Anesthesia for Non-cardiac Surgery in the Patients with Cardiac Disease

Article information

J Korean Med Assoc. 2007;50(12):1081-1089

Publication date (electronic) : 2007 December 31

doi : https://doi.org/10.5124/jkma.2007.50.12.1081

Department of Anesthesiology and Pain Medicine, Chonnam National University College of Medicine, Korea. kyyoo@jnu.ac.kr

Abstract

Perioperative myocardial infarction is a major cause of morbidity and mortality in patients who undergo non-cardiac surgery, while an increasing number of patients with a coronary artery disease are presenting for surgery. In order to cope with this problem, one should first evaluate risk factors of these complications, and then manage the patient at risk to reduce or eliminate the risk factors. Risk assessment evaluates patients' co-morbidities and exercise tolerance, as well as the type of surgery to be performed, to determine the overall risk of perioperative cardiac complications. Previous or current cardiac disease, diabetes, and renal insufficiency all confer higher risks for perioperative cardiac complications. Poor exercise tolerance and high-risk surgical procedures (e.g., vascular, prolonged thoracic, or abdominal operations) also predict worse perioperative outcomes. Stress testing should be reserved for patients at moderate to high risk undergoing moderate- or high-risk surgery and those who have poor exercise capacity. After the assessment of the risk of cardiac complications, one should take measures to reduce it, including medical therapy and coronary intervention. Medical therapy using beta blockers, statins, and alpha-2 agonists may be effective to reduce perioperative risk and to obviate the need for more invasive procedures in high-risk patients. Coronary intervention should be performed for those patients who are indicated independent of the non-cardiac surgery. There appears to be no single best myocardium-protective anesthetic management, and therefore, the choice of anesthesia and intraoperative monitors is left at the discretion of the anesthesia care team.

Keywords: Cardiac disease; Perioperative evaluation; Cardiac risk; Anesthesia

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Article information Continued

Table 1

Clinical Predictors of Increased Perioperative Cardiovascular Risk (Myocardial Infarction, Heart Failure, Death)

ECG: electrocardiogram

^*Adapted from ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery(4).

Table 2

Estimated Energy Requirements for Various Activities^*

MET: metabolic equivalent.

^*Adapted from ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery(3).

Table 3

Cardiac Risk^* Stratification for Noncardiac Surgical Procedures

^*Combined incidence of cardiac death and nonfatal myocardial infarction.

^†Do not generally require further preoperative cardiac testing.

^*Adapted from ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery(3).