Symptomatic Atherosclerosis: the tip of the iceberg

Vascular surgery patients are at increased risk for developing adverse cardiac events, such as myocardial ischemia or infarction, associated with postoperative morbidity and mortality. Perioperative cardiac complications, therefore, remain an area of clinical interest and concern in patients undergoing vascular surgery. Importantly, it has been demonstrated that the great majority of cardiac events in vascular surgery patients are asymptomatic. The high frequency of perioperative cardiac complications reflects the high prevalence of underlying coronary artery disease. Surgical procedures can be classified to be associated with low-risk (<1%), intermediate-risk (1-5%), or high-risk (>5%) for the development of perioperative cardiac complications. Open lower extremity revascularization and open aortic procedures are considered high-risk surgery. Carotid surgery and endovascular aortic aneurysm repair are considered to have intermediate cardiac risk. Over the years, perioperative risk assessment has evolved significantly in order to detect surgical patients with myocardium at risk due to coronary artery disease. Several risk indices have been developed to identify patients at risk, of which the Revised Cardiac Risk index is currently widely used. Cardiac risk factors imbedded in the Revised Cardiac Risk index are (i) ischemic heart disease, (ii) symptomatic heart failure, (iii) cerebrovascular disease, (iv) insulin dependent diabetes mellitus, (v) renal dysfunction, and (vi) high-risk surgery. However, preoperative risk stratification for adverse cardiac outcome using traditional cardiac risk indices is considered suboptimal, indicating the necessity to improve cardiac evaluation before surgery. These days, the physician needs to inform the patient about his or her perioperative risk. When preoperative risk stratification with, for instance, the use of the Revised Cardiac Risk index identifies the patient to have an increased cardiac risk, additional cardiac testing to diagnose or exclude coronary artery disease is warranted.