Perioperative Cardiac Care: From Guidelines to Clinical Practice

Cardiovascular disease is the major cause of death and disability in the Western world. The main disease underlying cardiovascular disorders is atherosclerosis. Atherosclerosis is a systemic disease affecting numerous vascular beds, including the coronary and peripheral circulation i.e. cerebrovascular, aortic and lower limb arterial circulation. The global ageing phenomenon will further increase the burden of cardiovascular disease and also enforce a change in health care towards the elderly population. Peripheral arterial disease (PAD) is a common condition. Importantly, only 1 out of 9 patients with PAD are symptomatic while vascular morbidity and mortality is estimated to be similar in patients with symptomatic or asymptomatic PAD. This poses PAD to be a major health burden. Risk factors for atherosclerotic disease are common and polyvascular disease is highly prevalent in the PAD population. The prognosis of patients with PAD is predominantly determined by the presence and extent of the underlying ischemic heart disease (IHD). The estimated cardiovascular risk in PAD is, moreover, as high as in IHD.3,4 Mc Dermott and colleagues reported already in 1997 that PAD patients received less intensive drug treatment compared to IHD patients, irrespective of comparable risk. Additionally, in a large risk factor matched population, patients with IHD received more cardiac medications, compared with PAD patients (beta-blockers 74% vs. 34%, aspirin 88% vs. 40%, nitrates 37% vs. 19%, statins 67% vs. 29% and ACE-inhibitors 57% vs. 31%, respectively). The observed poor medical control of PAD patients may be an explanation for the worse outcome of PAD patients compared with IHD patients as observed by the study of Welten et al. The REACH registry showed that cardiovascular events increased in a stepwise fashion with the number of symptomatic vascular beds.4 The combined 1-year outcome of atherothrombotic events ranged from 17% in patients with PAD as a single affected vascular bed to 26% in patients with 3 diseased vascular beds. Patients with PAD undergoing vascular surgery are known to be at higher risk for both early and late cardiovascular events compared to patients with IHD.3,7 Hertzer’s landmark study in 1000 consecutive patients undergoing surgery for PAD who underwent preoperative cardiac catheterizations reported that only 8% had normal coronary arteries, and approximately one third had severe-correctable or severe-inoperable IHD.

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