Preoperative cardiac risk assessment and management of elderly men with an abdominal aortic aneurysm

Abstract

A 70-year old man presented with an abdominal aortic aneurysm. He was worried as his mother died suddenly of a ruptured aortic aneurysm at the age of 55 years and requested for an ultrasound examination. The ultrasound showed an aortic aneurysm of 72 mm. The patient was referred to a vascular surgeon. He gave a history of hypercholesterolemia but was intolerant to statins. Interestingly muscle complaints did not resolved after stopping statins. Two years earlier he had started beta-blocker therapy for mild hypertension. He smoked ten cigarettes a day for the last 40 years, but stopped when the aneurysm was diagnosed. He had chest pain which progressed the year prior to his admission and dyspnea with moderate exercise at a round of golf. He was referred to a cardiologist for preoperative screening. Physical examination showed a friendly man, with blood pressure 145/58 mmHg and an irregular pulse of 88 bpm. Examination of the chest revealed no abnormalities of the heart. Palpation of the abdomen showed an aortic aneurysm with an estimated diameter of 7 cm. Routine preoperative blood tests showed an elevated fasting glucose of 5.2 mmol/L and low-density lipoprotein (LDL) cholesterol of 4.8 mmol/L. Electrocardiography showed atrial fibrillation and pathological Q-waves in leads V1-V3, suggestive of an old anterior myocardial infarction. A coronary CT-scan was performed that revealed a significant lesion of the left anterior descending coronary artery (LAD). Left ventricular function was normal with an ejection fraction of 48%. The recently diagnosed atrial fibrillation was managed with Coumadin therapy. Coronary angiography was requested. It confirmed the presence of single-vessel coronary artery disease and in the same session a coronary stent was placed successfully in the LAD (Fig. 1.1a, b).