Perioperative risk stratification in non cardiac surgery: role of pharmacological stress echocardiography

Risk stratification before major vascular surgery is an everyday challenge for the clinical cardiologist. The prediction of events in this set of patients bears important implications, epidemiological, clinical and practical. In fact, the size of the problem is not negligible. Cardiovascular complications account for approximately half of all mortality after non cardiac surgery and are the leading cause of death in those patients [1]. Moreover, patients with peripheral vascular artery disease have a higher chance of dying for cardiac and cardiovascular causes compared to patients with no peripheral vessel disease [2]. When both severe and symptomatic peripheral vascular disease were present, the risk of death due to coronary artery disease was 10 to 15 times higher [2]. In this set of patients the incidence of hard cardiac events (myocardial infarction and death) in the post-operative period is higher when compared to other type of non cardiac surgery. These patients are not only at risk for perioperative events, but they are also subject to late hard cardiac events.The need of an effective risk stratification is to select patients in order to face safely the surgical procedure, by balancing the benefit of each procedure with the inherent risks. Once the aim of risk stratification is stated, i.e. the identification of patients with a high probability of experiencing a hard cardiac event, the criteria of selection have to be discussed.The lack of controlled and randomized trials designed to assess the best strategy of stratification for patient evaluation before major vascular non cardiac surgery brought to the definition of guidelines by the American Heart Association/American College of Cardiology [3]with the aim of: 1 – identify patients at extremely high risk in whom surgery should be canceled, or other less hazardous procedures should be considered; 2 – identify those patients in whom the optimization of medical therapy or a coronary revascularization before sur