Presurgical CV Risk Reduction Should Be Goal

NEW YORK — A patient's preoperative cardiovascular assessment should do more than determine whether a patient is cleared for surgery.

Ideally, it also should take measures to reduce a patient's surgical risk. A major focus is to resolve cardiovascular disease and cut the patient's risk for a perioperative or postoperative myocardial infarction, Dr. Howard Weinstein said at a symposium on cardiovascular disease in cancer patients sponsored by the University of Texas M.D. Anderson Cancer Center.

Most postoperative MIs occur within the first 48 hours after surgery; these events generally do not involve plaque rupture but occur when myocardial oxygen demand outstrips coronary supply, said Dr. Weinstein, a cardiologist at Memorial Sloan-Kettering Cancer Center in New York. Demand ischemia occurs when one or more coronary vessels have greater than 70% stenosis and the patient has prolonged, stress-induced ischemia.

Prolonged operations that involve large fluid shifts or blood loss carry a high cardiac risk, and such surgeries are common for cancer. Surgery with an intermediate risk for cardiac events includes intraperitoneal and intrathoracic surgery, orthopedic surgery, and prostate surgery, all of which are also common in cancer patients. Endoscopic, superficial, and breast surgery all produce low increased risks for cardiac events, he said.

Guidelines for gauging presurgical risk for cardiac events, published in 2007 by the American College of Cardiology and the American Heart Association, focus on comorbidities. Coexisting disorders that increase surgical risk include histories of ischemic heart disease, heart failure, cerebrovascular disease, diabetes, renal insufficiency, arrhythmia, and severe valvular disease.

The key cause of postoperative MIs seems to be postoperative stress, including emergence from anesthesia, leading to cardiac ischemia, infarction, and myocardial death. Only about 1 in 13,000 patients dies directly because of anesthesia, Dr. Weinstein said at the meeting, also sponsored by the American College of Cardiology and the Society for Geriatric Cardiology.

Poor functional status just before surgery is another key risk factor. In a study reported last year by Dr. Weinstein and his associates, 2 of 53 (4%) patients with an exercise capacity of more than seven METs (metabolic equivalents) had a postsurgical hospital stay of 10 or more days, while 26 of 138 (19%) patients with an exercise capacity of seven METs or less had a prolonged postsurgical hospitalization.

If nonsurgical treatment is not an option, another approach is to do the least-extensive procedure possible that will accomplish the goal. A third option is to defer surgery. Operations for prostate, renal, and benign tumors can generally be delayed for several months. Surgery for lung, colon, and head or neck tumors can be postponed for a few weeks. Aggressive cancers with rapid growth or the immediate threat of lost function, as well as leukemias and lymphomas, are the only tumors that require surgery within days.

Coronary revascularization before surgery requires careful assessment of the potential risks and benefits. Coronary artery bypass is generally not a good option because the recovery time is too long. Following coronary artery stenting, patients need treatment with aspirin indefinitely, and with clopidogrel for 1 month for bare-metal stents and ideally for at least a year with drug-eluting stents. Most surgeons stop clopidogrel treatment before an operation, but the trend now is to maintain patients on aspirin right up to the time of surgery and restart as soon as possible. The need for antiplatelet therapy following stent placement makes coronary revascularization by balloon angioplasty alone a reasonable alternative. Surgery is possible starting about 2 weeks after angioplasty, Dr. Weinstein said.

The value of presurgical revascularization was challenged by the Coronary Artery Revascularization Prophylaxis (CARP) study, which randomized 510 patients who were scheduled for elective vascular surgery and had coronary artery disease to revascularization or to presurgical medical management only (N. Engl. J. Med. 2004;351:2795–804). In the revascularization group, 41% underwent bypass surgery and 59% were stented. After the subsequent vascular surgery, the incidence of MIs was 12% in the revascularization group and 14% in the medical management group, a difference that was not statistically significant. After a mean follow-up of 2.7 years, the cumulative rate of death was essentially identical in the two groups, with rates of 22% and 23%.

The CARP study was not large enough to assess the benefit of presurgical revascularization in patients with high-risk coronary disease, Dr. Weinstein noted.

NEW YORK — A patient's preoperative cardiovascular assessment should do more than determine whether a patient is cleared for surgery.

Ideally, it also should take measures to reduce a patient's surgical risk. A major focus is to resolve cardiovascular disease and cut the patient's risk for a perioperative or postoperative myocardial infarction, Dr. Howard Weinstein said at a symposium on cardiovascular disease in cancer patients sponsored by the University of Texas M.D. Anderson Cancer Center.

Most postoperative MIs occur within the first 48 hours after surgery; these events generally do not involve plaque rupture but occur when myocardial oxygen demand outstrips coronary supply, said Dr. Weinstein, a cardiologist at Memorial Sloan-Kettering Cancer Center in New York. Demand ischemia occurs when one or more coronary vessels have greater than 70% stenosis and the patient has prolonged, stress-induced ischemia.

Prolonged operations that involve large fluid shifts or blood loss carry a high cardiac risk, and such surgeries are common for cancer. Surgery with an intermediate risk for cardiac events includes intraperitoneal and intrathoracic surgery, orthopedic surgery, and prostate surgery, all of which are also common in cancer patients. Endoscopic, superficial, and breast surgery all produce low increased risks for cardiac events, he said.

Guidelines for gauging presurgical risk for cardiac events, published in 2007 by the American College of Cardiology and the American Heart Association, focus on comorbidities. Coexisting disorders that increase surgical risk include histories of ischemic heart disease, heart failure, cerebrovascular disease, diabetes, renal insufficiency, arrhythmia, and severe valvular disease.

The key cause of postoperative MIs seems to be postoperative stress, including emergence from anesthesia, leading to cardiac ischemia, infarction, and myocardial death. Only about 1 in 13,000 patients dies directly because of anesthesia, Dr. Weinstein said at the meeting, also sponsored by the American College of Cardiology and the Society for Geriatric Cardiology.

Poor functional status just before surgery is another key risk factor. In a study reported last year by Dr. Weinstein and his associates, 2 of 53 (4%) patients with an exercise capacity of more than seven METs (metabolic equivalents) had a postsurgical hospital stay of 10 or more days, while 26 of 138 (19%) patients with an exercise capacity of seven METs or less had a prolonged postsurgical hospitalization.

If nonsurgical treatment is not an option, another approach is to do the least-extensive procedure possible that will accomplish the goal. A third option is to defer surgery. Operations for prostate, renal, and benign tumors can generally be delayed for several months. Surgery for lung, colon, and head or neck tumors can be postponed for a few weeks. Aggressive cancers with rapid growth or the immediate threat of lost function, as well as leukemias and lymphomas, are the only tumors that require surgery within days.

Coronary revascularization before surgery requires careful assessment of the potential risks and benefits. Coronary artery bypass is generally not a good option because the recovery time is too long. Following coronary artery stenting, patients need treatment with aspirin indefinitely, and with clopidogrel for 1 month for bare-metal stents and ideally for at least a year with drug-eluting stents. Most surgeons stop clopidogrel treatment before an operation, but the trend now is to maintain patients on aspirin right up to the time of surgery and restart as soon as possible. The need for antiplatelet therapy following stent placement makes coronary revascularization by balloon angioplasty alone a reasonable alternative. Surgery is possible starting about 2 weeks after angioplasty, Dr. Weinstein said.

The value of presurgical revascularization was challenged by the Coronary Artery Revascularization Prophylaxis (CARP) study, which randomized 510 patients who were scheduled for elective vascular surgery and had coronary artery disease to revascularization or to presurgical medical management only (N. Engl. J. Med. 2004;351:2795–804). In the revascularization group, 41% underwent bypass surgery and 59% were stented. After the subsequent vascular surgery, the incidence of MIs was 12% in the revascularization group and 14% in the medical management group, a difference that was not statistically significant. After a mean follow-up of 2.7 years, the cumulative rate of death was essentially identical in the two groups, with rates of 22% and 23%.

The CARP study was not large enough to assess the benefit of presurgical revascularization in patients with high-risk coronary disease, Dr. Weinstein noted.

NEW YORK — A patient's preoperative cardiovascular assessment should do more than determine whether a patient is cleared for surgery.

Ideally, it also should take measures to reduce a patient's surgical risk. A major focus is to resolve cardiovascular disease and cut the patient's risk for a perioperative or postoperative myocardial infarction, Dr. Howard Weinstein said at a symposium on cardiovascular disease in cancer patients sponsored by the University of Texas M.D. Anderson Cancer Center.

Most postoperative MIs occur within the first 48 hours after surgery; these events generally do not involve plaque rupture but occur when myocardial oxygen demand outstrips coronary supply, said Dr. Weinstein, a cardiologist at Memorial Sloan-Kettering Cancer Center in New York. Demand ischemia occurs when one or more coronary vessels have greater than 70% stenosis and the patient has prolonged, stress-induced ischemia.

Prolonged operations that involve large fluid shifts or blood loss carry a high cardiac risk, and such surgeries are common for cancer. Surgery with an intermediate risk for cardiac events includes intraperitoneal and intrathoracic surgery, orthopedic surgery, and prostate surgery, all of which are also common in cancer patients. Endoscopic, superficial, and breast surgery all produce low increased risks for cardiac events, he said.

Guidelines for gauging presurgical risk for cardiac events, published in 2007 by the American College of Cardiology and the American Heart Association, focus on comorbidities. Coexisting disorders that increase surgical risk include histories of ischemic heart disease, heart failure, cerebrovascular disease, diabetes, renal insufficiency, arrhythmia, and severe valvular disease.

The key cause of postoperative MIs seems to be postoperative stress, including emergence from anesthesia, leading to cardiac ischemia, infarction, and myocardial death. Only about 1 in 13,000 patients dies directly because of anesthesia, Dr. Weinstein said at the meeting, also sponsored by the American College of Cardiology and the Society for Geriatric Cardiology.

Poor functional status just before surgery is another key risk factor. In a study reported last year by Dr. Weinstein and his associates, 2 of 53 (4%) patients with an exercise capacity of more than seven METs (metabolic equivalents) had a postsurgical hospital stay of 10 or more days, while 26 of 138 (19%) patients with an exercise capacity of seven METs or less had a prolonged postsurgical hospitalization.

If nonsurgical treatment is not an option, another approach is to do the least-extensive procedure possible that will accomplish the goal. A third option is to defer surgery. Operations for prostate, renal, and benign tumors can generally be delayed for several months. Surgery for lung, colon, and head or neck tumors can be postponed for a few weeks. Aggressive cancers with rapid growth or the immediate threat of lost function, as well as leukemias and lymphomas, are the only tumors that require surgery within days.

Coronary revascularization before surgery requires careful assessment of the potential risks and benefits. Coronary artery bypass is generally not a good option because the recovery time is too long. Following coronary artery stenting, patients need treatment with aspirin indefinitely, and with clopidogrel for 1 month for bare-metal stents and ideally for at least a year with drug-eluting stents. Most surgeons stop clopidogrel treatment before an operation, but the trend now is to maintain patients on aspirin right up to the time of surgery and restart as soon as possible. The need for antiplatelet therapy following stent placement makes coronary revascularization by balloon angioplasty alone a reasonable alternative. Surgery is possible starting about 2 weeks after angioplasty, Dr. Weinstein said.

The value of presurgical revascularization was challenged by the Coronary Artery Revascularization Prophylaxis (CARP) study, which randomized 510 patients who were scheduled for elective vascular surgery and had coronary artery disease to revascularization or to presurgical medical management only (N. Engl. J. Med. 2004;351:2795–804). In the revascularization group, 41% underwent bypass surgery and 59% were stented. After the subsequent vascular surgery, the incidence of MIs was 12% in the revascularization group and 14% in the medical management group, a difference that was not statistically significant. After a mean follow-up of 2.7 years, the cumulative rate of death was essentially identical in the two groups, with rates of 22% and 23%.

The CARP study was not large enough to assess the benefit of presurgical revascularization in patients with high-risk coronary disease, Dr. Weinstein noted.