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Cardiovascular problems in noncardiac surgery

London, Martin J

Current Opinion in Critical Care: August 2009 - Volume 15 - Issue 4 - p 333–341
doi: 10.1097/MCC.0b013e32832e4795
Postoperative problems: Edited by Jukka Takala

Purpose of review: Perioperative cardiac complications remain a major area of concern as our surgical population increases in volume, age and frequency of comorbidity. A variety of strategies can be used to optimize patients and potentially reduce the incidence of these serious complications.

Recent findings: Recent literature suggests a trend towards less invasive testing for detection and quantification of coronary artery disease and greater interest in pharmacologic ‘cardioprotection’ using β-blockers, statins and other agents targeting heart rate control and other mechanisms (e.g. reducing inflammatory responses). The recent Perioperative Ischemic Evaluation study has substantially altered this approach at least towards widespread application to lower/intermediate risk cohorts. Considerable attention has been focused on ensuring optimal standardized perioperative management of patients with a recent percutaneous coronary intervention, particularly those with an intracoronary stent. Widespread surveillance of postoperative troponin release and increasing recognition of the prognostic potential of elevated preoperative brain natriuretic peptides point towards changing strategies for long-term risk stratification.

Summary: The complexity of a particular patient's physiologic responses to a wide variety of surgical procedures, which are undergoing constant technological refinement generally associated with lesser degrees of invasivity and stress make calculation of patients' perioperative risk very challenging. At the present time, adequate information is available for the clinician to screen patients with high-risk preoperative predictors, delay elective surgery for patients with recent intracoronary stents and continue chronic β-blockade in appropriate patients. New large-scale database and subanalyses of major trials (e.g. Perioperative Ischemic Evaluation and Coronary Artery Revascularization Prophylaxis) should provide additional information to minimize perioperative cardiac risk.

Department of Anesthesia and Perioperative Care, University of California and San Francisco Veterans Affairs Medical Center, San Francisco, California, USA

Correspondence to Martin J. London, MD, Professor of Clinical Anesthesia, Anesthesia (129), 4150 Clement Street, San Francisco, CA 94121, USA Tel: +1 415 750 2069; fax: +1 415 750 6653; e-mail: londonm@anesthesia.ucsf.edu

© 2009 Lippincott Williams & Wilkins, Inc.