Vascular surgery

Only 8% of patients undergoing vascular surgery have normal coronary angiograms and 60% have significant angiographic coronary artery disease and are at increased risk for perioperative cardiac morbidity (Hertzer).

High risk patients with vascular surgery have up to a 24% incidence of cardiac events secondary to the high incidence of underlying coronary artery disease (Landesberg).

100% of patients scheduled for elective vascular surgery have coronary artery calcifications on electron-beam tomography.

Patients with abnormal stress echocardiograms receiving bisoprolol or placebo pre and postoperatively with vascular surgery have a marked reduction in the risk of myocardial infarction and death at 30 days in the treated group.

The pathogenesis of perioperative myocardial infarction not totally understood, but suspected surgical stress with surge of catecholamines can lead to hemodynamic stress, vasospasm, reduced fibrinolysis , activation of platelets and hyper coagulation (Mangano).

May increase activities that lead to rupture of coronary artery plaques by monocytic-macrophage activities increased as a result of inflammation accompanying the surgery.

In a double blind study, placebo controlled random assignment of a statin (Fluvastatin), and a beta-blocker or placebo before undergoing vascular surgery: postoperative myocardial ischemia occurred in 10.8% of Fluvastatin patients and in 19% of placebo treated patients, death occurred in 4.8% of the Fluvastatin group and 10.1% of placebo group (Dutch Echocardiographic Cardiac Risk Evaluation applying Stress Echocardiography Study group-DECREASE III Trial).

In the DECREASE III Trial Fluvastatin 80mg daily initiated a median of 37 days before vascular surgery compared to a placebo in individuals not previously given a statin: reduction of perioperative myocardial ischemia, death from cardiovascular causes or non fatal myocardial infarctions, reductions in serum lipids, reduction in inflammatory markers of high-sensitivity CRP and interleukin-6 levels were al associated with the Fluvastatin agent.

Autopsy studies of patients with fatal myocardial infarction after vascular surgery reveal that half of the patients have mismatch between myocardial oxygen supply and demand and coronary plaque ruptures account for the other 50% (Dawood, MM, Cohen, MC).

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