Strategies in the high-risk cardiac patient undergoing non-cardiac surgery

The risk of perioperative myocardial infarction or cardiac death in patients undergoing non-cardiac surgery may be estimated by clinical risk factor analysis and by myocardial stress testing. While stress testing modalities accurately delineate reversible myocardial ischaemia, their positive predictive value is low, and it is not clear whether their implementation improves outcome when compared to risk stratification alone. Similarly, it remains to be shown that preoperative coronary revascularization is an effective strategy in reducing perioperative risk. Recent reports indicate that surgery undertaken in the first weeks after percutaneous coronary interventions may be associated with a significantly increased rate of major complications. Administration of β-blockers and α2-adrenergic agonists to high-risk patients reduces surgical morbidity and mortality, and the benefits observed with β-blockers may extend long after the operative period. In high-risk patients undergoing major surgery, pulmonary artery catheter-guided haemodynamic optimization has not been associated with better outcomes, whereas use of regional anesthetic techniques decreases the incidence of postoperative pulmonary, but not cardiac, complications.