Chapter 8 Perioperative Cardiovascular Evaluation and Care for Noncardiac SurgeryClass III
Routine use of a pulmonary artery catheter peri-
operatively, especially in patients at low risk of
developing hemodynamic disturbances, is not rec-
ommended. (Level of Evidence: A)
Recommendations for intraoperative and
postoperative use of ST-segment monitoring
Class IIa
Intraoperative and postoperative ST-segment moni-
toring can be useful to monitor patients with known
CAD or those undergoing vascular surgery, with
computerized ST-segment analysis, when available,
used to detect myocardial ischemia during the peri-
operative period. (Level of Evidence: B)
Class IIb
Intraoperative and postoperative ST-segment moni-
toring may be considered in patients with single or
multiple risk factors for CAD who are undergoing
noncardiac surgery. (Level of Evidence: B)
Recommendations for surveillance for
perioperative MI
Class I
Postoperative troponin measurement is recom-
mended in patients with ECG changes or chest pain
typical of acute coronary syndrome. (Level of Evi-
dence: C)
Class IIb
The use of postoperative troponin measurement
is not well established in patients who are clini-
cally stable and have undergone vascular and
intermediate-risk surgery. (Level of Evidence: C)
Class III
Postoperative troponin measurement is not recom-
mended in asymptomatic stable patients who
have undergone low-risk surgery. (Level of
Evidence: C)
Other guidelines
Currently, the only other Guideline devoted to the
subject was published in 1997 by Palda and Detsky
for the American College of Physicians [27]. Given
the decade since the publication of this Guideline,
and the fact there has been signifi cant new evidence
since its publication, its recommendations require
updating. There is currently a task force of the Euro-
pean Society of Cardiology on preoperative cardiac
risk assessment and perioperative cardiac manage-
ment in non-cardiac surgery, but Guidelines are still
being developed.Recent studies and future directions
Since publication of the Guidelines, the POISE study
group reported on their randomized controlled trial
of perioperative beta-blockers in 8351 patients with
a history of coronary artery disease, peripheral artery
disease, stroke, or congestive heart failure within the
last three years; who were undergoing major vascu-
lar surgery; or who had three of the following seven
risk factors: undergoing high-risk surgery, having a
history of CHF, having diabetes mellitus, having
renal insuffi ciency, being 70 years of age or older,
having a history of transient ischemic attack, or
undergoing urgent/emergent surgery [28].
Patients were recruited from 193 centers and were
randomized to receive either metoprolol CR or
placebo started two to four hours preoperatively and
continued for 30 days. The dose of metoprolol
administered was 100 mg in the preoperative period,
100 mg in the six-hour postoperative period, 200 mg
12 hours later, and 200 mg daily thereafter out to 30
days. The primary outcome included cardiovascular
death, nonfatal MI, and nonfatal cardiac arrest by
30 days after randomization. Secondary outcomes
included total mortality, cardiovascular death, MI,
cardiac revascularization, clinically signifi cant atrial
fi brillation, clinically signifi cant bradycardia, clini-
cally signifi cant hypotension, and stroke.
The investigators reported a signifi cant reduction
in the primary outcome in the metoprolol group
(5.8% vs. 6.9%), with the major effect being a reduc-
tion in nonfatal myocardial infarction. Of note, the
incidence of all cause mortality was signifi cantly
greater in the metoprolol group (3.1% vs. 2.3%,
odds ratio 1.33, CI 1.03–1.74)) and stroke (1.0% vs.
0.5%, odds ratio 2.17, CI 1.26–3.74). There were no
specifi c subgroups of patients who would achieve
the greatest benefi t compared to risk. Therefore,
starting perioperative metoprolol in beta-blocker
naïve patients the morning of surgery is associated