Preoperative evaluation of patients with, or at risk of, coronary artery disease undergoing non‐cardiac surgery

• Published in: British journal of anaesthesia : BJA Vol. 89; no. 5; pp. 747 - 759
• Main Authors: Chassot, P.‐G., Delabays, A., Spahn, D. R.
• Format: Journal Article
• Language: English
• Published: Oxford Oxford University Press 01.11.2002; Oxford Publishing Limited (England)
• Subjects: Adrenergic beta-Antagonists - adverse effects; Aged; Algorithms; Anesthesia; Anesthesia depending on patient's condition; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Biological and medical sciences; Cardiology. Vascular system; coronary artery disease; Coronary Disease - complications; Coronary heart disease; Diabetes Complications; Echocardiography, Stress; Electrocardiography - methods; Heart; Humans; Male; Medical sciences; Myocardial Infarction - complications; Myocardial Ischemia - complications; Myocardial Revascularization - adverse effects; non‐cardiac; Predictive Value of Tests; preoperative assessment; Preoperative Care - methods; Risk Assessment; Risk Factors; surgery; Surgical Procedures, Operative; Vascular Surgical Procedures - adverse effects; heart, coronary artery disease; surgery, non‐cardiac; surgery, preoperative assessment; Human; Evaluation; Surgery; surgery, preoperative assessment; Cardiovascular disease; Review; Preoperative; heart, coronary artery disease; surgery, non-cardiac; Balance; Coronary heart disease
• ISSN: 0007-0912; 1471-6771
• DOI: 10.1093/bja/89.5.747

The increasing number of patients with coronary artery disease undergoing major non‐cardiac surgery justifies guidelines concerning preoperative evaluation, stress testing, coronary angiography, and revascularization. A review of the recent literature shows that stress testing should be limited to patients with suspicion of a myocardium at risk of ischaemia, and coronary angiography to situations where revascularization can improve long‐term survival. Recent data have shown that any event in the coronary circulation, be it new ischaemia, infarction, or revascularization, induces a high‐risk period of 6 weeks, and an intermediate‐risk period of 3 months. A 3‐month minimum delay is therefore indicated before performing non‐cardiac surgery after myocardial infarction or revascularization. However, this delay may be too long if an urgent surgical procedure is requested, as for instance with rapidly spreading tumours, impending aneurysm rupture, infections requiring drainage, or bone fractures. It is then appropriate to use perioperative beta‐block, which reduces the cardiac complication rate in patients with, or at risk of, coronary artery disease. The objective of this review is to offer a comprehensive algorithm to help clinicians in the preoperative assessment of patients undergoing non‐cardiac surgery. Br J Anaesth 2002; 89: 747–59