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KEY POINTS

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KEY POINTS

  1. Patients with preoperative blood pressure elevation have exaggerated perioperative blood pressure fluctuations. The American College of Cardiology/American Heart Association (ACC/AHA) Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery recommend that antihypertensive medication be continued during the perioperative period. Particular care should be taken to avoid withdrawal of β-blockers and clonidine because of the potential for withdrawal syndromes.1

  2. Recommendations for patients taking diuretics call for withholding diuretics on the day of surgery unless evidence suggests volume overload or signs and symptoms of overt congestive heart failure (CHF). In stable asymptomatic patients with chronic mild-to-moderate hypokalemia and in the absence of dysrhythmias or digitalis use, anesthesia and surgery can proceed.

  3. α2-Agonists have many desirable effects, such as minimum alveolar concentration (MAC) reduction, analgesia, anxiolysis, sedation, and sympatholysis. However, in the large multicenter, international, double-blinded, randomized, controlled Perioperative Ischemic Evaluation 2 (POISE-2) trial, clonidine did not reduce the rate of death or nonfatal myocardial infarction, but it did increase the rate of nonfatal cardiac arrest and clinically important hypotension.2 The 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery do not recommend administration of α2-agonists for prevention of cardiac events in patients undergoing noncardiac surgery.2

  4. During the perioperative period, patients maintained on angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers through the morning of the surgery have an increased number of hypotensive episodes requiring treatment with vasopressors but no difference in outcome.

  5. Perioperatively, intravenous (IV) nitroglycerin may be used for treatment of myocardial ischemia, CHF, acute volume overload, systemic and pulmonary hypertension, and coronary artery spasm. It enhances blood flow to the subendocardium and areas of ischemia by both decreasing left ventricular end-diastolic pressure and volume and improving blood flow to areas of ischemia.

  6. Multiple studies demonstrated that prophylactic perioperative β-blockade reduces cardiac mortality and morbidity. However, their aggressive prophylactic use without proper titration may result in an increased incidence of hypotension, stroke, and mortality. The ACC/AHA guidelines state that β-blockers should be titrated to effect. This should occur preferably with drugs other than metoprolol days to weeks before elective surgery in patients at risk for or with evidence of ischemia or high Revised Cardiac Risk Index scores.

  7. The calcium channel blockers represent a diverse group of compounds with dissimilar structures and pharmacologic effects. Unlike β-blockers, which all depend on blockade of receptors for their activity, the sites and mechanisms of action of the individual calcium channel blockers vary, as do their individual actions on different tissues.

  8. The use of most antidysrhythmic drugs has been dramatically limited because of increased awareness of their proarrhythmic potential and their negative impact on survival. Advances in ablation techniques and the widespread use of implantable cardioverter-defibrillators have largely replaced antidysrhythmic medications in the management of ventricular dysrhythmias.

  9. Amiodarone is considered by some the most efficacious antidysrhythmic agent available. In the intraoperative and postoperative settings, intravenous amiodarone may be used ...

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