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Coronary Artery Disease Assessment of Perioperative Cardiac Risk of Patients Undergoing Noncardiac Surgery Using Coronary Computed Tomographic Angiography Ji-won Hwang, MD; Eun-Kyung Kim, MD; Jung-Hoon Yang, MD; Sung-A Chang, MD, PhD; Young Bin Song, MD, PhD; Joo-Yong Hahn, MD, PhD; Seung Hyuk Choi, MD, PhD; Hyeon-Cheol Gwon, MD, PhD; Sang-Hoon Lee, MD, PhD; Sung-Mok Kim, MD, PhD; Yeon Hyeon Choe, MD, PhD; Jae K. Oh, MD, PhD; Jin-Ho Choi, MD, PhD
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Background—The appropriate indication for coronary computed tomographic angiography (CTA) as a part of preoperative evaluation has not been defined yet. We investigated the value of coronary CTA in patients undergoing noncardiac surgery. Methods and Results—We included 844 patients (median age, 67 years; male sex, 62%) who underwent coronary CTA for screening of coronary artery disease before noncardiac surgery. Clinically determined revised cardiac risk index were compared with the extent and severity of coronary artery disease assessed by coronary CTA. Perioperative major cardiac event (PMCE), defined as cardiac death, myocardial infarction, or pulmonary edema within postoperative 30 days, developed in 25 patients (3.0%). Significant coronary CTA finding was defined as >3 any lesions with ≥1 (diameter stenosis ≥70%) stenosis based on the relationship between the severity of coronary artery disease and PMCE risk. The risk of PMCE was 14.0% in patients with significant CTA findings, whereas 2.2% of patients without significant CTA findings regardless of revised cardiac risk index score. The predictive performance of revised cardiac risk index could be improved significantly after addition of significant coronary CTA findings (c-statistics=0.631 versus 0.757; net reclassification improvement=0.923; integrated discrimination improvement=0.051). On the basis of revised cardiac risk index and coronary CTA, the risk of PMCE could be estimated with sensitivity, specificity, positive predictive value, and negative predictive value of 76%, 73%, 8%, and 99%, respectively. Conclusions—Addition of coronary CTA to clinical risk improved perioperative risk stratification. Absence of significant coronary CTA findings conferred low PMCE risk with high specificity and negative predictive value regardless of clinical risk. Coronary CTA may improve perioperative risk stratification in patients undergoing noncardiac surgery. (Circ Cardiovasc Imaging. 2015;8:e002582. DOI: 10.1161/CIRCIMAGING.114.002582.) Key Words: coronary artery disease ◼ computed tomography ◼ perioperative care
he prediction of perioperative major cardiac events (PMCE), such as acute myocardial infarction, pulmonary edema, or primary cardiac death, of patients undergoing elective noncardiac surgery is a conspicuous component of the clinical practice. PMCE is frequently silent but one of the leading causes of death in perioperative period.1–3 Estimation of PMCE risk would be important to allow physicians doing informed decision about the appropriateness of surgery and planning perioperative management. Several clinically determined risk algorithms have been developed but showed moderate predictive performance.4,5 There is a need of a simple and strongly predictive noninvasive test that improves risk stratification.
oxygen supply demand or hypercoagulable status secondary to surgical stress or tissue injury.6–8 Therefore, assessing the presence or extent of obstructive coronary stenosis, which causes myocardial ischemia or leads to intracoronary thrombi formation at the site of ruptured plaque may be the most reasonable approach to predict PMCE. The current European Society of Cardiology or American College of Cardiology/American Heart Association guidelines recommend noninvasive pharmacological stress testing for patients who are at an elevated risk for noncardiac surgery.2,3 However, cardiac stress tests depend on the stressinduced increase of myocardial oxygen demand or hyperemia, which may not be tolerated or not be applied optimally in a considerable number of patients.9 Coronary computed tomographic angiography (CTA) is a noninvasive modality that excludes or finds coronary artery
See Clinical Perspective See Editorial by LaBounty and Eagle The most plausible pathophysiology of PMCE is myocardial infarction (MI) caused by mismatch of myocardial
2 Hwang et al Perioperative Risk Evaluation by Coronary CT
Figure 1. Study flow. *Malignant thymoma adjacent to left ventricle. CT indicates computed tomography.
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disease (CAD) with high sensitivity and specificity.10 Coronary CTA does not need any induction of cardiac stress. The prognostic value of CAD burden assessed by coronary CTA has been validated in both stable and acute patients.11–13 However, appropriate indications of coronary CTA as a part of preoperative evaluation has not been defined in the current European Society of Cardiology or American College of Cardiology/American Heart Association guidelines, mainly because of the paucity of data on coronary CTA in the setting of preoperative risk stratification.14 We investigated whether coronary CTA improves perioperative risk stratification in patients undergoing noncardiac surgery.
From January 2006 to October 2012, we included 850 patients who underwent clinically indicated coronary CTA for screening of CAD before elective surgery. Coronary CTA was performed when the patient had not been evaluated for CAD, had >1 clinical cardiovascular risk factors or taking cardiovascular medications, and had no contraindication for CT, such as renal failure, any potential of pregnancy, contraindications to β-blockade or nitroglycerin. The median interval between coronary CTA and surgery was 13 days. We did not enroll patients who had history of coronary revascularization to avoid potential bias related to stent or bypass graft. One patient who underwent removal of thymoma adjacent to left ventricle, and 5 patients with inadequate CTA image were excluded. Finally 844 patients were enrolled in the analysis (Figure 1). This study was approved by the local institutional review board and individual consent was waived.
Assessment of Preoperative Clinical Data Dedicated research nurses investigated clinical data on electric medical records. The patient’s clinical history and functional capacity were evaluated according to the American College of Cardiology/American Heart Association guidelines on perioperative cardiovascular evaluation for noncardiac surgery.15 Basic laboratory tests, including electrocardiography (ECG), chest x-ray, blood tests, and body mass index were evaluated within 4 weeks before surgery. Functional capacity was determined by the patient’s ability to perform a spectrum of daily activities.2 Clinical perioperative cardiac risk was assessed by revised cardiac risk index (RCRI). Briefly, RCRI score is the number of the following perioperative risk factors, such as high-risk surgery, history of ischemic
Table 1. Clinical Characteristics All (n=844)
No PMCE (n=819)
Clinical risk factors Age, y Male sex
67 (58–73) 527 (62.4)
Oral hypoglycemic agent
Body mass index, kg/m2
4 (16.0) 23.5 (21.3–26.4)
0.63 0.70 0.23
Functional capacity 703 (90.4)
Moderate to good
21 (84.0) 2 (8.0)
Poor or sedentary
Laboratory tests Hemoglobin, g/dL
C-reactive protein, mg/dL
Medications Antiplatelet agents
Calcium channel blockers
Data are shown as median (first to third quartile) or n (%). P Value by χ test or Mann–Whitney test. ACEi indicates angiotensinconverting enzyme inhibitor; ARB, angiotensin II receptor blocker; and PMCE, perioperative major cardiac event. 2
3 Hwang et al Perioperative Risk Evaluation by Coronary CT heart disease, pulmonary edema, cerebrovascular disease, insulin-dependent diabetes mellitus, and serum creatinine >2.0 mg/dL.16
Perioperative Major Cardiac Event PMCE was defined as MI, pulmonary edema, or cardiac death within 30 days after noncardiac surgery. MI was defined by the third universal definition of MI, based on troponin I exceeding 99th percentile of reference value.17 Pulmonary edema was defined by chest x-ray in an appropriate clinical setting. Cardiac death was defined by unexplained sudden death or death secondary to MI or other cardiovascular disease.
Acquisition of Coronary CT Angiography Data
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CT was performed with a 64- or 128-slice multidetector scanner (Aquilion 64; Toshiba Medical Systems, Tokyo, Japan and SOMATOM Definition Flash; Siemens Medical Solution, Forchheim, Germany). Oral β-blocker was used to keep heart rate <65/min. Sublingual nitroglycerin was given 1 minute before scanning. A bolus of 80 to 100 mL of nonionic contrast medium was injected intravenously at a flow rate of 5 mL/s followed by an injection of saline 50 mL at 5 mL/s. The scan of 64-slice CT was retrospective gated helical mode without ECG pulsing. Scan parameters were 120-kV tube voltage, 400-mA tube current, 400-ms gantry rotation time, 0.22 to 0.25 pitch, and 64×0.5-mm detector collimation. A volume image data set was reconstructed to 0.5-mm slices. For 128-slice scanner, retrospective ECG-gated helical technique with the full radiation dose window set at 68% to 78% of the R–R interval was applied. A reduced dose with 4% of full radiation dose during acquisition window was adapted for the rest of the R–R interval to minimize radiation. Scan parameters were 120-kV tube voltage, 400-mA tube current, 280-ms gantry rotation time, 0.22 to 0.24 pitch, and 2×64×0.6-mm detector collimation resulting in 2×128×0.6-mm sections. Images were reconstructed using 0.6-mm slices. Coronary artery calcium (CAC) imaging was not done in most patients to save irradiation.
Analysis of the Severity, Extent, and Proximity of Coronary Artery Plaque A dedicated workstation (iNtuition; Terarecon, Foster City, CA) was used. The extent and severity of CAD was assessed by the following methods that have been validated and shown prognostic implication.18,19 The degree of stenosis in 3 major epicardial arteries and the largest firstorder branches of each major epicardial arteries were assessed.20 Luminal diameter stenosis (DS) was classified as none (DS=0%), minimal (1%– 24%), mild (25%–49%), moderate (50%–69%), severe (70%–99%), and total obstruction (100%). We assumed the same hemodynamic significance for DS=0% and DS=1% to 24%, and merged them into single category. One-, 2-, or 3-vessel disease was defined based on the presence of DS≥50% in major epicardial arteries. The overall extent of CAD was assessed by Segment Involvement score, which is the number of coronary artery segments with stenosis irrespective of the severity (0–16). The severity and proximity of stenosis was measured using Duke Jeopardy score, which is defined by the presence of DS≥50% in left main or DS≥70% in left anterior descending artery, diagonal branch, left circumflex coronary artery, obtuse marginal branch, or posterior descending artery. Each segment is assigned 2 points and the maximum score is 12.21
Results Patients All patients were followed ≤30 days after surgery. PMCE occurred in 25 patients (3.0%; median age, 70 years; 16 men) and comprised 15 nonfatal acute myocardial infarction, 6 fatal MI, 1 pulmonary edema, and 3 primary cardiac death. Patients with PMCE had lower serum albumin and higher creatinine (P<0.05). A preoperative β-blocker or statin was used in 20.3% and 19.9%, respectively, and was not related to PMCE (P=NS; Table 1). The risk of PMCE in each surgical procedure is shown in Table 2.
Coronary CTA Overall, the more severe the stenosis or extent of CAD, the lesser the number of the patients. Approximately half of the patients showed none to mild (DS=0%–24%) stenosis (n=364; 46.7%). Less than one fourth of the patients had significant stenosis defined by DS≥50% (n=201; 23.8%). The number of patients with mild stenosis (DS=25%–49%), moderate stenosis (DS=50%–69%), severe stenosis (DS=70%–99%), and total occlusion (DS=100%) was 249 (29.5%), 131 (15.5%), 45 (5.3%), and 25 (3.0%), respectively. Single-, 2-, and 3- vessel disease was found in 119 (14.1%), 50 (5.9%), and 31 (3.7%) patients, respectively (Table 3).
Predictive Value of RCRI and Coronary CTA PMCE risk increased according to the RCRI score, from 1.2% to 6.3%. Using RCRI=1 as a reference group, patients with RCRI ≥3 had 5-fold increased odds of PMCE (P=0.034). PMCE risk also increased consistently according to the severity of stenosis or the number of obstructive major coronary artery (P<0.001, all). Using DS=0% to 24% as a reference group, the odds of PMCE increased consistently and significantly ≤15-fold according to the maximal severity of stenosis. Compared with coronary arteries with nonobstructive stenosis (DS<50%), patients with 1-, 2-, or 3-vessel disease had 4- to 17-fold increased odds of PMCE (P<0.001; Table 3). Table 2. Risk of PMCE in Each Surgical Procedure n
Surgery 496 (58.8)
Analysis was done on per-patient basis if not indicated otherwise. Continuous variables are shown as median with first to third quartiles. Continuous and categorical variables were compared using Mann–Whitney, Kruskal–Wallis, or χ2 test, appropriately. The dosedependent response between PMCE risk and clinical score or coronary CTA scores was assessed by Jonckheere–Terpstra test. Optimal cutoff of each scoring system was derived from Youden J statistic. The predictive performance of clinical score or coronary CTA scores were calculated and compared each other using receiver operating characteristics analysis, integrated discrimination improvement, and net reclassification improvement.22,23 R version 3.1.1 (R Foundation for Statistical Computing, Vienna, Austria) was used. A 2-tailed P<0.05 was considered statistically significant.
Head and neck, neurosurgery
Spinal or local anesthesia
All surgery Anesthesia
Data are shown as n (%). In the number of patients, percentage is based on the number of all surgery. In the number of PMCE, percentage is based on the number of patients in the first column. PMCE indicates perioperative major cardiac event.
4 Hwang et al Perioperative Risk Evaluation by Coronary CT Table 3. RCRI, the Severity of Coronary Artery Disease, and the Risk of PMCE Frequency (n, %)
Event (n, %)
Odds ratio (95% CI)
Maximal stenosis of any coronary artery 0%–24%
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PMCE increased consistently according to maximal stenosis or the number of obstructive major coronary artery. P<0.001 by Kruskal–Wallis test and Jonckheere–Terpstra test, all. CI indicates confidence interval; PMCE, perioperative major cardiac event; and RCRI, revised cardiac risk index.
Comparison of Coronary CT Angiography Scores and RCRI Patients with RCRI scores higher than optimal cutoff (RCRI>2) showed 2.7-fold increased odds of PMCE compared with patients with lower RCRI scores (P=0.018). Patients with coronary CTA scores higher than optimal cutoff showed 5- to 8-fold increased odds of PMCE compared with patients with coronary CTA scores lower than optimal cutoff, even after adjusted with RCRI (P<0.001, all; Table 4).
Additive Value of Coronary CT Angiography Scores on the Predictive Value of RCRI Receiver operating characteristic curve and reclassification analyses showed that 2 coronary CTA scores, Segment Involvement score >3 and Duke Jeopardy score >0, were both
additive to the risk predicted by RCRI and also additive to each other (P<0.05, all; Table 5; Figure 2). Coronary CTA could reclassify the PMCE risk of patients with the same RCRI score. In RCRI category 2 to 3, the odds of PMCE was 3- to 17-fold higher in patients with significant coronary CTA finding compared with patients without significant CTA finding (P<0.05; Figure 3; Table 6). Statistical results were not available in RCRI category 1 or 4 because of limited number of PMCE cases. On the basis of RCRI and significant CTA findings, the risk of PMCE could be estimated with sensitivity, specificity, positive likelihood ratio (+LR), negative likelihood ratio (−LR), positive predictive value (PPV), and negative predictive value of 76.0% (54.9%–90.6%), 72.8% (69.6%–75.8%), 2.8 (2.2–3.5), 0.3 (0.2–1.7), 7.9% (4.8%–12.0%), and 99.0% (97.8%–99.6%), respectively.
Table 4. The Optimal Cutoff Values of RCRI and CT Scores for Prediction of PMCE Scores
Optimal Cutoff Value
Odds Ratio (95% CI)
Adjusted with RCRI Stenosis ≥70%
… 0 (0– 0)
Adjusted with RCRI
Duke Jeopardy score
Adjusted with RCRI Segment Involvement score Adjusted with RCRI
… 0 (0–1) … 0 (0–5)
P Value 0.018 <0.001
Optimal cutoff value of clinical or CT scores were calculated by Youden J statistic. The range of each scores were RCRI, 1 to 4; Segment Involve score, 0 to 16; Duke Jeopardy, 0 to 12. Any stenosis ≥50% or ≥70% were dichotomous values and treated as 0 or 1. CI indicates confidence interval; CT, computed tomography; PMCE, perioperative major cardiac event; and RCRI, revised cardiac risk index.
5 Hwang et al Perioperative Risk Evaluation by Coronary CT Table 5. Additive Value of Coronary Computed Tomographic Angiography Scores On the Predictive Value of RCRI Receiver Operating Characteristics
IDI indicates integrated discrimination improvement; NRI, net reclassification improvement; and RCRI, revised cardiac risk index. *P Value compared with RCRI is shown. Downloaded from http://circimaging.ahajournals.org/ by guest on April 4, 2017
Discussion Our result is the largest of its kind that investigated the clinical role of preoperative coronary CTA. Coronary CTA enabled discrimination of high-risk subgroup from low-risk subgroup in patients with the same clinical risk. On the other side, patients without significant coronary CTA finding showed low PMCE risk irrespective of the clinically determined risk.
Rationale of Coronary CT Angiography for Perioperative Risk Stratification Coronary CTA provides reliable comprehensive characterization of CAD and does not need induction of cardiac stress. Therefore, coronary CTA can be performed even when the other noninvasive modalities are not adequate or contraindicated. Indeed, coronary CTA is well suited to patients intolerant to cardiac stress test (eg, orthopedic or vascular surgery, poor general condition), patients with contraindication to pharmacological agents (eg, asthma or AV block), left ventricular dysfunction, or left bundle branch block.24 Coronary CTA is also sensitive to high-risk coronary anatomy (eg, left main disease or multivessel disease involving proximal left anterior descending artery), in which stress test may carry risk and revascularization would be prioritized during elective noncardiac surgery.25 Negative predictive value was high (99.0%) but PPV was only 7.9% in our study. It is explained by Bayes’ theorem, that is, any test attempting to predict a relatively uncommon event would have high negative predictive value but low PPV. However, the predictive performance of coronary CTA was comparable with the historical data of the other noninvasive tests. In European Society of Cardiology and American College of Cardiology/American Heart Association guidelines, the PPV and negative predictive value were 2% to 20% and 97% to 100% for myocardial perfusion scintigraphy, and 0% to 33% and 93% to 100% for dobutamine stress echocardiography.2,15 The +LR and −LR of coronary CTA were 2.8 (95% confidence interval, 2.2–3.5) and 0.3 (0.2–1.7), respectively, whereas a recent meta-analysis of noninvasive stress tests reported +LR=1.8 (1.6–2.1) and −LR=0.4 (0.4–0.5) for myocardial perfusion scintigraphy, +LR=4.1 (3.2–6.7) and −LR=0.2 (0.2–0.3) for stress echocardiography, respectively.26
On the basis of our data, perioperative CTA cannot be endorsed in all patients. However, selective coronary CTA may be beneficial for risk stratification of high-risk patients with RCRI>2 as shown in Figure 3. The cost, radiation exposure, and risk of renal injury related to contrast dye should be also taken into account.
Future Development in Coronary CTA for Prediction of Perioperative Risk In our study, both the severity and the extent of CAD were significantly related to the risk of PMCE. Consequently, combination of Segment Involvement score and Duke Jeopardy score, which reflect both findings, showed the highest predictive performance. Interestingly, the optimal cutoff of CAD burden was >3 plaques accompanied by ≥1 severe (DS≥70%) stenosis. Invasive hemodynamic studies have shown poor correlation between anatomic stenosis and hemodynamic significance. Less than half of anatomically significant stenosis causes myocardial ischemia, and a considerable portion of anatomic multivessel disease is functionally single-vessel disease.27–29 Additional myocardial perfusion imaging or sophisticated computational analysis of CTA that enables noninvasive
Figure 2. The c-statistic of revised cardiac risk index (RCRI) increases by addition of Segment Involvement score and Duke Jeopardy score. *P<0.05 between RCRI and the other variables.
6 Hwang et al Perioperative Risk Evaluation by Coronary CT A
C Downloaded from http://circimaging.ahajournals.org/ by guest on April 4, 2017
Figure 3. Addition of coronary computed tomographic angiography (CTA) scores to revised cardiac risk index (RCRI) enabled reclassification of perioperative major cardiac event (PMCE) risk into high risk and low risk. The area of bubble matches the number of patients in each category. *P<0.05. A, PMCE risk of each RCRI category is shown in gray bubbles. P<0.001 by Jonckheere–Terpstra test for trend. B to D, In patients with RCRI=1, PMCE risk was not different between patients with and without significant coronary computed tomographic angiography (CTA) findings (p=NS). In patients with RCRI>1, patients with significant coronary CTA findings showed higher PMCE risk (red bubbles) compared with patients without significant coronary CTA findings (blue bubbles). See Table 6 for detailed statistics.
assessment of myocardial ischemia or coronary flow may increase vastly the value of preoperative coronary CTA.30–33 Our result may offer the clue to the mechanism of PMCE and the strategy of selective preventive measures. On the basis
of our result, ischemia-inducing lesion seems to be crucial for the development of PMCE. Perioperative use of β-blockers decreased the risk of MI but increased the risk of stroke and death in the PeriOperative ISchemic Evaluation (POISE)
Table 6. Reclassification of the Risk of PMCE Based on the Coronary Computed Tomographic Angiography Coronary CT Angiography Scores RCRI
Segment Involvement Score≤3
Segment Involvement Score>3
Odds Ratio (95% CI)
Duke Jeopardy=0 1
Segment Involvement score≤3 and Duke Jeopardy=0
Segment Involvement score>3 and Duke Jeopardy>0
Data are shown as the number of patients having PMCE/the number of patients (percentage of the ratio). CI indicates confidence interval; CT, computed tomography; PMCE, perioperative major cardiac event; and RCRI, revised cardiac risk index.
7 Hwang et al Perioperative Risk Evaluation by Coronary CT wtrial.34 Coronary CTA may enable selective use of preoperative β-blockers for patients having hemodynamically significant lesions and maximize the efficacy of β-blockade.35 Perioperative use of aspirin, which was not beneficial in POISE-2 trial, may also be determined based on the result of CTA to maximize the protective effect.36 However, coronary CTA may lead treating more patients based on the CTA findings. Further study would be required to investigate the true benefit of perioperative medication and the role of coronary CTA. Preoperative coronary CTA may also guide selection of invasive coronary angiography or revascularization, which should be decided prudently and balanced against the surgical risk, extent of myocardial ischemia, and the overall clinical benefit of patients.2,3,37,38
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Our result represents a single-center experience. Therefore, the optimal cutoff used in our study cannot be applied in all perioperative groups. Further work would need to be performed to determine if these values can be considered optimal in other populations. Although coronary CTA was done based on prespecified criteria, CTA was neither first-line nor obligatory test in all patients who conformed to the criteria during the study period, which might lead selection bias. PMCE risk (3.0%) was adequate considering the study population, which has low-to-intermediate risk (1%–5% risk), but it limited the value of modeling, especially PPV. The prevalence of significant CAD was 24%, which may be considerably high. However, our data showed the lowest prevalence of CAD among published preoperative coronary CTA studies, in which prevalence of CAD ranged from 26% to 32%.25,39–42 Coronary CTA was not compared with the other noninvasive stress tests or biomarkers.43–46 Elevated cardiac troponin suggests not only coronary causes of myocardial injury but also the other noncoronary cause, such as stress-induced cardiomyopathy, sepsis, pulmonary embolism, acute heart failure, or use of cardiotoxic drugs,47 and is associated with postoperative prognosis.48,49 The value of preoperative coronary CTA needs to be compared with biomarkers or other noninvasive tests in the future study. CAC scoring imaging was not done to minimize irradiation. CAC scoring does not need contrast agent but has shown poor correlation with obstructive CAD.50 The role of CAC in the risk stratification was shown in a previous study,41 but needs further investigation and should be balanced against the additional information from CAC and potentially increased radiation exposure. Considering the cost and unavoidable exposure to contrast agent and radiation, the benefit of preoperative coronary CTA should be validated by large clinical trials in a prospective manner.9
Conclusions The perioperative risk stratification could be improved significantly by assessing the burden of coronary atherosclerosis by coronary CTA. Given the high and additive predictive performance, coronary CTA deserves to be validated its clinical benefit in a large prospective clinical trials.
Sources of Funding This study was funded by the Heart Vascular and Stroke Institute, Samsung Medical Center, Seoul, Korea.
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CLINICAL PERSPECTIVE Perioperative major cardiac event (PMCE) after elective noncardiac surgery is an important determinant of perioperative morbidity and mortality. Therefore, prediction of PMCE is invaluable to both physicians and patients for informed decision about the surgery and planning perioperative care. The most plausible pathophysiology of PMCE is myocardial infarction caused by myocardial oxygen supply demand mismatch or incracoronary thrombi formation secondary to surgically induced hypercoagulable status. Therefore, direct imaging of the burden of coronary plaque would be the most plausible modality for the prediction of PMCE. This study is the largest of its kind that investigated the predictive value of coronary computed tomographic angiography (CTA), a noninvasive coronary artery and plaque imaging modality. Compared with clinical risk, the severity and extent of coronary plaque imaged by coronary CTA was better and also additive for the prediction of PMCE. Importantly, coronary CTA could discriminate high-risk subgroup from low-risk subgroup in groups with the same clinical risk. However, absence of significant coronary CTA findings warranted low PMCE risk with high specificity and negative predictive value regardless of clinical risk. Two academic tasks would be envisioned. First, the benefit of coronary CTA needs to be investigated in a various population or in a large scale. Second, selective perioperative medication based on coronary CTA deserves to be validated its clinical benefit in a large prospective trials because perioperative medications, including β-blocker or aspirin failed to show the clinical benefit in large trials, despite numerous theoretical clinical benefits.
Assessment of Perioperative Cardiac Risk of Patients Undergoing Noncardiac Surgery Using Coronary Computed Tomographic Angiography Ji-won Hwang, Eun-Kyung Kim, Jung-Hoon Yang, Sung-A Chang, Young Bin Song, Joo-Yong Hahn, Seung Hyuk Choi, Hyeon-Cheol Gwon, Sang-Hoon Lee, Sung-Mok Kim, Yeon Hyeon Choe, Jae K. Oh and Jin-Ho Choi Downloaded from http://circimaging.ahajournals.org/ by guest on April 4, 2017
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