Evaluation of perioperative risk of cardiac complications

O.O. Pavlov, S.A. Lutsyk


Advances in medical care, including treatment strategies for acute coronary syndrome and sudden death led to improved survival of patients with chronic diseases such as atherosclerosis, hypertension and diabetes. One of the factors caused this positive dynamics was wide using of rating scales. Patients with heart failure are of high risk of postoperative complications as the patients with coronary heart disease, and they should be thoroughly examined to ensure good tolerance of surgery and anesthesia. Goldman and colleagues proposed a multifactor model of risk for heart failure patients in general surgery, later called the original Cardiac Risk Index, and significantly improved the classification of the American Society of Anesthesiologists (ASA). It is worth noting that other authors developed evaluation system for postoperative complications risk. Howe­ver the estimation of patient’s clinical condition by any scale, the study of history and analysis of basic laboratory parameters are considered as a component of routine preoperative preparation. Goldman et al. have analyzed 1001 patients older than 40 years, which underwent extended planned general surgery. Multivariate models were identified using 9 standard clinical signs and laboratory indices with the formation of four independent factors that demonstrated postoperative high risk for cardiovascular complications. This model served as the basis for many years for assessing preoperative risk. However, the lack of verification of the proposed model in terms of multicenter studies, variability of performance and difficulties with the classification of possible complications resulted in the development of other assessment systems. The above estimation model emerged after the study of 455 patients evaluated preoperatively. The mathematical analysis discovered zone of accumulation risk of the original CH characteristics at 0.69 points lower than in the original studies. They have simplified scoring system, added indicator of severity of angina attacks and proposed criteria of modified HF, which provided improved index more than 0.76 points as compared to the original system. Though it was essentially improved rating scale, due to doubts and prejudice this method did not found widespread usage. In order to further improve existing cardiac risk stratification test more simple risk stratification tool was proposed; it consists of 6 simple factors derived from studies of 4315 patients older than 50 years, examined before investigation or directly at the hospital. Major cardiovascular events occurred in 2 % of patients in the study group and in 2.5 % patients in the control group. Independent risk factors were high-risk surgical intervention, revealed heart failure, revealed brain vascular diseases, preoperative treatment with insulin and preoperative blood creatinine levels more than 2.0 mg/dL (> 176.8 mmol/l). Mathematical modeling by this method showed clustering area of 0.806 compared to 0.582 by modified Cardiac Risk Index, 0.701 for the original Cardiac Risk Index and 0.706 for the classification of ASA. In general, such a simplified approach effectively grouped the patients into 3 groups. It should be noted that during the trial insulin therapy and preoperative creatinine level in blood serum were not so important factors. Another limitation was that the model cannot take into account changes in the patient’s clinical condition over time. For example, if a patient with decompensated heart failure after anesthesiologist’s examination was postponed for a month, and after this period his clinical condition improved, the patient’s calculated risk remains the same, and that may not reflect reality. Exactly the same applies to the patients with acute coronary syndrome, which after coronary artery revascularization are considered as being in need of delay or postpone of operation for a few months. Application of new methods such as biomarkers measurement can more accurately determine the likelihood of heart failure development and allows predict or early diagnosis of heart failure in patients undergoing extended operation.


heart failure; perioperative examination; complications


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