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Expired CME Article

Perioperative Cardiac Evaluation: Novel Interventions and Clinical Challenges

Donna L. Mercado, MD, David Y. Ling, MD, Gerald W. Smetana, MD
Volume: 100 Issue: 5 May, 2007

Abstract:

Cardiac complications are one of the most important sources of morbidity and mortality after noncardiac surgery. In this review, we discuss the pathophysiology of postoperative cardiac complications and published risk indices and guidelines that allow an estimation of preoperative risk. Recent evidence has challenged the primary role of perioperative beta blockers as a risk reduction strategy. The highest level of evidence for their use is for patients with coronary artery disease or multiple risk factors undergoing vascular surgery. Beta blockers may provide no benefit or may be potentially harmful for low- and intermediate-risk patients and surgeries. For patients with contraindications to beta blockers, diltiazem and clonidine are alternative agents that reduce cardiac risk. Statins are emerging as another potential strategy to reduce cardiac risk, although the evidence is based primarily on retrospective analyses. Coronary artery revascularization does not reduce cardiac complications after noncardiac surgery among patients with stable coronary artery disease.


Key Points


* Postoperative cardiac complications are common and are a major cause of perioperative morbidity and mortality.


* The Revised Cardiac Risk Index and the American Heart Association/American College of Cardiology guidelines on preoperative cardiovascular evaluation each provide tools to estimate cardiac risk before surgery.


* Recent evidence has questioned the value of perioperative beta blockers; benefit remains likely for intermediate- and high-risk patients.


* Diltiazem, clonidine, and statins each may reduce risk in selected patients.


* Coronary revascularization does not reduce perioperative cardiac risk for patients with stable coronary artery disease.

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