Outcomes/Effectiveness Research

Both invasive and noninvasive strategies can reduce the cardiac risks of noncardiac surgery

Strategies to reduce the cardiac risks of noncardiac surgery during hospitalization are important, given that 50,000 patients a year have a heart attack related to noncardiac surgery. Invasive strategies, such as prophylactic coronary artery bypass graft surgery and angioplasty, and noninvasive strategies, such as use of beta-blockers, alpha-antagonists, and statins, may reduce preoperative cardiac risk for patients undergoing noncardiac surgery. However, they are not without their controversies, concludes a review of strategies by Steven L. Cohn, M.D., F.A.C.P. of the State University of New York, and Andrew D. Auerbach, M.D., M.P.H., of the University of California, San Francisco.

The researchers make several recommendations to classify the preoperative cardiac risk of patients undergoing noncardiac surgery. First, evaluate patients for new or unstable cardiopulmonary symptoms that would prompt evaluation in the absence of potential surgery. In some cases, delay in surgery may be appropriate. In other cases, surgery can be done, but with close attention to postoperative monitoring or use of cardioprotective agents.

If there are no new symptoms, clinicians can proceed to use a clinical risk stratification rule. Low-risk patients can proceed to surgery with no need for beta- blockers or additional noninvasive stress testing. Moderate-risk patients may have to have their functional status and current level of angina symptoms or limb pain and weakness (claudication) assessed.

Moderate-risk patients with a history of angina or claudication and poor functional status should be considered for noninvasive stress testing. Those with good functional status do not require additional testing and should receive beta-blockers around the time of surgery.

High-risk patients (three or more revised cardiac risk index criteria) should probably have noninvasive stress testing prior to surgery and should be targeted for beta-blocker therapy. A positive stress test should be interpreted with caution before pursuing revascularization. Normal noninvasive tests should be reassuring, even for patients with a high-risk clinical profile.

The study was supported by the Agency for Healthcare Research and Quality (HS11416).

More details are in "Preoperative cardiac risk stratification 2007: Evolving evidence, evolving strategies," by Drs. Cohn and Auerbach, in the May 2007 Journal of Hospital Medicine 2(3), pp. 174-180.

Editor's Note: A related AHRQ-supported study (HS10888) found that four acute heart failure clinical prediction rules varied in their ability to predict short-term death or serious outcomes among patients hospitalized for heart failure. More details are in: Auble, T.E., Hsieh, M., McCausland, J.B., and Yealy, D.M. "Comparison of four clinical prediction rules for estimating risk in heart failure." (2007, August). Annals of Emergency Medicine 50, pp. 127-135.

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