures denote low risk Vascular surgery represents a unique group of patients in whom there is extensive evidence regarding preoperative testing and perioperative interventions

bull Importance of exercise tolerancebull Exercise tolerance is one of the most important determinants of

perioperative risk and the need for invasive monitoring If a patient can walk a mile without becoming short of breath than the probability of extensive coronary artery disease is small Alternatively if patients become dyspneic associated with chest pain during minimal exertion then the probability of extensive coronary artery disease is high Reilly and colleagues demonstrated that the likelihood of a serious complication occurring was inversely related to the number of blocks that could be walked or flights of stairs that could be climbed7 Exercise tolerance can be assessed with formal treadmill testing or with a questionnaire that assesses activities of daily living

bull Reilly DF McNeely MJ Doerner D Greenberg DL Staiger TO Geist MJ Vedovatti PA Coffey JE Mora MW Johnson TR Guray ED Van Norman GA Fihn SD Self-reported exercise tolerance and the risk of serious perioperative complications Arch Intern Med 1999 159 2185-92

Fleisher LA Beckman JA Brown KA Calkins H Chaikof E Fleischmann KE Freeman WK Froehlich JB Kasper EK Kersten JR Riegel B Robb JF Smith SC Jr Jacobs AK Adams CD Anderson JL Antman EM Faxon DP Fuster V Halperin JL Hiratzka LF Hunt SA Lytle BW Nishimura R Page RL Riegel B

ACCAHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery focused update on perioperative beta-blocker therapy

a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography American Society of Nuclear Cardiology Heart Rhythm Society Society of Cardiovascular Anesthesiologists Society for Cardiovascular Angiography and Interventions and Society for Vascular Medicine and Biology

Circulation 2006 113 2662-74

bull Yang H Raymer K Butler R Parlow J Roberts R The effects of perioperative beta-blockade results of the Metoprolol after Vascular Surgery (MaVS) study a randomized controlled trial Am Heart J 2006 152 983-90

bull Juul AB Wetterslev J Gluud C Kofoed-Enevoldsen A Jensen G Callesen T Norgaard P Fruergaard K Bestle M Vedelsdal R Miran A Jacobsen J Roed J Mortensen MB Jorgensen L Jorgensen J Rovsing ML Petersen PL Pott F Haas M Albret R Nielsen LL Johansson G Stjernholm P Molgaard Y Foss NB Elkjaer J Dehlie B Boysen K Zaric D Munksgaard A Madsen JB Oberg B Khanykin B Blemmer T Yndgaard S Perko G Wang LP Winkel P Hilden J Jensen P Salas N Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery randomised placebo controlled blinded multicentre trial Bmj 2006 332 1482

bull Wallace AW Galindez D Salahieh A Layug EL Lazo EA Haratonik KA Boisvert DM Kardatzke D Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery Anesthesiology 2004 101 284-93

bull Hindler K Shaw AD Samuels J Fulton S Collard CD Riedel B Improved postoperative outcomes associated with preoperative statin therapy Anesthesiology 2006 105 1260-72

Durazzo AE Machado FS Ikeoka DT De Bernoche C Monachini MC Puech-Leao P Caramelli B Reduction in cardiovascular events after vascular surgery with atorvastatin a randomized trial J Vasc Surg 200439 967-75

bull (httpwwwaccorgqualityandscienceclinicaltopictopichtm)

Key wordsbull perioperative riskbull cardiac risk bull noncardiac surgerybull intraoperative riskbull postoperative risk bull risk stratification bull cardiac complication bull cardiac evaluationbull perioperative care bull preoperative evaluationbull preoperative assessmentbull intraoperative complications

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

I marcatori clinici condizioni associate ad alto rischio per complicanze cardiovascolari perioperatorie

bull 1)instabilitagrave coronaricaper esempio un MI recente o una angina instabile o severa

bull 2)Insufficienza cardiaca scompensataNYHA Classe IV o una insufficienza in peggioramento o di nuova insorgenza

bull 3)aritmie significativeblocco AV di alto grado(Mobitz 2BAV 3aritmie ventricolari sintomatichearitmie sopraventricolari con ritmo cardiaco non controllatotachicardia sintomaticatachicardia ventricolare di nuova scoperta

bull 4)malattia valvolare severacioegrave stenosi aortica serrata o stenosi mitralica sintomatica

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

MET equivalenti energetici indice delle possibilitagrave energetiche per varie attivitagrave

bull scaletta dei MET risposta a domande sempliciqualibull sei in grado di avere cura di te stessomangiarebereusare la toilette(MET 1)bull puoi camminare in casa (MET 2) bull puoi camminare 100-200m in piano alla velocitagrave di 3-45 Kmh(Met 3)bull puoi eseguire lavori di casa leggeri come spolverare o lavare i piatti(MET 4)bull puoi salire una rampa di scale o in salitao camminare in piano a 65 Kmh o

correre per una breve distanza(Met 5)bull Puoi fare lavori di casa pesanti come spazzare i pavimenti o sollevare o muovere

mobilio pesante(Met 6-7) bull Puoi partecipare a attivitagrave ricreative leggere come giocare a golfa

bocceballaregiocare a tennis in doppioo lanciare la palla a baseball o calcio(MET 8-9)

bull Puoi partecipare a sport pesanti come il nuototennis in singolocalciopallacanestro o sci(Met 10)

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

La stratificazione chirurgica degli interventi dal punto di vista del rischio cardiaco

bull rischio di MI o morte cardiaca superiore al 5 ndash chirurgia vascolare maggiore(aortica) e quella periferica

bull a rischio intermedio compreso fra 1 e 5

la chirurgia intraperitoneale ed intratoracica

endoarterectomia carotidea

chirurgia della testa e del collo

chirurgia ortopedica maggiore

chir prostatica

bull rischio minoreinferiore allrsquo1 ndash procedure endoscopichendash superficie corporeandash chirurgia per cataratta ndash Chir mammaria

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

bull Importance of exercise tolerancebull Exercise tolerance is one of the most important determinants of

perioperative risk and the need for invasive monitoring If a patient can walk a mile without becoming short of breath than the probability of extensive coronary artery disease is small Alternatively if patients become dyspneic associated with chest pain during minimal exertion then the probability of extensive coronary artery disease is high Reilly and colleagues demonstrated that the likelihood of a serious complication occurring was inversely related to the number of blocks that could be walked or flights of stairs that could be climbed7 Exercise tolerance can be assessed with formal treadmill testing or with a questionnaire that assesses activities of daily living

bull Reilly DF McNeely MJ Doerner D Greenberg DL Staiger TO Geist MJ Vedovatti PA Coffey JE Mora MW Johnson TR Guray ED Van Norman GA Fihn SD Self-reported exercise tolerance and the risk of serious perioperative complications Arch Intern Med 1999 159 2185-92

Fleisher LA Beckman JA Brown KA Calkins H Chaikof E Fleischmann KE Freeman WK Froehlich JB Kasper EK Kersten JR Riegel B Robb JF Smith SC Jr Jacobs AK Adams CD Anderson JL Antman EM Faxon DP Fuster V Halperin JL Hiratzka LF Hunt SA Lytle BW Nishimura R Page RL Riegel B

ACCAHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery focused update on perioperative beta-blocker therapy

a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography American Society of Nuclear Cardiology Heart Rhythm Society Society of Cardiovascular Anesthesiologists Society for Cardiovascular Angiography and Interventions and Society for Vascular Medicine and Biology

Circulation 2006 113 2662-74

bull Yang H Raymer K Butler R Parlow J Roberts R The effects of perioperative beta-blockade results of the Metoprolol after Vascular Surgery (MaVS) study a randomized controlled trial Am Heart J 2006 152 983-90

bull Juul AB Wetterslev J Gluud C Kofoed-Enevoldsen A Jensen G Callesen T Norgaard P Fruergaard K Bestle M Vedelsdal R Miran A Jacobsen J Roed J Mortensen MB Jorgensen L Jorgensen J Rovsing ML Petersen PL Pott F Haas M Albret R Nielsen LL Johansson G Stjernholm P Molgaard Y Foss NB Elkjaer J Dehlie B Boysen K Zaric D Munksgaard A Madsen JB Oberg B Khanykin B Blemmer T Yndgaard S Perko G Wang LP Winkel P Hilden J Jensen P Salas N Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery randomised placebo controlled blinded multicentre trial Bmj 2006 332 1482

bull Wallace AW Galindez D Salahieh A Layug EL Lazo EA Haratonik KA Boisvert DM Kardatzke D Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery Anesthesiology 2004 101 284-93

bull Hindler K Shaw AD Samuels J Fulton S Collard CD Riedel B Improved postoperative outcomes associated with preoperative statin therapy Anesthesiology 2006 105 1260-72

Durazzo AE Machado FS Ikeoka DT De Bernoche C Monachini MC Puech-Leao P Caramelli B Reduction in cardiovascular events after vascular surgery with atorvastatin a randomized trial J Vasc Surg 200439 967-75

bull (httpwwwaccorgqualityandscienceclinicaltopictopichtm)

Key wordsbull perioperative riskbull cardiac risk bull noncardiac surgerybull intraoperative riskbull postoperative risk bull risk stratification bull cardiac complication bull cardiac evaluationbull perioperative care bull preoperative evaluationbull preoperative assessmentbull intraoperative complications

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

I marcatori clinici condizioni associate ad alto rischio per complicanze cardiovascolari perioperatorie

bull 1)instabilitagrave coronaricaper esempio un MI recente o una angina instabile o severa

bull 2)Insufficienza cardiaca scompensataNYHA Classe IV o una insufficienza in peggioramento o di nuova insorgenza

bull 3)aritmie significativeblocco AV di alto grado(Mobitz 2BAV 3aritmie ventricolari sintomatichearitmie sopraventricolari con ritmo cardiaco non controllatotachicardia sintomaticatachicardia ventricolare di nuova scoperta

bull 4)malattia valvolare severacioegrave stenosi aortica serrata o stenosi mitralica sintomatica

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

MET equivalenti energetici indice delle possibilitagrave energetiche per varie attivitagrave

bull scaletta dei MET risposta a domande sempliciqualibull sei in grado di avere cura di te stessomangiarebereusare la toilette(MET 1)bull puoi camminare in casa (MET 2) bull puoi camminare 100-200m in piano alla velocitagrave di 3-45 Kmh(Met 3)bull puoi eseguire lavori di casa leggeri come spolverare o lavare i piatti(MET 4)bull puoi salire una rampa di scale o in salitao camminare in piano a 65 Kmh o

correre per una breve distanza(Met 5)bull Puoi fare lavori di casa pesanti come spazzare i pavimenti o sollevare o muovere

mobilio pesante(Met 6-7) bull Puoi partecipare a attivitagrave ricreative leggere come giocare a golfa

bocceballaregiocare a tennis in doppioo lanciare la palla a baseball o calcio(MET 8-9)

bull Puoi partecipare a sport pesanti come il nuototennis in singolocalciopallacanestro o sci(Met 10)

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

La stratificazione chirurgica degli interventi dal punto di vista del rischio cardiaco

bull rischio di MI o morte cardiaca superiore al 5 ndash chirurgia vascolare maggiore(aortica) e quella periferica

bull a rischio intermedio compreso fra 1 e 5

la chirurgia intraperitoneale ed intratoracica

endoarterectomia carotidea

chirurgia della testa e del collo

chirurgia ortopedica maggiore

chir prostatica

bull rischio minoreinferiore allrsquo1 ndash procedure endoscopichendash superficie corporeandash chirurgia per cataratta ndash Chir mammaria

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

bull Reilly DF McNeely MJ Doerner D Greenberg DL Staiger TO Geist MJ Vedovatti PA Coffey JE Mora MW Johnson TR Guray ED Van Norman GA Fihn SD Self-reported exercise tolerance and the risk of serious perioperative complications Arch Intern Med 1999 159 2185-92

Fleisher LA Beckman JA Brown KA Calkins H Chaikof E Fleischmann KE Freeman WK Froehlich JB Kasper EK Kersten JR Riegel B Robb JF Smith SC Jr Jacobs AK Adams CD Anderson JL Antman EM Faxon DP Fuster V Halperin JL Hiratzka LF Hunt SA Lytle BW Nishimura R Page RL Riegel B

ACCAHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery focused update on perioperative beta-blocker therapy

a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography American Society of Nuclear Cardiology Heart Rhythm Society Society of Cardiovascular Anesthesiologists Society for Cardiovascular Angiography and Interventions and Society for Vascular Medicine and Biology

Circulation 2006 113 2662-74

bull Yang H Raymer K Butler R Parlow J Roberts R The effects of perioperative beta-blockade results of the Metoprolol after Vascular Surgery (MaVS) study a randomized controlled trial Am Heart J 2006 152 983-90

bull Juul AB Wetterslev J Gluud C Kofoed-Enevoldsen A Jensen G Callesen T Norgaard P Fruergaard K Bestle M Vedelsdal R Miran A Jacobsen J Roed J Mortensen MB Jorgensen L Jorgensen J Rovsing ML Petersen PL Pott F Haas M Albret R Nielsen LL Johansson G Stjernholm P Molgaard Y Foss NB Elkjaer J Dehlie B Boysen K Zaric D Munksgaard A Madsen JB Oberg B Khanykin B Blemmer T Yndgaard S Perko G Wang LP Winkel P Hilden J Jensen P Salas N Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery randomised placebo controlled blinded multicentre trial Bmj 2006 332 1482

bull Wallace AW Galindez D Salahieh A Layug EL Lazo EA Haratonik KA Boisvert DM Kardatzke D Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery Anesthesiology 2004 101 284-93

bull Hindler K Shaw AD Samuels J Fulton S Collard CD Riedel B Improved postoperative outcomes associated with preoperative statin therapy Anesthesiology 2006 105 1260-72

Durazzo AE Machado FS Ikeoka DT De Bernoche C Monachini MC Puech-Leao P Caramelli B Reduction in cardiovascular events after vascular surgery with atorvastatin a randomized trial J Vasc Surg 200439 967-75

bull (httpwwwaccorgqualityandscienceclinicaltopictopichtm)

Key wordsbull perioperative riskbull cardiac risk bull noncardiac surgerybull intraoperative riskbull postoperative risk bull risk stratification bull cardiac complication bull cardiac evaluationbull perioperative care bull preoperative evaluationbull preoperative assessmentbull intraoperative complications

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

I marcatori clinici condizioni associate ad alto rischio per complicanze cardiovascolari perioperatorie

bull 1)instabilitagrave coronaricaper esempio un MI recente o una angina instabile o severa

bull 2)Insufficienza cardiaca scompensataNYHA Classe IV o una insufficienza in peggioramento o di nuova insorgenza

bull 3)aritmie significativeblocco AV di alto grado(Mobitz 2BAV 3aritmie ventricolari sintomatichearitmie sopraventricolari con ritmo cardiaco non controllatotachicardia sintomaticatachicardia ventricolare di nuova scoperta

bull 4)malattia valvolare severacioegrave stenosi aortica serrata o stenosi mitralica sintomatica

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

MET equivalenti energetici indice delle possibilitagrave energetiche per varie attivitagrave

bull scaletta dei MET risposta a domande sempliciqualibull sei in grado di avere cura di te stessomangiarebereusare la toilette(MET 1)bull puoi camminare in casa (MET 2) bull puoi camminare 100-200m in piano alla velocitagrave di 3-45 Kmh(Met 3)bull puoi eseguire lavori di casa leggeri come spolverare o lavare i piatti(MET 4)bull puoi salire una rampa di scale o in salitao camminare in piano a 65 Kmh o

correre per una breve distanza(Met 5)bull Puoi fare lavori di casa pesanti come spazzare i pavimenti o sollevare o muovere

mobilio pesante(Met 6-7) bull Puoi partecipare a attivitagrave ricreative leggere come giocare a golfa

bocceballaregiocare a tennis in doppioo lanciare la palla a baseball o calcio(MET 8-9)

bull Puoi partecipare a sport pesanti come il nuototennis in singolocalciopallacanestro o sci(Met 10)

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

La stratificazione chirurgica degli interventi dal punto di vista del rischio cardiaco

bull rischio di MI o morte cardiaca superiore al 5 ndash chirurgia vascolare maggiore(aortica) e quella periferica

bull a rischio intermedio compreso fra 1 e 5

la chirurgia intraperitoneale ed intratoracica

endoarterectomia carotidea

chirurgia della testa e del collo

chirurgia ortopedica maggiore

chir prostatica

bull rischio minoreinferiore allrsquo1 ndash procedure endoscopichendash superficie corporeandash chirurgia per cataratta ndash Chir mammaria

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Fleisher LA Beckman JA Brown KA Calkins H Chaikof E Fleischmann KE Freeman WK Froehlich JB Kasper EK Kersten JR Riegel B Robb JF Smith SC Jr Jacobs AK Adams CD Anderson JL Antman EM Faxon DP Fuster V Halperin JL Hiratzka LF Hunt SA Lytle BW Nishimura R Page RL Riegel B

ACCAHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery focused update on perioperative beta-blocker therapy

a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography American Society of Nuclear Cardiology Heart Rhythm Society Society of Cardiovascular Anesthesiologists Society for Cardiovascular Angiography and Interventions and Society for Vascular Medicine and Biology

Circulation 2006 113 2662-74

bull Yang H Raymer K Butler R Parlow J Roberts R The effects of perioperative beta-blockade results of the Metoprolol after Vascular Surgery (MaVS) study a randomized controlled trial Am Heart J 2006 152 983-90

bull Juul AB Wetterslev J Gluud C Kofoed-Enevoldsen A Jensen G Callesen T Norgaard P Fruergaard K Bestle M Vedelsdal R Miran A Jacobsen J Roed J Mortensen MB Jorgensen L Jorgensen J Rovsing ML Petersen PL Pott F Haas M Albret R Nielsen LL Johansson G Stjernholm P Molgaard Y Foss NB Elkjaer J Dehlie B Boysen K Zaric D Munksgaard A Madsen JB Oberg B Khanykin B Blemmer T Yndgaard S Perko G Wang LP Winkel P Hilden J Jensen P Salas N Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery randomised placebo controlled blinded multicentre trial Bmj 2006 332 1482

bull Wallace AW Galindez D Salahieh A Layug EL Lazo EA Haratonik KA Boisvert DM Kardatzke D Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery Anesthesiology 2004 101 284-93

bull Hindler K Shaw AD Samuels J Fulton S Collard CD Riedel B Improved postoperative outcomes associated with preoperative statin therapy Anesthesiology 2006 105 1260-72

Durazzo AE Machado FS Ikeoka DT De Bernoche C Monachini MC Puech-Leao P Caramelli B Reduction in cardiovascular events after vascular surgery with atorvastatin a randomized trial J Vasc Surg 200439 967-75

bull (httpwwwaccorgqualityandscienceclinicaltopictopichtm)

Key wordsbull perioperative riskbull cardiac risk bull noncardiac surgerybull intraoperative riskbull postoperative risk bull risk stratification bull cardiac complication bull cardiac evaluationbull perioperative care bull preoperative evaluationbull preoperative assessmentbull intraoperative complications

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

I marcatori clinici condizioni associate ad alto rischio per complicanze cardiovascolari perioperatorie

bull 1)instabilitagrave coronaricaper esempio un MI recente o una angina instabile o severa

bull 2)Insufficienza cardiaca scompensataNYHA Classe IV o una insufficienza in peggioramento o di nuova insorgenza

bull 3)aritmie significativeblocco AV di alto grado(Mobitz 2BAV 3aritmie ventricolari sintomatichearitmie sopraventricolari con ritmo cardiaco non controllatotachicardia sintomaticatachicardia ventricolare di nuova scoperta

bull 4)malattia valvolare severacioegrave stenosi aortica serrata o stenosi mitralica sintomatica

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

MET equivalenti energetici indice delle possibilitagrave energetiche per varie attivitagrave

bull scaletta dei MET risposta a domande sempliciqualibull sei in grado di avere cura di te stessomangiarebereusare la toilette(MET 1)bull puoi camminare in casa (MET 2) bull puoi camminare 100-200m in piano alla velocitagrave di 3-45 Kmh(Met 3)bull puoi eseguire lavori di casa leggeri come spolverare o lavare i piatti(MET 4)bull puoi salire una rampa di scale o in salitao camminare in piano a 65 Kmh o

correre per una breve distanza(Met 5)bull Puoi fare lavori di casa pesanti come spazzare i pavimenti o sollevare o muovere

mobilio pesante(Met 6-7) bull Puoi partecipare a attivitagrave ricreative leggere come giocare a golfa

bocceballaregiocare a tennis in doppioo lanciare la palla a baseball o calcio(MET 8-9)

bull Puoi partecipare a sport pesanti come il nuototennis in singolocalciopallacanestro o sci(Met 10)

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

La stratificazione chirurgica degli interventi dal punto di vista del rischio cardiaco

bull rischio di MI o morte cardiaca superiore al 5 ndash chirurgia vascolare maggiore(aortica) e quella periferica

bull a rischio intermedio compreso fra 1 e 5

la chirurgia intraperitoneale ed intratoracica

endoarterectomia carotidea

chirurgia della testa e del collo

chirurgia ortopedica maggiore

chir prostatica

bull rischio minoreinferiore allrsquo1 ndash procedure endoscopichendash superficie corporeandash chirurgia per cataratta ndash Chir mammaria

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

bull Yang H Raymer K Butler R Parlow J Roberts R The effects of perioperative beta-blockade results of the Metoprolol after Vascular Surgery (MaVS) study a randomized controlled trial Am Heart J 2006 152 983-90

bull Juul AB Wetterslev J Gluud C Kofoed-Enevoldsen A Jensen G Callesen T Norgaard P Fruergaard K Bestle M Vedelsdal R Miran A Jacobsen J Roed J Mortensen MB Jorgensen L Jorgensen J Rovsing ML Petersen PL Pott F Haas M Albret R Nielsen LL Johansson G Stjernholm P Molgaard Y Foss NB Elkjaer J Dehlie B Boysen K Zaric D Munksgaard A Madsen JB Oberg B Khanykin B Blemmer T Yndgaard S Perko G Wang LP Winkel P Hilden J Jensen P Salas N Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery randomised placebo controlled blinded multicentre trial Bmj 2006 332 1482

bull Wallace AW Galindez D Salahieh A Layug EL Lazo EA Haratonik KA Boisvert DM Kardatzke D Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery Anesthesiology 2004 101 284-93

bull Hindler K Shaw AD Samuels J Fulton S Collard CD Riedel B Improved postoperative outcomes associated with preoperative statin therapy Anesthesiology 2006 105 1260-72

Durazzo AE Machado FS Ikeoka DT De Bernoche C Monachini MC Puech-Leao P Caramelli B Reduction in cardiovascular events after vascular surgery with atorvastatin a randomized trial J Vasc Surg 200439 967-75

bull (httpwwwaccorgqualityandscienceclinicaltopictopichtm)

Key wordsbull perioperative riskbull cardiac risk bull noncardiac surgerybull intraoperative riskbull postoperative risk bull risk stratification bull cardiac complication bull cardiac evaluationbull perioperative care bull preoperative evaluationbull preoperative assessmentbull intraoperative complications

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

I marcatori clinici condizioni associate ad alto rischio per complicanze cardiovascolari perioperatorie

bull 1)instabilitagrave coronaricaper esempio un MI recente o una angina instabile o severa

bull 2)Insufficienza cardiaca scompensataNYHA Classe IV o una insufficienza in peggioramento o di nuova insorgenza

bull 3)aritmie significativeblocco AV di alto grado(Mobitz 2BAV 3aritmie ventricolari sintomatichearitmie sopraventricolari con ritmo cardiaco non controllatotachicardia sintomaticatachicardia ventricolare di nuova scoperta

bull 4)malattia valvolare severacioegrave stenosi aortica serrata o stenosi mitralica sintomatica

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

MET equivalenti energetici indice delle possibilitagrave energetiche per varie attivitagrave

bull scaletta dei MET risposta a domande sempliciqualibull sei in grado di avere cura di te stessomangiarebereusare la toilette(MET 1)bull puoi camminare in casa (MET 2) bull puoi camminare 100-200m in piano alla velocitagrave di 3-45 Kmh(Met 3)bull puoi eseguire lavori di casa leggeri come spolverare o lavare i piatti(MET 4)bull puoi salire una rampa di scale o in salitao camminare in piano a 65 Kmh o

correre per una breve distanza(Met 5)bull Puoi fare lavori di casa pesanti come spazzare i pavimenti o sollevare o muovere

mobilio pesante(Met 6-7) bull Puoi partecipare a attivitagrave ricreative leggere come giocare a golfa

bocceballaregiocare a tennis in doppioo lanciare la palla a baseball o calcio(MET 8-9)

bull Puoi partecipare a sport pesanti come il nuototennis in singolocalciopallacanestro o sci(Met 10)

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

La stratificazione chirurgica degli interventi dal punto di vista del rischio cardiaco

bull rischio di MI o morte cardiaca superiore al 5 ndash chirurgia vascolare maggiore(aortica) e quella periferica

bull a rischio intermedio compreso fra 1 e 5

la chirurgia intraperitoneale ed intratoracica

endoarterectomia carotidea

chirurgia della testa e del collo

chirurgia ortopedica maggiore

chir prostatica

bull rischio minoreinferiore allrsquo1 ndash procedure endoscopichendash superficie corporeandash chirurgia per cataratta ndash Chir mammaria

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

bull (httpwwwaccorgqualityandscienceclinicaltopictopichtm)

Key wordsbull perioperative riskbull cardiac risk bull noncardiac surgerybull intraoperative riskbull postoperative risk bull risk stratification bull cardiac complication bull cardiac evaluationbull perioperative care bull preoperative evaluationbull preoperative assessmentbull intraoperative complications

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

I marcatori clinici condizioni associate ad alto rischio per complicanze cardiovascolari perioperatorie

bull 1)instabilitagrave coronaricaper esempio un MI recente o una angina instabile o severa

bull 2)Insufficienza cardiaca scompensataNYHA Classe IV o una insufficienza in peggioramento o di nuova insorgenza

bull 3)aritmie significativeblocco AV di alto grado(Mobitz 2BAV 3aritmie ventricolari sintomatichearitmie sopraventricolari con ritmo cardiaco non controllatotachicardia sintomaticatachicardia ventricolare di nuova scoperta

bull 4)malattia valvolare severacioegrave stenosi aortica serrata o stenosi mitralica sintomatica

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

MET equivalenti energetici indice delle possibilitagrave energetiche per varie attivitagrave

bull scaletta dei MET risposta a domande sempliciqualibull sei in grado di avere cura di te stessomangiarebereusare la toilette(MET 1)bull puoi camminare in casa (MET 2) bull puoi camminare 100-200m in piano alla velocitagrave di 3-45 Kmh(Met 3)bull puoi eseguire lavori di casa leggeri come spolverare o lavare i piatti(MET 4)bull puoi salire una rampa di scale o in salitao camminare in piano a 65 Kmh o

correre per una breve distanza(Met 5)bull Puoi fare lavori di casa pesanti come spazzare i pavimenti o sollevare o muovere

mobilio pesante(Met 6-7) bull Puoi partecipare a attivitagrave ricreative leggere come giocare a golfa

bocceballaregiocare a tennis in doppioo lanciare la palla a baseball o calcio(MET 8-9)

bull Puoi partecipare a sport pesanti come il nuototennis in singolocalciopallacanestro o sci(Met 10)

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

La stratificazione chirurgica degli interventi dal punto di vista del rischio cardiaco

bull rischio di MI o morte cardiaca superiore al 5 ndash chirurgia vascolare maggiore(aortica) e quella periferica

bull a rischio intermedio compreso fra 1 e 5

la chirurgia intraperitoneale ed intratoracica

endoarterectomia carotidea

chirurgia della testa e del collo

chirurgia ortopedica maggiore

chir prostatica

bull rischio minoreinferiore allrsquo1 ndash procedure endoscopichendash superficie corporeandash chirurgia per cataratta ndash Chir mammaria

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Key wordsbull perioperative riskbull cardiac risk bull noncardiac surgerybull intraoperative riskbull postoperative risk bull risk stratification bull cardiac complication bull cardiac evaluationbull perioperative care bull preoperative evaluationbull preoperative assessmentbull intraoperative complications

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

I marcatori clinici condizioni associate ad alto rischio per complicanze cardiovascolari perioperatorie

bull 1)instabilitagrave coronaricaper esempio un MI recente o una angina instabile o severa

bull 2)Insufficienza cardiaca scompensataNYHA Classe IV o una insufficienza in peggioramento o di nuova insorgenza

bull 3)aritmie significativeblocco AV di alto grado(Mobitz 2BAV 3aritmie ventricolari sintomatichearitmie sopraventricolari con ritmo cardiaco non controllatotachicardia sintomaticatachicardia ventricolare di nuova scoperta

bull 4)malattia valvolare severacioegrave stenosi aortica serrata o stenosi mitralica sintomatica

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

MET equivalenti energetici indice delle possibilitagrave energetiche per varie attivitagrave

bull scaletta dei MET risposta a domande sempliciqualibull sei in grado di avere cura di te stessomangiarebereusare la toilette(MET 1)bull puoi camminare in casa (MET 2) bull puoi camminare 100-200m in piano alla velocitagrave di 3-45 Kmh(Met 3)bull puoi eseguire lavori di casa leggeri come spolverare o lavare i piatti(MET 4)bull puoi salire una rampa di scale o in salitao camminare in piano a 65 Kmh o

correre per una breve distanza(Met 5)bull Puoi fare lavori di casa pesanti come spazzare i pavimenti o sollevare o muovere

mobilio pesante(Met 6-7) bull Puoi partecipare a attivitagrave ricreative leggere come giocare a golfa

bocceballaregiocare a tennis in doppioo lanciare la palla a baseball o calcio(MET 8-9)

bull Puoi partecipare a sport pesanti come il nuototennis in singolocalciopallacanestro o sci(Met 10)

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

La stratificazione chirurgica degli interventi dal punto di vista del rischio cardiaco

bull rischio di MI o morte cardiaca superiore al 5 ndash chirurgia vascolare maggiore(aortica) e quella periferica

bull a rischio intermedio compreso fra 1 e 5

la chirurgia intraperitoneale ed intratoracica

endoarterectomia carotidea

chirurgia della testa e del collo

chirurgia ortopedica maggiore

chir prostatica

bull rischio minoreinferiore allrsquo1 ndash procedure endoscopichendash superficie corporeandash chirurgia per cataratta ndash Chir mammaria

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Scopi della valutazione cardiaca preop

bull 1)identificazione dei pazienti con rischio cardiaco troppo altonon accettabile

bull 2)identificazione dei paz con malattia cardiaca che possono essere migliorati o curati preop

bull 3)identificazione dei pazienti che possono beneficiare di intervento di CABG

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

I marcatori clinici condizioni associate ad alto rischio per complicanze cardiovascolari perioperatorie

bull 1)instabilitagrave coronaricaper esempio un MI recente o una angina instabile o severa

bull 2)Insufficienza cardiaca scompensataNYHA Classe IV o una insufficienza in peggioramento o di nuova insorgenza

bull 3)aritmie significativeblocco AV di alto grado(Mobitz 2BAV 3aritmie ventricolari sintomatichearitmie sopraventricolari con ritmo cardiaco non controllatotachicardia sintomaticatachicardia ventricolare di nuova scoperta

bull 4)malattia valvolare severacioegrave stenosi aortica serrata o stenosi mitralica sintomatica

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

MET equivalenti energetici indice delle possibilitagrave energetiche per varie attivitagrave

bull scaletta dei MET risposta a domande sempliciqualibull sei in grado di avere cura di te stessomangiarebereusare la toilette(MET 1)bull puoi camminare in casa (MET 2) bull puoi camminare 100-200m in piano alla velocitagrave di 3-45 Kmh(Met 3)bull puoi eseguire lavori di casa leggeri come spolverare o lavare i piatti(MET 4)bull puoi salire una rampa di scale o in salitao camminare in piano a 65 Kmh o

correre per una breve distanza(Met 5)bull Puoi fare lavori di casa pesanti come spazzare i pavimenti o sollevare o muovere

mobilio pesante(Met 6-7) bull Puoi partecipare a attivitagrave ricreative leggere come giocare a golfa

bocceballaregiocare a tennis in doppioo lanciare la palla a baseball o calcio(MET 8-9)

bull Puoi partecipare a sport pesanti come il nuototennis in singolocalciopallacanestro o sci(Met 10)

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

La stratificazione chirurgica degli interventi dal punto di vista del rischio cardiaco

bull rischio di MI o morte cardiaca superiore al 5 ndash chirurgia vascolare maggiore(aortica) e quella periferica

bull a rischio intermedio compreso fra 1 e 5

la chirurgia intraperitoneale ed intratoracica

endoarterectomia carotidea

chirurgia della testa e del collo

chirurgia ortopedica maggiore

chir prostatica

bull rischio minoreinferiore allrsquo1 ndash procedure endoscopichendash superficie corporeandash chirurgia per cataratta ndash Chir mammaria

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Come puograve la visita preop modificare il trattamento

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

I marcatori clinici condizioni associate ad alto rischio per complicanze cardiovascolari perioperatorie

bull 1)instabilitagrave coronaricaper esempio un MI recente o una angina instabile o severa

bull 2)Insufficienza cardiaca scompensataNYHA Classe IV o una insufficienza in peggioramento o di nuova insorgenza

bull 3)aritmie significativeblocco AV di alto grado(Mobitz 2BAV 3aritmie ventricolari sintomatichearitmie sopraventricolari con ritmo cardiaco non controllatotachicardia sintomaticatachicardia ventricolare di nuova scoperta

bull 4)malattia valvolare severacioegrave stenosi aortica serrata o stenosi mitralica sintomatica

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

MET equivalenti energetici indice delle possibilitagrave energetiche per varie attivitagrave

bull scaletta dei MET risposta a domande sempliciqualibull sei in grado di avere cura di te stessomangiarebereusare la toilette(MET 1)bull puoi camminare in casa (MET 2) bull puoi camminare 100-200m in piano alla velocitagrave di 3-45 Kmh(Met 3)bull puoi eseguire lavori di casa leggeri come spolverare o lavare i piatti(MET 4)bull puoi salire una rampa di scale o in salitao camminare in piano a 65 Kmh o

correre per una breve distanza(Met 5)bull Puoi fare lavori di casa pesanti come spazzare i pavimenti o sollevare o muovere

mobilio pesante(Met 6-7) bull Puoi partecipare a attivitagrave ricreative leggere come giocare a golfa

bocceballaregiocare a tennis in doppioo lanciare la palla a baseball o calcio(MET 8-9)

bull Puoi partecipare a sport pesanti come il nuototennis in singolocalciopallacanestro o sci(Met 10)

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

La stratificazione chirurgica degli interventi dal punto di vista del rischio cardiaco

bull rischio di MI o morte cardiaca superiore al 5 ndash chirurgia vascolare maggiore(aortica) e quella periferica

bull a rischio intermedio compreso fra 1 e 5

la chirurgia intraperitoneale ed intratoracica

endoarterectomia carotidea

chirurgia della testa e del collo

chirurgia ortopedica maggiore

chir prostatica

bull rischio minoreinferiore allrsquo1 ndash procedure endoscopichendash superficie corporeandash chirurgia per cataratta ndash Chir mammaria

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Fattori che determinano il rischio cardiaco periop

bull Marcatori clinici

bull Capacitagrave funzionale

bull Intervento chirurgico

I marcatori clinici condizioni associate ad alto rischio per complicanze cardiovascolari perioperatorie

bull 1)instabilitagrave coronaricaper esempio un MI recente o una angina instabile o severa

bull 2)Insufficienza cardiaca scompensataNYHA Classe IV o una insufficienza in peggioramento o di nuova insorgenza

bull 3)aritmie significativeblocco AV di alto grado(Mobitz 2BAV 3aritmie ventricolari sintomatichearitmie sopraventricolari con ritmo cardiaco non controllatotachicardia sintomaticatachicardia ventricolare di nuova scoperta

bull 4)malattia valvolare severacioegrave stenosi aortica serrata o stenosi mitralica sintomatica

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

MET equivalenti energetici indice delle possibilitagrave energetiche per varie attivitagrave

bull scaletta dei MET risposta a domande sempliciqualibull sei in grado di avere cura di te stessomangiarebereusare la toilette(MET 1)bull puoi camminare in casa (MET 2) bull puoi camminare 100-200m in piano alla velocitagrave di 3-45 Kmh(Met 3)bull puoi eseguire lavori di casa leggeri come spolverare o lavare i piatti(MET 4)bull puoi salire una rampa di scale o in salitao camminare in piano a 65 Kmh o

correre per una breve distanza(Met 5)bull Puoi fare lavori di casa pesanti come spazzare i pavimenti o sollevare o muovere

mobilio pesante(Met 6-7) bull Puoi partecipare a attivitagrave ricreative leggere come giocare a golfa

bocceballaregiocare a tennis in doppioo lanciare la palla a baseball o calcio(MET 8-9)

bull Puoi partecipare a sport pesanti come il nuototennis in singolocalciopallacanestro o sci(Met 10)

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

La stratificazione chirurgica degli interventi dal punto di vista del rischio cardiaco

bull rischio di MI o morte cardiaca superiore al 5 ndash chirurgia vascolare maggiore(aortica) e quella periferica

bull a rischio intermedio compreso fra 1 e 5

la chirurgia intraperitoneale ed intratoracica

endoarterectomia carotidea

chirurgia della testa e del collo

chirurgia ortopedica maggiore

chir prostatica

bull rischio minoreinferiore allrsquo1 ndash procedure endoscopichendash superficie corporeandash chirurgia per cataratta ndash Chir mammaria

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

I marcatori clinici condizioni associate ad alto rischio per complicanze cardiovascolari perioperatorie

bull 1)instabilitagrave coronaricaper esempio un MI recente o una angina instabile o severa

bull 2)Insufficienza cardiaca scompensataNYHA Classe IV o una insufficienza in peggioramento o di nuova insorgenza

bull 3)aritmie significativeblocco AV di alto grado(Mobitz 2BAV 3aritmie ventricolari sintomatichearitmie sopraventricolari con ritmo cardiaco non controllatotachicardia sintomaticatachicardia ventricolare di nuova scoperta

bull 4)malattia valvolare severacioegrave stenosi aortica serrata o stenosi mitralica sintomatica

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

MET equivalenti energetici indice delle possibilitagrave energetiche per varie attivitagrave

bull scaletta dei MET risposta a domande sempliciqualibull sei in grado di avere cura di te stessomangiarebereusare la toilette(MET 1)bull puoi camminare in casa (MET 2) bull puoi camminare 100-200m in piano alla velocitagrave di 3-45 Kmh(Met 3)bull puoi eseguire lavori di casa leggeri come spolverare o lavare i piatti(MET 4)bull puoi salire una rampa di scale o in salitao camminare in piano a 65 Kmh o

correre per una breve distanza(Met 5)bull Puoi fare lavori di casa pesanti come spazzare i pavimenti o sollevare o muovere

mobilio pesante(Met 6-7) bull Puoi partecipare a attivitagrave ricreative leggere come giocare a golfa

bocceballaregiocare a tennis in doppioo lanciare la palla a baseball o calcio(MET 8-9)

bull Puoi partecipare a sport pesanti come il nuototennis in singolocalciopallacanestro o sci(Met 10)

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

La stratificazione chirurgica degli interventi dal punto di vista del rischio cardiaco

bull rischio di MI o morte cardiaca superiore al 5 ndash chirurgia vascolare maggiore(aortica) e quella periferica

bull a rischio intermedio compreso fra 1 e 5

la chirurgia intraperitoneale ed intratoracica

endoarterectomia carotidea

chirurgia della testa e del collo

chirurgia ortopedica maggiore

chir prostatica

bull rischio minoreinferiore allrsquo1 ndash procedure endoscopichendash superficie corporeandash chirurgia per cataratta ndash Chir mammaria

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

bull The overriding theme of this document is that intervention is rarely necessary to simply lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context

bull The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patientrsquos current medical status make recommendations concerning the evaluation management and risk of cardiac problems over the entire perioperative period and provide a clinical risk profile that the patient primary physician and nonphysician caregivers anesthesiologist and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes

bull No test should be performed unless it is likely to influence patient treatment

bull The goal of the consultation is the optimal care of the patient

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

MET equivalenti energetici indice delle possibilitagrave energetiche per varie attivitagrave

bull scaletta dei MET risposta a domande sempliciqualibull sei in grado di avere cura di te stessomangiarebereusare la toilette(MET 1)bull puoi camminare in casa (MET 2) bull puoi camminare 100-200m in piano alla velocitagrave di 3-45 Kmh(Met 3)bull puoi eseguire lavori di casa leggeri come spolverare o lavare i piatti(MET 4)bull puoi salire una rampa di scale o in salitao camminare in piano a 65 Kmh o

correre per una breve distanza(Met 5)bull Puoi fare lavori di casa pesanti come spazzare i pavimenti o sollevare o muovere

mobilio pesante(Met 6-7) bull Puoi partecipare a attivitagrave ricreative leggere come giocare a golfa

bocceballaregiocare a tennis in doppioo lanciare la palla a baseball o calcio(MET 8-9)

bull Puoi partecipare a sport pesanti come il nuototennis in singolocalciopallacanestro o sci(Met 10)

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

La stratificazione chirurgica degli interventi dal punto di vista del rischio cardiaco

bull rischio di MI o morte cardiaca superiore al 5 ndash chirurgia vascolare maggiore(aortica) e quella periferica

bull a rischio intermedio compreso fra 1 e 5

la chirurgia intraperitoneale ed intratoracica

endoarterectomia carotidea

chirurgia della testa e del collo

chirurgia ortopedica maggiore

chir prostatica

bull rischio minoreinferiore allrsquo1 ndash procedure endoscopichendash superficie corporeandash chirurgia per cataratta ndash Chir mammaria

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Condizioni associate ad alto rischio per complicanze cardiovascolari

perioperatorie

bull Presenza dei fattori predittivi di aumentato rischio cardiovascolare periop

bull Scarsa capacitagrave funzionale(lt4 MET)bull Chirurgia ad alto rischio (rischio

cardiovascolare periop gt 5)

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

MET equivalenti energetici indice delle possibilitagrave energetiche per varie attivitagrave

bull scaletta dei MET risposta a domande sempliciqualibull sei in grado di avere cura di te stessomangiarebereusare la toilette(MET 1)bull puoi camminare in casa (MET 2) bull puoi camminare 100-200m in piano alla velocitagrave di 3-45 Kmh(Met 3)bull puoi eseguire lavori di casa leggeri come spolverare o lavare i piatti(MET 4)bull puoi salire una rampa di scale o in salitao camminare in piano a 65 Kmh o

correre per una breve distanza(Met 5)bull Puoi fare lavori di casa pesanti come spazzare i pavimenti o sollevare o muovere

mobilio pesante(Met 6-7) bull Puoi partecipare a attivitagrave ricreative leggere come giocare a golfa

bocceballaregiocare a tennis in doppioo lanciare la palla a baseball o calcio(MET 8-9)

bull Puoi partecipare a sport pesanti come il nuototennis in singolocalciopallacanestro o sci(Met 10)

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

La stratificazione chirurgica degli interventi dal punto di vista del rischio cardiaco

bull rischio di MI o morte cardiaca superiore al 5 ndash chirurgia vascolare maggiore(aortica) e quella periferica

bull a rischio intermedio compreso fra 1 e 5

la chirurgia intraperitoneale ed intratoracica

endoarterectomia carotidea

chirurgia della testa e del collo

chirurgia ortopedica maggiore

chir prostatica

bull rischio minoreinferiore allrsquo1 ndash procedure endoscopichendash superficie corporeandash chirurgia per cataratta ndash Chir mammaria

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Active Cardiac Conditions for Which the PatientShould Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I Level of Evidence B)major clinical predictors

Estimated Energy Requirements for Various Activities

MET equivalenti energetici indice delle possibilitagrave energetiche per varie attivitagrave

bull scaletta dei MET risposta a domande sempliciqualibull sei in grado di avere cura di te stessomangiarebereusare la toilette(MET 1)bull puoi camminare in casa (MET 2) bull puoi camminare 100-200m in piano alla velocitagrave di 3-45 Kmh(Met 3)bull puoi eseguire lavori di casa leggeri come spolverare o lavare i piatti(MET 4)bull puoi salire una rampa di scale o in salitao camminare in piano a 65 Kmh o

correre per una breve distanza(Met 5)bull Puoi fare lavori di casa pesanti come spazzare i pavimenti o sollevare o muovere

mobilio pesante(Met 6-7) bull Puoi partecipare a attivitagrave ricreative leggere come giocare a golfa

bocceballaregiocare a tennis in doppioo lanciare la palla a baseball o calcio(MET 8-9)

bull Puoi partecipare a sport pesanti come il nuototennis in singolocalciopallacanestro o sci(Met 10)

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

La stratificazione chirurgica degli interventi dal punto di vista del rischio cardiaco

bull rischio di MI o morte cardiaca superiore al 5 ndash chirurgia vascolare maggiore(aortica) e quella periferica

bull a rischio intermedio compreso fra 1 e 5

la chirurgia intraperitoneale ed intratoracica

endoarterectomia carotidea

chirurgia della testa e del collo

chirurgia ortopedica maggiore

chir prostatica

bull rischio minoreinferiore allrsquo1 ndash procedure endoscopichendash superficie corporeandash chirurgia per cataratta ndash Chir mammaria

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Estimated Energy Requirements for Various Activities

MET equivalenti energetici indice delle possibilitagrave energetiche per varie attivitagrave

bull scaletta dei MET risposta a domande sempliciqualibull sei in grado di avere cura di te stessomangiarebereusare la toilette(MET 1)bull puoi camminare in casa (MET 2) bull puoi camminare 100-200m in piano alla velocitagrave di 3-45 Kmh(Met 3)bull puoi eseguire lavori di casa leggeri come spolverare o lavare i piatti(MET 4)bull puoi salire una rampa di scale o in salitao camminare in piano a 65 Kmh o

correre per una breve distanza(Met 5)bull Puoi fare lavori di casa pesanti come spazzare i pavimenti o sollevare o muovere

mobilio pesante(Met 6-7) bull Puoi partecipare a attivitagrave ricreative leggere come giocare a golfa

bocceballaregiocare a tennis in doppioo lanciare la palla a baseball o calcio(MET 8-9)

bull Puoi partecipare a sport pesanti come il nuototennis in singolocalciopallacanestro o sci(Met 10)

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

La stratificazione chirurgica degli interventi dal punto di vista del rischio cardiaco

bull rischio di MI o morte cardiaca superiore al 5 ndash chirurgia vascolare maggiore(aortica) e quella periferica

bull a rischio intermedio compreso fra 1 e 5

la chirurgia intraperitoneale ed intratoracica

endoarterectomia carotidea

chirurgia della testa e del collo

chirurgia ortopedica maggiore

chir prostatica

bull rischio minoreinferiore allrsquo1 ndash procedure endoscopichendash superficie corporeandash chirurgia per cataratta ndash Chir mammaria

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

MET equivalenti energetici indice delle possibilitagrave energetiche per varie attivitagrave

bull scaletta dei MET risposta a domande sempliciqualibull sei in grado di avere cura di te stessomangiarebereusare la toilette(MET 1)bull puoi camminare in casa (MET 2) bull puoi camminare 100-200m in piano alla velocitagrave di 3-45 Kmh(Met 3)bull puoi eseguire lavori di casa leggeri come spolverare o lavare i piatti(MET 4)bull puoi salire una rampa di scale o in salitao camminare in piano a 65 Kmh o

correre per una breve distanza(Met 5)bull Puoi fare lavori di casa pesanti come spazzare i pavimenti o sollevare o muovere

mobilio pesante(Met 6-7) bull Puoi partecipare a attivitagrave ricreative leggere come giocare a golfa

bocceballaregiocare a tennis in doppioo lanciare la palla a baseball o calcio(MET 8-9)

bull Puoi partecipare a sport pesanti come il nuototennis in singolocalciopallacanestro o sci(Met 10)

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

La stratificazione chirurgica degli interventi dal punto di vista del rischio cardiaco

bull rischio di MI o morte cardiaca superiore al 5 ndash chirurgia vascolare maggiore(aortica) e quella periferica

bull a rischio intermedio compreso fra 1 e 5

la chirurgia intraperitoneale ed intratoracica

endoarterectomia carotidea

chirurgia della testa e del collo

chirurgia ortopedica maggiore

chir prostatica

bull rischio minoreinferiore allrsquo1 ndash procedure endoscopichendash superficie corporeandash chirurgia per cataratta ndash Chir mammaria

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions known cardiovascular disease

or cardiac risk factors for patients 50 years of age or greater

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

La stratificazione chirurgica degli interventi dal punto di vista del rischio cardiaco

bull rischio di MI o morte cardiaca superiore al 5 ndash chirurgia vascolare maggiore(aortica) e quella periferica

bull a rischio intermedio compreso fra 1 e 5

la chirurgia intraperitoneale ed intratoracica

endoarterectomia carotidea

chirurgia della testa e del collo

chirurgia ortopedica maggiore

chir prostatica

bull rischio minoreinferiore allrsquo1 ndash procedure endoscopichendash superficie corporeandash chirurgia per cataratta ndash Chir mammaria

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

bull See Table 2 for active clinical conditions bull daggerSee Table 3 for estimated MET level equivalent

DaggerClinical risk factors include ischemic heart disease compensated or prior HF diabetes mellitus renalinsufficiency and cerebrovascular disease sectConsider perioperative beta blockade (see Table 11) for populations in which this has beenshown to reduce cardiac morbiditymortality ACCAHA indicates American College of CardiologyAmerican Heart Association HRheart rate LOE level of evidence and MET metabolic equivalent

La stratificazione chirurgica degli interventi dal punto di vista del rischio cardiaco

bull rischio di MI o morte cardiaca superiore al 5 ndash chirurgia vascolare maggiore(aortica) e quella periferica

bull a rischio intermedio compreso fra 1 e 5

la chirurgia intraperitoneale ed intratoracica

endoarterectomia carotidea

chirurgia della testa e del collo

chirurgia ortopedica maggiore

chir prostatica

bull rischio minoreinferiore allrsquo1 ndash procedure endoscopichendash superficie corporeandash chirurgia per cataratta ndash Chir mammaria

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

La stratificazione chirurgica degli interventi dal punto di vista del rischio cardiaco

bull rischio di MI o morte cardiaca superiore al 5 ndash chirurgia vascolare maggiore(aortica) e quella periferica

bull a rischio intermedio compreso fra 1 e 5

la chirurgia intraperitoneale ed intratoracica

endoarterectomia carotidea

chirurgia della testa e del collo

chirurgia ortopedica maggiore

chir prostatica

bull rischio minoreinferiore allrsquo1 ndash procedure endoscopichendash superficie corporeandash chirurgia per cataratta ndash Chir mammaria

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Cardiac Risk Stratification for NoncardiacSurgical Procedures

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Scopi dei test aggiuntivi cardiovascolari

bull Fornire una misura obbiettiva di capacitagrave funzionale

bull Identificare una ischemia preop miocardica importante

bull Diagnosticare aritmie cardiache rilevantibull Stimare il rischio cardiaco periop e definire una prognosi

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Dipiridamolo tallio

bull the presence of a redistribution defect on dipyridamole thallium imaging in patients undergoing peripheral vascular surgery is predictive of postoperative cardiac events In order to increase the predictive value of the test several strategies have been suggested Lung uptake left ventricular cavity dilation and redistribution defect size have all been shown to be predictive of subsequent morbidity10

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Dobutamine stress testbull Dobutamine stress echocardiography has been suggested as the best

preoperative test in several recent meta-analyses11 The appearance of new or worsened regional wall motion abnormalities is considered a positive test The advantage of this test is that it is a dynamic assessment of ventricular function Dobutamine echocardiography has also been studied and was found to have among the best positive and negative predictive values Poldermans et al demonstrated that the group at greatest risk were those who demonstrated regional wall motion abnormalities at low heart rates12 The presence of 5 or more segments of new regional wall motion abnormalities denotes a high risk group who did not benefit from perioperative beta blockade in one trial13 Beattie and colleagues performed a meta-analysis of stress echocardiography versus thallium imaging and demonstrate that stress echocardiography has better negative predicative characteristics11 A moderate-to-large perfusion defect by either test predicted postoperative MI and death

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Noninvasive Stress TestingRecommendations for Noninvasive Stress Testing Before

Noncardiac Surgerybull CLASS Ibull 1 Patients with active cardiac conditions (see Table 2) in whom noncardiac surgery is planned should be

evaluated and treated per ACCAHA guidelinesdagger before noncardiac surgery (Level of Evidence B)bull CLASS IIabull 1 Noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity

(less than 4 METs) who require vascular surgeryDagger is reasonable if it will change management (Level of Evidence B)

bull CLASS IIbbull 1 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and poor

functional capacity (less than 4 METs) who require intermediate-risk noncardiac surgery if it will change management (Level of Evidence B)

bull 2 Noninvasive stress testing may be considered for patients with at least 1 to 2 clinical risk factors and good functional capacity (greater than or equal to 4 METs) who are undergoing vascular surgery (Level of Evidence B)

bull CLASS IIIbull 1 Noninvasive testing is not useful for patients with no clinical risk factors undergoing ntermediate-risk

noncardiac surgery (Level of Evidence C)bull 2 Noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence

C)

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Razionale dei test non invasivi preop nella valutazione del rischio

Test non invasivi Paz con valori del test anormali

Valori predittivi per morte o MI periop

Positivo negativo

Monitoraggio ECG ambulat

9-39 4-15 1-16

Esercizio con monitoraggio ECG

16-70 5-25 90-100

Dipiridamolo-tallio

Chir vasc 22-69 4-20 95-100

Chir non vasc 23-47 8-27 98-100

Eco cardio grafia stress dobutamina

23-50 7-23 93-100

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

EF preop e outcome cardiaco postop(Franco et alJ Vasc Surg 106561989)

EFgt55N=50

EF 35-55N=20

EF 20-35N=15

MI 19 15 20

Morte 0 0 13

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Chir vasc dopo precedente rivascolarizzazione

Chir vascolare senza prec edente rivascolarizzazione

Complicazioni Mortalitagrave Complicazioni Mortalitagrave

angiografia 02-05 01-05 - -

PTCACABG 3-13 1-55 - -

Chir vasc 03-2 03-04 06-117 06-10

Rischio globale 35-105 14-124 06-117 08-10

Mahelliphellip Le arterie coronarie rivascolarizzate Le stenosi coronariche immodificate

Diminuiscono il rischio cardiovascolare a lungo termine

Aumentano il rischio cardiaco a lungo termine

Rischio globale a lungo termine

Sono comparabili

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Outcome cardiaco per chirurgia maggiore non cardiaca Eagle et alCirculation 1997 96

1892-7

N=395

N=582

N=964

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Cardiac outcome in low risk surgeryn=1297

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Incidenza di mortalitagrave periop in pazienti con CAD(n=1632) Eagle et al

High risk surgery gt=4 Low risk surgerylt=4

Abdominal 4 Urologic 18

Vascolare 113 Orthopedic 12

Thoracic 77 Skin 0

Head neck 73 Miscellaneous 3

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Cardiac outcome in noncardiac surgery following CABG

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Class I indications for preop coronary angiography in non cardiac surgery

bull High risk results during non invasive testingbull Amgina pectoris unresponsive to adequate

medical therapybull Most patients with unstable angina pectorisbull Nondiagnostic or equivocal noninvasive test

result in a high risk patient undergoing a high risk noncardiac surgical procedure

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Proposed approach to the management of patients with previous percutaneous coronary intervention (PCI) who require noncardiac

surgery based on expert opinion

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

BETA BLOCCANTI E CHIRURGIA NON CARDIACA

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Perioperative Beta-Blocker TherapyRecommendations for Beta-Blocker Medical Therapy

bull CLASS Ibull 1 Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers to treat angina

symptomatic arrhythmias hypertension or other ACCAHA class I guideline indications (Level of Evidence C)bull 2 Beta blockers should be given to patients undergoing vascular surgery who are at high cardiac risk owing to the

finding of ischemia on preoperative testing (Level of Evidence B)bull CLASS IIabull 1 Beta blockers are probably recommended for patients undergoing vascular surgery in whom preoperative

assessment identifies CHD (Level of Evidence B)bull 2 Beta blockers are probably recommended for patients in whom preoperative assessment for vascular surgery

identifies high cardiac risk as defined by the presence of more than 1 clinical risk factor (Level of Evidence B)bull 3 Beta blockers are probably recommended for patients in whom preoperative assessment identifies CHD or high

cardiac risk as defined by the presence of more than 1 clinical risk factor who are undergoing intermediate-risk or vascular surgery (Level of Evidence B)

bull CLASS IIbbull 1 The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or

vascular surgery in whom preoperative assessment identifies a single clinical risk factor (Level of Evidence C) bull 2 The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with no clinical risk factors who

are not currently taking beta blockers (Level of Evidence B) bull CLASS IIIbull 1 Beta blockers should not be given to patients undergoing surgery who have absolute contraindications to beta

blockade (Level of Evidence C)

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Indicazioni ai beta bloccanti bull i betabloccanti devono essere continuati nel periop per coloro che li assumono

per indicazione di anginaaritmie sitomaticheipertensione o altre indicazioni delle linee guida ACCAHA di classe I

bull i betabloccanti devono essere somministrati ai candidati a chirurgia vascolare ad alto rischio cardiaco che presentino ischemia agli esami preop (Livello di evidenza B)

bull I beta bloccanti sono poi probabilmente indicati per i candidati a chirurgia vascolare nei quali la valutazione preop identifichi coronaropatia eo un elevato rischio cardiaco definito come la presenza di piugrave di 1 fattore di rischio clinico anche se vanno incontro a chirurgia classificata come rischio intermedio

bull lrsquoutilitagrave dei betabloccanti rimane incerta in pazienti candidati a chirurgia di rischio intermedio o vascolare con un solo fattore di rischio clinico(Livello di evidenza C)e per i candidati a chir vascolare senza fattori di rischio e che non stanno assumendo i farmaci( Livello di evidenza B)

bull Ovviamente i betabloccanti non devono essere somministrati a coloro che presentano controindicazioni assolute al loro impiego

bull In conclusione dosaggi terapeutici di betabloccanti devono essere utilizzati in pazienti ad alto-intermedio rischio cardiaco

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Bisoprolol and perioperative cardiac outcome Poldermans et al NEJM 19993411789-94

Bisoprolol n=59 Standard care n=53

Cardiac death 2(34) 9(17)

Non fatal MI 0 9(17)

Total 2(34) 18(34)

=plt002 =plt001

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

bull N Engl J Med 1999 Dec 9341(24)1789-94 Links

bull Comment in N Engl J Med 1999 Dec 9341(24)1838-40 N Engl J Med 2000 Apr 6342(14)1051-2 author reply 1052-3 N Engl J Med 2000 Apr 6342(14)1052 author reply 1052-3 Rev Cardiovasc Med 2001 Winter2(1)25-6 The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

bull Poldermans D Boersma E Bax JJ Thomson IR van de Ven LL Blankensteijn JD Baars HF Yo TI Trocino G Vigna C Roelandt JR van Urk H

bull Erasmus Medical Center Rotterdam The Netherlands

bull BACKGROUND Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery METHODS We performed a randomized multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol RESULTS A total of 1351 patients were screened and 846 were found to have one or more cardiac risk factors Of these 846 patients 173 had positive results on dobutamine echocardiography Fifty-nine patients were randomly assigned to receive bisoprolol and 53 to receive standard care Fifty-three patients were excluded from randomization because they were already taking a beta-blocker and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing Two patients in the bisoprolol group died of cardiac causes (34 percent) as compared with nine patients in the standard-care group (17 percent P=002) Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (Plt0001) Thus the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (34 percent) and 18 patients in the standard-care group (34 percent Plt0001) CONCLUSIONS Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery

Weksler N Klein M Szendro G Rozentsveig V Schily M Brill S Tarnopolski A Ovadia L Gurman GM The dilemma of immediate preoperative hypertension to treat and operate or to postpone

surgery J Clin Anesth 2003 15 179-83

bull There is a great deal of debate regarding a trigger to delay or cancel a surgical procedure in a patient with poorly or untreated hypertension

bull In the absence of end-organ changes such as renal insufficiency or left ventricular hypertrophy with strain it would seem appropriate to proceed with surgery

bull A randomized trial of treated hypertensive patients without known CAD who presented the morning of surgery with an elevated diastolic blood pressure was unable to demonstrate any difference in outcome between those who were actively treated versus those in whom surgery was delayed

bull In contrast a patient with a markedly elevated blood pressure and the new onset of a headache should have surgery delayed for further evaluation and potential treatment

Howell SJ Sear YM Yeates D Goldacre M Sear JW Foeumlx P Hypertension admission blood pressure and perioperative

cardiovascular risk Anaesthesia 1996511000-1004

bull A retrospective case-controlled study which found that a history of hypertension was an important predictor for perioperative cardiac death but not admission blood pressure

bull The study implies that end-organ damage resulting from hypertension is the likely villain in this group of patients

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

bull Adrenergic Receptor Genotype but Not Perioperative

bull Bisoprolol Therapy May Determine Cardiovascular Outcome

bull in At-risk Patients Undergoing Surgery with Spinal Block

bull The Swiss Beta Blocker in Spinal Anesthesia (BBSA) Study A Double-blinded

bull Placebo-controlled Multicenter Trial with 1-Year Follow-up

bull Michael Zaugg MD Lukas Bestmann PhDdagger Johannes Wacker MDDagger Eliana Lucchinetti PhDsect Anita Boltres MD

bull Christian Schulz MD Martin Hersberger PhD Gabriela Kauml lin BSc Lukas Furrer MDdaggerdagger Christoph Hofer MDDaggerDagger

bull Stephan Blumenthal MDsectsect Annabelle Muuml ller PhD Andreas Zollinger MD Donat R Spahn MD Alain Borgeat MDdaggerdaggerdagger

bull Background Neuraxial blockade is used as primary anesthetic

bull technique in one third of surgical procedures The authors tested

bull whether bisoprolol would protect patients at risk for cardiovascular

bull complications undergoing surgery with spinal block

bull Methods The authors performed a double-blinded placebocontrolled

bull multicenter trial to compare the effect of bisoprolol

bull with that of placebo on 1-yr composite outcome including cardiovascular

bull mortality nonfatal myocardial infarction unstable angina

bull congestive heart failure and cerebrovascular insult Bisoprolol

bull was given orally before and after surgery for a maximum of 10

bull days Adrenergic receptor polymorphisms and safety outcome

bull measures of bisoprolol therapy were also determined

bull Results A total of 224 patients were enrolled Spinal block could

bull not be established in 5 patients One hundred ten patients were

bull assigned to the bisoprolol group and 109 patients were assigned

bull to the placebo group The mean duration of treatment was 49 days

bull in the bisoprolol group and 51 days in the placebo group Bisoprolol therapy reduced mean heart rate by 10 beatsmin The

bull primary outcome was identical between treatment groups and

bull occurred in 25 patients (227) in the bisoprolol group and 24

bull patients (220) in the placebo group during the 1-yr follow-up

bull (hazard ratio 097 95 confidence interval 055ndash169 P 090)

bull However carriers of at least one Gly allele of the 1-adrenergic

bull receptor polymorphism Arg389Gly showed a higher number of

bull adverse events than Arg homozygous (324 vs 187 hazard

bull ratio 187 95 confidence interval 104ndash335 P 004)

bull Conclusions Perioperative bisoprolol therapy did not affect

bull cardiovascular outcome in these elderly at-risk patients undergoing

bull surgery with spinal block

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlandsbull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative

mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Howell SJ Sear YM Yeates D Goldacre M Sear JW Foeumlx P Hypertension admission blood pressure and perioperative

cardiovascular risk Anaesthesia 1996511000-1004

bull A retrospective case-controlled study which found that a history of hypertension was an important predictor for perioperative cardiac death but not admission blood pressure

bull The study implies that end-organ damage resulting from hypertension is the likely villain in this group of patients

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

bull Adrenergic Receptor Genotype but Not Perioperative

bull Bisoprolol Therapy May Determine Cardiovascular Outcome

bull in At-risk Patients Undergoing Surgery with Spinal Block

bull The Swiss Beta Blocker in Spinal Anesthesia (BBSA) Study A Double-blinded

bull Placebo-controlled Multicenter Trial with 1-Year Follow-up

bull Michael Zaugg MD Lukas Bestmann PhDdagger Johannes Wacker MDDagger Eliana Lucchinetti PhDsect Anita Boltres MD

bull Christian Schulz MD Martin Hersberger PhD Gabriela Kauml lin BSc Lukas Furrer MDdaggerdagger Christoph Hofer MDDaggerDagger

bull Stephan Blumenthal MDsectsect Annabelle Muuml ller PhD Andreas Zollinger MD Donat R Spahn MD Alain Borgeat MDdaggerdaggerdagger

bull Background Neuraxial blockade is used as primary anesthetic

bull technique in one third of surgical procedures The authors tested

bull whether bisoprolol would protect patients at risk for cardiovascular

bull complications undergoing surgery with spinal block

bull Methods The authors performed a double-blinded placebocontrolled

bull multicenter trial to compare the effect of bisoprolol

bull with that of placebo on 1-yr composite outcome including cardiovascular

bull mortality nonfatal myocardial infarction unstable angina

bull congestive heart failure and cerebrovascular insult Bisoprolol

bull was given orally before and after surgery for a maximum of 10

bull days Adrenergic receptor polymorphisms and safety outcome

bull measures of bisoprolol therapy were also determined

bull Results A total of 224 patients were enrolled Spinal block could

bull not be established in 5 patients One hundred ten patients were

bull assigned to the bisoprolol group and 109 patients were assigned

bull to the placebo group The mean duration of treatment was 49 days

bull in the bisoprolol group and 51 days in the placebo group Bisoprolol therapy reduced mean heart rate by 10 beatsmin The

bull primary outcome was identical between treatment groups and

bull occurred in 25 patients (227) in the bisoprolol group and 24

bull patients (220) in the placebo group during the 1-yr follow-up

bull (hazard ratio 097 95 confidence interval 055ndash169 P 090)

bull However carriers of at least one Gly allele of the 1-adrenergic

bull receptor polymorphism Arg389Gly showed a higher number of

bull adverse events than Arg homozygous (324 vs 187 hazard

bull ratio 187 95 confidence interval 104ndash335 P 004)

bull Conclusions Perioperative bisoprolol therapy did not affect

bull cardiovascular outcome in these elderly at-risk patients undergoing

bull surgery with spinal block

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlandsbull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative

mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

bull In the absence of major contraindications therapeutic dosages of beta adrenergic antagonists should be given to patients with an intermediate or high risk of cardiac complications

bull Adrenergic Receptor Genotype but Not Perioperative

bull Bisoprolol Therapy May Determine Cardiovascular Outcome

bull in At-risk Patients Undergoing Surgery with Spinal Block

bull The Swiss Beta Blocker in Spinal Anesthesia (BBSA) Study A Double-blinded

bull Placebo-controlled Multicenter Trial with 1-Year Follow-up

bull Michael Zaugg MD Lukas Bestmann PhDdagger Johannes Wacker MDDagger Eliana Lucchinetti PhDsect Anita Boltres MD

bull Christian Schulz MD Martin Hersberger PhD Gabriela Kauml lin BSc Lukas Furrer MDdaggerdagger Christoph Hofer MDDaggerDagger

bull Stephan Blumenthal MDsectsect Annabelle Muuml ller PhD Andreas Zollinger MD Donat R Spahn MD Alain Borgeat MDdaggerdaggerdagger

bull Background Neuraxial blockade is used as primary anesthetic

bull technique in one third of surgical procedures The authors tested

bull whether bisoprolol would protect patients at risk for cardiovascular

bull complications undergoing surgery with spinal block

bull Methods The authors performed a double-blinded placebocontrolled

bull multicenter trial to compare the effect of bisoprolol

bull with that of placebo on 1-yr composite outcome including cardiovascular

bull mortality nonfatal myocardial infarction unstable angina

bull congestive heart failure and cerebrovascular insult Bisoprolol

bull was given orally before and after surgery for a maximum of 10

bull days Adrenergic receptor polymorphisms and safety outcome

bull measures of bisoprolol therapy were also determined

bull Results A total of 224 patients were enrolled Spinal block could

bull not be established in 5 patients One hundred ten patients were

bull assigned to the bisoprolol group and 109 patients were assigned

bull to the placebo group The mean duration of treatment was 49 days

bull in the bisoprolol group and 51 days in the placebo group Bisoprolol therapy reduced mean heart rate by 10 beatsmin The

bull primary outcome was identical between treatment groups and

bull occurred in 25 patients (227) in the bisoprolol group and 24

bull patients (220) in the placebo group during the 1-yr follow-up

bull (hazard ratio 097 95 confidence interval 055ndash169 P 090)

bull However carriers of at least one Gly allele of the 1-adrenergic

bull receptor polymorphism Arg389Gly showed a higher number of

bull adverse events than Arg homozygous (324 vs 187 hazard

bull ratio 187 95 confidence interval 104ndash335 P 004)

bull Conclusions Perioperative bisoprolol therapy did not affect

bull cardiovascular outcome in these elderly at-risk patients undergoing

bull surgery with spinal block

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlandsbull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative

mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

bull Adrenergic Receptor Genotype but Not Perioperative

bull Bisoprolol Therapy May Determine Cardiovascular Outcome

bull in At-risk Patients Undergoing Surgery with Spinal Block

bull The Swiss Beta Blocker in Spinal Anesthesia (BBSA) Study A Double-blinded

bull Placebo-controlled Multicenter Trial with 1-Year Follow-up

bull Michael Zaugg MD Lukas Bestmann PhDdagger Johannes Wacker MDDagger Eliana Lucchinetti PhDsect Anita Boltres MD

bull Christian Schulz MD Martin Hersberger PhD Gabriela Kauml lin BSc Lukas Furrer MDdaggerdagger Christoph Hofer MDDaggerDagger

bull Stephan Blumenthal MDsectsect Annabelle Muuml ller PhD Andreas Zollinger MD Donat R Spahn MD Alain Borgeat MDdaggerdaggerdagger

bull Background Neuraxial blockade is used as primary anesthetic

bull technique in one third of surgical procedures The authors tested

bull whether bisoprolol would protect patients at risk for cardiovascular

bull complications undergoing surgery with spinal block

bull Methods The authors performed a double-blinded placebocontrolled

bull multicenter trial to compare the effect of bisoprolol

bull with that of placebo on 1-yr composite outcome including cardiovascular

bull mortality nonfatal myocardial infarction unstable angina

bull congestive heart failure and cerebrovascular insult Bisoprolol

bull was given orally before and after surgery for a maximum of 10

bull days Adrenergic receptor polymorphisms and safety outcome

bull measures of bisoprolol therapy were also determined

bull Results A total of 224 patients were enrolled Spinal block could

bull not be established in 5 patients One hundred ten patients were

bull assigned to the bisoprolol group and 109 patients were assigned

bull to the placebo group The mean duration of treatment was 49 days

bull in the bisoprolol group and 51 days in the placebo group Bisoprolol therapy reduced mean heart rate by 10 beatsmin The

bull primary outcome was identical between treatment groups and

bull occurred in 25 patients (227) in the bisoprolol group and 24

bull patients (220) in the placebo group during the 1-yr follow-up

bull (hazard ratio 097 95 confidence interval 055ndash169 P 090)

bull However carriers of at least one Gly allele of the 1-adrenergic

bull receptor polymorphism Arg389Gly showed a higher number of

bull adverse events than Arg homozygous (324 vs 187 hazard

bull ratio 187 95 confidence interval 104ndash335 P 004)

bull Conclusions Perioperative bisoprolol therapy did not affect

bull cardiovascular outcome in these elderly at-risk patients undergoing

bull surgery with spinal block

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlandsbull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative

mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Periop statin therapybull Recommendations for Statin Therapybull CLASS Ibull 1 For patients currently taking statins and scheduled for

noncardiac surgery statins should be continued (Level of Evidence B)

bull CLASS IIabull 1 For patients undergoing vascular surgery with or without

clinical risk factors statin use is reasonable (Level of Evidence B)

bull CLASS IIbbull 1 For patients with at least 1 clinical risk factor who are

undergoing intermediate-risk procedures statins may be considered (Level of Evidence C)

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlandsbull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative

mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

terapia preoperatoria con statinebull La terapia preoperatoria con statine deve essere

continuata per coloro che le assumono giagrave (livello di evidenza B)

bull la loro somministrazione egrave ragionevole per i candidati a chirurgia vascolare con o senza fattori di rischio clinici (livello di evidenza B)

bull Le statine possono essere prese in considerazione per i pazienti con almeno 1 fattore di rischio clinico candidati a chirurgia di rischio intermedio (livello di evidenza C)

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlandsbull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative

mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

bull usinSchouten Olaf MD a Poldermans Don MD PhD b Visser Loes MD b Kertai Miklos D MD c Klein Jan MD PhD b van Urk Hero MD PhD a Simoons Maarten L MD PhD c van de Ven Louis L MD PhD c Vermeulen Maarten MSc c Bax Jeroen J MD PhD d Lameris Thomas W MD PhD c Boersma Eric PhD c Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery Rationale and design of the DECREASE-IV study American Heart Journal 148(6)1047-1052 December 2004

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlandsbull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative

mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in

the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery

Kertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR Poldermans D

bull Department of Cardiology Erasmus MC Rotterdam The Netherlandsbull OBJECTIVE To investigate the combined beneficial effect of statin and beta-blocker use on perioperative

mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA) BACKGROUND Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers METHODS We studied 570 patients (mean age 69+-9 years 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC Patients were evaluated for clinical risk factors (agegt70 years histories of MI angina diabetes mellitus stroke renal failure heart failure and pulmonary disease) DSE statin and beta-blocker use The main outcome was a composite of perioperative mortality and MI within 30 days of surgery RESULTS Perioperative mortality or MI occurred in 51 (89) patients The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001) After correcting for other covariates the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR 024 95 CI 010-070 p=001) Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054) Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

Eur J Vasc Endovasc Surg 2004 Oct28(4)343-52 LinksA combination of statins and beta-blockers is independently associated with a reduction in the incidence of perioperative mortality and nonfatal myocardial

infarction in patients undergoing abdominal aortic aneurysm surgeryKertai MD Boersma E Westerhout CM Klein J Van Urk H Bax JJ Roelandt JR

Poldermans Dbull 570 pazienti sottoposti a chirurgic dellrsquoaorta addominale bull Perioperative mortality or MI occurred in 51 (89) patients bull Perioperative mortality or MI significantly lower in statin users compared

to nonusers (37 vs 110 crude odds ratio (OR) 031 95 confidence interval (CI) 013-074 p=001)

bull Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR 024 95 CI 011-054)

bull Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata particularly patients with 3 or more risk factors experienced significantly lower perioperative events CONCLUSIONS A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk

bull

bull Attenzione perograve che egrave necessario che il beta bloccante sia effettivamente efficace nel controllare la FCinfatti solo se la FC rimane lt 100 bpm se ne dimostra lrsquoefficaciahelliphelliphelliphellip

Anesth Analg 20081061039 ndash48 Beattie WS Wijeysundera DN Karkouti K McCluskey S Tait G)

bull Metanalisimolti degli studi sullrsquoargomento sono estremamente eterogenei e solo quando la massima frequenza cardiaca misurata era inferiore a 100 bpm si aveva un significativo effetto protettivo (OR 023 95 CI 008ndash065 P=0005) mentre quando questo target non era raggiunto non vi era alcuna efficacia dimostrabile (OR 117 95 CI 079ndash180 P=043)

bull Inoltre con lrsquoutilizzo di una meta-regressione si dimostra unrsquoassociazione lineare tra l`effetto del Bbloccante sulla frequenza cardiaca (media massima e sulla sua variazione) e l`incidenza di IM (r2=063 P=0001) dove una maggiore efficacia del Bbloccante era associato ad una riduzione di incidenza di IM postoperatorio

Anesthesiology 2004 Aug101(2)284-93Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery

Wallace AW Galindez D Salahieh A Layug EL Lazo EA Haratonik KA Boisvert DM Kardatzke D

bull Department of Anesthesia and Perioperative Care University of California USA awallacecardiacengineeringcom

bull BACKGROUND Perioperative myocardial ischemia occurs in 20-40 of patients at risk for cardiac morbidity and is associated with a ninefold increase in risk of cardiac morbidity METHODS In a prospective double-blinded clinical trial we studied 190 patients with or at risk for coronary artery disease in two study groups with a 21 ratio (clonidine n = 125 vs placebo n = 65) to test the hypothesis that prophylactic clonidine reduces the incidence of perioperative myocardial ischemia and postoperative death in patients undergoing noncardiac surgery Clonidine (02 mg orally as well as a patch) or placebo (tablet and patch) was administered the night before surgery and clonidine (02 mg orally) or placebo (tablet) was administered on the morning of surgery The patch or placebo remained on the patient for 4 days and was then removed RESULTS The incidence of perioperative myocardial ischemia was significantly reduced with clonidine (intraoperative and postoperative 18 of 125 14 vs placebo 20 of 65 31 P = 001) Prophylactic clonidine administration had minimal hemodynamic effects Clonidine reduced the incidence of postoperative mortality for up to 2 yr (clonidine 19 of 125 [15] vs placebo 19 of 65 [29] relative risk = 043 [confidence interval 021-089] P = 0035) CONCLUSIONS Perioperative administration of clonidine for 4 days to patients at risk for coronary artery disease significantly reduces the incidence of perioperative myocardial ischemia and postoperative death

Anesth Analg 20081061039 ndash48 Beattie WS Wijeysundera DN Karkouti K McCluskey S Tait G)

bull Metanalisimolti degli studi sullrsquoargomento sono estremamente eterogenei e solo quando la massima frequenza cardiaca misurata era inferiore a 100 bpm si aveva un significativo effetto protettivo (OR 023 95 CI 008ndash065 P=0005) mentre quando questo target non era raggiunto non vi era alcuna efficacia dimostrabile (OR 117 95 CI 079ndash180 P=043)

bull Inoltre con lrsquoutilizzo di una meta-regressione si dimostra unrsquoassociazione lineare tra l`effetto del Bbloccante sulla frequenza cardiaca (media massima e sulla sua variazione) e l`incidenza di IM (r2=063 P=0001) dove una maggiore efficacia del Bbloccante era associato ad una riduzione di incidenza di IM postoperatorio

Anesthesiology 2004 Aug101(2)284-93Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery

Wallace AW Galindez D Salahieh A Layug EL Lazo EA Haratonik KA Boisvert DM Kardatzke D

bull Department of Anesthesia and Perioperative Care University of California USA awallacecardiacengineeringcom

bull BACKGROUND Perioperative myocardial ischemia occurs in 20-40 of patients at risk for cardiac morbidity and is associated with a ninefold increase in risk of cardiac morbidity METHODS In a prospective double-blinded clinical trial we studied 190 patients with or at risk for coronary artery disease in two study groups with a 21 ratio (clonidine n = 125 vs placebo n = 65) to test the hypothesis that prophylactic clonidine reduces the incidence of perioperative myocardial ischemia and postoperative death in patients undergoing noncardiac surgery Clonidine (02 mg orally as well as a patch) or placebo (tablet and patch) was administered the night before surgery and clonidine (02 mg orally) or placebo (tablet) was administered on the morning of surgery The patch or placebo remained on the patient for 4 days and was then removed RESULTS The incidence of perioperative myocardial ischemia was significantly reduced with clonidine (intraoperative and postoperative 18 of 125 14 vs placebo 20 of 65 31 P = 001) Prophylactic clonidine administration had minimal hemodynamic effects Clonidine reduced the incidence of postoperative mortality for up to 2 yr (clonidine 19 of 125 [15] vs placebo 19 of 65 [29] relative risk = 043 [confidence interval 021-089] P = 0035) CONCLUSIONS Perioperative administration of clonidine for 4 days to patients at risk for coronary artery disease significantly reduces the incidence of perioperative myocardial ischemia and postoperative death

Anesthesiology 2004 Aug101(2)284-93Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery

Wallace AW Galindez D Salahieh A Layug EL Lazo EA Haratonik KA Boisvert DM Kardatzke D

bull Department of Anesthesia and Perioperative Care University of California USA awallacecardiacengineeringcom

bull BACKGROUND Perioperative myocardial ischemia occurs in 20-40 of patients at risk for cardiac morbidity and is associated with a ninefold increase in risk of cardiac morbidity METHODS In a prospective double-blinded clinical trial we studied 190 patients with or at risk for coronary artery disease in two study groups with a 21 ratio (clonidine n = 125 vs placebo n = 65) to test the hypothesis that prophylactic clonidine reduces the incidence of perioperative myocardial ischemia and postoperative death in patients undergoing noncardiac surgery Clonidine (02 mg orally as well as a patch) or placebo (tablet and patch) was administered the night before surgery and clonidine (02 mg orally) or placebo (tablet) was administered on the morning of surgery The patch or placebo remained on the patient for 4 days and was then removed RESULTS The incidence of perioperative myocardial ischemia was significantly reduced with clonidine (intraoperative and postoperative 18 of 125 14 vs placebo 20 of 65 31 P = 001) Prophylactic clonidine administration had minimal hemodynamic effects Clonidine reduced the incidence of postoperative mortality for up to 2 yr (clonidine 19 of 125 [15] vs placebo 19 of 65 [29] relative risk = 043 [confidence interval 021-089] P = 0035) CONCLUSIONS Perioperative administration of clonidine for 4 days to patients at risk for coronary artery disease significantly reduces the incidence of perioperative myocardial ischemia and postoperative death

Wallace AW Galindez D Salahieh A Layug EL Lazo EA Haratonik KA Boisvert DM Kardatzke D Effect of clonidine on cardiovascular morbidity

andmortality after noncardiac surgeryAnesthesiology 2004

Aug101(2)284-93

Long term protection offered by 4 days of perioperative clonidine in patients at risk of CAD

bull Am J Med 2009 Jan 28 [Epub ahead of print] Links

bull Perioperative Beta-blockers for Major Noncardiac Surgery Primum Non Nocere

bull Chopra V Plaisance B Cavusoglu E Flanders SA Eagle KA

bull Division of General Medicine Department of Internal Medicine University of Michigan Health System Ann Arbor

bull Recent studies have called into question the benefit of perioperative beta blockade especially in patients at low to moderate risk of cardiac events Once considered standard of care the role of beta-blocker therapy now lies mired in conflicting data that are difficult to apply to the at-risk patient We provide an overview of the evolution of perioperative beta blockade beginning with the physiology of the adrenergic system with emphasis on the biologic rationale for the perioperative implementation of beta-blockers Although initial studies were small in size and statistically limited early data showed cardiac benefit with the use of perioperative beta-blockers However larger more recent studies now suggest a lack of benefit and potential harm from this practice This paradigm holds true especially in those at low-to-moderate cardiovascular risk profiles Potential explanations for these paradoxical results are discussed stressing the key differences between earlier and current studies that may explain these divergent outcomes We conclude by commenting on performance measures as they relate to perioperative beta-blockers and make recommendations for the continued safe implementation of this practice

bull Am J Med 2009 Jan 28 [Epub ahead of print] Links

bull Perioperative Beta-blockers for Major Noncardiac Surgery Primum Non Nocere

bull Chopra V Plaisance B Cavusoglu E Flanders SA Eagle KA

bull Division of General Medicine Department of Internal Medicine University of Michigan Health System Ann Arbor

bull Recent studies have called into question the benefit of perioperative beta blockade especially in patients at low to moderate risk of cardiac events Once considered standard of care the role of beta-blocker therapy now lies mired in conflicting data that are difficult to apply to the at-risk patient We provide an overview of the evolution of perioperative beta blockade beginning with the physiology of the adrenergic system with emphasis on the biologic rationale for the perioperative implementation of beta-blockers Although initial studies were small in size and statistically limited early data showed cardiac benefit with the use of perioperative beta-blockers However larger more recent studies now suggest a lack of benefit and potential harm from this practice This paradigm holds true especially in those at low-to-moderate cardiovascular risk profiles Potential explanations for these paradoxical results are discussed stressing the key differences between earlier and current studies that may explain these divergent outcomes We conclude by commenting on performance measures as they relate to perioperative beta-blockers and make recommendations for the continued safe implementation of this practice

bull Lancet 2008 Dec 6372(9654)1962-76 Epub 2008 Nov 13 Links

bull Comment in Lancet 2008 Dec 6372(9654)1930-2 Perioperative beta blockers in patients having non-cardiac surgery a meta-analysis

bull Bangalore S Wetterslev J Pranesh S Sawhney S Gluud C Messerli FH

bull Division of Cardiology Brigham and Womens Hospital Boston MA USA

bull BACKGROUND American College of Cardiology and American Heart Association (ACCAHA) guidelines on perioperative assessment recommend perioperative beta blockers for non-cardiac surgery although results of some clinical trials seem not to support this recommendation We aimed to critically review the evidence to assess the use of perioperative beta blockers in patients having non-cardiac surgery METHODS We searched Pubmed and Embase for randomised controlled trials investigating the use of beta blockers in non-cardiac surgery We extracted data for 30-day all-cause mortality cardiovascular mortality non-fatal myocardial infarction non-fatal stroke heart failure and myocardial ischaemia safety outcomes of perioperative bradycardia hypotension and bronchospasm FINDINGS 33 trials included 12 306 patients beta blockers were not associated with any significant reduction in the risk of all-cause mortality cardiovascular mortality or heart failure but were associated with a decrease (odds ratio [OR] 065 95 CI 054-079) in non-fatal myocardial infarction (number needed to treat [NNT] 63) and decrease (OR 036 026-050) in myocardial ischaemia (NNT 16) at the expense of an increase (OR 201 127-368) in non-fatal strokes (number needed to harm [NNH] 293) The beneficial effects were driven mainly by trials with high risk of bias For the safety outcomes beta blockers were associated with a high risk of perioperative bradycardia requiring treatment (NNH 22) and perioperative hypotension requiring treatment (NNH 17) We recorded no increased risk of bronchospasm INTERPRETATION Evidence does not support the use of beta-blocker therapy for the prevention of perioperative clinical outcomes in patients having non-cardiac surgery The ACCAHA guidelines committee should soften their advocacy for this intervention until conclusive evidence is available

bull Anesth Analg 2007 Jan104(1)27-41 Links

bull Comment in Anesth Analg 2007 Jan104(1)1-3 Perioperative beta-blockers for preventing surgery-related mortality and morbidity a systematic review and meta-analysis

bull Wiesbauer F Schlager O Domanovits H Wildner B Maurer G Muellner M Blessberger H Schillinger M

bull Department of Cardiology Vienna General Hospital Medical University Vienna Austria franzwiesbauermeduniwienacat

bull BACKGROUND Perioperative beta-blockers are suggested to reduce cardiovascular mortality myocardial-ischemiainfarction and supraventricular arrhythmias after surgery We reviewed the evidence regarding the effectiveness of perioperative beta-blockers for improving patient outcomes after cardiac and noncardiac surgery METHODS Eleven large databases were searched from the time of their inception until October 2005 Various online-resources were consulted for the identification of unpublished trials and conference abstracts We included randomized controlled trials comparing perioperative beta-blockers with either placebo or the standard-of-care Of the 3680 retrieved titles 69 met inclusion criteria for analysis Odds ratios (OR) assuming random effects were computed in the absence of significant clinical heterogeneityRESULTS Beta-blockers reduced the frequency of ventricular tachyarrhythmias [OR (cardiac surgery) 028 95 CI 013-057 OR (noncardiac surgery) 056 95 CI 021-145] atrial fibrillationflutter [OR (cardiac surgery) 037 95 CI 028-048] other supraventricular arrhythmias [OR (cardiac surgery) 025 95 CI 018-035 OR (noncardiac surgery) 043 95 CI 014-137] and myocardial ischemia [OR (cardiac surgery) 049 95 CI 017-14 OR (noncardiac surgery) 038 95 CI 021-069] Length of hospitalization was not reduced [weighted mean difference (cardiac surgery) -035 days 95 CI -077-007 weighted mean difference (noncardiac surgery) -559 days 95 CI -1222-104] and in contrast to previous reports beta-blockers did not reduce mortality [OR (cardiac surgery) 055 95 CI 017-183 OR (noncardiac surgery) 078 95 CI 033-187] and they had no influence on the occurrence of perioperative myocardial infarction [OR (cardiac surgery) 089 95 CI 053-15 OR (noncardiac surgery) 059 025-139]CONCLUSIONS Beta-blockers reduced perioperative arrhythmias and myocardial ischemia but they had no effect on myocardial infarction mortality or length of hospitalization

bull Diabetics share the same risks as patients with cardiac ischemiarenal insufficiency or cerebrovascular atherosclerotic disease(42 Haffner

bull Risks of the diabtiecsautonomic dysfunction

bull Difficult intubationhelliphelliphellipsee lavoro Nova pub

bull Anesth Analg 2008 Dec107(6)1919-23 Links

bull The extended Mallampati score and a diagnosis of diabetes mellitus are predictors of difficult laryngoscopy in the morbidly obese

bull Mashour GA Kheterpal S Vanaharam V Shanks A Wang LY Sandberg WS Tremper KK

bull Department of Anesthesiology University of Michigan Medical School Ann Arbor Michigan USA gmashourumichedu

bull BACKGROUND The modified Mallampati (MMP) classification is a standard method of oropharyngeal evaluation for predicting difficult laryngoscopy Previous studies have demonstrated that the predictive value of the MMP is improved when the patients craniocervical junction is extended rather than neutral (Extended Mallampati Score EMS) In the present study we compared the predictive value of the MMP and EMS in the morbidly obese METHODS We performed a prospective study of adult patients with a Body Mass Index (BMI) gt or = 40 over a 12-mo period comparing the MMP and EMS The performance of the MMP EMS and other commonly used tests was compared for the ability to predict difficult laryngoscopy defined as a Cormack-Lehane grade of 3 or 4 Positioning and direct laryngoscopic techniques were not standardized The incidence of difficult laryngoscopy and difficult intubation was compared in patients with BMI gt or = or lt 40 RESULTS Three-hundred-forty-six patients with a BMI gt or = 40 were evaluated with both the MMP and EMS and received direct laryngoscopy On average craniocervical extension decreased the MMP class (P lt 00001) Compared to the MMP the EMS improved specificity and predictive value while maintaining sensitivity Compared to the MMP and other tests an EMS class of 3 or 4 and a diagnosis of diabetes mellitus were the only statistically significant predictors of difficult laryngoscopy in the morbidly obese There was no difference in the incidence of difficult laryngoscopy or intubation in the morbidly obese compared to patients with a BMI lt 40 CONCLUSIONS The EMS was superior to the MMP in the prediction of difficult laryngoscopy in the morbidly obese population A diagnosis of diabetes mellitus also warrants further investigation as a predictor of difficult laryngoscopy in this population Finally this study supports previous findings that morbid obesity is not itself a predictor of difficult laryngoscopy or intubation

bull Risks of the diabtiecsautonomic dysfunction

bull Difficult intubationhelliphelliphellipsee lavoro Nova pub

bull Anesth Analg 2008 Dec107(6)1919-23 Links

bull The extended Mallampati score and a diagnosis of diabetes mellitus are predictors of difficult laryngoscopy in the morbidly obese

bull Mashour GA Kheterpal S Vanaharam V Shanks A Wang LY Sandberg WS Tremper KK

bull Department of Anesthesiology University of Michigan Medical School Ann Arbor Michigan USA gmashourumichedu

bull BACKGROUND The modified Mallampati (MMP) classification is a standard method of oropharyngeal evaluation for predicting difficult laryngoscopy Previous studies have demonstrated that the predictive value of the MMP is improved when the patients craniocervical junction is extended rather than neutral (Extended Mallampati Score EMS) In the present study we compared the predictive value of the MMP and EMS in the morbidly obese METHODS We performed a prospective study of adult patients with a Body Mass Index (BMI) gt or = 40 over a 12-mo period comparing the MMP and EMS The performance of the MMP EMS and other commonly used tests was compared for the ability to predict difficult laryngoscopy defined as a Cormack-Lehane grade of 3 or 4 Positioning and direct laryngoscopic techniques were not standardized The incidence of difficult laryngoscopy and difficult intubation was compared in patients with BMI gt or = or lt 40 RESULTS Three-hundred-forty-six patients with a BMI gt or = 40 were evaluated with both the MMP and EMS and received direct laryngoscopy On average craniocervical extension decreased the MMP class (P lt 00001) Compared to the MMP the EMS improved specificity and predictive value while maintaining sensitivity Compared to the MMP and other tests an EMS class of 3 or 4 and a diagnosis of diabetes mellitus were the only statistically significant predictors of difficult laryngoscopy in the morbidly obese There was no difference in the incidence of difficult laryngoscopy or intubation in the morbidly obese compared to patients with a BMI lt 40 CONCLUSIONS The EMS was superior to the MMP in the prediction of difficult laryngoscopy in the morbidly obese population A diagnosis of diabetes mellitus also warrants further investigation as a predictor of difficult laryngoscopy in this population Finally this study supports previous findings that morbid obesity is not itself a predictor of difficult laryngoscopy or intubation

bull Anesth Analg 2008 Dec107(6)1919-23 Links

bull The extended Mallampati score and a diagnosis of diabetes mellitus are predictors of difficult laryngoscopy in the morbidly obese

bull Mashour GA Kheterpal S Vanaharam V Shanks A Wang LY Sandberg WS Tremper KK

bull Department of Anesthesiology University of Michigan Medical School Ann Arbor Michigan USA gmashourumichedu

bull BACKGROUND The modified Mallampati (MMP) classification is a standard method of oropharyngeal evaluation for predicting difficult laryngoscopy Previous studies have demonstrated that the predictive value of the MMP is improved when the patients craniocervical junction is extended rather than neutral (Extended Mallampati Score EMS) In the present study we compared the predictive value of the MMP and EMS in the morbidly obese METHODS We performed a prospective study of adult patients with a Body Mass Index (BMI) gt or = 40 over a 12-mo period comparing the MMP and EMS The performance of the MMP EMS and other commonly used tests was compared for the ability to predict difficult laryngoscopy defined as a Cormack-Lehane grade of 3 or 4 Positioning and direct laryngoscopic techniques were not standardized The incidence of difficult laryngoscopy and difficult intubation was compared in patients with BMI gt or = or lt 40 RESULTS Three-hundred-forty-six patients with a BMI gt or = 40 were evaluated with both the MMP and EMS and received direct laryngoscopy On average craniocervical extension decreased the MMP class (P lt 00001) Compared to the MMP the EMS improved specificity and predictive value while maintaining sensitivity Compared to the MMP and other tests an EMS class of 3 or 4 and a diagnosis of diabetes mellitus were the only statistically significant predictors of difficult laryngoscopy in the morbidly obese There was no difference in the incidence of difficult laryngoscopy or intubation in the morbidly obese compared to patients with a BMI lt 40 CONCLUSIONS The EMS was superior to the MMP in the prediction of difficult laryngoscopy in the morbidly obese population A diagnosis of diabetes mellitus also warrants further investigation as a predictor of difficult laryngoscopy in this population Finally this study supports previous findings that morbid obesity is not itself a predictor of difficult laryngoscopy or intubation

bull J Postgrad Med 2000 Apr-Jun46(2)75-9 Links

bull The palm print as a sensitive predictor of difficult laryngoscopy in diabetics a comparison with other airway evaluation indices

bull Vani V Kamath SK Naik LD

bull Department of Anaesthesiology Seth G S Medical College and K E M Hospital Parel Mumbai - 400 012 India

bull AIMS To evaluate the ink impression made by the palm of the dominant hand as a screening tool for difficult laryngoscopy in diabetic patients SUBJECTS AND METHODS In this prospective study airway of 50 adult diabetic patients undergoing elective surgery under general anaesthesia was assessed preoperatively using the common clinical indices such as Modified Mallampati test thyromental distance degree of head extension and a specific index- the palm print test Following induction of anaesthesia and neuromuscular relaxation laryngoscopy was performed and the laryngoscopic view scored The sensitivity specificity and positive predictive value of each airway evaluation index were calculated RESULTS The incidence of difficult laryngoscopy was 16 The palm print test had the highest sensitivity (75) of all the indices The thyromental distance less than six cm had the highest specificity (952) but was least sensitive (25) 87 of patients with difficult laryngoscopy had two or more indices abnormal CONCLUSION Though the palm print test was the most sensitive index of the four indices studied a better prediction of difficult laryngoscopy can be achieved by evaluating all the four airway indices preoperatively

bull Anesth Analg 1998 Mar86(3)516-9 Links

bull Diabetes mellitus and difficult laryngoscopy in renal and pancreatic transplant patients

bull Warner ME Contreras MG Warner MA Schroeder DR Munn SR Maxson PM

bull Department of Anesthesiology Mayo Clinic and Foundation Rochester Minnesota 55905 USA

bull Limited mobility of the cervical spine or temperomandibular joint may contribute to increased difficulty of laryngoscopy in patients who have severe diabetes mellitus The frequency of difficult laryngoscopy in diabetics undergoing renal andor pancreatic transplants has been reported to be as high as 32 We retrospectively reviewed the anesthetic records of all adult patients who underwent renal andor pancreatic transplant and endotracheal intubation from January 1 1985 to October 31 1995 Characteristics specifically reviewed included the presence of diabetes mellitus type of organ donor age gender body mass index previous difficult laryngoscopy known characteristics potentially related to difficult laryngoscopy and degree of difficulty with laryngoscopy Laryngoscopy was graded as easy minimally to moderately difficult and moderately to extremely difficult to perform Factors associated with any degree of difficult intubation were univariately assessed by using Fishers exact test Of 725 patients 15 (21) were identified as having difficult laryngoscopies although all underwent successful endotracheal intubations Factors associated with difficult laryngoscopy were diabetes mellitus (P = 0002) and characteristics known to be related to difficult laryngoscopy (P = 002) These findings confirm an increase in the frequency of difficult laryngoscopy in diabetic patients undergoing renal andor pancreatic transplant although no laryngoscopies were rated as moderately to extremely difficult We conclude that the frequency of difficult laryngoscopy in these diabetic patients is much lower than previous reports have suggested IMPLICATIONS Previous studies have suggested that airway management of many diabetic patients may be difficult Our medical record review of patients with severe diabetes undergoing organ transplants showed that extraordinary techniques were not required to successfully manage their airways

bull (44) while Anesth Analg 1998 Mar86(3)516-9 Links

bull Diabetes mellitus and difficult laryngoscopy in renal and pancreatic transplant patients

bull Warner ME Contreras MG Warner MA Schroeder DR Munn SR Maxson PM

bull Department of Anesthesiology Mayo Clinic and Foundation Rochester Minnesota 55905 USA

bull Limited mobility of the cervical spine or temperomandibular joint may contribute to increased difficulty of laryngoscopy in patients who have severe diabetes mellitus The frequency of difficult laryngoscopy in diabetics undergoing renal andor pancreatic transplants has been reported to be as high as 32 We retrospectively reviewed the anesthetic records of all adult patients who underwent renal andor pancreatic transplant and endotracheal intubation from January 1 1985 to October 31 1995 Characteristics specifically reviewed included the presence of diabetes mellitus type of organ donor age gender body mass index previous difficult laryngoscopy known characteristics potentially related to difficult laryngoscopy and degree of difficulty with laryngoscopy Laryngoscopy was graded as easy minimally to moderately difficult and moderately to extremely difficult to perform Factors associated with any degree of difficult intubation were univariately assessed by using Fishers exact test Of 725 patients 15 (21) were identified as having difficult laryngoscopies although all underwent successful endotracheal intubations Factors associated with difficult laryngoscopy were diabetes mellitus (P = 0002) and characteristics known to be related to difficult laryngoscopy (P = 002) These findings confirm an increase in the frequency of difficult laryngoscopy in diabetic patients undergoing renal andor pancreatic transplant although no laryngoscopies were rated as moderately to extremely difficult We conclude that the frequency of difficult laryngoscopy in these diabetic patients is much lower than previous reports have suggested IMPLICATIONS Previous studies have suggested that airway management of many diabetic patients may be difficult Our medical record review of patients with severe diabetes undergoing organ transplants showed that extraordinary techniques were not required to successfully manage their airways

bull Difficult Laryngoscopy and

bull Diabetes Mellitus

bull Key Words INTUBATION TRACHEAL-diabetes

bull and COMPLICATIONS DIABETES MELLITUS

bull METABOLISM DIABETES MELLITUS

bull To the Editor

bull Like the authors we too were surprised by the extremely

bull high incidence (32) of difficult laryngoscopy in diabetic

bull renal transplant patients reported by Hogan et al (1) They

bull suggested that stiff joint syndrome a condition occasionally

bull seen in type I insulin-dependent diabetics may have

bull been a major cause of this finding Because their results

bull were so striking we investigated the incidence of difficult

bull laryngoscopy and intubation in similar patients at our

bull institution

bull From January 1986 to December 1988 68 diabetic and

bull 108 nondiabetic adult patients underwent renal transplant

bull for chronic renal failure Causes and proportions of chronic

bull renal failure in our patients were similar to those of the

bull previous study (1) The incidence of difficult laryngoscopy

bull and intubation was determined by cross-linkage of our

bull renal transplant and anesthesia data bases Only 1 (15) of

bull the 68 diabetic patients was judged to be difficult to

bull intubate There was no difficult intubation in the 108

bull nondiabetic patients These findings preclude further analysis

bull of transplant subgroups (cadaveric versus living donor)

bull or demographic and laboratory differences

bull Why the marked discrepancy in results Difficult laryngoscopy

bull and intubation at our institution is a judgment

bull made by our staff anesthesiologists and is similar but

bull probably not identical to that used by Hogan et al To

bull ascertain the influence of any differences in criteria for

bull difficult intubation on our results we evaluated our institutions

bull overall incidence of difficult intubation during the

bull same time span Of 89380 intubations 568 (06) were

bull judged to be difficult This rate is similar to the overall norm

bull of 05 reported by Hogan et al Another confounding

bull variable may have been the age of our patients All of our

bull patients were adults we are unable to discern how many

bull children were included in the study of Hogan et al Hogan

bull et al did not however find age to be a predictor of difficult

bull laryngoscopy

bull Based on our findings we are unable to corroborate

bull their report of very strong association between difficult

bull laryngoscopy in diabetic but not nondiabetic renal transplant

bull recipients

bull Mary E Warner MD

bull Mark A Warner MD

bull Bradly J Narr MD

bull Department of Anesthesiology

bull Mayo Clinic and Mayo Medical School

bull Rochester MN 55905

bull Reference

bull 1 Hogan K Rusy D Springman SR Difficult laryngoscopy and diabetes

bull mellitus Anesth Analg 1988671162-5

bull In Response

bull We commend the efforts of Warner et al in reviewing their

bull experience with laryngoscopy and kidney transplantation

bull from January 1986 to December 1988 Our experience with

bull 247 patients from January 1988 to May 1989 is summarized

bull in Table 1

bull A few observations are perhaps warranted First the

bull problem of difficult laryngoscopy in renal transplant recipients

bull has not gone away at our institution Second diabetes

bull mellitus remains a predictor of difficult laryngoscopy

bull LETTERS TO THE EDITOR ANESTH ANALG 551

bull 198969548-53

bull Table 1 Routine versus Difficult Laryngoscopy

bull Vocal

bull Vocal Cords

bull Cords Not Other Difficult

bull Operation Seen Seen Difficult Routine Difficult

bull Cadaver renal transplant

bull Diabetic 24 5 4 933 27

bull Nondiabetic 73 10 2 1285 14

bull Diabetic 13 4 417 24

bull Nondiabetic 68 5 1 674 8

bull Pancreas and renal 31 6 1 738 14

bull transplant (diabetic)

bull Total 209 30 8

bull Living donor transplant

bull Unspecified difficult laryngoscopy in record eg anterior larynx

bull Third nondiabetic kidney recipients appear to be at increased

bull risk in comparison with our previous report (1)

bull Since that investigation we no longer perform isolated

bull pancreas transplants living donor transplants for diabetic

bull renal recipients have halved and living donor transplants

bull for nondiabetic recipients have doubled These demographic

bull changes coupled with heightened awareness of

bull potential airway complications on the part of our anesthesiologists

bull may explain differences between the sampled

bull intervals The direction and magnitude of these effects can

bull only be matters for speculation with existing data

bull It is even more difficult to reconcile the different incidences

bull reported between institutions on the basis of chart

bull review Because the scored variable is explicit (ie can the

bull vocal cords be seen or not) judgmental differences are

bull unlikely to play a significant role but cannot be ruled out

bull with certitude The findings of Warner et al reinforce our

bull conviction that a prospective investigation incorporating

bull data from more than a single institution is required before

bull the association of diabetes mellitus kidney transplantation

bull and difficult laryngoscopy may be considered proven or

bull refuted

bull Kirk J Hogan MD

bull Deborah Rusy BS

bull Scott R Springman MD

bull Department of Anesthesiology

bull University of WI

bull Madison WI 53792

bull Reference

bull 1 Hogan KJ Rusy D Springman SR Difficult laryngoscopy and diabetes

bull mellitus Anesth Analg 1988671162-5 Difficult Intubation in

bull Severe Diabetics

bull Key Words COMPLICATIONS DIABETES-tracheal

bull intubation INTUBATION TRACHEAL

bull To the Editor

bull Hogan et al (1) report a startlingly high and heretofore

bull unappreciated 40 incidence of difficult laryngoscopy in a

bull group of severe diabetics If this phenomenon is confirmed

bull it will be an important contribution to decreasing intubation-

bull related morbidity

bull A few important but obtainable factors were not mentioned

bull in the paper Which laryngoscope blades were used

bull Was correct sniffing position employed Who was doing

bull the laryngoscopy-residents nurse anesthetists or attendings

bull Was the extent of relaxation confirmed or at least had

bull an adequate dose of relaxant been given Were simple and

bull effective maneuvers such as posterior and superior displacement

bull of the larynx tried

bull Although the 05 institutional rate of difficult laryngoscopy

bull is admirable and in line with published rates the

bull skeptical reader might wonder whether this unblinded

bull retrospective study could have been subject to a departmental

bull conviction that diabetics posed difficulties during

bull intubation The authors seem correct in stating that there

bull was no selection bias but the possibility of other preconceptions

bull among members of their department is not so easily

bull dispelled For example it is possible that being apprehensive

bull or flustered when approaching an intubation might

bull have left the intubator less adept Unconscious bias might

bull have prevented laryngoscopists from optimally positioning

bull the head a very common cause of failed intubation in a

bull patient with normal anatomy (23)

bull From years of watching nurse anesthetists and residents

bull intubate it is my opinion that identifying whether the

bull laryngoscopy is truly difficult (versus a problem with the

bull conditions or the intubationist) is not an rdquoexplicitrdquo task but

bull rather requires judgment and therefore may admit bias

bull Ronald M Meyer MD

bull Columbus Hospital

bull Chicago IL 60614

bull References

bull 1 Hogan K Rusy D Springman SR Difficult laryngoscopy and diabetes

bull 2 Finucane BT Santora AH Principles of airway management Philadel-

bull 3 Latto IP Rosen M Difficulties in tracheal intubation Philadelphia

bull rnellitus Anesth Analg 1988671162-5

bull phia F A Davis 1988144

bull Bailliere Tindall 1985llO

bull Difficult Laryngascapy and

bull Diabetes Mellitus

bull In Response

bull Ronald Meyer (rdquoDifficult Intubation in Severe Diabeticsrdquo

bull Anesth Analg 198969419) is correct in observing that a few

bull factors pertinent to difficult laryngoscopy in diabetes mellitus

bull were not mentioned in our study We did consider the

bull items he lists of course and many others as well A

bull retrospective search however is constrained by the limitations

bull of chart review Often readily available data are of

bull no apparent value For example what useful conclusions

bull can be drawn from the inventory of laryngoscope blades

bull used in our study (Table l) Other factors (sniffing position

bull degree of relaxation displacement maneuvers) defy meaningful

bull classification in an ex post facto analysis Hence

bull there is no alternative but to assume adherence to equivalent

bull standards of care in matching categories In every

bull instance laryngoscopy was under the direct supervision of

bull the attending anesthesiologist When difficulties arise

bull here as in other institutions the laryngoscope is passed to

bull the individual with the most experienced hand who is

bull responsible in turn for the accuracy of notations alerting

bull subsequent anesthesiologists

bull The association of airway disasters with pancreas transplantation

bull was apparent early on in part because of the

bull novel and highly experimental nature of the surgery A

bull departmental conviction that pancreas recipients pose special

bull hazards therefore was disseminated Pancreastransplant

bull patients were approached with trepidation and

bull if anything greater attention to the details of laryngoscopy

bull throughout the remainder of the study period

bull Meyerrsquos concern for unconscious bias on the part of

bull anesthesiologists flustered in the care of kidney recipients

bull is more easily dispelled Because all pancreas candidates

Heart failure as a risk factor

Hammill BGCurtisLHBennett-Guerrior EOrsquoConnorCMJollis JCSchulman KAHernandez AFImpact of heart failure on patients

undergoing major noncardiac surgeryAnesthesiology 2008108559-67

bull Medicare 5 standard analytic filesbull Inpatients fee for service claims 2000-20004bull Patients gt65 for major noncardiac surgery

ndash Carotid endarterectomyndash Lower extr bypassndash Open AAAndash Hip replacementndash Knee replacementndash Spinal fusionndash Above and below knee amputationndash Open and laparoscopic cholecystectomyndash Cancer resection abdominallungcolon

Hammill et alImpact of heart failure on patients undergoing major noncardiac surgeryAnesthesiology

bull Main outcome ndash Operative mortalityndash 30 days readmission

Hammill et al Impact of heart failure on patients undergoing major noncardiac surgeryAnesthesiology 2008108(4) 559-567

bull I pazienti di etagrave ge65 annibull inseriti nel programma assicurativo statunitense Medicarebull sottoposti tra il 2000 e il 2004 ad uno tra tredici tipi di chirurgia maggiore non-

cardiaca bull esclusi dallrsquoanalisi i pazienti con insufficienza renale terminale e quelli che non

avessero soddisfatto da almeno un anno i criteri Medicarereg per la sottoscrizione di una polizza

bull 159327 interventi 18 eseguiti in pazienti con insufficienza cardiaca e il 34 in pazienti con cardiopatia ischemica

bull I rischi relativi corretti di mortalitagrave e riammissione per i pazienti con insufficienza cardiaca rispetto a quelli che non presentavano neacute insufficienza cardiaca neacute cardiopatia ischemica erano 163 (intervallo confidenza 95 152-174) e 151 (intervallo confidenza 95 145-158) rispettivamente

bull I rischi relativi corretti di mortalitagrave e riammissione per i pazienti con cardiopatia ischemica rispetto a quelli che non presentavano neacute insufficienza cardiaca neacute cardiopatia ischemica erano 108 (intervallo confidenza 95 101-116) e 116 (intervallo confidenza 95 112-120) rispettivamente

Characteristics of the study population by disease group

heart faliure Cad normal

etagrave 794 753 756

Masch i 42 488 344

nerii 85 52 56

teaching hospitali 169 197 163

admitted form a skilled nursing facilityi 15 04 04

urgent admissioni 192 138 145

emergent admissionji 30 19 167

COPDi 451 311 222

CADi 81 100 0

dementiai 91 51 41

diabetesi 434 305 196

histrory of strokei 269 215 114

hypertensioni 864 824 668

periph vascdiseasei 463 363 179

renal diseasei 152 52 27

Operative mortalityHF CAD normal

total 8 31 24

gt Knee amput 258 18 16

ltknee amput 128 104 72

Carotid endarterec tomy 25 12 09

Colon cancer resection 119 63 54

Hip replacement 84 39 28

Knee replacement 09 04 03

Laparoscopic cholecystectomy

56 21 18

Lower extremity bypass 81 37 41

Open AAA repair 103 58 48

Other abdominal cancer resections

118 43 49

Pulmonary cancer resection

102 60 41

Spinal fusion 38 21 13

30 day readmissionHF CAD normal

total 171 108 81

gt Knee amput 252 216 189

ltknee amput 241ns 234ns 199 ns

Carotid endarterectomy 152 108 87

Colon cancer resection 18 132 105

Hip replacement 166 103 88

Knee replacement 99 62 47

Laparoscopic cholecystectomy

164 101 84

Lower extremity bypass 272 182 162

Open AAA repair 148 103 114

Other abdominal cancer resections

173 126 118

Pulmonary cancer resection

174 155 113

Spinal fusion 133 94 77

Effect of heart failure and CAD on mortality per procedure

Operative mortality and readmission rate for HF patients with or without CAD

Conclusion from the study of Hammil et al

bull Heart Failure patients ndashmortality risk 63 ndashReadmission risk 51

Hernandez AF Whellan DJ Stroud S Sun JL OrsquoConnor CM Jollis JGOutcomes in heart failure patients after major noncardiac surgery J

Am Coll Cardiol 200444(7)1446-1453

bull OBJECTIVES The purpose of this study was to evaluate mortality and readmission rates of heart failure (HF) patients after major noncardiac surgery BACKGROUND There is a lack of generalizable outcome data on HF patients undergoing major noncardiac surgery because previous studies have been limited to a few academic centers or have not focused on this group of patients METHODS Using the 1997 to 1998 Standard Analytic File 5 Sample of Medicare beneficiaries we identified patients with HF who underwent major noncardiac surgery A multivariable logistic regression model was used to provide adjusted mortality and readmission rates in patients after noncardiac surgery Patients with coronary artery disease (CAD) and all other remaining patients (Control) who had similar surgery served as reference groups RESULTS Of 23340 HF patients and 28710 CAD patients 1532 (656) HF patients and 1757 (612) CAD patients underwent major noncardiac surgery There were 44512 patients in the Control group with major noncardiac surgery After accounting for demographic characteristics type of surgery and comorbid conditions the risk-adjusted operative mortality (death before discharge or within 30 days of surgery) was HF 117 CAD 66 and Control 62 (HF vs CAD p lt 0001 CAD vs Control p = 0518) The risk-adjusted 30-day readmission rate was HF 200 CAD 142 and Control 110 (p lt 0001) CONCLUSIONS In patients 65 years of age and older HF patients undergoing major noncardiac surgery suffer substantial morbidity and mortality despite advances in perioperative care whereas patients with CAD without HF have similar mortality compared with a more general population

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG

CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-

288

bull il rischio operatorio viene minimizzato dalla ottimizzazione preoperatoria effettuata dal servizio di medicina interna con abbattimento notevole della mortalitagrave e morbilitagrave solo la sopravvivenza ad un anno egrave ridotta rispetto ai pazienti di controllocome egrave logico attendersi in ogni caso in pazienti portatori di malattia cronica seria

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

Postop survival time of HF patients after noncardiac major surgeryYE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M

WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-288

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM

ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

bull Our data suggest that perioperative mortality is surprisingly low (lt2) in patients with clinically stable HFmdash regardless of EFmdashundergoing elective noncardiac surgery

bull At 1 year crude mortality rates for patients with HF with reduced EF (135) or with preserved EF (63) were significantly higher than for controls (31) However we found no evidence to suggest that the immediate postoperative period was associated with a significantly higher risk of death than the subsequent months This raises the possibility that the long-term postoperative mortality rate that we observed in the patients with HF particularly those with low EF represents the background mortality expected in patients with chronic illnesses

bull Our findings contrast with previous studies that have focused on the perioperative outcomes of patients with HF

Perioperative mortality and 30 days readmission rate for patients with HF operated for noncardiac surgery

Preoperative evaluation at the Internal Medicine PreoperativeAssessment Consultation and Treatment (IMPACT)Center at the Cleveland Clinic

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

Hammill BGCurtisLHBennett-Guerrior EOrsquoConnorCMJollis JCSchulman KAHernandez AFImpact of heart failure on patients

undergoing major noncardiac surgeryAnesthesiology 2008108559-67

bull Medicare 5 standard analytic filesbull Inpatients fee for service claims 2000-20004bull Patients gt65 for major noncardiac surgery

ndash Carotid endarterectomyndash Lower extr bypassndash Open AAAndash Hip replacementndash Knee replacementndash Spinal fusionndash Above and below knee amputationndash Open and laparoscopic cholecystectomyndash Cancer resection abdominallungcolon

Hammill et alImpact of heart failure on patients undergoing major noncardiac surgeryAnesthesiology

bull Main outcome ndash Operative mortalityndash 30 days readmission

Hammill et al Impact of heart failure on patients undergoing major noncardiac surgeryAnesthesiology 2008108(4) 559-567

bull I pazienti di etagrave ge65 annibull inseriti nel programma assicurativo statunitense Medicarebull sottoposti tra il 2000 e il 2004 ad uno tra tredici tipi di chirurgia maggiore non-

cardiaca bull esclusi dallrsquoanalisi i pazienti con insufficienza renale terminale e quelli che non

avessero soddisfatto da almeno un anno i criteri Medicarereg per la sottoscrizione di una polizza

bull 159327 interventi 18 eseguiti in pazienti con insufficienza cardiaca e il 34 in pazienti con cardiopatia ischemica

bull I rischi relativi corretti di mortalitagrave e riammissione per i pazienti con insufficienza cardiaca rispetto a quelli che non presentavano neacute insufficienza cardiaca neacute cardiopatia ischemica erano 163 (intervallo confidenza 95 152-174) e 151 (intervallo confidenza 95 145-158) rispettivamente

bull I rischi relativi corretti di mortalitagrave e riammissione per i pazienti con cardiopatia ischemica rispetto a quelli che non presentavano neacute insufficienza cardiaca neacute cardiopatia ischemica erano 108 (intervallo confidenza 95 101-116) e 116 (intervallo confidenza 95 112-120) rispettivamente

Characteristics of the study population by disease group

heart faliure Cad normal

etagrave 794 753 756

Masch i 42 488 344

nerii 85 52 56

teaching hospitali 169 197 163

admitted form a skilled nursing facilityi 15 04 04

urgent admissioni 192 138 145

emergent admissionji 30 19 167

COPDi 451 311 222

CADi 81 100 0

dementiai 91 51 41

diabetesi 434 305 196

histrory of strokei 269 215 114

hypertensioni 864 824 668

periph vascdiseasei 463 363 179

renal diseasei 152 52 27

Operative mortalityHF CAD normal

total 8 31 24

gt Knee amput 258 18 16

ltknee amput 128 104 72

Carotid endarterec tomy 25 12 09

Colon cancer resection 119 63 54

Hip replacement 84 39 28

Knee replacement 09 04 03

Laparoscopic cholecystectomy

56 21 18

Lower extremity bypass 81 37 41

Open AAA repair 103 58 48

Other abdominal cancer resections

118 43 49

Pulmonary cancer resection

102 60 41

Spinal fusion 38 21 13

30 day readmissionHF CAD normal

total 171 108 81

gt Knee amput 252 216 189

ltknee amput 241ns 234ns 199 ns

Carotid endarterectomy 152 108 87

Colon cancer resection 18 132 105

Hip replacement 166 103 88

Knee replacement 99 62 47

Laparoscopic cholecystectomy

164 101 84

Lower extremity bypass 272 182 162

Open AAA repair 148 103 114

Other abdominal cancer resections

173 126 118

Pulmonary cancer resection

174 155 113

Spinal fusion 133 94 77

Effect of heart failure and CAD on mortality per procedure

Operative mortality and readmission rate for HF patients with or without CAD

Conclusion from the study of Hammil et al

bull Heart Failure patients ndashmortality risk 63 ndashReadmission risk 51

Hernandez AF Whellan DJ Stroud S Sun JL OrsquoConnor CM Jollis JGOutcomes in heart failure patients after major noncardiac surgery J

Am Coll Cardiol 200444(7)1446-1453

bull OBJECTIVES The purpose of this study was to evaluate mortality and readmission rates of heart failure (HF) patients after major noncardiac surgery BACKGROUND There is a lack of generalizable outcome data on HF patients undergoing major noncardiac surgery because previous studies have been limited to a few academic centers or have not focused on this group of patients METHODS Using the 1997 to 1998 Standard Analytic File 5 Sample of Medicare beneficiaries we identified patients with HF who underwent major noncardiac surgery A multivariable logistic regression model was used to provide adjusted mortality and readmission rates in patients after noncardiac surgery Patients with coronary artery disease (CAD) and all other remaining patients (Control) who had similar surgery served as reference groups RESULTS Of 23340 HF patients and 28710 CAD patients 1532 (656) HF patients and 1757 (612) CAD patients underwent major noncardiac surgery There were 44512 patients in the Control group with major noncardiac surgery After accounting for demographic characteristics type of surgery and comorbid conditions the risk-adjusted operative mortality (death before discharge or within 30 days of surgery) was HF 117 CAD 66 and Control 62 (HF vs CAD p lt 0001 CAD vs Control p = 0518) The risk-adjusted 30-day readmission rate was HF 200 CAD 142 and Control 110 (p lt 0001) CONCLUSIONS In patients 65 years of age and older HF patients undergoing major noncardiac surgery suffer substantial morbidity and mortality despite advances in perioperative care whereas patients with CAD without HF have similar mortality compared with a more general population

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG

CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-

288

bull il rischio operatorio viene minimizzato dalla ottimizzazione preoperatoria effettuata dal servizio di medicina interna con abbattimento notevole della mortalitagrave e morbilitagrave solo la sopravvivenza ad un anno egrave ridotta rispetto ai pazienti di controllocome egrave logico attendersi in ogni caso in pazienti portatori di malattia cronica seria

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

Postop survival time of HF patients after noncardiac major surgeryYE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M

WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-288

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM

ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

bull Our data suggest that perioperative mortality is surprisingly low (lt2) in patients with clinically stable HFmdash regardless of EFmdashundergoing elective noncardiac surgery

bull At 1 year crude mortality rates for patients with HF with reduced EF (135) or with preserved EF (63) were significantly higher than for controls (31) However we found no evidence to suggest that the immediate postoperative period was associated with a significantly higher risk of death than the subsequent months This raises the possibility that the long-term postoperative mortality rate that we observed in the patients with HF particularly those with low EF represents the background mortality expected in patients with chronic illnesses

bull Our findings contrast with previous studies that have focused on the perioperative outcomes of patients with HF

Perioperative mortality and 30 days readmission rate for patients with HF operated for noncardiac surgery

Preoperative evaluation at the Internal Medicine PreoperativeAssessment Consultation and Treatment (IMPACT)Center at the Cleveland Clinic

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

Hammill et alImpact of heart failure on patients undergoing major noncardiac surgeryAnesthesiology

bull Main outcome ndash Operative mortalityndash 30 days readmission

Hammill et al Impact of heart failure on patients undergoing major noncardiac surgeryAnesthesiology 2008108(4) 559-567

bull I pazienti di etagrave ge65 annibull inseriti nel programma assicurativo statunitense Medicarebull sottoposti tra il 2000 e il 2004 ad uno tra tredici tipi di chirurgia maggiore non-

cardiaca bull esclusi dallrsquoanalisi i pazienti con insufficienza renale terminale e quelli che non

avessero soddisfatto da almeno un anno i criteri Medicarereg per la sottoscrizione di una polizza

bull 159327 interventi 18 eseguiti in pazienti con insufficienza cardiaca e il 34 in pazienti con cardiopatia ischemica

bull I rischi relativi corretti di mortalitagrave e riammissione per i pazienti con insufficienza cardiaca rispetto a quelli che non presentavano neacute insufficienza cardiaca neacute cardiopatia ischemica erano 163 (intervallo confidenza 95 152-174) e 151 (intervallo confidenza 95 145-158) rispettivamente

bull I rischi relativi corretti di mortalitagrave e riammissione per i pazienti con cardiopatia ischemica rispetto a quelli che non presentavano neacute insufficienza cardiaca neacute cardiopatia ischemica erano 108 (intervallo confidenza 95 101-116) e 116 (intervallo confidenza 95 112-120) rispettivamente

Characteristics of the study population by disease group

heart faliure Cad normal

etagrave 794 753 756

Masch i 42 488 344

nerii 85 52 56

teaching hospitali 169 197 163

admitted form a skilled nursing facilityi 15 04 04

urgent admissioni 192 138 145

emergent admissionji 30 19 167

COPDi 451 311 222

CADi 81 100 0

dementiai 91 51 41

diabetesi 434 305 196

histrory of strokei 269 215 114

hypertensioni 864 824 668

periph vascdiseasei 463 363 179

renal diseasei 152 52 27

Operative mortalityHF CAD normal

total 8 31 24

gt Knee amput 258 18 16

ltknee amput 128 104 72

Carotid endarterec tomy 25 12 09

Colon cancer resection 119 63 54

Hip replacement 84 39 28

Knee replacement 09 04 03

Laparoscopic cholecystectomy

56 21 18

Lower extremity bypass 81 37 41

Open AAA repair 103 58 48

Other abdominal cancer resections

118 43 49

Pulmonary cancer resection

102 60 41

Spinal fusion 38 21 13

30 day readmissionHF CAD normal

total 171 108 81

gt Knee amput 252 216 189

ltknee amput 241ns 234ns 199 ns

Carotid endarterectomy 152 108 87

Colon cancer resection 18 132 105

Hip replacement 166 103 88

Knee replacement 99 62 47

Laparoscopic cholecystectomy

164 101 84

Lower extremity bypass 272 182 162

Open AAA repair 148 103 114

Other abdominal cancer resections

173 126 118

Pulmonary cancer resection

174 155 113

Spinal fusion 133 94 77

Effect of heart failure and CAD on mortality per procedure

Operative mortality and readmission rate for HF patients with or without CAD

Conclusion from the study of Hammil et al

bull Heart Failure patients ndashmortality risk 63 ndashReadmission risk 51

Hernandez AF Whellan DJ Stroud S Sun JL OrsquoConnor CM Jollis JGOutcomes in heart failure patients after major noncardiac surgery J

Am Coll Cardiol 200444(7)1446-1453

bull OBJECTIVES The purpose of this study was to evaluate mortality and readmission rates of heart failure (HF) patients after major noncardiac surgery BACKGROUND There is a lack of generalizable outcome data on HF patients undergoing major noncardiac surgery because previous studies have been limited to a few academic centers or have not focused on this group of patients METHODS Using the 1997 to 1998 Standard Analytic File 5 Sample of Medicare beneficiaries we identified patients with HF who underwent major noncardiac surgery A multivariable logistic regression model was used to provide adjusted mortality and readmission rates in patients after noncardiac surgery Patients with coronary artery disease (CAD) and all other remaining patients (Control) who had similar surgery served as reference groups RESULTS Of 23340 HF patients and 28710 CAD patients 1532 (656) HF patients and 1757 (612) CAD patients underwent major noncardiac surgery There were 44512 patients in the Control group with major noncardiac surgery After accounting for demographic characteristics type of surgery and comorbid conditions the risk-adjusted operative mortality (death before discharge or within 30 days of surgery) was HF 117 CAD 66 and Control 62 (HF vs CAD p lt 0001 CAD vs Control p = 0518) The risk-adjusted 30-day readmission rate was HF 200 CAD 142 and Control 110 (p lt 0001) CONCLUSIONS In patients 65 years of age and older HF patients undergoing major noncardiac surgery suffer substantial morbidity and mortality despite advances in perioperative care whereas patients with CAD without HF have similar mortality compared with a more general population

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG

CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-

288

bull il rischio operatorio viene minimizzato dalla ottimizzazione preoperatoria effettuata dal servizio di medicina interna con abbattimento notevole della mortalitagrave e morbilitagrave solo la sopravvivenza ad un anno egrave ridotta rispetto ai pazienti di controllocome egrave logico attendersi in ogni caso in pazienti portatori di malattia cronica seria

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

Postop survival time of HF patients after noncardiac major surgeryYE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M

WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-288

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM

ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

bull Our data suggest that perioperative mortality is surprisingly low (lt2) in patients with clinically stable HFmdash regardless of EFmdashundergoing elective noncardiac surgery

bull At 1 year crude mortality rates for patients with HF with reduced EF (135) or with preserved EF (63) were significantly higher than for controls (31) However we found no evidence to suggest that the immediate postoperative period was associated with a significantly higher risk of death than the subsequent months This raises the possibility that the long-term postoperative mortality rate that we observed in the patients with HF particularly those with low EF represents the background mortality expected in patients with chronic illnesses

bull Our findings contrast with previous studies that have focused on the perioperative outcomes of patients with HF

Perioperative mortality and 30 days readmission rate for patients with HF operated for noncardiac surgery

Preoperative evaluation at the Internal Medicine PreoperativeAssessment Consultation and Treatment (IMPACT)Center at the Cleveland Clinic

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

Hammill et al Impact of heart failure on patients undergoing major noncardiac surgeryAnesthesiology 2008108(4) 559-567

bull I pazienti di etagrave ge65 annibull inseriti nel programma assicurativo statunitense Medicarebull sottoposti tra il 2000 e il 2004 ad uno tra tredici tipi di chirurgia maggiore non-

cardiaca bull esclusi dallrsquoanalisi i pazienti con insufficienza renale terminale e quelli che non

avessero soddisfatto da almeno un anno i criteri Medicarereg per la sottoscrizione di una polizza

bull 159327 interventi 18 eseguiti in pazienti con insufficienza cardiaca e il 34 in pazienti con cardiopatia ischemica

bull I rischi relativi corretti di mortalitagrave e riammissione per i pazienti con insufficienza cardiaca rispetto a quelli che non presentavano neacute insufficienza cardiaca neacute cardiopatia ischemica erano 163 (intervallo confidenza 95 152-174) e 151 (intervallo confidenza 95 145-158) rispettivamente

bull I rischi relativi corretti di mortalitagrave e riammissione per i pazienti con cardiopatia ischemica rispetto a quelli che non presentavano neacute insufficienza cardiaca neacute cardiopatia ischemica erano 108 (intervallo confidenza 95 101-116) e 116 (intervallo confidenza 95 112-120) rispettivamente

Characteristics of the study population by disease group

heart faliure Cad normal

etagrave 794 753 756

Masch i 42 488 344

nerii 85 52 56

teaching hospitali 169 197 163

admitted form a skilled nursing facilityi 15 04 04

urgent admissioni 192 138 145

emergent admissionji 30 19 167

COPDi 451 311 222

CADi 81 100 0

dementiai 91 51 41

diabetesi 434 305 196

histrory of strokei 269 215 114

hypertensioni 864 824 668

periph vascdiseasei 463 363 179

renal diseasei 152 52 27

Operative mortalityHF CAD normal

total 8 31 24

gt Knee amput 258 18 16

ltknee amput 128 104 72

Carotid endarterec tomy 25 12 09

Colon cancer resection 119 63 54

Hip replacement 84 39 28

Knee replacement 09 04 03

Laparoscopic cholecystectomy

56 21 18

Lower extremity bypass 81 37 41

Open AAA repair 103 58 48

Other abdominal cancer resections

118 43 49

Pulmonary cancer resection

102 60 41

Spinal fusion 38 21 13

30 day readmissionHF CAD normal

total 171 108 81

gt Knee amput 252 216 189

ltknee amput 241ns 234ns 199 ns

Carotid endarterectomy 152 108 87

Colon cancer resection 18 132 105

Hip replacement 166 103 88

Knee replacement 99 62 47

Laparoscopic cholecystectomy

164 101 84

Lower extremity bypass 272 182 162

Open AAA repair 148 103 114

Other abdominal cancer resections

173 126 118

Pulmonary cancer resection

174 155 113

Spinal fusion 133 94 77

Effect of heart failure and CAD on mortality per procedure

Operative mortality and readmission rate for HF patients with or without CAD

Conclusion from the study of Hammil et al

bull Heart Failure patients ndashmortality risk 63 ndashReadmission risk 51

Hernandez AF Whellan DJ Stroud S Sun JL OrsquoConnor CM Jollis JGOutcomes in heart failure patients after major noncardiac surgery J

Am Coll Cardiol 200444(7)1446-1453

bull OBJECTIVES The purpose of this study was to evaluate mortality and readmission rates of heart failure (HF) patients after major noncardiac surgery BACKGROUND There is a lack of generalizable outcome data on HF patients undergoing major noncardiac surgery because previous studies have been limited to a few academic centers or have not focused on this group of patients METHODS Using the 1997 to 1998 Standard Analytic File 5 Sample of Medicare beneficiaries we identified patients with HF who underwent major noncardiac surgery A multivariable logistic regression model was used to provide adjusted mortality and readmission rates in patients after noncardiac surgery Patients with coronary artery disease (CAD) and all other remaining patients (Control) who had similar surgery served as reference groups RESULTS Of 23340 HF patients and 28710 CAD patients 1532 (656) HF patients and 1757 (612) CAD patients underwent major noncardiac surgery There were 44512 patients in the Control group with major noncardiac surgery After accounting for demographic characteristics type of surgery and comorbid conditions the risk-adjusted operative mortality (death before discharge or within 30 days of surgery) was HF 117 CAD 66 and Control 62 (HF vs CAD p lt 0001 CAD vs Control p = 0518) The risk-adjusted 30-day readmission rate was HF 200 CAD 142 and Control 110 (p lt 0001) CONCLUSIONS In patients 65 years of age and older HF patients undergoing major noncardiac surgery suffer substantial morbidity and mortality despite advances in perioperative care whereas patients with CAD without HF have similar mortality compared with a more general population

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG

CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-

288

bull il rischio operatorio viene minimizzato dalla ottimizzazione preoperatoria effettuata dal servizio di medicina interna con abbattimento notevole della mortalitagrave e morbilitagrave solo la sopravvivenza ad un anno egrave ridotta rispetto ai pazienti di controllocome egrave logico attendersi in ogni caso in pazienti portatori di malattia cronica seria

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

Postop survival time of HF patients after noncardiac major surgeryYE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M

WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-288

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM

ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

bull Our data suggest that perioperative mortality is surprisingly low (lt2) in patients with clinically stable HFmdash regardless of EFmdashundergoing elective noncardiac surgery

bull At 1 year crude mortality rates for patients with HF with reduced EF (135) or with preserved EF (63) were significantly higher than for controls (31) However we found no evidence to suggest that the immediate postoperative period was associated with a significantly higher risk of death than the subsequent months This raises the possibility that the long-term postoperative mortality rate that we observed in the patients with HF particularly those with low EF represents the background mortality expected in patients with chronic illnesses

bull Our findings contrast with previous studies that have focused on the perioperative outcomes of patients with HF

Perioperative mortality and 30 days readmission rate for patients with HF operated for noncardiac surgery

Preoperative evaluation at the Internal Medicine PreoperativeAssessment Consultation and Treatment (IMPACT)Center at the Cleveland Clinic

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

Characteristics of the study population by disease group

heart faliure Cad normal

etagrave 794 753 756

Masch i 42 488 344

nerii 85 52 56

teaching hospitali 169 197 163

admitted form a skilled nursing facilityi 15 04 04

urgent admissioni 192 138 145

emergent admissionji 30 19 167

COPDi 451 311 222

CADi 81 100 0

dementiai 91 51 41

diabetesi 434 305 196

histrory of strokei 269 215 114

hypertensioni 864 824 668

periph vascdiseasei 463 363 179

renal diseasei 152 52 27

Operative mortalityHF CAD normal

total 8 31 24

gt Knee amput 258 18 16

ltknee amput 128 104 72

Carotid endarterec tomy 25 12 09

Colon cancer resection 119 63 54

Hip replacement 84 39 28

Knee replacement 09 04 03

Laparoscopic cholecystectomy

56 21 18

Lower extremity bypass 81 37 41

Open AAA repair 103 58 48

Other abdominal cancer resections

118 43 49

Pulmonary cancer resection

102 60 41

Spinal fusion 38 21 13

30 day readmissionHF CAD normal

total 171 108 81

gt Knee amput 252 216 189

ltknee amput 241ns 234ns 199 ns

Carotid endarterectomy 152 108 87

Colon cancer resection 18 132 105

Hip replacement 166 103 88

Knee replacement 99 62 47

Laparoscopic cholecystectomy

164 101 84

Lower extremity bypass 272 182 162

Open AAA repair 148 103 114

Other abdominal cancer resections

173 126 118

Pulmonary cancer resection

174 155 113

Spinal fusion 133 94 77

Effect of heart failure and CAD on mortality per procedure

Operative mortality and readmission rate for HF patients with or without CAD

Conclusion from the study of Hammil et al

bull Heart Failure patients ndashmortality risk 63 ndashReadmission risk 51

Hernandez AF Whellan DJ Stroud S Sun JL OrsquoConnor CM Jollis JGOutcomes in heart failure patients after major noncardiac surgery J

Am Coll Cardiol 200444(7)1446-1453

bull OBJECTIVES The purpose of this study was to evaluate mortality and readmission rates of heart failure (HF) patients after major noncardiac surgery BACKGROUND There is a lack of generalizable outcome data on HF patients undergoing major noncardiac surgery because previous studies have been limited to a few academic centers or have not focused on this group of patients METHODS Using the 1997 to 1998 Standard Analytic File 5 Sample of Medicare beneficiaries we identified patients with HF who underwent major noncardiac surgery A multivariable logistic regression model was used to provide adjusted mortality and readmission rates in patients after noncardiac surgery Patients with coronary artery disease (CAD) and all other remaining patients (Control) who had similar surgery served as reference groups RESULTS Of 23340 HF patients and 28710 CAD patients 1532 (656) HF patients and 1757 (612) CAD patients underwent major noncardiac surgery There were 44512 patients in the Control group with major noncardiac surgery After accounting for demographic characteristics type of surgery and comorbid conditions the risk-adjusted operative mortality (death before discharge or within 30 days of surgery) was HF 117 CAD 66 and Control 62 (HF vs CAD p lt 0001 CAD vs Control p = 0518) The risk-adjusted 30-day readmission rate was HF 200 CAD 142 and Control 110 (p lt 0001) CONCLUSIONS In patients 65 years of age and older HF patients undergoing major noncardiac surgery suffer substantial morbidity and mortality despite advances in perioperative care whereas patients with CAD without HF have similar mortality compared with a more general population

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG

CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-

288

bull il rischio operatorio viene minimizzato dalla ottimizzazione preoperatoria effettuata dal servizio di medicina interna con abbattimento notevole della mortalitagrave e morbilitagrave solo la sopravvivenza ad un anno egrave ridotta rispetto ai pazienti di controllocome egrave logico attendersi in ogni caso in pazienti portatori di malattia cronica seria

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

Postop survival time of HF patients after noncardiac major surgeryYE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M

WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-288

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM

ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

bull Our data suggest that perioperative mortality is surprisingly low (lt2) in patients with clinically stable HFmdash regardless of EFmdashundergoing elective noncardiac surgery

bull At 1 year crude mortality rates for patients with HF with reduced EF (135) or with preserved EF (63) were significantly higher than for controls (31) However we found no evidence to suggest that the immediate postoperative period was associated with a significantly higher risk of death than the subsequent months This raises the possibility that the long-term postoperative mortality rate that we observed in the patients with HF particularly those with low EF represents the background mortality expected in patients with chronic illnesses

bull Our findings contrast with previous studies that have focused on the perioperative outcomes of patients with HF

Perioperative mortality and 30 days readmission rate for patients with HF operated for noncardiac surgery

Preoperative evaluation at the Internal Medicine PreoperativeAssessment Consultation and Treatment (IMPACT)Center at the Cleveland Clinic

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

Operative mortalityHF CAD normal

total 8 31 24

gt Knee amput 258 18 16

ltknee amput 128 104 72

Carotid endarterec tomy 25 12 09

Colon cancer resection 119 63 54

Hip replacement 84 39 28

Knee replacement 09 04 03

Laparoscopic cholecystectomy

56 21 18

Lower extremity bypass 81 37 41

Open AAA repair 103 58 48

Other abdominal cancer resections

118 43 49

Pulmonary cancer resection

102 60 41

Spinal fusion 38 21 13

30 day readmissionHF CAD normal

total 171 108 81

gt Knee amput 252 216 189

ltknee amput 241ns 234ns 199 ns

Carotid endarterectomy 152 108 87

Colon cancer resection 18 132 105

Hip replacement 166 103 88

Knee replacement 99 62 47

Laparoscopic cholecystectomy

164 101 84

Lower extremity bypass 272 182 162

Open AAA repair 148 103 114

Other abdominal cancer resections

173 126 118

Pulmonary cancer resection

174 155 113

Spinal fusion 133 94 77

Effect of heart failure and CAD on mortality per procedure

Operative mortality and readmission rate for HF patients with or without CAD

Conclusion from the study of Hammil et al

bull Heart Failure patients ndashmortality risk 63 ndashReadmission risk 51

Hernandez AF Whellan DJ Stroud S Sun JL OrsquoConnor CM Jollis JGOutcomes in heart failure patients after major noncardiac surgery J

Am Coll Cardiol 200444(7)1446-1453

bull OBJECTIVES The purpose of this study was to evaluate mortality and readmission rates of heart failure (HF) patients after major noncardiac surgery BACKGROUND There is a lack of generalizable outcome data on HF patients undergoing major noncardiac surgery because previous studies have been limited to a few academic centers or have not focused on this group of patients METHODS Using the 1997 to 1998 Standard Analytic File 5 Sample of Medicare beneficiaries we identified patients with HF who underwent major noncardiac surgery A multivariable logistic regression model was used to provide adjusted mortality and readmission rates in patients after noncardiac surgery Patients with coronary artery disease (CAD) and all other remaining patients (Control) who had similar surgery served as reference groups RESULTS Of 23340 HF patients and 28710 CAD patients 1532 (656) HF patients and 1757 (612) CAD patients underwent major noncardiac surgery There were 44512 patients in the Control group with major noncardiac surgery After accounting for demographic characteristics type of surgery and comorbid conditions the risk-adjusted operative mortality (death before discharge or within 30 days of surgery) was HF 117 CAD 66 and Control 62 (HF vs CAD p lt 0001 CAD vs Control p = 0518) The risk-adjusted 30-day readmission rate was HF 200 CAD 142 and Control 110 (p lt 0001) CONCLUSIONS In patients 65 years of age and older HF patients undergoing major noncardiac surgery suffer substantial morbidity and mortality despite advances in perioperative care whereas patients with CAD without HF have similar mortality compared with a more general population

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG

CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-

288

bull il rischio operatorio viene minimizzato dalla ottimizzazione preoperatoria effettuata dal servizio di medicina interna con abbattimento notevole della mortalitagrave e morbilitagrave solo la sopravvivenza ad un anno egrave ridotta rispetto ai pazienti di controllocome egrave logico attendersi in ogni caso in pazienti portatori di malattia cronica seria

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

Postop survival time of HF patients after noncardiac major surgeryYE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M

WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-288

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM

ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

bull Our data suggest that perioperative mortality is surprisingly low (lt2) in patients with clinically stable HFmdash regardless of EFmdashundergoing elective noncardiac surgery

bull At 1 year crude mortality rates for patients with HF with reduced EF (135) or with preserved EF (63) were significantly higher than for controls (31) However we found no evidence to suggest that the immediate postoperative period was associated with a significantly higher risk of death than the subsequent months This raises the possibility that the long-term postoperative mortality rate that we observed in the patients with HF particularly those with low EF represents the background mortality expected in patients with chronic illnesses

bull Our findings contrast with previous studies that have focused on the perioperative outcomes of patients with HF

Perioperative mortality and 30 days readmission rate for patients with HF operated for noncardiac surgery

Preoperative evaluation at the Internal Medicine PreoperativeAssessment Consultation and Treatment (IMPACT)Center at the Cleveland Clinic

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

30 day readmissionHF CAD normal

total 171 108 81

gt Knee amput 252 216 189

ltknee amput 241ns 234ns 199 ns

Carotid endarterectomy 152 108 87

Colon cancer resection 18 132 105

Hip replacement 166 103 88

Knee replacement 99 62 47

Laparoscopic cholecystectomy

164 101 84

Lower extremity bypass 272 182 162

Open AAA repair 148 103 114

Other abdominal cancer resections

173 126 118

Pulmonary cancer resection

174 155 113

Spinal fusion 133 94 77

Effect of heart failure and CAD on mortality per procedure

Operative mortality and readmission rate for HF patients with or without CAD

Conclusion from the study of Hammil et al

bull Heart Failure patients ndashmortality risk 63 ndashReadmission risk 51

Hernandez AF Whellan DJ Stroud S Sun JL OrsquoConnor CM Jollis JGOutcomes in heart failure patients after major noncardiac surgery J

Am Coll Cardiol 200444(7)1446-1453

bull OBJECTIVES The purpose of this study was to evaluate mortality and readmission rates of heart failure (HF) patients after major noncardiac surgery BACKGROUND There is a lack of generalizable outcome data on HF patients undergoing major noncardiac surgery because previous studies have been limited to a few academic centers or have not focused on this group of patients METHODS Using the 1997 to 1998 Standard Analytic File 5 Sample of Medicare beneficiaries we identified patients with HF who underwent major noncardiac surgery A multivariable logistic regression model was used to provide adjusted mortality and readmission rates in patients after noncardiac surgery Patients with coronary artery disease (CAD) and all other remaining patients (Control) who had similar surgery served as reference groups RESULTS Of 23340 HF patients and 28710 CAD patients 1532 (656) HF patients and 1757 (612) CAD patients underwent major noncardiac surgery There were 44512 patients in the Control group with major noncardiac surgery After accounting for demographic characteristics type of surgery and comorbid conditions the risk-adjusted operative mortality (death before discharge or within 30 days of surgery) was HF 117 CAD 66 and Control 62 (HF vs CAD p lt 0001 CAD vs Control p = 0518) The risk-adjusted 30-day readmission rate was HF 200 CAD 142 and Control 110 (p lt 0001) CONCLUSIONS In patients 65 years of age and older HF patients undergoing major noncardiac surgery suffer substantial morbidity and mortality despite advances in perioperative care whereas patients with CAD without HF have similar mortality compared with a more general population

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG

CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-

288

bull il rischio operatorio viene minimizzato dalla ottimizzazione preoperatoria effettuata dal servizio di medicina interna con abbattimento notevole della mortalitagrave e morbilitagrave solo la sopravvivenza ad un anno egrave ridotta rispetto ai pazienti di controllocome egrave logico attendersi in ogni caso in pazienti portatori di malattia cronica seria

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

Postop survival time of HF patients after noncardiac major surgeryYE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M

WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-288

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM

ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

bull Our data suggest that perioperative mortality is surprisingly low (lt2) in patients with clinically stable HFmdash regardless of EFmdashundergoing elective noncardiac surgery

bull At 1 year crude mortality rates for patients with HF with reduced EF (135) or with preserved EF (63) were significantly higher than for controls (31) However we found no evidence to suggest that the immediate postoperative period was associated with a significantly higher risk of death than the subsequent months This raises the possibility that the long-term postoperative mortality rate that we observed in the patients with HF particularly those with low EF represents the background mortality expected in patients with chronic illnesses

bull Our findings contrast with previous studies that have focused on the perioperative outcomes of patients with HF

Perioperative mortality and 30 days readmission rate for patients with HF operated for noncardiac surgery

Preoperative evaluation at the Internal Medicine PreoperativeAssessment Consultation and Treatment (IMPACT)Center at the Cleveland Clinic

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

Effect of heart failure and CAD on mortality per procedure

Operative mortality and readmission rate for HF patients with or without CAD

Conclusion from the study of Hammil et al

bull Heart Failure patients ndashmortality risk 63 ndashReadmission risk 51

Hernandez AF Whellan DJ Stroud S Sun JL OrsquoConnor CM Jollis JGOutcomes in heart failure patients after major noncardiac surgery J

Am Coll Cardiol 200444(7)1446-1453

bull OBJECTIVES The purpose of this study was to evaluate mortality and readmission rates of heart failure (HF) patients after major noncardiac surgery BACKGROUND There is a lack of generalizable outcome data on HF patients undergoing major noncardiac surgery because previous studies have been limited to a few academic centers or have not focused on this group of patients METHODS Using the 1997 to 1998 Standard Analytic File 5 Sample of Medicare beneficiaries we identified patients with HF who underwent major noncardiac surgery A multivariable logistic regression model was used to provide adjusted mortality and readmission rates in patients after noncardiac surgery Patients with coronary artery disease (CAD) and all other remaining patients (Control) who had similar surgery served as reference groups RESULTS Of 23340 HF patients and 28710 CAD patients 1532 (656) HF patients and 1757 (612) CAD patients underwent major noncardiac surgery There were 44512 patients in the Control group with major noncardiac surgery After accounting for demographic characteristics type of surgery and comorbid conditions the risk-adjusted operative mortality (death before discharge or within 30 days of surgery) was HF 117 CAD 66 and Control 62 (HF vs CAD p lt 0001 CAD vs Control p = 0518) The risk-adjusted 30-day readmission rate was HF 200 CAD 142 and Control 110 (p lt 0001) CONCLUSIONS In patients 65 years of age and older HF patients undergoing major noncardiac surgery suffer substantial morbidity and mortality despite advances in perioperative care whereas patients with CAD without HF have similar mortality compared with a more general population

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG

CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-

288

bull il rischio operatorio viene minimizzato dalla ottimizzazione preoperatoria effettuata dal servizio di medicina interna con abbattimento notevole della mortalitagrave e morbilitagrave solo la sopravvivenza ad un anno egrave ridotta rispetto ai pazienti di controllocome egrave logico attendersi in ogni caso in pazienti portatori di malattia cronica seria

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

Postop survival time of HF patients after noncardiac major surgeryYE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M

WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-288

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM

ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

bull Our data suggest that perioperative mortality is surprisingly low (lt2) in patients with clinically stable HFmdash regardless of EFmdashundergoing elective noncardiac surgery

bull At 1 year crude mortality rates for patients with HF with reduced EF (135) or with preserved EF (63) were significantly higher than for controls (31) However we found no evidence to suggest that the immediate postoperative period was associated with a significantly higher risk of death than the subsequent months This raises the possibility that the long-term postoperative mortality rate that we observed in the patients with HF particularly those with low EF represents the background mortality expected in patients with chronic illnesses

bull Our findings contrast with previous studies that have focused on the perioperative outcomes of patients with HF

Perioperative mortality and 30 days readmission rate for patients with HF operated for noncardiac surgery

Preoperative evaluation at the Internal Medicine PreoperativeAssessment Consultation and Treatment (IMPACT)Center at the Cleveland Clinic

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

Operative mortality and readmission rate for HF patients with or without CAD

Conclusion from the study of Hammil et al

bull Heart Failure patients ndashmortality risk 63 ndashReadmission risk 51

Hernandez AF Whellan DJ Stroud S Sun JL OrsquoConnor CM Jollis JGOutcomes in heart failure patients after major noncardiac surgery J

Am Coll Cardiol 200444(7)1446-1453

bull OBJECTIVES The purpose of this study was to evaluate mortality and readmission rates of heart failure (HF) patients after major noncardiac surgery BACKGROUND There is a lack of generalizable outcome data on HF patients undergoing major noncardiac surgery because previous studies have been limited to a few academic centers or have not focused on this group of patients METHODS Using the 1997 to 1998 Standard Analytic File 5 Sample of Medicare beneficiaries we identified patients with HF who underwent major noncardiac surgery A multivariable logistic regression model was used to provide adjusted mortality and readmission rates in patients after noncardiac surgery Patients with coronary artery disease (CAD) and all other remaining patients (Control) who had similar surgery served as reference groups RESULTS Of 23340 HF patients and 28710 CAD patients 1532 (656) HF patients and 1757 (612) CAD patients underwent major noncardiac surgery There were 44512 patients in the Control group with major noncardiac surgery After accounting for demographic characteristics type of surgery and comorbid conditions the risk-adjusted operative mortality (death before discharge or within 30 days of surgery) was HF 117 CAD 66 and Control 62 (HF vs CAD p lt 0001 CAD vs Control p = 0518) The risk-adjusted 30-day readmission rate was HF 200 CAD 142 and Control 110 (p lt 0001) CONCLUSIONS In patients 65 years of age and older HF patients undergoing major noncardiac surgery suffer substantial morbidity and mortality despite advances in perioperative care whereas patients with CAD without HF have similar mortality compared with a more general population

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG

CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-

288

bull il rischio operatorio viene minimizzato dalla ottimizzazione preoperatoria effettuata dal servizio di medicina interna con abbattimento notevole della mortalitagrave e morbilitagrave solo la sopravvivenza ad un anno egrave ridotta rispetto ai pazienti di controllocome egrave logico attendersi in ogni caso in pazienti portatori di malattia cronica seria

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

Postop survival time of HF patients after noncardiac major surgeryYE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M

WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-288

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM

ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

bull Our data suggest that perioperative mortality is surprisingly low (lt2) in patients with clinically stable HFmdash regardless of EFmdashundergoing elective noncardiac surgery

bull At 1 year crude mortality rates for patients with HF with reduced EF (135) or with preserved EF (63) were significantly higher than for controls (31) However we found no evidence to suggest that the immediate postoperative period was associated with a significantly higher risk of death than the subsequent months This raises the possibility that the long-term postoperative mortality rate that we observed in the patients with HF particularly those with low EF represents the background mortality expected in patients with chronic illnesses

bull Our findings contrast with previous studies that have focused on the perioperative outcomes of patients with HF

Perioperative mortality and 30 days readmission rate for patients with HF operated for noncardiac surgery

Preoperative evaluation at the Internal Medicine PreoperativeAssessment Consultation and Treatment (IMPACT)Center at the Cleveland Clinic

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

Conclusion from the study of Hammil et al

bull Heart Failure patients ndashmortality risk 63 ndashReadmission risk 51

Hernandez AF Whellan DJ Stroud S Sun JL OrsquoConnor CM Jollis JGOutcomes in heart failure patients after major noncardiac surgery J

Am Coll Cardiol 200444(7)1446-1453

bull OBJECTIVES The purpose of this study was to evaluate mortality and readmission rates of heart failure (HF) patients after major noncardiac surgery BACKGROUND There is a lack of generalizable outcome data on HF patients undergoing major noncardiac surgery because previous studies have been limited to a few academic centers or have not focused on this group of patients METHODS Using the 1997 to 1998 Standard Analytic File 5 Sample of Medicare beneficiaries we identified patients with HF who underwent major noncardiac surgery A multivariable logistic regression model was used to provide adjusted mortality and readmission rates in patients after noncardiac surgery Patients with coronary artery disease (CAD) and all other remaining patients (Control) who had similar surgery served as reference groups RESULTS Of 23340 HF patients and 28710 CAD patients 1532 (656) HF patients and 1757 (612) CAD patients underwent major noncardiac surgery There were 44512 patients in the Control group with major noncardiac surgery After accounting for demographic characteristics type of surgery and comorbid conditions the risk-adjusted operative mortality (death before discharge or within 30 days of surgery) was HF 117 CAD 66 and Control 62 (HF vs CAD p lt 0001 CAD vs Control p = 0518) The risk-adjusted 30-day readmission rate was HF 200 CAD 142 and Control 110 (p lt 0001) CONCLUSIONS In patients 65 years of age and older HF patients undergoing major noncardiac surgery suffer substantial morbidity and mortality despite advances in perioperative care whereas patients with CAD without HF have similar mortality compared with a more general population

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG

CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-

288

bull il rischio operatorio viene minimizzato dalla ottimizzazione preoperatoria effettuata dal servizio di medicina interna con abbattimento notevole della mortalitagrave e morbilitagrave solo la sopravvivenza ad un anno egrave ridotta rispetto ai pazienti di controllocome egrave logico attendersi in ogni caso in pazienti portatori di malattia cronica seria

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

Postop survival time of HF patients after noncardiac major surgeryYE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M

WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-288

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM

ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

bull Our data suggest that perioperative mortality is surprisingly low (lt2) in patients with clinically stable HFmdash regardless of EFmdashundergoing elective noncardiac surgery

bull At 1 year crude mortality rates for patients with HF with reduced EF (135) or with preserved EF (63) were significantly higher than for controls (31) However we found no evidence to suggest that the immediate postoperative period was associated with a significantly higher risk of death than the subsequent months This raises the possibility that the long-term postoperative mortality rate that we observed in the patients with HF particularly those with low EF represents the background mortality expected in patients with chronic illnesses

bull Our findings contrast with previous studies that have focused on the perioperative outcomes of patients with HF

Perioperative mortality and 30 days readmission rate for patients with HF operated for noncardiac surgery

Preoperative evaluation at the Internal Medicine PreoperativeAssessment Consultation and Treatment (IMPACT)Center at the Cleveland Clinic

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

Hernandez AF Whellan DJ Stroud S Sun JL OrsquoConnor CM Jollis JGOutcomes in heart failure patients after major noncardiac surgery J

Am Coll Cardiol 200444(7)1446-1453

bull OBJECTIVES The purpose of this study was to evaluate mortality and readmission rates of heart failure (HF) patients after major noncardiac surgery BACKGROUND There is a lack of generalizable outcome data on HF patients undergoing major noncardiac surgery because previous studies have been limited to a few academic centers or have not focused on this group of patients METHODS Using the 1997 to 1998 Standard Analytic File 5 Sample of Medicare beneficiaries we identified patients with HF who underwent major noncardiac surgery A multivariable logistic regression model was used to provide adjusted mortality and readmission rates in patients after noncardiac surgery Patients with coronary artery disease (CAD) and all other remaining patients (Control) who had similar surgery served as reference groups RESULTS Of 23340 HF patients and 28710 CAD patients 1532 (656) HF patients and 1757 (612) CAD patients underwent major noncardiac surgery There were 44512 patients in the Control group with major noncardiac surgery After accounting for demographic characteristics type of surgery and comorbid conditions the risk-adjusted operative mortality (death before discharge or within 30 days of surgery) was HF 117 CAD 66 and Control 62 (HF vs CAD p lt 0001 CAD vs Control p = 0518) The risk-adjusted 30-day readmission rate was HF 200 CAD 142 and Control 110 (p lt 0001) CONCLUSIONS In patients 65 years of age and older HF patients undergoing major noncardiac surgery suffer substantial morbidity and mortality despite advances in perioperative care whereas patients with CAD without HF have similar mortality compared with a more general population

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG

CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-

288

bull il rischio operatorio viene minimizzato dalla ottimizzazione preoperatoria effettuata dal servizio di medicina interna con abbattimento notevole della mortalitagrave e morbilitagrave solo la sopravvivenza ad un anno egrave ridotta rispetto ai pazienti di controllocome egrave logico attendersi in ogni caso in pazienti portatori di malattia cronica seria

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

Postop survival time of HF patients after noncardiac major surgeryYE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M

WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-288

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM

ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

bull Our data suggest that perioperative mortality is surprisingly low (lt2) in patients with clinically stable HFmdash regardless of EFmdashundergoing elective noncardiac surgery

bull At 1 year crude mortality rates for patients with HF with reduced EF (135) or with preserved EF (63) were significantly higher than for controls (31) However we found no evidence to suggest that the immediate postoperative period was associated with a significantly higher risk of death than the subsequent months This raises the possibility that the long-term postoperative mortality rate that we observed in the patients with HF particularly those with low EF represents the background mortality expected in patients with chronic illnesses

bull Our findings contrast with previous studies that have focused on the perioperative outcomes of patients with HF

Perioperative mortality and 30 days readmission rate for patients with HF operated for noncardiac surgery

Preoperative evaluation at the Internal Medicine PreoperativeAssessment Consultation and Treatment (IMPACT)Center at the Cleveland Clinic

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG

CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-

288

bull il rischio operatorio viene minimizzato dalla ottimizzazione preoperatoria effettuata dal servizio di medicina interna con abbattimento notevole della mortalitagrave e morbilitagrave solo la sopravvivenza ad un anno egrave ridotta rispetto ai pazienti di controllocome egrave logico attendersi in ogni caso in pazienti portatori di malattia cronica seria

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

Postop survival time of HF patients after noncardiac major surgeryYE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M

WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-288

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM

ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

bull Our data suggest that perioperative mortality is surprisingly low (lt2) in patients with clinically stable HFmdash regardless of EFmdashundergoing elective noncardiac surgery

bull At 1 year crude mortality rates for patients with HF with reduced EF (135) or with preserved EF (63) were significantly higher than for controls (31) However we found no evidence to suggest that the immediate postoperative period was associated with a significantly higher risk of death than the subsequent months This raises the possibility that the long-term postoperative mortality rate that we observed in the patients with HF particularly those with low EF represents the background mortality expected in patients with chronic illnesses

bull Our findings contrast with previous studies that have focused on the perioperative outcomes of patients with HF

Perioperative mortality and 30 days readmission rate for patients with HF operated for noncardiac surgery

Preoperative evaluation at the Internal Medicine PreoperativeAssessment Consultation and Treatment (IMPACT)Center at the Cleveland Clinic

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

Postop survival time of HF patients after noncardiac major surgeryYE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M

WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-288

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM

ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

bull Our data suggest that perioperative mortality is surprisingly low (lt2) in patients with clinically stable HFmdash regardless of EFmdashundergoing elective noncardiac surgery

bull At 1 year crude mortality rates for patients with HF with reduced EF (135) or with preserved EF (63) were significantly higher than for controls (31) However we found no evidence to suggest that the immediate postoperative period was associated with a significantly higher risk of death than the subsequent months This raises the possibility that the long-term postoperative mortality rate that we observed in the patients with HF particularly those with low EF represents the background mortality expected in patients with chronic illnesses

bull Our findings contrast with previous studies that have focused on the perioperative outcomes of patients with HF

Perioperative mortality and 30 days readmission rate for patients with HF operated for noncardiac surgery

Preoperative evaluation at the Internal Medicine PreoperativeAssessment Consultation and Treatment (IMPACT)Center at the Cleveland Clinic

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

Postop survival time of HF patients after noncardiac major surgeryYE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M

WHINNEY ASHOK PANNEERSELVAM ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin Proc 200883(3)280-288

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM

ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

bull Our data suggest that perioperative mortality is surprisingly low (lt2) in patients with clinically stable HFmdash regardless of EFmdashundergoing elective noncardiac surgery

bull At 1 year crude mortality rates for patients with HF with reduced EF (135) or with preserved EF (63) were significantly higher than for controls (31) However we found no evidence to suggest that the immediate postoperative period was associated with a significantly higher risk of death than the subsequent months This raises the possibility that the long-term postoperative mortality rate that we observed in the patients with HF particularly those with low EF represents the background mortality expected in patients with chronic illnesses

bull Our findings contrast with previous studies that have focused on the perioperative outcomes of patients with HF

Perioperative mortality and 30 days readmission rate for patients with HF operated for noncardiac surgery

Preoperative evaluation at the Internal Medicine PreoperativeAssessment Consultation and Treatment (IMPACT)Center at the Cleveland Clinic

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

YE OLIVIA XU-CAI DANIEL J BROTMAN CHRISTOPHER O PHILLIPS FRANKLIN A MICHOTAW H WILSON TANG CHRISTOPHER M WHINNEY ASHOK PANNEERSELVAM

ERIC D HIXSONMARIO GARCIA GARY S FRANCIS AMIR K JAFFER Outcomes of Patients With Stable Heart Failure Undergoing Elective Noncardiac SurgeryMayo Clin

Proc 200883(3)280-288

bull Our data suggest that perioperative mortality is surprisingly low (lt2) in patients with clinically stable HFmdash regardless of EFmdashundergoing elective noncardiac surgery

bull At 1 year crude mortality rates for patients with HF with reduced EF (135) or with preserved EF (63) were significantly higher than for controls (31) However we found no evidence to suggest that the immediate postoperative period was associated with a significantly higher risk of death than the subsequent months This raises the possibility that the long-term postoperative mortality rate that we observed in the patients with HF particularly those with low EF represents the background mortality expected in patients with chronic illnesses

bull Our findings contrast with previous studies that have focused on the perioperative outcomes of patients with HF

Perioperative mortality and 30 days readmission rate for patients with HF operated for noncardiac surgery

Preoperative evaluation at the Internal Medicine PreoperativeAssessment Consultation and Treatment (IMPACT)Center at the Cleveland Clinic

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

Perioperative mortality and 30 days readmission rate for patients with HF operated for noncardiac surgery

Preoperative evaluation at the Internal Medicine PreoperativeAssessment Consultation and Treatment (IMPACT)Center at the Cleveland Clinic

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

Unrecognized MI and silent myocardial ischemia

bull Unrecognized MI determined by rest wall motion abnormalities in the absence of a history of MI

bull Silent myocardial ischemia stress-induced wall motion abnormalities in the absence of angina pectoris

bull 23 and 28 respectiverly in pts undergoing major vascular surgeryndash Feringa HH Karagiannis SE Vidakovic R Elhendy A ten Cate FJ Noordzij PG

van Domburg RT Bax JJ Poldermans D The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery Coron Artery Dis 2007 Nov18(7)571-6

N-TERMINAL PRO-BRAIN NATRIURETIC PEPTIDE

ENDOGENOUS NITRIC OXIDE SYNTHASE INHIBITOR ASYMMETRIC DIMETHYLARGININE

POLYMORPHISMS IN PLATELET GLYCOPROTEIN (GP) IIIA AND GPIB[ALPHA]

Laboratory markers for cardiac risk after noncardiac surgery

Laboratory markers for cardiac risk after noncardiac surgery

bull Elevated NT-proBNP levels are independently associated with an increase in the risk of perioperative cardiovascular KOndash Yun KH Jeong MH Oh SK Choi JH Rhee SJ Park EM Yoo NJ Kim NH Ahn YK Jeong JWPreoperative plasma N-terminal pro-brain natriuretic

peptide concentration and perioperative cardiovascular risk in elderly patientsCirc J2008 Feb72(2)195-9

ndash Leibowitz D Planer D Rott D Elitzur Y Chajek-Shaul T Weiss ATBrain natriuretic peptide levels predict perioperative events in cardiac patients undergoing noncardiac surgery a prospective study Cardiology 2008110(4)266-70 Epub 2007 Dec 12

bull per 01-micromolL increment in plasma ADMA concentration the odds ratio to experience the primary end point increased by 126ndash Maas R Dentz L Schwedhelm E Thoms W Kuss O Hiltmeyer N Haddad M Kloumlss T Standl T Boumlger RHElevated plasma concentrations of the

endogenous nitric oxide synthase inhibitor asymmetric dimethylarginine predict adverse events in patients undergoing noncardiac surgery Crit Care Med 2007 Aug35(8)1876-81

bull Polymorphisms in platelet glycoprotein (GP) IIIa and GPIb[alpha] Pro33 and Met145 genotypes were independent predictors of composite ischemic outcome ndash Faraday Nauder Martinez Elizabeth A Scharpf Robert B Kasch-Semenza Laura Dorman Todd Pronovost Peter J

Perler Bruce Gerstenblith Gary Bray Paul F Fleisher Lee A Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297 December 2004

Laboratory markers for cardiac risk after noncardiac surgery

bull Elevated NT-proBNP levels are independently associated with an increase in the risk of perioperative cardiovascular KOndash Yun KH Jeong MH Oh SK Choi JH Rhee SJ Park EM Yoo NJ Kim NH Ahn YK Jeong JWPreoperative plasma N-terminal pro-brain natriuretic

peptide concentration and perioperative cardiovascular risk in elderly patientsCirc J2008 Feb72(2)195-9

ndash Leibowitz D Planer D Rott D Elitzur Y Chajek-Shaul T Weiss ATBrain natriuretic peptide levels predict perioperative events in cardiac patients undergoing noncardiac surgery a prospective study Cardiology 2008110(4)266-70 Epub 2007 Dec 12

bull per 01-micromolL increment in plasma ADMA concentration the odds ratio to experience the primary end point increased by 126ndash Maas R Dentz L Schwedhelm E Thoms W Kuss O Hiltmeyer N Haddad M Kloumlss T Standl T Boumlger RHElevated plasma concentrations of the

endogenous nitric oxide synthase inhibitor asymmetric dimethylarginine predict adverse events in patients undergoing noncardiac surgery Crit Care Med 2007 Aug35(8)1876-81

bull Polymorphisms in platelet glycoprotein (GP) IIIa and GPIb[alpha] Pro33 and Met145 genotypes were independent predictors of composite ischemic outcome ndash Faraday Nauder Martinez Elizabeth A Scharpf Robert B Kasch-Semenza Laura Dorman Todd Pronovost Peter J

Perler Bruce Gerstenblith Gary Bray Paul F Fleisher Lee A Platelet Gene Polymorphisms and Cardiac Risk Assessment in Vascular Surgical Patients Anesthesiology 101(6)1291-1297 December 2004

Mahellipgli eventi avversi emodinamici intraoperatori come vengono raccolti e definiti

bull Esame delle cartelle di anestesia scritte a manohelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

bull raccolta automatica dei datindash Anesth Analg 2004 Mar98(3)569-77The incidence and prediction of automatically detected

intraoperative cardiovascular events in noncardiac surgeryRoumlhrig R Junger A Hartmann B Klasen J Quinzio L Jost A Benson M Hempelmann G

ndash gli eventi cardiovascolari avversi si accompagnavano ad una aumentata mortalitagrave (21 versus 10)

ndash Perograve questi eventi non erano previsti negrave dalla classificazione ASA neacute dallrsquo indice di rischio cardiaco riveduto e corretto Revised Cardiac Risk Index (RCRI)

Levels of Thromboembolism Risk in Surgical Patients Without Prophylaxis

Livelli di rischio tromboembolico in pazienti senza profilassi (Goertz et al 114 AHAACC

DVT PE

Livello di rischio polpaccio

prossimale Evento clinico

fatale Strategia di prevenzione con successo

BassoChir minore in paz lt40 anni senza fattori di rischio

2 04 02 lt001 No profilassideambulazione precoceaggressiva

ModerataChir minore in paz con fattori di rischio aggiuntiviChir in paz 40-60 anni senza fattori di rischio aggiuntivi

10-20 2-4 1-2 02-04

Hep(ogni 12 h)LMWH lt3400GCSIPC

Altachir in pazgt60 a tra 40-60 con fattdi rischio(VTEcancroipercoagulabilitagrave molecolare)

20-40 4-8 2-4 04-1 HEP ogni 8 hLMWHgt3400Ipc

AltissimaChir in paz con fattori di rischio multipliArtroprotesi anca ginocchioFrattura ancaTrauma maggioreTrauma midollare spinale

40-80 10-20 4-10 02-5 LMWHgt3400fondaparinuxVit K antag p os(INR 2-3)IPC o GCS+LMWH o Hep

IPCcpmpressione penumatica intermittente

Hepeparina non frazionata

LMDWeparina a basso peso molecolare

GCScalze a compressione graduale intermittente

bull J Am Coll Surg 2007 Jun204(6)1211-21 Links

bull Multivariable predictors of postoperative venous thromboembolic events after general and vascular surgery results from the patient safety in surgery study

bull Rogers SO Jr Kilaru RK Hosokawa P Henderson WG Zinner MJ Khuri SF

bull Department of Surgery and Center for Surgery and Public Health Brigham and Womens Hospital Boston MA 02115 USA srogerspartnersorg

bull BACKGROUND Venous thromboembolism (VTE) is a potentially preventable postoperative complication Accurate risk prediction is an essential first step toward limiting serious and sometimes fatal postoperative VTE We sought to develop and test a model to predict patients at high risk for postoperative VTE STUDY DESIGN Data from the Patient Safety in Surgery (PSS) Study were used to develop and test a predictive model of VTE using multiple logistic regression analyses RESULTS VTE occurred in 1162 of 183069 (063) patients undergoing vascular and general surgical procedures The 30-day mortality in patients who suffered a VTE was 1119 Fifteen variables independently associated with increased risk of VTE included patient factors (female gender higher American Society of Anesthesiologists class ventilator dependence preoperative dyspnea disseminated cancer chemotherapy within 30 days and gt 4 U packed red blood cell transfusion in the 72 hours before operation) preoperative laboratory values (albumin lt 35 mgdL bilirubin gt 10 mgdL sodium gt 145 mmolL and hematocrit lt 38) and operative characteristics (type of surgical procedure emergency operation work relative value units and infectedcontaminated wounds) These variables were used to develop a predictive model for postoperative VTE (c-index = 07647) and a risk score that can be used in the preoperative assessment of patients undergoing major operations CONCLUSIONS Venous thromboembolic events after noncardiac operations are relatively infrequent but highly lethal Important multivariable risk factors for VTE in this setting were identified in the large PSS database The risk-prediction scoring system developed by using the logistic regression odds ratios helps to identify patients at risk for postoperative VTE and to institute appropriate perioperative prophylactic measures

bull J Oral Maxillofac Surg 2007 Jun65(6)1149-54 Links

bull Oral surgery in patients on anticoagulant treatment without therapy interruption

bull Ferrieri GB Castiglioni S Carmagnola D Cargnel M Strohmenger L Abati S

bull Department of Medicine Universitagrave degli Studi di Milano Milano Italy giovanniferrieriunimiit

bull PURPOSE Conflicting opinions exist in literature concerning the management of oral surgery in patients on oral anticoagulants because no consensus on perioperative protocols is available including precise guidelines regarding the need for therapy modification or withdrawal The aim of this study was to evaluate bleeding complications associated with oral surgery performed on patients on oral anticoagulants without therapy modification or withdrawal but following a standardized comprehensive perioperative management protocol PATIENTS AND METHODS Patients on oral anticoagulant therapy with warfarin and in need of oral surgery underwent a thorough general and oral clinical evaluation to assess thromboembolic and bleeding risk 255 subjects who on the morning of surgery had INR values ltor=55 were included in the study An atraumatic surgical technique was carried out and all patients received postoperative careful instructions RESULTS Five cases (196) of bleeding complication were observed in patients with moderate to high thromboembolic and bleeding risk CONCLUSION The findings from this study suggest that a comprehensive perioperative management protocol for oral surgery in patients on oral anticoagulants including 1) thromboembolic and bleeding risk assessment 2) an atraumatic surgical technique and 3) postoperative careful instructions can lead to safe and successful results with minimal complications

Choice of Anesthetic Technique andAgent

bull Recommendations for Use of Volatile Anesthetic Agents

bull CLASS Iia 1 It can be beneficial to use volatile anesthetic agents during noncardiac surgery for the maintenance of general anesthesia in hemodynamically stable patients at risk for myocardial ischemia (Level of Evidence B)

Livelli di rischio tromboembolico in pazienti senza profilassi (Goertz et al 114 AHAACC

DVT PE

Livello di rischio polpaccio

prossimale Evento clinico

fatale Strategia di prevenzione con successo

BassoChir minore in paz lt40 anni senza fattori di rischio

2 04 02 lt001 No profilassideambulazione precoceaggressiva

ModerataChir minore in paz con fattori di rischio aggiuntiviChir in paz 40-60 anni senza fattori di rischio aggiuntivi

10-20 2-4 1-2 02-04

Hep(ogni 12 h)LMWH lt3400GCSIPC

Altachir in pazgt60 a tra 40-60 con fattdi rischio(VTEcancroipercoagulabilitagrave molecolare)

20-40 4-8 2-4 04-1 HEP ogni 8 hLMWHgt3400Ipc

AltissimaChir in paz con fattori di rischio multipliArtroprotesi anca ginocchioFrattura ancaTrauma maggioreTrauma midollare spinale

40-80 10-20 4-10 02-5 LMWHgt3400fondaparinuxVit K antag p os(INR 2-3)IPC o GCS+LMWH o Hep

IPCcpmpressione penumatica intermittente

Hepeparina non frazionata

LMDWeparina a basso peso molecolare

GCScalze a compressione graduale intermittente

bull J Am Coll Surg 2007 Jun204(6)1211-21 Links

bull Multivariable predictors of postoperative venous thromboembolic events after general and vascular surgery results from the patient safety in surgery study

bull Rogers SO Jr Kilaru RK Hosokawa P Henderson WG Zinner MJ Khuri SF

bull Department of Surgery and Center for Surgery and Public Health Brigham and Womens Hospital Boston MA 02115 USA srogerspartnersorg

bull BACKGROUND Venous thromboembolism (VTE) is a potentially preventable postoperative complication Accurate risk prediction is an essential first step toward limiting serious and sometimes fatal postoperative VTE We sought to develop and test a model to predict patients at high risk for postoperative VTE STUDY DESIGN Data from the Patient Safety in Surgery (PSS) Study were used to develop and test a predictive model of VTE using multiple logistic regression analyses RESULTS VTE occurred in 1162 of 183069 (063) patients undergoing vascular and general surgical procedures The 30-day mortality in patients who suffered a VTE was 1119 Fifteen variables independently associated with increased risk of VTE included patient factors (female gender higher American Society of Anesthesiologists class ventilator dependence preoperative dyspnea disseminated cancer chemotherapy within 30 days and gt 4 U packed red blood cell transfusion in the 72 hours before operation) preoperative laboratory values (albumin lt 35 mgdL bilirubin gt 10 mgdL sodium gt 145 mmolL and hematocrit lt 38) and operative characteristics (type of surgical procedure emergency operation work relative value units and infectedcontaminated wounds) These variables were used to develop a predictive model for postoperative VTE (c-index = 07647) and a risk score that can be used in the preoperative assessment of patients undergoing major operations CONCLUSIONS Venous thromboembolic events after noncardiac operations are relatively infrequent but highly lethal Important multivariable risk factors for VTE in this setting were identified in the large PSS database The risk-prediction scoring system developed by using the logistic regression odds ratios helps to identify patients at risk for postoperative VTE and to institute appropriate perioperative prophylactic measures

bull J Oral Maxillofac Surg 2007 Jun65(6)1149-54 Links

bull Oral surgery in patients on anticoagulant treatment without therapy interruption

bull Ferrieri GB Castiglioni S Carmagnola D Cargnel M Strohmenger L Abati S

bull Department of Medicine Universitagrave degli Studi di Milano Milano Italy giovanniferrieriunimiit

bull PURPOSE Conflicting opinions exist in literature concerning the management of oral surgery in patients on oral anticoagulants because no consensus on perioperative protocols is available including precise guidelines regarding the need for therapy modification or withdrawal The aim of this study was to evaluate bleeding complications associated with oral surgery performed on patients on oral anticoagulants without therapy modification or withdrawal but following a standardized comprehensive perioperative management protocol PATIENTS AND METHODS Patients on oral anticoagulant therapy with warfarin and in need of oral surgery underwent a thorough general and oral clinical evaluation to assess thromboembolic and bleeding risk 255 subjects who on the morning of surgery had INR values ltor=55 were included in the study An atraumatic surgical technique was carried out and all patients received postoperative careful instructions RESULTS Five cases (196) of bleeding complication were observed in patients with moderate to high thromboembolic and bleeding risk CONCLUSION The findings from this study suggest that a comprehensive perioperative management protocol for oral surgery in patients on oral anticoagulants including 1) thromboembolic and bleeding risk assessment 2) an atraumatic surgical technique and 3) postoperative careful instructions can lead to safe and successful results with minimal complications

Choice of Anesthetic Technique andAgent

bull Recommendations for Use of Volatile Anesthetic Agents

bull CLASS Iia 1 It can be beneficial to use volatile anesthetic agents during noncardiac surgery for the maintenance of general anesthesia in hemodynamically stable patients at risk for myocardial ischemia (Level of Evidence B)

bull J Am Coll Surg 2007 Jun204(6)1211-21 Links

bull Multivariable predictors of postoperative venous thromboembolic events after general and vascular surgery results from the patient safety in surgery study

bull Rogers SO Jr Kilaru RK Hosokawa P Henderson WG Zinner MJ Khuri SF

bull Department of Surgery and Center for Surgery and Public Health Brigham and Womens Hospital Boston MA 02115 USA srogerspartnersorg

bull BACKGROUND Venous thromboembolism (VTE) is a potentially preventable postoperative complication Accurate risk prediction is an essential first step toward limiting serious and sometimes fatal postoperative VTE We sought to develop and test a model to predict patients at high risk for postoperative VTE STUDY DESIGN Data from the Patient Safety in Surgery (PSS) Study were used to develop and test a predictive model of VTE using multiple logistic regression analyses RESULTS VTE occurred in 1162 of 183069 (063) patients undergoing vascular and general surgical procedures The 30-day mortality in patients who suffered a VTE was 1119 Fifteen variables independently associated with increased risk of VTE included patient factors (female gender higher American Society of Anesthesiologists class ventilator dependence preoperative dyspnea disseminated cancer chemotherapy within 30 days and gt 4 U packed red blood cell transfusion in the 72 hours before operation) preoperative laboratory values (albumin lt 35 mgdL bilirubin gt 10 mgdL sodium gt 145 mmolL and hematocrit lt 38) and operative characteristics (type of surgical procedure emergency operation work relative value units and infectedcontaminated wounds) These variables were used to develop a predictive model for postoperative VTE (c-index = 07647) and a risk score that can be used in the preoperative assessment of patients undergoing major operations CONCLUSIONS Venous thromboembolic events after noncardiac operations are relatively infrequent but highly lethal Important multivariable risk factors for VTE in this setting were identified in the large PSS database The risk-prediction scoring system developed by using the logistic regression odds ratios helps to identify patients at risk for postoperative VTE and to institute appropriate perioperative prophylactic measures

bull J Oral Maxillofac Surg 2007 Jun65(6)1149-54 Links

bull Oral surgery in patients on anticoagulant treatment without therapy interruption

bull Ferrieri GB Castiglioni S Carmagnola D Cargnel M Strohmenger L Abati S

bull Department of Medicine Universitagrave degli Studi di Milano Milano Italy giovanniferrieriunimiit

bull PURPOSE Conflicting opinions exist in literature concerning the management of oral surgery in patients on oral anticoagulants because no consensus on perioperative protocols is available including precise guidelines regarding the need for therapy modification or withdrawal The aim of this study was to evaluate bleeding complications associated with oral surgery performed on patients on oral anticoagulants without therapy modification or withdrawal but following a standardized comprehensive perioperative management protocol PATIENTS AND METHODS Patients on oral anticoagulant therapy with warfarin and in need of oral surgery underwent a thorough general and oral clinical evaluation to assess thromboembolic and bleeding risk 255 subjects who on the morning of surgery had INR values ltor=55 were included in the study An atraumatic surgical technique was carried out and all patients received postoperative careful instructions RESULTS Five cases (196) of bleeding complication were observed in patients with moderate to high thromboembolic and bleeding risk CONCLUSION The findings from this study suggest that a comprehensive perioperative management protocol for oral surgery in patients on oral anticoagulants including 1) thromboembolic and bleeding risk assessment 2) an atraumatic surgical technique and 3) postoperative careful instructions can lead to safe and successful results with minimal complications

Choice of Anesthetic Technique andAgent

bull Recommendations for Use of Volatile Anesthetic Agents

bull CLASS Iia 1 It can be beneficial to use volatile anesthetic agents during noncardiac surgery for the maintenance of general anesthesia in hemodynamically stable patients at risk for myocardial ischemia (Level of Evidence B)

bull J Oral Maxillofac Surg 2007 Jun65(6)1149-54 Links

bull Oral surgery in patients on anticoagulant treatment without therapy interruption

bull Ferrieri GB Castiglioni S Carmagnola D Cargnel M Strohmenger L Abati S

bull Department of Medicine Universitagrave degli Studi di Milano Milano Italy giovanniferrieriunimiit

bull PURPOSE Conflicting opinions exist in literature concerning the management of oral surgery in patients on oral anticoagulants because no consensus on perioperative protocols is available including precise guidelines regarding the need for therapy modification or withdrawal The aim of this study was to evaluate bleeding complications associated with oral surgery performed on patients on oral anticoagulants without therapy modification or withdrawal but following a standardized comprehensive perioperative management protocol PATIENTS AND METHODS Patients on oral anticoagulant therapy with warfarin and in need of oral surgery underwent a thorough general and oral clinical evaluation to assess thromboembolic and bleeding risk 255 subjects who on the morning of surgery had INR values ltor=55 were included in the study An atraumatic surgical technique was carried out and all patients received postoperative careful instructions RESULTS Five cases (196) of bleeding complication were observed in patients with moderate to high thromboembolic and bleeding risk CONCLUSION The findings from this study suggest that a comprehensive perioperative management protocol for oral surgery in patients on oral anticoagulants including 1) thromboembolic and bleeding risk assessment 2) an atraumatic surgical technique and 3) postoperative careful instructions can lead to safe and successful results with minimal complications

Choice of Anesthetic Technique andAgent

bull Recommendations for Use of Volatile Anesthetic Agents

bull CLASS Iia 1 It can be beneficial to use volatile anesthetic agents during noncardiac surgery for the maintenance of general anesthesia in hemodynamically stable patients at risk for myocardial ischemia (Level of Evidence B)

Choice of Anesthetic Technique andAgent

bull Recommendations for Use of Volatile Anesthetic Agents

bull CLASS Iia 1 It can be beneficial to use volatile anesthetic agents during noncardiac surgery for the maintenance of general anesthesia in hemodynamically stable patients at risk for myocardial ischemia (Level of Evidence B)