Perioperative cardiac events vary from brief asymptomatic injury to irreversible infarct. They may be a result of acute plaque ruptures or subtle imbalances of supply and demand. All degrees and mechanisms may result in postoperative morbidity; thus, perioperative cardiac care requires attention to many factors, including energy expenditure, circulation, inflammation, nutrition, plaque stability, and endothelial function.
Preoperative cardiac testing is usually not needed in patients who have good functional status or are undergoing low-risk procedures. Further testing is unlikely to change management, and these patients may proceed directly to surgery.
The history and physical examination, reports of previous investigations, and a relatively few specifically indicated tests are often adequate to determine the anesthetic plan even for patients in high-risk situations.
Anesthesiologists should maintain an active role in preoperative assessment. Understanding how complex medical disease influences preoperative management will benefit the patient’s preoperative experience and postoperative outcome, and anesthesiologists are well positioned to lead future research in quality improvement, safety, and best practices in preoperative medicine.
Modern perioperative medicine practice requires a working knowledge of complex medical disease, surgical techniques and their physiologic effects, as well as advances in anesthesia techniques and practices. Perioperative physicians, including internists, family practitioners, anesthesiologists, surgeons, and intensivists, are given the task of shepherding very high-risk patients through the entire surgical experience. Determining a patient’s readiness for surgery and which, if any, additional information is needed is a challenge. The risks, benefits, and alternatives to surgery must be individualized for each patient, with consideration given to comorbidities, prognosis, and goals of therapy. Perioperative testing can assist in achieving an individualized approach but should only be considered when the results of a test would indicate the need for a change in approach or therapy. For instance, some surgical procedures are unlikely to cause any more stress than activities of daily living. In those cases, perioperative testing may be inappropriate regardless of the patient’s comorbidities. Knowledge of the surgical plan as well as the medical history and anesthetic options can position the well-informed anesthesiologist to decide which preoperative investigations and preparations are needed. In essence, the paradigm of preoperative assessment is shifting from predicting risk to actively managing risk.1 The issue is less whether to cancel surgery and more whether indicated cardiac tests and management need to be done preoperatively under the supervision of the perioperative physician or postoperatively in a more elective fashion by primary care clinicians. As medical therapy of cardiovascular disease improves, routine care is sometimes as effective as interventional therapy in reducing cardiac morbidity and mortality.2
This chapter reviews the current understanding of the physiology of perioperative ischemia, followed by examination of how an individual patient’s perioperative risk can be assessed. More important, it then discusses when and how more detailed risk management should be undertaken.
The primary focus is on the patient presenting for noncardiac surgery. ...