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 Risk Stratification and Risk Factors

Bruce S. Cutler, M.D., William C. Mackey, M.D.


  • Cardiac Risk Evaluation
  • Pulmonary Risk Evaluation
  • Atherosclerotic Risk Factor Assessment
  • Lipid Disorder Evaluation and Management

I. Cardiac Disease

1. Recognize the frequent association of coronary artery and peripheral vascular disease.

2. Understand the risk factors predictiveof perioperative myocardial infarction or cardiac death.

3. Be able to quote basic statistics regarding the frequency of severe CAD in patients with symptomatic peripheral vascular disease.

4. Be familiar with the early and late cardiac mortality figures following major vascular surgery.

II. Anatomy and Pathophysiology

1. Describe normal coronary artery anatomy

2. Understand the clinical significance of chronic stable angina, unstable angina, recent and remote myocardial infarction and congestive heart failure

3. Understand how an imbalance of myocardial oxygen supply and demand may lead to myocardial ischemia

4. Describe those factors that may lead to an increased demand for myocardial oxygen, and/or a decreased supply that will contribute to myocardial ischemia.

5. Understand the clinical and histological difference between a subendocardial and transmural infarction.

6. Understand the effects of general and regional anesthesia on myocardial oxygen demand and myocardial ischemia.

7. Understand the most important factors present intraoperatively and in the post-operative period that contribute to myocardial ischemia.

III. Diagnosis

1. Understand the signs and symptoms of chronic stable angina, unstable angina, myocardial infarction and congestive heart failure.

2. Know the risks of operation in a patient with a recent myocardial infarction, unstable angina, or poorly compensated congestive heart failure.

3. Be familiar with the currently used methods for screening for coronary artery disease, and their limitations. ( e.g . Dipyridamole thallium scanning, Exercise testing, Dobutamine stress echo, ambulatory Holter monitoring)

4. Know which patients should undergo a preoperative test for coronary artery disease

5. Know how to interpret the results of thallium scans

6. Know what further evaluation a patient with a positive study should have.

7. Know which patients should have coronary angiography prior to vascular surgery.

8. Understand that the magnitude of the operation should be tailored to the severity of the patients cardiac risk. Know when to employ an extra anatomic, or limited procedure instead of an intra-abdominal operation.

9. Understand when, during the course of a vascular operation and subsequent recovery, a patient is most likely to suffer a myocardial infarction

IV. Treatment

1. Recognize that most patients with even severe CAD can survive a major vascular operation, but they should have close postoperative cardiology follow up and subsequent consideration for coronary revascularization for the best long term survival.

2. Know when CABG may be indicated to correct severe CAD prior to peripheral vascular surgery.

3. Understand the indications for a combined CABG and CEA or AAA operation.

4. Understand the reasons for controlling myocardial ischemia intraoperatively , and during recovery from a major vascular operation

5. Know how to detect and treat myocardial ischemia postoperatively

6. Know how to diagnose and treat common complications of myocardial infarction.

Pulmonary Disease

I. Introduction

1. Recognize that many of the same risk factors that accelerate the development of peripheral vascular disease, also cause the development of chronic obstructive pulmonary disease (COPD)

2. Understand that long operations, intra-abdominal and thoracic incisions, and poor left ventricular function increase the risk of pulmonary complications even in the absence of underlying COPD.

3. Understand that cardiac and other co-morbid conditions are more important in determining postoperative pulmonary complications than pre-existing pulmonary disease

II. Diagnosis

1. Know the risk factors for pulmonary disease, including: history of tobacco use, chest wall deformities, industrial dust exposure, previous pulmonary resection, dyspnea on mild exertion, pulmonary hypertension, recurrent respiratory tract infections, bronchospasm , obesity, advanced age and hypercapnia or hypoxia at rest.

2. Understand the signs and symptoms of COPD.

3. Know what to look for in the physical examination of a patient with suspected pulmonary insufficiency

4. Understand that clinical assessment is at least as accurate as routine preoperative pulmonary function tests in predicting which patients will have a postoperative pulmonary complication.

5. Understand that the primary benefit of preoperative pulmonary function studies is to make the diagnosis of pulmonary disease and as an aid in choosing between treatment alternatives.

6. Understand that there is no pulmonary function test, or index that can accurately predict that a patient will need prolonged postoperative mechanical ventilation.

7. Understand that general anesthesia interferes with pulmonary gas exchange and pulmonary defense mechanisms, particularly the mucociliary transport mechanism.

8. Know how to interpret the results of pulmonary function tests, and know which patients might benefit from the perioperative use of bronchodilators, antibiotics, inhalers etc.

9. Know which patients might benefit from a preoperative pulmonary or anesthesia consultation to help with the operative and postoperative management of a patient with known pulmonary insufficiency

III. Treatment

1. Understand how to reduce the pulmonary risk of a vascular operation by the choice of operation and anesthesia.

2. Understand which pulmonary conditions may benefit from the perioperative use of steroids, bronchodilators, antibiotics and inhalers

3. Understand the causes and treatment of the adult respiratory distress syndrome (ARDS)


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Posted June 2010