Full text of DOI:10.1007/s12019-001-0007-3

O R I G I N A L A R T I C L E
Strategies for perioperative risk assessment in
patients undergoing noncardiac surgery vary among
physicians and are aimed to estimate the risk and
minimize complications. We propose simplistic guide-
lines for assessing and modifying risk for patients
undergoing a wide variety of procedures.
I N T R O D U C T I O N
Surgical procedures may be complicated by cardio-
vascular disease, which is often clinically occult
prior to surgery. Thus, coronary artery disease
(CAD) accounts for most deaths in patients undergo-
ing noncardiac surgery.1 Strategies for perioperative
risk assessment are designed to estimate the risk and
minimize complications in a rational fashion.
Approximately, 5% of the elderly population in US
undergo noncardiac surgery each year, and about
one-third of these are at risk for CAD with estimated
in-hospital and long-term complications occurring in
1.5 million patients.1,2 A wide variability exists in
regards to the physician’s approach to preoperative
risk assessment for cardiac events in patients under-
going noncardiac surgery. This article reviews the
available literature and provides simplistic guide-
lines for assessing and modifying risk for patients
undergoing a wide variety of surgical procedures.
Cardiac Risk
Assessment
for Noncardiac
Surgery:
Current Concepts
AMAN CHUGH, MD
EDUARDO BOSSONE, MD
RAJENDRA H. MEHTA, MD
Division of Cardiology
University of Michigan, and
Ann Arbor Veterans Affairs Health System
Ann Arbor, Mich
P E R I O P E R A T I V E R I S K O F E V E N T S
A large number of surgical procedures (including
high-risk procedures) are performed in the elderly
population, which has been increasing steadily.1
While patients with no prior history of myocardial
infarction (MI) have low risk of perioperative MI
(0.1%–0.6%), those with a history of prior MI are at
a significantly higher risk (2.8%–7%).3-6 Occurrence
of MI within 3 months increases the risk of a peri-
operative cardiac event to 37%, MI within 3-6
months to 16%, and 4% in patients ≥ 6 months past
their MI.5 More recent data suggests a lower risk
than reported earlier, but still elevated above nor-
mal in patients with recent MI. The majority of
perioperative MIs are known to occur in the first
three days with peak incidence on day two.4,6 Most
lack the classic presentation with chest pain, but
rather have an atypical presentation such as new
REPRINTS
Rajendra H. Mehta, MD, Clinical Assistant Professor of Internal Medicine, Divi-
sion of Cardiology, 7E 111A, Ann Arbor VA Medical Center, 2215 Fuller Road,
Ann Arbor, MI 48105 USA
Submitted for publication: November 16, 1999. Accepted: January 18, 2000.
COMP THER. 2001;27(1):47–55
47

onset congestive heart failure (CHF), hypotension,
arrhythmias, nausea, or altered mental status. Peri-
operative MI is associated with high mortality rang-
ing from 26%–70%.1-7 Therefore, it is imperative to
identify those patients at risk for untoward out-
comes after surgery by using a systematic stepwise
strategic preoperative evaluation, using guidelines
such as those of the ACC/AHA task force.7-10
artery bypass surgery (CABG) in past 5 years or per-
cutaneus transluminal coronary angioplasty (PTCA)
in past 6 months to 5 years and who are functional-
ly active and free of clinical evidence of ischemia in
the interim, have a very low likelihood of perioper-
ative cardiac events.8-11 Such patients may proceed
to surgery without further cardiac testing.
Has the Patient Been Evaluated for CAD in
the Past Two Years? In patients who have been
evaluated in the past two years with either invasive
or noninvasive techniques with favorable findings,
no further cardiac work-up is generally necessary,
assuming they have been free of cardiac symptoms
after the test. Patients with changing symptoms
and/or signs of ischemia should be considered for
further evaluation.8-10
A S T E P W I S E A P P R O A C H F O R
P E R I O P E R A T I V E R I S K A S S E S S M E N T
O F A P A T I E N T U N D E R G O I N G
N O N C A R D I A C S U R G E R Y
The following questions need to be asked for assessing
risk for patients undergoing noncardiac surgery:8-10
1. What is the urgency of the surgery?
2. Has prior revascularization been performed
in the patient?
3. Has the patient been evaluated for CAD in
the past 2 years?
4. What clinical risk factors are present?
5. What is the patient’s functional capacity?
6. What is the probability of cardiac complica-
tions for a patient based on the type of
surgery and the institutional experience?
7. Is stress testing or other diagnostic procedure
necessary?
8. Do the benefits of operation outweigh the
probability of cardiac complications after
surgery?
9. What is needed to reduce the probability of
cardiac complications after surgery in terms
of modifying preoperative, intraoperative,
and postoperative care?
What Clinical Risk Factors Are Present? Base-
line history, physical examination, and electrocar-
diogram (ECG) provide sufficient data to estimate
cardiac risk. Table 1 lists clinical predictors of
adverse cardiac outcomes based on the work of sev-
eral authors.9,12-14 Prior studies have combined vari-
ous clinical features associated with poor prognosis
into composite scores to help quantitate the risk of
postoperative events.14,15 More recent studies have
used more simplistic algorithms.8,16 If a patient has a
major clinical predictor as listed in Table 1, and is
scheduled for an elective surgery, it is best to post-
pone surgery until the cardiac problem is clarified
(sometimes by coronary arteriography) and treated
appropriately.7-10 Patients with moderate or excel-
lent functional capacity and one or more intermedi-
ate predictors of clinical risk can undergo low and
intermediate risk surgery (Table 2) with low periop-
erative event rates. On the other hand, patients
with poor functional capacity or a combination of
high-risk surgery and moderate functional capacity
and intermediate predictors of cardiac risk (especial-
ly if two or more) should be evaluated by further
noninvasive cardiac testing. Patient with minor or
no clinical predictors of risk and with moderate or
excellent functional capacity (≥ 4-6 metabolic equiv-
alents) can generally safely undergo most noncar-
diac surgeries.8-10
10. What long-term risk stratification and man-
agement strategies should be implemented?
What is the Urgency of Noncardiac Surgery?
The urgency of surgery is dictated by patient- or
surgery-specific factors, and in such instances, there
may not be time for further cardiac assessment.
Efforts should then be focused to help minimize
perioperative cardiovascular risk by perioperative
surveillance (daily electrocardiograms, hemodynam-
ic monitoring and cardiac enzyme measurements) in
selected unstable patients and by aggressive periop-
erative medical management that includes the use
of β-adrenergic blocking drugs to reduce heart rate
to between 50 and 60 beats/minute. Selected
patients, at high risk of long-term coronary events,
should undergo risk stratification after their com-
plete recovery from surgery.8-10
What is the Patient’s Functional Capacity?
Functional status reliably predicts future cardiac
events17 and should be assessed by history in all pre-
operative patients. Functional capacity is usually
expressed as metabolic equivalent (MET) levels; one
MET being equivalent to the oxygen consumption
(VO2) of a 70 kg, 40-year old man in a resting state
(= 3.5 mL/kg/min). Functional capacity may be clas-
sified as excellent (> 7 METs), moderate (4 to 7
METs), poor (< 4 METs) or unknown. Table 3 repre-
Has Prior Revascularization Been Performed
in the Patient? Patients, who have undergone
complete revascularization in the form of coronary
48
COMP THER. 2001;27(1)

TABLE 1
TABLE 2
Clinical Predictors of Increased Perioperative
Cardiavascular Risk (Myocardial Infarction,
Congestive Heart Failure, Death)9,14,15
Surgery Specific Cardiac Risk (Combined Risk of
Cardiac Death and Non-Fatal MI)9,14,16,20,22
High (Reported cardiac risk often > 5%)
Major
• Emergent major operation particularly in
elderly
• Aortic and other major vascular
• Peripheral vascular
• Anticipated prolonged surgical procedures
associated with large fluid shifts and/or
blood loss
• Unstable or severe angina (Canadian Class
III or IV)
• Recent myocardial infarction (> 7 days but
≤ 30 days) with evidence of important
ischemic risk by clinical symptoms or non-
invasive testing.
• Decompensated congestive heart failure.
Intermediate (Reported cardiac risk
generally < 5%)
• Symptomatic arrhythmias including high
grade atrioventricular block, symptomatic
ventricular arrhythmia in presence of
underlying heart disease and supraventricu-
lar arrhythmias with uncontrolled ventricu-
lar rate.
• Carotid endarterectomy
• Head and neck
• Intraperitoneal and intrathoracic
• Orthopedic
Intermediate
• Prostate
• Mild angina (Canadian Class I and II)
Low (Reported cardiac risk generally < 1%)
• Endoscopic procedures
• Superficial procedures
• Cataract
• Prior myocardial infarction by history or
ECG
• Compensated or prior congestive
heart failure
• Diabetes mellitus
• Breast
Minor
• Advanced age
• Abnormal ECG (left ventricular hypertrophy,
left bundle branch block, ST-T abnormalities)
TABLE 3
Functional Capacity Assessment from Clinical History8-10,18,19
• Rhythm other than sinus (e.g., atrial
fibrillation)
• Low functional capacity
• History of stroke
Excellent (Activities requiring > 7 METs)
• Carry 24 lb up 8 steps
• Carry objects that weigh 80 lb
• Outdoor work (shovel snow, spade soil)
• Uncontrolled systemic hypertension.
• Recreation (ski, basketball, squash, hand-
ball, jog/walk 5 mph)
sents a sample of activities that characterizes each
functional class.8,18,19 Poor functional capacity is a
marker for increased perioperative cardiac and long-
term events. These patients should be considered for
noninvasive cardiac risk assessment before elective
cardiac surgery depending on the type of surgery
and presence of clinical risk predictors, as discussed
above. Patients with moderate or excellent function-
al capacity and low clinical predictors of risks or
patients with combination of intermediate predictors
of cardiac risk, low or intermediate risk surgery,
combined with preserved functional capacity can
generally proceed to elective surgery without under-
going further cardiac work-up. Patients with inter-
mediate predictors of clinical risk facing high-risk
Moderate (Activity requiring > 4 METs but
< 7 METs)
• Have sexual intercourse without stopping
• Walk at 4 mph on level ground
• Outdoor work (garden, rake, weed)
• Recreation (roller skate, dance, fox trot)
Poor (Activity requiring < 4 METs)
• Shower/dress without stopping, strip and
make bed, dusting, dish washing
• Walk at 2.5 mph on level ground
• Outdoor work (clean windows)
• Recreation (play golf, bowl)
COMP THER. 2001;27(1)
49

surgery should be considered for noninvasive car-
diac evaluation risk preoperatively.8-10
patients to exercise secondary to their diseases or
comorbidities limits the widespread use of exercise
ECG in all patients.
What is the Probability of Cardiac Complica-
tions for a Patient Based on the Type of
Surgery and the Institutional Experience? The
specific type of surgery determines the probability of
cardiac complications.4,5,9,14,16,20 Surgical procedures
are classified as high, intermediate or low risk as
outlined in Table 2.9 Emergency surgery is associat-
ed with a four- to five-fold increase in risk compared
to elective surgery.14 In addition, patients undergo-
ing aortic, peripheral and other major vascular surg-
eries or operations associated with large fluid shifts
and/or blood loss have relatively high probability
(nearly two- to three-fold increase) of cardiac compli-
cations. Risk classification of various surgeries
should be considered along with the predictors of
clinical risk and functional capacity in properly risk
stratifying patients prior to noncardiac surgery.8-10
Is Stress Testing or Other Diagnostic Proce-
dures Necessary? Simple strategies for preopera-
tive noninvasive testing, proposed by Eagle and his
colleagues and other investigators, have been reiter-
ated in current ACC/AHA task force recommenda-
tions.8,9,16 Patients classified as low clinical risk
generally do not need any risk stratification. Those
with major predictors of high clinical risk have a
high probability of left main or triple vessel CAD
and deserve consideration for a more aggressive
approach, including, in selected patients, preopera-
tive coronary angiography and coronary revascular-
ization. The intermediate clinical risk group
warrants noninvasive testing.21 Noninvasive testing
is aimed at identifying the degree of ischemic bur-
den, inducible arrhythmias, as well as the function-
al capacity of a patient.
Current Evidence for Diagnostic Testing in
Perioperative Risk Assessment. Exercise electro-
cardiogram. The role of exercise stress testing in
preoperative assessment has been validated in
numerous studies.22-29 McPhail et al.29 reported
using preoperative exercise testing in 100 patients
undergoing vascular surgery. The highest cardiac
complication rate (33%) was evident in patients
with exercise-induced ischemia and low workload.
Cutler et al.24 documented that the ability to attain
75%–85% of their maximal predicted heart rate
(MPHR) (high workload) is predictive of a low peri-
operative cardiac event rate. Poor functional capaci-
ty associated with ischemia identifies patients at
high risk for perioperative cardiac events.30
Ischemia in patients with excellent functional
capacity appears to confer a small increase in risk.8
Baseline ECG abnormalities and/or inability of
Pharmacological stress test and myocardial perfusion
imaging. The utility of preoperative dipyridamole-
thallium imaging for risk stratification was first
defined by Boucher et al.31 and since been validated
in numerous studies.16,32-37 The positive predictive
value has been consistently low, between 4% and
20%. This is attributed in part to the fact that stress
testing results are now utilized for risk modification
in the form of preoperative coronary revasculariza-
tion, adjustment of medical management, aggres-
sive monitoring, selection of a different surgical or
anesthetic approach and for certain patients, can-
cellation of elective surgery.8-10 On the other hand
most studies have reported a consistently high neg-
ative predictive value, at or above 95% for this
technique. Presence of thallium redistribution,
especially in increasing numbers of segments, iden-
tifies patients at high risk of perioperative cardiac
complications,32,36 whereas fixed defects identifies
patients at intermediate risk, particularly for late
cardiac events.35
Dobutamine stress echocardiography. Dobutamine
stress echocardiography has been less extensively
studied as compared to dipyridamole-thallium.
Available data support its utility and safety with
acceptable patient tolerance.36-40 The degree of wall
motion abnormality and/or wall motion change at
low infusion rates of dobutamine identified high-risk
patients. The positive predictive and negative predic-
tive values for unambiguous endpoints (MI and
death) were comparable to that of dipyridamole-thal-
lium at 7% to 23% and 93% to 100%, respectively.
Ambulatory electrocardiographic monitoring. Studies
using preoperative ambulatory ECG monitoring have
demonstrated a negative predictive value similar to
that of dipyridamole thallium.41-44 However, current
evidence does not support its sole use to identify
patients to be referred for coronary angiography.9
Coronary angiography in perioperative evaluation for
patients undergoing noncardiac surgery. Coronary
angiography should be performed in patients who
have unstable angina, angina refractory to medical
treatment, high-risk results on noninvasive testing
and/or a nondiagnostic test in high-risk patients
undergoing high-risk noncardiac surgery. It should
be considered on an individual basis in patients
with intermediate-risk results during noninvasive
testing, a nondiagnostic test in a low-risk patient
undergoing high-risk surgery, urgent noncardiac
surgery in a patient convalescing from MI and in
patients who sustain a perioperative MI.8,45
50
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Do the Benefits of Operation Outweigh the
Probability of Cardiac Complications After
Surgery? All information obtained from such a sys-
tematic stepwise approach for preoperative cardiac
risk assessment for noncardiac surgery should then
be utilized to decide whether the risk of periopera-
tive cardiac events is sufficiently low to proceed
with surgery. For patients identified at high cardiac
risk who are not coronary revascularization candi-
dates, this may result in a decision to perform a less
extensive procedure or cancel the surgery. Once a
decision is made to proceed with noncardiac
surgery, the next goal is to attempt to modify car-
diac risk by additional therapies, including coronary
revascularization in high-risk individuals. The peri-
operative complication rate of revascularization
must be carefully weighed against the risk of car-
diac complications in such individuals.8-10
Role of preoperative coronary angioplasty. To our
knowledge, no randomized trial has addressed peri-
operative cardiac risk reduction following preopera-
tive PTCA. Based on retrospective series with small
numbers of patient, a select group of symptomatic
patients facing high-risk surgery may benefit from
preoperative PTCA.51-53 The noncardiac surgery
should probably be timed several days after PTCA
as arterial recoil and acute thrombosis may occur
within first few days and hypercoaguability may
increase the risk of thrombosis. On the other hand,
delaying surgery beyond one or two months follow-
ing PTCA may increase the risk because of the pos-
sibility of restenosis. However, since the incidence
of coronary restenosis is reduced beyond 6 months,
patients who are asymptomatic and physically very
active between 6 months to 5 years do not generally
require further preoperative risk assessment before
noncardiac surgery.8-10
What Is Needed To Reduce the Probability
of Cardiac Complications After Surgery in
Terms of Modifying Preoperative, Intraopera-
tive, and Postoperative Care? Role of preoperative
coronary artery bypass surgery. Retrospective studies
have suggested protection against postoperative car-
diac complications and improved 5-year survival
after noncardiac surgery in patient who have had
prior CABG.12,13,46-48 Eagle et al.49 reexamined the
value of CABG on patients undergoing specific non-
cardiac surgery among the patients enrolled in the
CASS registry. Nonrevascularized patients undergo-
ing high-risk surgery, including abdominal, vascu-
lar, thoracic, and head and neck procedures each
had a combined MI/death rate of greater than 4%.
Prior CABG was associated with a reduced inci-
dence of postoperative death (1.7% versus 3.3%, P
= .03) and MI (0.8% versus 2.7%, P = .002) as
compared with the medical treatment group.
Patients undergoing low risk procedures, such as
urologic, orthopedic, breast and skin operations had
low mortality of less than 1% regardless of prior
revascularization. Prior CABG was also found to be
more protective in patients with more severe angi-
na and/or multivessel CAD.49
Patients with prior CABG usually require no fur-
ther preoperative testing unless they have devel-
oped new coronary symptoms or are beyond 5
years of their CABG.6-8 Indications for prior CABG
in patients requiring noncardiac surgery includes
acceptable coronary revascularization risk and
viable myocardium with left main CAD, triple-ves-
sel CAD in conjunction with left ventricular dys-
function, two-vessel CAD with proximal left
anterior descending stenosis, and angina refractory
to maximal medical management.50
Role of medical therapy. Small studies have evalu-
ated the use of perioperative β-adrenergic blocking
drugs in reducing cardiac risk.54-56 Stone et al.54 gave
oral β-blockers two hours before the induction of
anesthesia in a small randomized trial of patients
with mild hypertension. The control group had
higher incidence of ischemia as compared with
treatment group (28% versus 2%). Similarly, the
incidence of perioperative ischemia and MI has
been shown to be reduced by metoprolol.55,56 More
recently, Mangano et al.57 showed that vascular
surgery patients randomized to atenolol versus
placebo had a reduced cardiac event rate over the
first year or two after surgery. Many consider this
the strongest evidence yet favoring perioperative
use of β-blockers. It should be noted that, an accom-
panying editorial58 identified several concerns about
the baseline differences between the atenolol and
placebo groups. Finally, Froehlich et al.59 recently
reported protection against cardiac death after vas-
cular surgery in patients treated with β-blockers in
a large observational study.59 Thus, in patients with
strong suspicion for CAD, β-blockers should be
given in perioperative period starting at least 24
hours prior to the procedure. Few data exist to sup-
port the use of calcium channel blockers or nitro-
glycerin. Currently, these are recommended for
high-risk patients previously on such drugs or for
those who have active signs of myocardial ischemia
without hypotension.9
Choice of anesthetic drugs. The choice of anesthetic
has not been found to play a significant role in the
development of postoperative cardiac complica-
tions.60-63 Because general anesthetics have a negative
inotropic action, spinal anesthesia may be preferred
COMP THER. 2001;27(1)
51

N O N C A R D I A C S U R G E R Y I N
P A T I E N T S W I T H S P E C I F I C
C A R D I O V A S C U L A R D I S E A S E
for patients with severe left ventricular dysfunction
or history of CHF. Pain management in the perioper-
ative period is crucial towards reducing cardiac risk.
Adequate pain control reduces catecholamine surges
which are likely responsible for increasing myocar-
dial oxygen demand, induction of coronary
vasospasm, increasing the tendency for plaque rup-
ture and development of a hypercoaguable state.
Role of intraoperative monitoring. Pulmonary artery
catheters are indicated for patients with limited
ventricular reserve undergoing procedures that are
likely to cause major hemodynamic shifts.64 There
is little data to recommend their use for the purpos-
es of monitoring for ischemia.9 The routine use of
intraoperative transesophageal echocardiography is
not recommended to monitor and guide therapy
during noncardiac surgery because of lack of robust
data. Literature supporting intraoperative ST-seg-
ment monitoring via telemetry or ambulatory moni-
toring in high-risk patients is limited.
Monitoring for perioperative myocardial infarction.
Few studies have examined the optimal strategy for
the diagnosis of perioperative MI.65 A protocol using
an ECG immediately after surgery and on first and
second postoperative days has highest sensitivity;
whereas routine measurements of serial creatine
kinase-MB (CK-MB) had a higher false positive rate
and does not increase the sensitivity. Higher levels
of CK-MB elevation have been associated with
worse survival.66 Current recommendations favor
monitoring for signs of cardiac dysfunction in
patients with evidence of CAD. In such patients
undergoing surgical procedures associated with high
cardiac risk, ECG at baseline, immediately after
surgery and on the first two postoperative days
should be performed. Measurement of cardiac
enzymes (CK-MB and Traponin) should be reserved
for patients at high risk or those who demonstrate
clinical, ECG or hemodynamic evidence of cardio-
vascular dysfunction.8
Valvular Heart Disease. Severe aortic stenosis
(AS) poses a high risk during noncardiac surgery.14
Patients with severe symptomatic AS should under-
go aortic valve replacement before noncardiac
surgery. In some instances balloon aortic valvulo-
plasty is justified before elective noncardiac surgery.
A retrospective study suggests that selected patients
with asymptomatic severe AS could safely undergo
noncardiac surgery provided hemodynamics were
carefully monitored.67 Heart rate should be con-
trolled to ensure sufficient diastolic filling period
and avoid pulmonary congestion in patients with
mild to moderate mitral stenosis. Patients with
severe mitral stenosis benefit from balloon mitral
valvuloplasty or surgical repair before high-risk
surgery. Patients with aortic and mitral regurgitation
benefit from volume control and afterload reduc-
tion. A slow heart rate increases diastolic filling per
minute and can exacerbate left ventricular volume
overload owing to aortic regurgitation. Faster heart
rates are better tolerated in this condition.
Patients with mechanical prostheses should have
their prothrombin times reduced briefly to low or
subtherapeutic range for minor procedures like den-
tal work and superficial biopsies, and resume their
anticoagulation immediately following the proce-
dure. Patients at high risk of bleeding taking oral
anticoagulants and at high risk of thrombotic com-
plications if taken off oral anticoagulants should
receive perioperative heparin. Between these two
extremes, individual assessment for the risk and
benefit of reduced coumadin anticoagulation versus
perioperative heparin (with brief interruption sur-
rounding surgery) should be made. Patients with
valvular heart disease require appropriate antibiotic
prophylaxis for endocarditis.
Arrhythmias and Conduction Defect. Cardiac
arrhythmias in the perioperative period are com-
mon, and are usually indicative of underlying car-
diopulmonary disease, drug toxicity, or metabolic
disturbances.14 Third degree atrioventricular block
can increase operative risk and necessitates pacing.9
Congestive Heart Failure and Left Ventricu-
lar Dysfunction. Congestive heart failure has been
identified as significant marker of cardiac risk for
noncardiac surgery.68 Every effort should be made
to identify the etiology of CHF. Patients should be
appropriately treated for CHF before noncardiac
surgery. Close monitoring of the volume status is
needed to avoid decompensation. Intravenous
inotropic drugs and/or vasodilators are often useful
What Long-Term Risk Stratification and
Management Strategies Should Be Implement-
ed? Postoperative care involves assessment and
treatment of modifiable cardiac risk factors, includ-
ing hypertension, hyperlipidemia, smoking, obesi-
ty, hyperglycemia, and physical inactivity. Patients
who sustain a perioperative MI or develop evi-
dence of ischemia should be carefully investigated
as they have substantial cardiac risk over the sub-
sequent 5 to 10 years. Noninvasive testing to assess
left ventricular function and inducible ischemia
should be undertaken to identify patients who may
benefit from revascularization or optimization of
medical therapy.8-10
52
COMP THER. 2001;27(1)

for a short duration in the perioperative period in
the prevention and treatment of CHF.
appropriate prophylaxis for bacterial endocarditis. A
recent retrospective report suggests that careful
monitoring and precautions as outlined earlier,
patients with right-to-left shunt could undergo non-
cardiac surgery with fewer complications.75 CT
Hypertrophic Cardiomyopathy. A decreased
preload (large amount of blood or fluid loss or pain-
induced tachycardia that reduces diastolic filling),
reduced afterload or increase in contractility
(caused by inotropic drugs) is poorly tolerated and
should be avoided in patients with hypertrophic
cardiomyopathy. Patients with hypertrophic car-
diomyopathy are at significant risk for developing
perioperative hypotension, CHF and arrhythmias
and should be monitored closely.69
R E F E R E N C E S
1. Mangano DT. Perioperative cardiac morbidity. Anesthesiolo-
gy. 1990;72:153–184.
2. National Center for Health Statistics: Health United States
1988: Public Health Service. Washington, D.C., U.S. Govern-
ment Printing Office, DHSS publication (PHS) 1989;1232:
10–17,66,67,100,101.
Congenital Heart Disease. Studies have demon-
strated that patients with left-to-right cardiac shunts
have residual hemodynamic abnormalities even
after surgical repair, including decreased cardiac
output response to exercise.70,71 Vigorous treatment
of CHF is required for such patients before noncar-
diac surgery. Patients with large left-to-right shunts,
but only a slight increase in pulmonary artery resis-
tance should undergo cardiac repair before noncar-
diac surgery. Patients with irreversible pulmonary
artery hypertension have an extremely high risk
associated with surgery and should not undergo
elective procedures.
3. Topkins MJ, Artusio JF. Myocardial infarction and surgery.
Anesth Analg. 1964;43:716–720.
4. Tarhan S, Moffitt EA, Taylor WF, Giuliani ER. Myocardial
infarction after general anesthesia. JAMA. 1972;220:1451–
1454.
5. Steen PA, Tinker JH, Tarhan S. Myocardial reinfarction
after anesthesia and surgery. JAMA. 1978;239:2566–2570.
6. Von Knorring J. Postoperative myocardial infarction: a
prospective study in a risk group of surgical patients.
Surgery. 1981;90:55–60.
7. Abraham SA, Coles NA, Coley CM, Strauss HW, Boucher
CA, Eagle KA. Coronary risk of noncardiac surgery. Prog
Cardiovasc Dis. 1991;34:205–234.
8. Paul SD, Eagle KA. A stepwise strategy for coronary risk
assessment for noncardiac surgery. Med Clin North Am.
1995;79:1241–1262.
Patients with prior repair of coarctation of the
aorta have a significant frequency of sudden death
during follow-up due to either residual cardiac
defects with CHF, rupture of a major vessel, dissect-
ing aneurysm, or complications arising from severe
atherosclerosis.72,73 Such patients also have a high
incidence of residual hypertension. Therefore, close
perioperative hemodynamic monitoring is required.
Patients with tetralogy of Fallot are also prone to
sudden cardiac death.74 Monitoring and treatment
of life-threatening arrhythmias such as ventricular
tachycardia or atrioventricular block is recommend-
ed for such patients in the perioperative period.
Surgery in patients with cyanotic congenital heart
disease with right-to-left shunts poses several
unique problems. Most cyanotic patients are poly-
cythemic, and therefore, are prone to thrombotic
complications. Use of diuretics should be avoided
for such patients, as dehydration may increase the
blood viscosity and further increase the risk of
thrombosis, particularly cerebral thrombosis.
Patients with a hematocrit greater than 70% should
undergo plasmapheresis before noncardiac surgery.
Phlebotomy is not advisable in this circumstance,
since this can decrease intravascular blood volume,
increasing cyanosis. Those with a hematocrit
between 55% and 65% should receive intravenous
fluids starting the night before the surgery. Patients
with congenital heart disease should also receive
9. Guidelines for perioperative evaluation for noncardiac
surgery. Committee on perioperative cardiovascular evalua-
tion for noncardiac surgery. J Am Coll Cardiol. 1996;27:910–
948.
10. Mehta RH, Eagle KA. How to assess cardiac risk before
noncardiac surgery? Int Med. 1998;19:27–39.
11. Mahar LJ, Steen PA, Tinker JH, Vielstra RE, Smith HC,
Pluth JR. Perioperative myocardial infarction in patients
with coronary artery disease with and without aorta-coro-
nary bypass grafts. J. Thorac Cardiovasc Surg. 1978;76:533–
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