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Patients scheduled for non-cardiac vascular surgery are at significant risk of cardiovascular morbidity and mortality due to underlying symptomatic or asymptomatic coronary artery disease (CAD). As was shown by Hertzer et al. in their landmark study in 1984 using coronary angiography in 1000 patients undergoing non-cardiac vascular surgery, 61% of all patients did have at least one significant lesion.1 In fact, only 8% of all patients had no abnormalities. More recent studies using functional tests for CAD such as dobutamine stress echocardiography confirmed these findings. In a study population of 1097 vascular surgical patients, the incidence of rest wall motion abnormalities was nearly 50%, while one-fifth of patients had stress-induced myocardial ischaemia.2The high prevalence of CAD in vascular surgical patients explains the adverse outcome in this patient population. The incidence of perioperative myocardial infarction, defined as the presence of two out of three of the following markers: (i) the presence of typical chest pain complaints; (ii) ECG abnormalities; and (iii) increased troponin levels, is ∼5%. Importantly, 75% of the perioperative myocardial infarctions remain asymptomatic and may therefore be difficult to assess. This might be attributable to the disguising effects of sedation and the simultaneous occurrence of symptoms directly … *Corresponding author. Tel: +31 10 4634613; fax: +31 10 436 2995. Email: d.poldermans{at}erasmusmc.nl

Preoperative cardiac risk assessment in vascular surgery patients: seeing beyond the perioperative period