, Volume 18, Issue 1, pp 21–27 | Cite as

Elektive nicht kardiochirurgische Operationen bei Patienten mit kardialer Grunderkrankung

Präoperative Risikoeinschätzung und perioperatives Vorgehen


Das perioperative Risiko einer unerwünschten kardialen Komplikation hängt im Wesentlichen von der präoperativen Konstitution des Patienten, dessen Begleiterkrankungen und der Größe bzw. Länge der geplanten Operation ab.

Um das perioperative kardiale Risiko besser einschätzen zu können und um die perioperative Behandlungsmöglichkeiten und das postoperative Ergebnis zu verbessern, hat die europäische Gesellschaft für Kardiologie in Zusammenarbeit mit der europäischen Gesellschaft für Anästhesiologie im Jahr 2009 neue Leitlinien verfasst. Diese Leitlinien setzen zwei Schwerpunkte: die präoperative Risikoeinschätzung, abgeleitet aus den Begleiterkrankungen des Patienten und aus der Schwere bzw. Länge des geplanten chirurgischen Eingriffes, sowie das perioperative Management in Abhängigkeit von der zuvor festgelegten Risikoeinschätzung.

In Anlehnung an diese Leitlinien gibt dieser Artikel einen kurzen Überblick zu dem Thema, wobei sich insbesondere auf die vorbestehenden kardialen Begleiterkrankungen und das perioperative kardiale Management konzentriert wird.


Perioperatives Risiko Präoperative Risikoeinschätzung Kardiale Risikofaktoren Nicht kardiochirurgische Operationen Perioperative Behandlung 



Metabolic equivalent


Transistorisch Ischämische Attacke


Automatic implantable cardioverter defibrillator

LV- Funktion

Linksventrikuläre Funktion


Nicht ST-Strecken Hebungsinfarkt


Bare metal Stent


Drug-eluting Stent


Perkutane koronar Intervention


Perkutane transluminale Ballonangioplastie

Elective non-cardiac surgery in patients with underlying cardiac disease

Preoperative risk assessment and perioperative approach


The perioperative risk of a cardiac complication is primarily determined by the patient’s preoperative constitution, any existing comorbidities as well as the extent and the duration of the intended surgery. Consequently, the European Society of Cardiology (ESC) endorsed by the European Society of Anaesthesiology (ESA) published guidelines in 2009 aiming at improving perioperative cardiac risk assessment and perioperative treatment as well as the postoperative outcome. In line with these objectives the guidelines mainly focus on two areas: the preoperative risk assessment based on the patients’ comorbidities and the anticipated severity of the intended surgery itself and secondly on the perioperative management derived from the outcome of the previous risk assessment. On the basis of these guidelines this article gives a brief overview on the subject focusing on existing cardiac comorbidities and perioperative cardiac management.


Perioperative risk Preoperative risk assessment Clinical risk factors Non-cardiac surgery Perioperative management 


  1. 1.
    Almanaseer Y, Mukherjee D, Kline-Rogers EM et al (2005) Implementation of the ACC/AHA guidelines for preoperative cardiac risk assessment in a general medicine preoperative clinic: improving efficiency and preserving outcomes. Cardiology 103:24–29PubMedCrossRefGoogle Scholar
  2. 2.
    Biondi-Zoccai GG, Lotrionte M, Agostoni P et al (2006) A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50,279 patients at risk for coronary artery disease. Eur Heart J 27:2667–2674PubMedCrossRefGoogle Scholar
  3. 3.
    Boersma E, Kertai MD, Schouten O et al (2005) Perioperative cardiovascular mortality in noncardiac surgery: validation of the Lee cardiac risk index. Am J Med 118:1134–1141PubMedCrossRefGoogle Scholar
  4. 4.
    Brady AR, Gibbs JS, Greenhalgh RM et al (2005) Perioperative beta-blockade (POBBLE) for patients undergoing infrarenal vascular surgery: results of a randomized double-blind controlled trial. J Vasc Surg 41:602–609PubMedCrossRefGoogle Scholar
  5. 5.
    Burger W, Chemnitius JM, Kneissl GD et al (2005) Low-dose aspirin for secondary cardiovascular prevention – cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation – review and meta-analysis. J Intern Med 257:399–414PubMedCrossRefGoogle Scholar
  6. 6.
    Devereaux PJ, Yang H, Yusuf S et al (2008) Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet 371:1839–1847PubMedCrossRefGoogle Scholar
  7. 7.
    Dickstein K, Cohen-Solal A, Filippatos G et al (2008) ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur Heart J 29:2388–2442PubMedCrossRefGoogle Scholar
  8. 8.
    Dunkelgrun M, Boersma E, Schouten O et al (2009) Bisoprolol and fluvastatin for the reduction of perioperative cardiac mortality and myocardial infarction in intermediate-risk patients undergoing noncardiovascular surgery: a randomized controlled trial (DECREASE-IV). Ann Surg 249:921–926PubMedCrossRefGoogle Scholar
  9. 9.
    Elhendy A, Valkema R, Van Domburg RT et al (1998) Safety of dobutamine-atropine stress myocardial perfusion scintigraphy. J Nucl Med 39:1662–1666PubMedGoogle Scholar
  10. 10.
    Ferguson TB Jr, Hammill BG, Peterson ED et al (2002) A decade of change – risk profiles and outcomes for isolated coronary artery bypass grafting procedures, 1990–1999: a report from the STS National Database Committee and the Duke Clinical Research Institute. Society of Thoracic Surgeons. Ann Thorac Surg 73:480–489; discussion 489–490PubMedCrossRefGoogle Scholar
  11. 11.
    Fox K, Garcia MA, Ardissino D et al (2006) Guidelines on the management of stable angina pectoris: executive summary: the task force on the management of stable angina pectoris of the European Society of Cardiology. Eur Heart J 27:1341–1381PubMedCrossRefGoogle Scholar
  12. 12.
    Graham I, Atar D, Borch-Johnsen K et al (2007) European guidelines on cardiovascular disease prevention in clinical practice: executive summary: fourth joint task force of the european society of cardiology and other societies on cardiovascular disease prevention in clinical practice (Constituted by representatives of nine societies and by invited experts). Eur Heart J 28:2375–2414PubMedCrossRefGoogle Scholar
  13. 13.
    Howard-Alpe GM, De Bono J, Hudsmith L et al (2007) Coronary artery stents and non-cardiac surgery. Br J Anaesth 98:560–574PubMedCrossRefGoogle Scholar
  14. 14.
    Huber KC, Evans MA, Bresnahan JF et al (1992) Outcome of noncardiac operations in patients with severe coronary artery disease successfully treated preoperatively with coronary angioplasty. Mayo Clinic proceedings. Mayo Clinic 67:15–21CrossRefGoogle Scholar
  15. 15.
    Juul AB, Wetterslev J, Gluud C et al (2006) Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial. BMJ (Clinical research ed.) 332:1482Google Scholar
  16. 16.
    Kaluza GL, Joseph J, Lee JR et al (2000) Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol 35:1288–1294PubMedCrossRefGoogle Scholar
  17. 17.
    Kelm M, Osterhues H, Hennerici MG et al (2010) Kommentar zu den ESC Guidelines for Pre-Operative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-Cardiac Surgery. Der Kardiologe 5:375–382CrossRefGoogle Scholar
  18. 18.
    Kertai MD, Boersma E, Bax JJ et al (2003) A meta-analysis comparing the prognostic accuracy of six diagnostic tests for predicting perioperative cardiac risk in patients undergoing major vascular surgery. Heart (British Cardiac Society) 89:1327–1334Google Scholar
  19. 19.
    Lee TH, Marcantonio ER, Mangione CM et al (1999) Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 100:1043–1049PubMedCrossRefGoogle Scholar
  20. 20.
    Mangano DT (2004) Perioperative medicine: NHLBI working group deliberations and recommendations. J Cardiothorac Vasc Anesth 18:1–6PubMedCrossRefGoogle Scholar
  21. 21.
    Mangano DT, Goldman L (1995) Preoperative assessment of patients with known or suspected coronary disease. N Engl J Med 333:1750–1756PubMedCrossRefGoogle Scholar
  22. 22.
    Mangano DT, Layug EL, Wallace A et al (1996) Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group. N Engl J Med 335:1713–1720PubMedCrossRefGoogle Scholar
  23. 23.
    Morris CK, Ueshima K, Kawaguchi T et al (1991) The prognostic value of exercise capacity: a review of the literature. Am Heart J 122:1423–1431PubMedCrossRefGoogle Scholar
  24. 24.
    Naughton C, Feneck RO (2007) The impact of age on 6-month survival in patients with cardiovascular risk factors undergoing elective non-cardiac surgery. Int J Clin Pract 61:768–776PubMedCrossRefGoogle Scholar
  25. 25.
    Nuttall GA, Brown MJ, Stombaugh JW et al (2008) Time and cardiac risk of surgery after bare-metal stent percutaneous coronary intervention. Anesthesiology 109:588–595PubMedCrossRefGoogle Scholar
  26. 26.
    Oosterga M, Voors AA, Pinto YM et al (2001) Effects of quinapril on clinical outcome after coronary artery bypass grafting (The QUO VADIS Study). QUinapril on Vascular Ace and Determinants of Ischemia. Am J Cardiol 87:542–546PubMedCrossRefGoogle Scholar
  27. 27.
    Poldermans D, Bax JJ, Boersma E et al (2009) Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. Eur Heart J 30:2769–2812PubMedCrossRefGoogle Scholar
  28. 28.
    Poldermans D, Bax JJ, Kertai MD et al (2003) Statins are associated with a reduced incidence of perioperative mortality in patients undergoing major noncardiac vascular surgery. Circulation 107:1848–1851PubMedCrossRefGoogle Scholar
  29. 29.
    Poldermans D, Bax JJ, Schouten O et al (2006) Should major vascular surgery be delayed because of preoperative cardiac testing in intermediate-risk patients receiving beta-blocker therapy with tight heart rate control? J Am Coll Cardiol 48:964–969PubMedCrossRefGoogle Scholar
  30. 30.
    Poldermans D, Boersma E, Bax JJ et al (1999) The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. N Engl J Med 341:1789–1794PubMedCrossRefGoogle Scholar
  31. 31.
    Rosenson RS, Tangney CC (1998) Antiatherothrombotic properties of statins: implications for cardiovascular event reduction. JAMA 279:1643–1650PubMedCrossRefGoogle Scholar
  32. 32.
    Schiefermueller J, Myerson S, Handa AI (2012) Preoperative assessment and perioperative management of cardiovascular risk. Angiology. Epub ahead of printGoogle Scholar
  33. 33.
    Sicari R, Nihoyannopoulos P, Evangelista A et al (2009) Stress echocardiography expert consensus statement-executive summary: European Association of Echocardiography (EAE) (a registered branch of the ESC). Eur Heart J 30:278–289PubMedCrossRefGoogle Scholar
  34. 34.
    Sun YP, Zhu BQ, Browne AE et al (2001) Comparative effects of ACE inhibitors and an angiotensin receptor blocker on atherosclerosis and vascular function. J Cardiovasc Pharmacol Ther 6:175–181PubMedCrossRefGoogle Scholar
  35. 35.
    Wiklund RA, Stein HD, Rosenbaum SH (2001) Activities of daily living and cardiovascular complications following elective, noncardiac surgery. YJBM 74:75–87PubMedGoogle Scholar
  36. 36.
    Yang H, Raymer K, Butler R et al (2006) The effects of perioperative beta-blockade: results of the Metoprolol after Vascular Surgery (MaVS) study, a randomized controlled trial. Am Heart J 152:983–990PubMedCrossRefGoogle Scholar
  37. 37.
    Zaugg M, Bestmann L, Wacker J et al (2007) Adrenergic receptor genotype but not perioperative bisoprolol therapy may determine cardiovascular outcome in at-risk patients undergoing surgery with spinal block: the Swiss Beta Blocker in Spinal Anesthesia (BBSA) study: a double-blinded, placebo-controlled, multicenter trial with 1-year follow-up. Anesthesiology 107:33–44PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  1. 1.Klinik und Poliklinik für Allgemeine und Interventionelle KardiologieUniversitäres Herzzentrum Hamburg (UHZ), Universitätsklinikum Hamburg-EppendorfHamburgDeutschland
  2. 2.Klinik und Poliklinik für GefäßmedizinUniversitäres Herzzentrum, Universitätsklinikum Hamburg-EppendorfHamburgDeutschland

Personalised recommendations