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Chapter 6: Cardiac Evaluation of the Vascular Patient

Lindsay Ahmed; Ramdas G. Pai

CARDIAC EVALUATION OF THE VASCULAR PATIENT

This chapter will explore the approach to assessing the cardiac health of patients with vascular disease, specifically addressing perioperative management in high-risk patients and identifying those who will need further cardiac examination and treatment prior to surgery. It will also offer an overview of cardiac conditions which may provide a source of arterial emboli leading to acute or chronic limb ischemia.

FIGURE 6-1

Preoperative surgical decision-making.

A chart explains the decision-making process involved before proceeding with surgery. Block states start here: emergency surgery? Yes points to proceed to surgery, and no points to elevated risk using prediction tool? No points to proceed to surgery, and yes points to order ECG, order troponin. This points to unexplained dyspnea or hx of LV dysfunction? Yes points to order TTE to assess LV function, and no points to METS greater than 4. Order TTE to assess LV function points to METS greater than 4. METS greater than 4 have a yes that points to the Proceed to surgery, consider statin, anti-platelet, beta blocker if appropriate, check post-op ECG and troponin, and no that points to cardiac stress test. Low-risk points to proceed to surgery, consider statin, anti-platelet, and beta-blocker if appropriate, check post-op ECG and troponin, and high-risk points to surgery can wait greater than 4 to 6 weeks? Yes points to angiogram and re-vascularization if indicated, which then points to the following: Proceed to surgery, consider statin, anti-platelet, beta blocker if appropriate, check post-op ECG and troponin, and no points to discuss risks and benefits of surgery and procedures, consider angiogram to define anatomy, temporizing measures like balloon angioplasty if needed.
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PREOPERATIVE RISK ASSESSMENT

Due to shared risk factors and similarities in underlying pathophysiology, the overlap between coronary artery disease (CAD) and peripheral arterial disease (PAD) is substantial. Patients with known PAD frequently have atherosclerosis of a second vascular bed, and prior studies have demonstrated an incidence of CAD in this population ranging from 46% to 71%.1,2 Due to the high pretest probability of CAD, cardiac risk assessment in patients planned for vascular surgery is vital in preventing untoward events. In addition, appropriate medical management is essential not only to reduce the perioperative risk but also to improve the long-term outlook.

Risk Assessment Tools

There are numerous tools available for predicting the risk of perioperative major adverse cardiac events (MACE) in patients undergoing noncardiac surgery, with the Revised Cardiac Risk Index (RCRI) being one of the most frequently used (Table 6-1). However, several other scoring systems have been created such as the American College of Surgeons National Surgical Quality Improvement Program (NSQIP), which appears to outperform the RCRI specifically in patients undergoing vascular surgery (Table 6-2).3 Guidelines do not support the use of any particular risk calculator over another, but do recommend the use of any validated risk prediction tool to help assess the risk of MACE.4

TABLE 6-1Revised Cardiac Risk Index
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TABLE 6-1 Revised Cardiac Risk Index

Revised Cardiac Risk Index (RCRI)

Each risk predictor is assigned one point:

  1. High-risk surgical procedures—intraperitoneal, intrathoracic, or suprainguinal vascular

  2. History of ischemic heart disease—prior myocardial infarction or positive stress test, ECG showing the presence of pathological Q waves, current chest pain felt to be due to cardiac ischemia, or current use of nitrate therapy

  3. Congestive heart failure—history of congestive heart failure, presence of paroxysmal nocturnal dyspnea, pulmonary edema or S3 gallop on exam, chest radiograph showing pulmonary vascular distribution

  4. History of cerebrovascular disease—including transient ischemic attack or stroke

  5. Preoperative treatment with insulin

  6. Preoperative serum creatinine >2.0 mg/dL / 176.8 µmol/L

Risk of major cardiac event, including myocardial infarction, pulmonary edema, ventricular fibrillation, primary cardiac arrest, and complete heart block:

  • 0 points – 0.4% risk

  • 1 point – 0.9% risk

  • 2 points – 6.6% risk

  • 3 or more points – 11% risk

Data from Lee TH, Marcantonio ER, Mangione CM, et ...

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