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Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk

From the Departments of Medicine and of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont. (Devereaux, Cook, Guyatt), the Department of Medicine, University of California, San Francisco, San Francisco, Calif. (Goldman), the Department of Medicine, University of Western Ontario, London, Ont. (Gilbert), the Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, and the Department of Pharmacology, University of Melbourne, Melbourne, Australia (Leslie)

Correspondence to: Dr. P.J. Devereaux, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, Rm. 2C8, McMaster University, 1200 Main St. W, Hamilton ON L8N 3Z5; fax 905 905 526-1353; philipj{at}mcmaster.ca

Abstract

THIS IS THE FIRST OF 2 ARTICLES EVALUATING cardiac events in patients undergoing noncardiac surgery. In this article, we review the magnitude of the problem, the pathophysiology of these events, approaches to risk assessment and communication of risk. The number of patients undergoing noncardiac surgery worldwide is growing, and annually 500 000 to 900 000 of these patients experience perioperative cardiac death, nonfatal myocardial infarction (MI) or nonfatal cardiac arrest. Although the evidence is limited, a substantial proportion of fatal perioperative MIs may not share the same pathophysiology as nonoperative MIs. A clearer understanding of the pathophysiology is needed to direct future research evaluating prophylactic, acute and long-term interventions. Researchers have developed tools to facilitate the estimation of perioperative cardiac risk. Studies suggest that the Lee index is the most accurate generic perioperative cardiac risk index. The limitations of the studies evaluating the ability of noninvasive cardiac tests to predict perioperative cardiac risk reveals considerable uncertainty as to the role of these popular tests. Similarly, there is uncertainty as to the predictive accuracy of the American College of Cardiology / American Heart Association algorithm for cardiac risk assessment. Patients are likely to benefit from improved estimation and communication of cardiac risk because the majority of noncardiac surgeries are elective and accurate risk estimation is important to allow informed patient and physician decision-making.

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