Perioperative cardiovascular risk identification and modification

Perioperative cardiovascular complications (including myocardial ischemia and myocardial infarction) are the predominant cause of morbidity and mortality in patients undergoing noncardiac surgery. The pathophysiology of perioperative myocardial infarction is complex. Prolonged myocardial ischemia due to the stress of surgery in the presence of a hemodynamically significant coronary lesion, leading to subendocardial ischemia, and acute coronary artery occlusion after plaque rupture and thrombus formation contribute equally to these devastating events. Perioperative management aims at optimizing the patient’s condition by identification and modification of underlying cardiac risk factors and diseases. The first part of this chapter covers current knowledge on preoperative risk assessment. Current risk indices, the value of additional testing as well as new preoperative cardiac risk makers are investigated. During recent decades there has been a shift from the assessment and treatment of the underlying culprit coronary lesion toward a systemic medical therapy aiming at prevention of myocardial oxygen supply demand mismatch and coronary plaque stabilization. In the second part of this chapter risk reduction strategies are discussed, including beta-blocker therapy, statins, aspirins and preoperative prophylactic coronary revascularization in noncardiac surgery. The final part of this chapter will focus on long-term cardiovascular risk reduction. Patients who underwent non-cardiac vascular surgery are particular prone to long-term adverse cardiac outcome. The goal of perioperative cardiovascular risk identification and modification should not be limited to the perioperative period, but should extent well into the postoperative period.