Step 6What is the functional capacity and magnitude of
surgical risk?
If there are intermediate clinical predictors, then order non-
invasive investigations if there is either poor function or high
surgical risk. Otherwise go to surgery.
Step 7Are there minor clinical predictors?
If so go to step 8. If not proceed to surgery.
Step 8What is the functional capacity and magnitude of
surgical risk?
If there are minor clinical predictors, then order non-invasive
investigations if there are both poor function and high surgical risk.
Step 9
All patients have now been assigned to surgery, angiography or
non-invasive testing. The results of non-invasive tests must
incorporate both the absolute result (positive or negative) and
quantification of the result (e.g. magnitude and regional location
of ischaemic area). These results will determine which patients
should proceed to angiography. Significant abnormalities require
further assessment by angiography. Minor and intermediate
abnormalities only require further assessment in the presence of
low functional capacity or major surgical risk.
It should be noted that, at least in high-risk patients under-
going vascular surgery, beta blockade is the only medical inter-
vention proven to have major impact on outcome.^2
RReeffeerreennccee
1 ACC/AHA guidelines for perioperative cardiovascular evaluation for
noncardiac surgery. Circulation1996; 9933 : 1280–1317.
2 Poldermans D, Boersma E, Bax JJ et al. The effect of bisoprolol on peri-
operative mortality and myocardial infarction in high-risk patients
undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk.
N Engl J Med1999; 334411 : 1789–94.