Perioperative myocardial infarction. for Perioperative Cardiac Events. Paul Lee, M.D., M.P.H. Perioperative Cardiac Risk in Non-Cardiac Surgery

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1 Perioperative Cardiac Risk in Non-Cardiac Surgery Perioperative Cardiac Risk in Non-Cardiac Surgery Paul Lee, M.D., M.P.H. Associate Clinical Professor of Medicine Medical Director, Section of Hospital Medicine Medical Director, International Services Associate Director, Medical House Staff Training Program Columbia University Medical Center 1 Risk Factors 2 Cardiac risk stratification 3 Perioperative medical interventions 4 Revascularization Conclusion Risk Factors for Perioperative Cardiac Events Perioperative myocardial infarction % perioperative MIs (by Tn or CK MB) 830 patients in POISE study 3% ischemic symptoms 6% ECG changes but no symptoms 74% of events within 48 hours of surgery perioperative MIs vs no MI significantly higher 30d mortality 11.6% vs. 2.2% Devereaux. Ann Intern Med 2011; 14:23. Troponins Predict Postsurgical Mortality prospective international study 1,000 noncardiac surgeries peak troponin levels 6-12 hours, days 1, 2, and 3 TnT (ng/ml) 30-day mortality % % % % A -year-old man is evaluated on admission for a planned abdominal aortic aneurysm repair. Which of the following if present in your patient has not been shown to be a risk factor for perioperative cardiovascular complications? 1. Blood Pressure 17/10 2. Hb a1c of 6.1 on Insulin 3. Creatinine of CHF with an EF 2%. Third Heart Sound (S3) on cardiac exam VISION Study Investigators. JAMA. 2012;307(21):

2 Individual Risk Factors Recent myocardial infarction (MI) Congestive heart failure (CHF) Age Arrhythmias Type of surgery Poor general medical status Recent myocardial infarction Definition: within 6 months prior to surgery Reinfarction rates in surgical patients with prior MI # patients 32,877 73, # prior MI months post-mi 37% 27% 6% 3-6 months post-mi 16% 11% 2% >6 months post-mi 4-% 4-% 1-2% Goldman. N Engl J Med 1977;297:84-0 Tarhan. JAMA 1972;220:141; Steen. JAMA 1978;239:266; Rao. Anesthesiol 1983;9:499 Recent myocardial infarction 63,842 surgeries hip surgery, cholecystectomy, colectomy, elective AAA repair, lower extremity amputation Recent myocardial infarction MI within 30 days of operation associated with higher risk of postop MI (RR range = ) 30-day mortality (RR range, ) 1-year mortality (RR range, ) Livhits. Annals of Surgery :,87. California Patient Discharge Database Livhits. Annals of Surgery :,87. California Patient Discharge Database Other Risk Factors Age > 70 years old Associated with 3-fold increased risk Arrhythmias Marker of poor ventricular function Associated with MI & heart failure Type of surgery Vascular surgery Emergency surgery Other Risk Factors General medical status Renal dysfunction Hypoxemia Hypercarbia Hypokalemia Acidosis Liver disease Goldman. N Engl J Med 1977;297:84-0 Goldman. N Engl J Med 1977;297:84-0

3 Cardiac risk stratification Goldman cardiac risk index Modified Detsky index Eagle Criteria Revised Cardiac Risk Index (RCRI) Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) Gupta Cardiac Risk Calculator AHA/ACC guidelines Goldman cardiac risk index multivariate analysis of 1001 patients major noncardiac surgery in > 40 years old Goldman. N Engl J Med 1977;297:84-0 Zeldin. Can J Surg ;402 History Physical exam EKG General status Operation Goldman cardiac risk index Age > 70 years old Pre-op MI within 6 months S3 gallop or increased JVP > 12 Significant aortic stenosis Rhythm other than sinus or atrial ectopy PVC s > /minute at any time PO2 < 60, pco2 > 0, K < 3, HCO3 < 20, BUN > 0 (17.8 mm/l), Cr > 3 (26 mm/l), chronic liver disease, debilitated Intraperitoneal, intrathoracic or aortic Emergent 10 Class I: 0- Class II: 6-12 Class III: 13-2 Class IV: >2 Total possible points: 3 Goldman. N Engl J Med 1977;297: Modified Detsky index Age > 70 years old Pre-op MI 6 months Pre-op MI > 6 months Class III angina (Canadian class) Class IV angina Unstable angina < 6 months Pulmonary edema within 1 week Pulmonary edema ever Suspected critical aortic stenosis 20 Rhythm other than sinus PVC s > /minute at any time 10 Poor general medical status Emergent Operation 10 Class I: 0-1 Class II: Class III: >30 Detsky. J Gen Intern Med 1986;1:211-9 Revised cardiac risk index (RCRI) Prospective study of 431 patients Derivation & validation cohorts Multivariate analysis of potential risk factors Factors predicting cardiac complications Adjusted odds ratio (derivation cohort) High risk surgery 2.8 Ischemic heart disease 2.4 History of CHF 1.9 History of cerebrovascular disease 3.2 Insulin therapy for diabetes 3.0 Preop serum creatinine > 2.0 (176.8 mm/l) 3.0 Lee, Goldman. Circ 1999;100:1043 Lee, Goldman. Circ 1999;100:1043

4 Revised cardiac risk index (RCRI) Class # factors Cardiac complication rates % Derivation Validation I II III IV Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) 20 New England hospitals derivation (n=8208); validation (n=1873) carotid endarterectomy (3%) lower-extremity bypass (27%) open (11%) or endovascular (10%) AAA repair 6.3% suffered periop cardiac complications 2.% MI, 3.9% arrhythmia, 1.8% CHF Lee, Goldman. Circ 1999;100:1043 Bertges. J Vasc Surg 2010; 2:674. Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) RCRI predicted risk after CEA reasonably well substantially underestimated risk after LEB, EVAR, and OAAA for low- and higher-risk patients Bertges. J Vasc Surg 2010; 2:674. Bertges. J Vasc Surg 2010; 2:674. NSQIP Cardiac Risk Calculator prospective database (20 hospitals) American College of Surgeons National Surgical Quality Improvement Program derivation n = (2007 data) validation n = (2008 data) NSQIP Cardiac Risk Calculator Outcomes MI or cardiac arrest up to 30 days after surgery predictors type of surgery dependent functional status creatinine ASA class age Gupta. Circulation 2011, 124: Gupta. Circulation 2011, 124:

5 NSQIP Cardiac Risk Calculator * also known as area under the receiver operating characteristic curve Gupta. Circulation 2011, 124: AHA/ACC guidelines Stratification based on risk from 3 areas Clinical predictors Functional capacity Procedure specific risks Clinical Predictors High Risk unstable coronary syndromes decompensated HF Intermediate Risk ischemic heart disease compensated or prior HF cerebrovascular disease significant arrhythmias severe valvular disease diabetes mellitus renal insufficiency Circ 1996;93:1278; JACC 2002;39:3:42; JACC. 2007;0:17;19. Minor Risk advanced age (>70 years) rhythm other than sinus JACC. 2007;0:17;19. uncontrolled systemic hypertension abnormal ECG (LVH, LBBB, ST-T abnormalities) Functional Capacity Procedure specific risks Image from: Harrison s Online adapted from JACC 2002;39:3:42 JACC. 2007;0:17;19.

6 Cardiac Risk After Joint Replacement 100,000 joint replacement matched controls not undergoing surgery Danish national health database Risk of AMI in first 2 weeks after THR (2-fold) return to background values after 6 weeks TKR (31-fold) dropped rapidly Lalmohamed. Arch Intern Med. 2012;172(16): AHA/ACC guidelines The essence of the algorithm Noninvasive testing recommended if: High-risk surgery 3 or more clinical predictors Poor or unknown functional capacity Would change management HR control recommended if: Intermediate- or High-risk surgery Any clinical predictors Poor or unknown functional capacity JACC. 2007;0:17;19. Glance. Ann Surg 2012 Apr; 2:696. Estimating Mortality 300,000 noncardiac surgery (ACS database) Perioperative Medical Interventions Perioperative -Blocker Blocker 2 -Agonists Statins

7 A -year-old man with HTN, diabetes and hyperlipidemia is evaluated on admission for a planned abdominal aortic aneurysm repair.. His meds include lisinopril, hydrochlorothiazide, glyburide and simvastatin. He plays golf weekly, walks 2 miles in 3 minutes 4 times weekly without symptoms. On exam, pulse rate 84/min, BP 140/87 mm Hg. The remainder of the examination is unremarkable. Results of ECG are consistent with LVH. Labs, including CBC, serum electrolyte level & renal function, are normal. Four hours before surgery, he is started on metoprolol extended-release 100 mg with the plan to continue it for 30 days. Which of the following would be most reasonably expected in this patient as a result of the perioperative beta-blocker use? 1. Increased risk for stroke 2. Decreased risk in mortality 3. Increased risk for heart failure 4. Increased risk for nonfatal MI. Increased risk for pulmonary complications Adapted from MKSAP 14. The Atenolol Study Multicenter Study of Perioperative Ischemia Research Group Double-blind RCT of 200 non-cardiac surgery With either CAD or 2 risk factors for CAD Given iv Atenolol 30 min preop Given po Atenolol until discharge up to 7 days Mangano. NEJM 1996;33:1713 The Atenolol Study The Atenolol Study Survival in atenolol vs placebo at 6 months: 100 % & 92% (P < 0.001) at 1 year: 97 % & 86 %, (P = 0.00) at 2 years: 90 % & 79 % (P = 0.019) 192 Patients after Noncardiac Surgery Who Survived to Hospital Discharge bias in favor of treatment group less coronary disease at study entry received ACE inhibitors more frequently less likely to have -blockers discontinued postoperatively differences in atenolol & placebo populations preop cardiac risk factors, particularly diabetes mellitus included long-term -blocker users most in -blocker group 19% vs 8% Mangano. NEJM 1996;33:1713 Eagle. N Engl J Med 33(23):1761 The Bisoprolol Study Prospective (Not blinded) RCT 112 major vascular surgery patients aortic or infrainguinal arterial reconstruction positive DBA stress echo Bisoprolol mg po qd Beginning one week before surgery Continued for 1 month post-op Outcome Cardiac death (within 30 days) Nonfatal MI (within 30 days) The Bisoprolol Study Bisoprolol group (n=9) Standard group (n=3) 3.4% 17% P = % 17% P Combined endpoint of cardiac death or nonfatal MI 3% 34% Poldermans. DECREASE Study Group. NEJM 1999;341:1789 Poldermans. NEJM 1999;341:1789

8 The Bisoprolol Study At 2 year follow-up Bisoprolol vs standard care Cardiac events: 12% vs 32% (P=0.02) Cardiac death: 6 vs 9 MI: 1 vs patients Cardiac death or MI: odds ratio 0.30 ( ) Lindenauer. N Engl J Med > 700,000 in national registry of 329 hospitals Only 18% on BB (n=122,338) Considered prophylaxis if given in 48h of hospitalization For RCRI score 0 or 1 increase in risk of death (43% & 13%) For scores 2, 3, or 4 or higher reduction in risk of death from 10% to 43% Poldermans. Eur Heart J 2001 Aug;22(1):133-8 Lindenauer N Engl J Med. 200; 33:349 POISE Study DBRCT of extended-release metoprolol or placebo 831 patients with (or at risk for) atherosclerotic disease started 2 4 h before surgery and continued for 30 days significantly lower cardiovascular death, nonfatal MI & nonfatal cardiac arrest.8% vs 6.9%; p=0.04 MI 4.2% vs.7%; p=0.002 significantly higher deaths 3.1% vs 2.3%; p=0.03 stroke 1.0% vs 0.%; p= strokes in metoprolol: 49 ischemic, 3 hemorrhagic, 8 uncertain POISE Study Group. Lancet. 2008; 371:1839. POISE Study: Inclusion criteria Age 4 or older Any one of following: CAD PAD Stroke Hospitalization for CHF within 3 years Undergoing major vascular surgery Any 3 of 7 criteria Undergoing intrathoracic or intraperitoneal surgery h/o CHF TIA DM Serum creatinine > 17 mmol/l Age > 70 Undergoing emergent or urgent surgery POISE Study Group. Lancet. 2008; 371:1839. POISE Study POISE Study RCT of Metoprolol extended-release 100 mg 2-4 h before surgery 6 h after surgery (earlier if HR 80 bpm) Followed by 200 mg or placebo for 30 days For every 1000 patients treated prevent 1 MIs excess of 8 deaths and severe disabling strokes POISE Study Group. Lancet. 2008; 371:1839. POISE Study Group. Lancet. 2008; 371:1839.

9 DECREASE-IV 1066 intermediate-risk surgery 2x2 factorial randomized design started 1 month before surgery bisoprolol (2. mg daily) titrated to HR 0-70 & sbp >100 mm Hg fluvastatin (80 mg daily) cardiac death plus nonfatal MI at 30-days significantly lower in bisoprolol 2.1% vs. 6.0%, P=0.002 nearly all nonfatal MIs no significant difference with fluvastatin 3.2% vs. 4.9%, P=0.17 Dunkelgrun. Ann Surg 2009; 249:921. DECREASE-IV Event rates 1.9% (bisoprolol only) 4.1% (fluvastatin only) 2.2% (both) 7.8% (neither) No significant difference in overall mortality No significant difference in stroke 0.7% (4 in bisoprolol) 0.6% (3 in control), p = 0.68 Dunkelgrun. Ann Surg 2009; 249:921. DECREASE-IV vs POISE DECREASE-IV low-dose bisoprolol 1 month before surgery titrated not placebo-controlled open-label, not blinded POISE medium-dose metoprolol several hours before surgery fixed dosing placebo-controlled double blinded Perioperative β-blockade in Long-Term Users 2000 on outpatient β-blockers colorectal or bariatric surgery prospective observational study in Washington State 66% discontinued β-blockers vs 34% continued significantly higher 90-day risk for death or cardiac complications % vs. 3% unadjusted adjusted odds ratios ~2.0 POISE Study Group. Lancet. 2008; 371:1839. Dunkelgrun. Ann Surg 2009; 249:921. Kwon. Surgical Care and Outcomes Assessment Program. Arch Surg 2012;147:467. Poldermans. Circulation Perioperative statins Poldermans. Circulation Kertai. Am J Med Lindenauer. JAMA Durazzo. J Vasc Surg DECREASE IV case control study of 2816 major vascular surgeries 160 case-patients (.8%) died in periop period (30d) two controls identified for each case-patient matched only by type of surgery statin use at time of surgery 8% vs 2% case-patients vs control (P < 0.001) despite higher prevalence of known CV disease among case-pts significantly lower perioperative mortality if on statin adjusted OR 0.22 (CI, 0.10 to 0.47) Poldermans. Circulation. 2003;107:1848.

10 Poldermans. Circulation limitations case control design all cause mortality analyzed (4% non-vascular deaths) methods of multivariate modeling not described in detail patients that died were sicker at baseline -blockers used less in those that died (p<0.001) Restricted analysis of those on -blockers No significant effect of statin on mortality OR 0.30 (9% CI ) Kertai. Am J Med Retrospective case control study of 10 patients abdominal aortic aneurysm repair followed for median of 4.7 years statin users after adjusting for clinical risk factors & beta-blocker use all-cause mortality HR 0.4 (9% CI 0.3 to 0.6; P0.001) cardiovascular mortality HR 0.3 (9% CI: 0.2 to 0.6; P 0.001) limitations Baseline characteristics between statin vs non-statin ACE 43% vs 29%, p=0.003 ASA 36% vs 18%, p<0.001 BB 71% vs 44%, p<0.001 Unclear how adjusted for covariates Poldermans. Circulation. 2003;107:1848. Kertai. Am J Med. 2004;116: Lindenauer. JAMA retrospective cohort 780,91 major noncardiac surgeries at 329 U.S. hospitals ~10% got lipid-lowering therapy periop ~3% died during hospitalization treatment with lipid-lowering agents assoc with lower crude mortality 2.13% vs 3.0%, P<.001 adjusted OR, 0.62; 9% CI, NNT to prevent postop death = 8 (9% CI, 77-98) Durazzo. J Vasc Surg double-blind RCT of atorvastatin 20 mg vs placebo 100 vascular surgery patients vascular surgery average 30 days after randomization cardiovascular events at 6-month follow-up death from cardiac cause, nonfatal MI, unstable angina, & stroke 4 (8.0%) vs 13 (26.0%) in atorvastatin vs placebo (p=.031) significant increase in AST (21 vs 19 U/L) & ALT (20 vs 1 U/L) Lindenauer. JAMA. 2004;291:2092. Durazzo. J Vasc Surg 2004;39: ACC Recommendations CLASS I Continue if on statins (B) CLASS IIa Reasonable for vascular surgery with or without risk factors (B) CLASS IIb Consider for intermediate-risk & at least 1 risk factor (C) Perioperative Statins retrospective study of 99,000 major surgeries abdominal, cardiac, thoracic, vascular within 3 days of hospitalization statin users matched to non-users risk for AKI or renal replacement therapy adjusted odds ratios in for three definitions of AKI 6.9% vs 8.% incidence Brunelli. Am J Med 2012; 12:119.

11 The -year-old man from the previous question admitted for planned AAA repair The vascular surgeon arranges preop nuclear exercise stress test which reveals a medium-sized anterior wall reversible defect. Revascularization for high-risk patients What would be expected as an outcome from coronary revascularization before proceeding to vascular surgery? 1. Decreased risk for perioperative MI. 2. Decreased risk for perioperative MI & mortality. 3. Increased risk for perioperative MI. 4. Increased risk for perioperative MI & mortality.. No difference in risk for perioperative MI & mortality. Adapted from MKSAP Revascularization Preoperative CABG Prophylactic revascularization vs medical treatment Only one controlled prospective study CASS registry 1961 high-risk surgery abd, vascular, thoracic, head /neck CABG vs medically managed CAD fewer postop deaths 1.7% vs 3.3%, P=.03 fewer MIs 0.8% vs 2.7%, P= low-risk surgery urologic, orthopedic, breast, skin 1% mortality regardless of prior coronary intervention Eagle. Circulation 1997 Sep 16;96(6):1882 Preoperative CABG Cardiac risk reduction in high-risk noncardiac surgery equaled risk of CABG itself 2-3% mortality of CABG in CASS registry Eagle. Circulation 1997 Sep 16;96(6):1882 Domanski. Am J Cardiol 199;7(12):829 Preoperative PTCA Bypass Angioplasty Revascularization Investigation (BARI) 934 patients with multivessel disease randomized to PTCA or CABG 01 had unplanned noncardiac surgery 20 after CABG & 21 after balloon angioplasty Cardiac event rates 0.8% vs 3.6% if revascularized < 4 yrs vs 4 yrs previously Perioperative event in subsequent noncardiac surgery CABG group PTCA group 30-day Mortality 1.6% 1.6% Nonfatal MI 0.8% 0.8% Hassan. Am J Med 2001;110(4):260

12 PCI: Bare-Metal Coronary Stents 40 stents within 6 weeks before surgery Adverse outcomes 11 major bleeding episodes 7 MI s 8 deaths PCI: Bare-Metal Coronary Stents delay elective surgery for 4-6 weeks but not for > 12 weeks restenosis may begin to occur allows proper thienopyridine use 1-week delay after discontinuation before surgery daily aspirin should be continued if possible All deaths & MI s stents within 2 weeks of noncardiac surgery Kaluza JACC 2000;3:1288 Coronary Artery Revascularization Prophylaxis Trial 10 undergoing vascular operations at 18 Veterans Affairs medical centers 70% coronary stenosis suitable for revascularization expanding abdominal aortic aneurysm (33%) arterial occlusive disease of the legs (67%) RCT of revascularization vs medical therapy percutaneous coronary intervention in 9% bypass surgery in 41% McFalls. N Engl J Med 2004;31:279 Coronary Artery Revascularization Prophylaxis Trial median time to vascular surgery 4 vs 18 days in revascularization vs no-revasc group (P<0.001) mortality at 2.7 years 22% vs 23% in revascularization vs no-revasc group relative risk 0.98 (9% CI, 0.70 to 1.37; P=0.92) postoperative myocardial infarction within 30 days defined by elevated troponin 12% vs 14% in revascularization vs no-revasc group (P=0.37) McFalls. N Engl J Med 2004;31:279 Coronary Artery Revascularization Prophylaxis Trial 680 patients who underwent coronary angiography excluded nonobstructive coronary arteries (363 patients) CAD not considered amenable to successful revascularization (21) at least 0% stenosis of left main coronary artery (4) left ventricular ejection fraction of < 20 % (11) severe aortic stenosis (8) Refusal to participate, by either patient or referring MD (29) Coronary Artery Revascularization Prophylaxis Trial Conclusion: revascularization before elective major vascular surgery does not improve long-term survival among patients with stable coronary artery disease McFalls. N Engl J Med 2004;31:279 McFalls. N Engl J Med 2004;31:279

13 DECREASE-V pilot study Randomized 101 vascular surgery with 3 risk factors & extensive ischemia on stress Revascularization + medical therapy vs medical alone PCI (DES 94%) in 6% & CABG in 3% dual antiplatelets continued No difference in outcomes 30-day all-cause death or nonfatal MI 43% vs 33% (OR: 1.4, 9% CI: 0.7 to 2.8, P=0.30) postoperative troponin elevations 38.8% vs 34.7% high 1-year all-cause death or MI 49% vs 44% (OR: 1.2, 9% CI: 0.7 to 2.3, P=0.48) Preoperative PCI: RCT CARP trial used bare-metal stents DECREASE-V pilot trial used DES neither showed preop PCI with stents prevents perioperative death or MI Poldermans. J Am Coll Cardiol 2007;49:1763. Indications for revascularization Perioperative Management of Prior PCI Same as if not facing noncardiac surgery Left main > 0% >70% LAD and > 70% L Cx Triple vessel CAD >70% prox LAD and extensive ischemia &/or EF<0% Stable angina with 1 or 2 vessel sig CAD without > 70% proximal LAD but with large area of ischemic myocardium at risk Significant ischemia despite max medical Rx Preoperative PCI: DES 192 surgeries within 2 years of PCI 48% bare-metal & 4% DES early-surgery (clopidogrel required) bare-metal stent 1 month sirolimus stent 3 months paclitaxel stent 6 months MACE (all fatal) at 30 days 13.3% vs 0.6% in early- vs in late-surgery all had discontinued antiplatelets before surgery no difference between BMS & DES transfusions 24% on antiplatelets & 20% off antiplatelets (p=0.0) Schouten J Am Coll Cardiol 2007;49:122 Preoperative PCI: DES largest prospective, observational multicenter study 103 surgeries within 12 months of stent bare-metal & DES stent type unknown in 79 4% combined complications All cardiac adverse events except two bleeding % cardiac death, 12% MI, 22% myocardial injury O.R if recent stent (<3 vs >90 days before surgery) only 4% bleeding complication even though all got therapeutic UFH or enoxaparin estimated % of stents from their institutions underwent subsequent noncardiac surgery Vicenzi. Br J Anaesth 2006;96:686

14 AHA/ACC/SCAI/ACS/ADA advisory report PCI candidates likely to require surgery within 12 months consider bare metal stent or balloon angioplasty instead of routine use of DES Elective procedures with significant risk of bleeding defer until completed thienopyridine therapy 12 months after DES 1 month for bare-metal stent DES should not be implanted. If 12 months of dual-antiplatelet therapy contraindicated such as planned noncardiac surgery Clopidogrel Before Vascular Surgery 10,000 vascular surgeries in multicenter registry Within 48 hours before surgery 69% on aspirin 2% on clopidogrel 10% on both 19% on neither incidence of reoperation for bleeding similar among all four groups about 1% For DES undergoing procedures that mandate discontinuation of thienopyridine aspirin should be continued if at all possible thienopyridine restarted as soon as possible Circulation 2007;11: no significant between-group differences in need for blood transfusion in average number of units given Stone. J Vasc Surg 2011; 4: year-old man with MI 4 years ago, type 2 DM, and HTN is being evaluated for TKR. Until 1 month ago, he was able to walk 4 blocks but now only 1 block due to knee pain. He has occasional chest pain that develops only after walking too quickly. There has been no change in the severity or frequency of the chest pain. Meds are metoprolol, fosinopril, atorvastatin, insulin glargine, and aspirin. His vitals are normal. Exam: no JVD, clear lungs and no murmurs or gallops. Cr 1. mg/dl (132.6 µmol/l). ECG shows old Q s inferiorly. Chest radiograph is normal. Which of the following is the most appropriate preoperative cardiac testing? 1. Coronary angiography 2. Dobutamine stress echocardiography 3. Exercise (treadmill) thallium imaging 4. Resting two-dimensional echocardiography. No additional testing is indicated Take Home Points Clinical predictors, functional status & type of procedure Patients with adequate functional capacity and without active cardiac conditions can usually proceed to surgery without preoperative cardiovascular testing. Several indices exist that can quantify perioperative cardiac risk. In patients with active cardiac conditions, noncardiac elective surgery should be delayed or canceled pending further evaluation and treatment. Medical Management Conflicting beta-blocker trials. β-blockers and statins should be continued perioperatively in patients already taking them. Revascularization No evidence to support prophylactic revascularization in asymptomatic ischemia or stable angina MKSAP 1.