Perioperative Cardiac Care: From Guidelines to Clinical Practice

Cardiovascular disease is the major cause of death and disability in the Western world. The main disease underlying cardiovascular disorders is atherosclerosis. Atherosclerosis is a systemic disease affecting numerous vascular beds, including the coronary and peripheral circulation i.e. cerebrovascular, aortic and lower limb arterial circulation. The global ageing phenomenon will further increase the burden of cardiovascular disease and also enforce a change in health care towards the elderly population. Peripheral arterial disease (PAD) is a common condition. Importantly, only 1 out of 9 patients with PAD are symptomatic while vascular morbidity and mortality is estimated to be similar in patients with symptomatic or asymptomatic PAD. This poses PAD to be a major health burden. Risk factors for atherosclerotic disease are common and polyvascular disease is highly prevalent in the PAD population. The prognosis of patients with PAD is predominantly determined by the presence and extent of the underlying ischemic heart disease (IHD). The estimated cardiovascular risk in PAD is, moreover, as high as in IHD.3,4 Mc Dermott and colleagues reported already in 1997 that PAD patients received less intensive drug treatment compared to IHD patients, irrespective of comparable risk. Additionally, in a large risk factor matched population, patients with IHD received more cardiac medications, compared with PAD patients (beta-blockers 74% vs. 34%, aspirin 88% vs. 40%, nitrates 37% v

Prognosis of Transient New-Onset Atrial Fibrillation During Vascular Surgery

AbstractBackgroundChronic atrial fibrillation (AF) in a non-surgical setting is associated with cardiovascular events. However, the prognosis of transient new-onset AF during vascular surgery is unknown.ObjectiveThe purpose of this study is to investigate the prognosis of new-onset AF during vascular surgery using continuous electrocardiographic monitoring (continuous-ECG).MethodsIn this study, 317 patients, all in sinus rhythm, scheduled for major vascular surgery were screened for cardiac risk factors. Continuous-ECG recordings for 72h and standard ECG on days 3, 7 and 30 were used to identify new-onset AF. Cardiac troponin T (cTnT) was measured routinely after surgery. Study endpoint was a composite of cardiac death, myocardial infarction, unstable angina and stroke (cardiovascular events) at 30 days after surgery and during late follow-up. Median follow-up was 12 (interquartile range 2–28) months.ResultsNew-onset AF was noted in 15 (4.7%) patients. All but three patients returned spontaneously to sinus rhythm. The composite endpoint of cardiovascular events within 30 days and during late follow-up occurred in 34 (11%) and 62 (20%) patients, respectively. Multivariate regression analysis showed that new-onset AF was associated with perioperative (hazard ratio (HR) 6.0; 95% CI: 2.4–15) and late cardiovascular events (HR 4.2, 95% CI: 2.1–8.8).ConclusionNew-onset AF during vascular surgery is associated with an increased incidence of 30-day and late cardiovascular events

The preoperative cardiology consultation: Indications and risk modification

Background The cardiologist is regularly consulted preop-eratively by anaesthesiologists. However, insights into the efficiency and usefulness of these consultations are unclear. Methods This is a retrospective study of 24,174 preoperatively screened patients ≥18 years scheduled for elective non-cardiac surgery, which resulted in 273 (1%) referrals to the cardiologist for further preoperative evaluation. Medical charts were reviewed for patient characteristics, main reason for referring, requested diagnostic tests, interventions, adjustment in medical therapy, 30-day mortality and major adverse cardiac events. Results The most common reason for consultation was the evaluation of a cardiac murmur (95 patients, 35%). In 167 (61%) patients, no change in therapy was initiated by the cardiologist. Six consultations (2%) led to invasive interventions (electrical cardioversion, percutaneous coronary intervention or coronary artery bypass surgery). On average, consultation delayed clearance for surgery by two weeks. Conclusion In most patients referred to the cardiologist after being screened at an outpatient anaesthesiology clinic, echocardiography is performed for ruling out specific conditions and to be sure that no further improvement can be made in the patient’s health. In the majority, no change in therapy was initiated by the cardiologist. A more careful consideration about the potential benefits of consulting must be made for every patient

Smoking Cessation has no Influence on Quality of Life in Patients with Peripheral Arterial Disease 5 Years Post-vascular Surgery

AbstractObjectivesSmoking is an important modifiable risk factor in patients with peripheral arterial disease (PAD). We investigated differences in quality of life (QoL) between patients who quitted smoking during follow-up and persistent smokers.DesignCohort study.MethodsData of 711 consecutively enrolled patients undergoing vascular surgery were collected in 11 hospitals in the Netherlands. Smoking status was obtained at baseline and at 3-year follow-up. A 5-year follow-up to measure QoL was performed with the EuroQol-5D (EQ-5D) and Peripheral Arterial Questionnaire (PAQ).ResultsAfter adjusting for clinical risk factors, patients, who quit smoking within 3 years after vascular surgery, did not report an impaired QoL (EQ-5D: odds ratio (OR) = 0.63, 95% confidence interval (CI) = 0.28–1.43; PAQ: OR = 0.76, 95% CI = 0.35–1.65; visual analogue scale (VAS): OR = 0.88, 95% CI = 0.42–1.84) compared with patients, who continued smoking. Current smokers were significantly more likely to have an impaired QoL (EQ-5D: OR = 1.86, 95% CI = 1.09–3.17; PAQ: OR = 1.63, 95% CI = 1.00–2.65), although no differences in VAS scores were found (OR = 1.17, 95% CI = 0.72–1.90).ConclusionsThere was no effect of smoking cessation on QoL in PAD patients undergoing vascular surgery. Nevertheless, given the link between smoking, complications and mortality in this patient group, smoking cessation should be a primary target in secondary prevention

Argon does not affect cerebral circulation or metabolism in male humans

Objective: Accumulating data have recently underlined argońs neuroprotective potential. However, to the best of our knowledge, no data are available on the cerebrovascular effects of argon (Ar) in humans. We hypothesized that argon inhalation does not affect mean blood flow velocity of the middle cerebral artery (Vmca), cerebral flow index (FI), zero flow pressure (ZFP), effective cerebral perfusion pressure (CPPe), resistance area product (RAP) and the arterio-jugular venous content differences of oxygen (AJVDO2), glucose (AJVDG), and lactate (AJVDL) in anesthetized patients. Materials and methods: In a secondary analysis of an earlier controlled cross-over trial we compared parameters of the cerebral circulation under 15 minutes exposure to 70%Ar/30%O2versus 70%N2/30%O2in 29 male patients under fentanyl-midazolam anaesthesia before coronary surgery. Vmca was measured by transcranial Doppler sonography. ZFP and RAP were estimated by linear regression analysis of pressure-flow velocity relationships of the middle cerebral artery. CPPe was calculated as the difference between mean arterial pressure and ZFP. AJVDO2, AJVDG and AJVDL were calculated as the differences in contents between arterial and jugular-venous blood of oxygen, glucose, and lactate. Statistical analysis was done by t-tests and ANOVA. Results: Mechanical ventilation with 70% Ar did not cause any significant changes in mean arterial pressure, Vmca, FI, ZFP, CPPe, RAP, AJVDO2, AJVDG, and AJVDL. Discussion: Short-term inhalation of 70% Ar does not affect global cerebral circulation or metabolism in male humans under general anaesthesia

Obesity - a risk factor for postoperative complications in general surgery?

Background: Obesity is generally believed to be a risk factor for the development of postoperative complications. Although being obese is associated with medical hazards, recent literature shows no convincing data to support this assumption. Moreover a paradox between body mass index and survival is described. This study was designed to determine influence of body mass index on postoperative complications and long-term survival after surgery. Methods: A single-centre prospective analysis of postoperative complications in 4293 patients undergoing general surgery was conducted, with a median follow-up time of 6.3 years. We analyzed the impact of bodyweight on postoperative morbidity and mortality, using univariate and multiv

Further validation of the peripheral artery questionnaire:Results from a peripheral vascular surgery survey in the Netherlands

AbstractObjectivesPeripheral arterial disease (PAD) is associated with adverse cardiovascular events and can significantly impair patients' health status. Recently, marked methodological improvements in the measurement of PAD patients' health status have been made. The Peripheral Artery Questionnaire (PAQ) was specifically developed for this purpose. We validated a Dutch version of the PAQ in a large sample of PAD patients.DesignCross-sectional study.MethodsThe Dutch PAQ was completed by 465 PAD patients (70% men, mean age 65±10 years) participating in the Euro Heart Survey Programme. Principal components analysis and reliability analyses were performed. Convergent validity was documented by comparing the PAQ with EQ-5D scales.ResultsThree factors were discerned; Physical Function, Perceived Disability, and Treatment Satisfaction (factor loadings between 0.50 and 0.90). Cronbach's α values were excellent (mean α=0.94). Shared variance of the PAQ domains with EQ-5D scales ranged from 3 to 50%.ConclusionsThe Dutch PAQ proved to have good measurement qualities; assessment of Physical Function, Perceived Disability, and Treatment Satisfaction facilitates the monitoring of patients' perceived health in clinical research and practice. Measuring disease-specific health status in a reliable way becomes essential in times were a wide array of treatment options are available for PAD patients