Preoperative evaluation of cardiac morbidity

Patients with active cardiac conditions (eg, unstable angina, decompensated heart failure, severe valcular disease, significant arrythmia) should be evaluated and treated per American College of Cardiology (ACC)/American Heart Association (AHA) guidelines before EVAR or OSR (Grade 1, Level B).

Noninvasive stress testing should be considered for patients with a history of three or more clinical risk factor factor (ie, coronary artery disease [CAD], congestive heart failure [CHF], cerebrovascular accident [CVA], diabetes mellitus [DM], chronic renal insufficiency [CRI]) and an unknown or poor functional capacity (MET <4) who are undergoing aneurysm repair, if it will change management (Grade 1, Level B).

A preoperative resting 12-lead ECG is recommended for all patients undergoing endovascular or open aneurysm repair within 30 days of planned treatment (Grade 1, Level A).

Preoperative echocardiography is recommended for patients undergoing aneurysm repair with dyspnea or heart failure (Grade 1, Level A).

Coronary revascularization prior to aneurysm repair

Coronary revascularization is recommended prior to aneurysm repair in patients with acute ST elevation MI, unstable angina, or stable angina with left main coronary artery or three-vessel disease (Grade 1, Level A).

Coronary revascularization is recommended prior to aneurysm repair in patients with stable angina with two-vessel disease that includes the proximal left anterior descending artery, and either ischemia on noninvasive testing or an ejection fraction of less than 0.5 (Grade 1, Level A).

In patients who may need AAA repair in the subsequent 12 months and in whom coronary revascularization with percutaneous coronary intervention (PCI) is appropriate, a strategy of balloon angioplasty or bare-metal stent placement followed by four to six weeks of dualantiplatelet therapy is suggested (Grade 2, Level B).

It is suggested to defer elective open AAA repair for four to six weeks after bare-metal coronary stent implantation or coronary artery bypass grafting or for 12 months after drug-eluting coronary stent implantation, if rupture risk is not high (Grade 2, Level C).

In patients who have received drug-eluting coronary stents and who must undergo open AAA repair, it is suggested to discontinue thienopyridine therapy 10 days preoperatively, continue aspirin, and restart the thienopyridine as soon as possible after surgery (Grade 2, Level C).

Perioperative medical management of coronary artery disease

Beta blockers should be continuedin patients undergoing aneurysm surgery who are currently receiving beta blockers to treat angina, symptomatic arrhythmias, or hypertension (Grade 1, Level A).

Beta blockade is recommended for patients undergoing aneurysm repair in whom preoperative assessment identifies CAD or who are at high cardiac risk due to the presence of one or more clinical risk factors (i.e. CAD, CHF, CVA, DM, CRI) (Grade 1, Level B).