Preoperative Cardiac Risk Assessment |
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and Management of Elderly Men with |
an Abdominal Aortic Aneurysm
Don Poldermans and Jeroen J. Bax
A 72-year-old male presented with an abdominal aortic aneurysm. He had a history of chest pain complaints and underwent percutaneous transluminal coronary angioplasty (PTCA) 6 years ago. After the PTCA procedure he had no chest pain symptoms until 2 years ago. The chest pain complaints are stable and he was able to perform moderate exercise, such as a round of golf, in 4.5 h. Physical examination showed a friendly man, with blood pressure 160/70 mmHg and pulse 92 bpm. Examination of the chest revealed no abnormalities of the heart. Palpation of the abdomen showed an aortic aneurysm with an estimated diameter of 7 cm. The patient was referred to the vascular surgeon. Blood test showed an elevated fasting glucose of 10.0 mmol/l and low-density lipoprotein (LDL) cholesterol of 4.1 mmol/l. Electrocardiography showed a sinus rhythm and pathological Q-waves in leads V1–V3, suggestive of an old anterior infarction.
Question 1
Which of the following statements regarding postoperative outcome in patients undergoing major vascular surgery is correct?
A. Cardiac complications are the major cause of perioperative morbidity and mortality. B. Perioperative myocardial infarctions are related to fixed coronary artery stenosis in all
patients.
C. Perioperative cardiac events are related to a sudden, unpredictable progression of a nonsignificant coronary artery stenosis in all patients.
D. Perioperative cardiac complications are related to both fixed and unstable coronary artery lesions.
This patient experienced angina pectoris in the past. He was successfully treated with a PTCA procedure, but recently angina pectoris reoccurred. Because of the multiple risk fac- torsandtheplannedhigh-risksurgeryadobutaminestressechocardiographywasperformed. Figure 1.1 shows the normal stress protocol, with increasing doses of dobutamine and test
D. Poldermans ( )
Department of Vascular Surgery, Erasmus MC, Rotterdam, The Netherlands
G. Geroulakos and B. Sumpio (eds.), Vascular Surgery, |
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DOI: 10.1007/978-1-84996-356-5_1, © Springer-Verlag London Limited 2011 |
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D. Poldermans and J.J. Bax |
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endpoints.InFig.1.2thescoringoftheleftventricleforwallmotionabnormalitiesisshown. Figure 1.3 is an example of a normal resting echocardiogram, showing respectively, apical viewsandoneshort-axisview.InFig.1.4,thedifferentstagesofthestresstestareshownfor theapicalfour-chamberview:rest,low-dosedobutamine,peakdosedobutamine,andrecov- ery. As indicated by arrows, the posterior septum shows an outward movement during peak stress, suggesting dyskinesia, and myocardial ischemia of the posterior septum.
Dobutamine-atropine Stress Echocardiography
40 Atropine 2 mg
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20Target heart rate
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Fig. 1.1 The normal stress protocol, with increasing doses of dobutamine and test endpoints
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= dyskinesia |
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Fig. 1.2 The scoring of the left ventricle for wall motion abnormalities. LAX, long axis; SAX, short axis; 4CH, four.chambers; 2CH, two chambers; LAD, left anterior descending artery; RCA, right coronary artery; LCX, left circumflex artery
1 Preoperative Cardiac Risk Assessment and Management of Elderly Men with an Abdominal Aortic Aneurysm |
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Fig. 1.3 An example of a normal resting echocardiogram, showing respectively, apical views and one short-axis view
Fig. 1.4 The different stages of the stress test of the apical four-chamber view, rest, low-dose dobutamine, peak dose dobutamine, and recovery. As shown and indicated with arrows, the posterior septum shows an outward movement during peak stress, suggestive of dyskinesia, and also myocardial ischemia of the posterior septum
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D. Poldermans and J.J. Bax |
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Question 2
Postoperative outcome in patients undergoing major vascular surgery has been improved in those taking beta-blockers and statins. Medical therapy may reduce the need for additional preoperative testing for coronary artery disease as the incidence of perioperative cardiac mortality is reduced to less than 1%, and may even reduce the indications for preoperative coronary revascularization.
A. Beta-blockers are associated with a reduced perioperative cardiac event rate in patients undergoing vascular surgery, both in retrospective and prospective studies.
B. Statin use is associated with an improved postoperative outcome.
C. Statin use is not associated with an increased incidence of perioperative myopathy. D. Beta-blockers and statins are independently associated with an improved postoperative
outcome.
Question 3
Preoperative beta-blocker therapy is widely used. However, the dose and duration of preoperative therapy is uncertain.
A. Beta-blockers should be started preferably 30 days prior to surgery. B. Beta-blockers should be initiated several hours before surgery.
C. Heart rate control should be aimed at a heart rate between 90 and 100 bpm. D. Heart rate control should be aimed at a heart rate between 60 and 70 bpm.
In this patient beta-blockers were started 6 weeks before surgery. Starting dose of bisoprolol was 2.5 mg; the dose was increased to 5.0 mg to obtain a resting heart between 60 and 70 bpm.
Question 4
Perioperative statin therapy has recently been introduced to improve postoperative outcome.
A. Statins improve postoperative outcome by reducing the cholesterol level.
B. Withdrawal of perioperative statin therapy is associated with an increased perioperative cardiac event rate.
C. Perioperative statin use is associated with an increased incidence of myopathy.
D. Perioperative statin use is associated with a reduced perioperative cardiac event rate in vascular surgery patients only.
Statins were prescribed in this patient, Lescol (fluvastatin) XL 80 mg daily, at the same time as beta-blockers were introduced.