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  • Image not available.Cardiovascular complications account for 25–50% of deaths following noncardiac surgery. Perioperative myocardial infarction (MI), pulmonary edema, congestive heart failure (CHF), arrhythmias, and thromboembolism are most commonly seen in patients with preexisting cardiovascular disease.
  • Image not available.The two most important preoperative risk factors are an unstable coronary syndrome and evidence of CHF. Generally accepted contraindications to elective noncardiac surgery include a myocardial infarction less than 1 month prior to surgery with evidence of persistent ischemic risk by symptoms or noninvasive testing, uncompensated heart failure, and severe aortic or mitral stenosis.
  • Image not available.Regardless of the level of preoperative blood pressure control, many patients with hypertension display an accentuated hypotensive response to induction of anesthesia, followed by an exaggerated hypertensive response to intubation. Hypertensive patients may display an exaggerated response to both endogenous catecholamines (from intubation or surgical stimulation) and exogenously administered sympathetic agonists.
  • Image not available.Patients with extensive (three-vessel or left main) coronary artery disease, a history of MI, or ventricular dysfunction are at greatest risk for cardiac complications. Perioperative risk following MI appears to be related to the amount of residual ischemia remaining (additional myocardium at risk of infarction).
  • Image not available.Holter monitoring, exercise electrocardiography, myocardial perfusion scans, and echocardiography are important in determining perioperative risk and the need for coronary angiography. But these tests are indicated only if their outcome would alter patient care.
  • Image not available.Sudden withdrawal of antianginal medication perioperatively—particularly β-blockers—can precipitate a sudden increase in ischemic episodes (rebound).
  • Image not available.The overwhelming priority in managing patients with ischemic heart disease is maintaining a favorable myocardial supply–demand relationship. Autonomic-mediated increases in heart rate and blood pressure should be controlled by deep anesthesia or adrenergic blockade, and excessive reductions in coronary perfusion pressure or arterial oxygen content are to be avoided.
  • Image not available.Intraoperative detection of ischemia depends on recognition of electrocardiographic changes, hemodynamic manifestations, or regional wall motion abnormalities on transesophageal echocardiography. Down-sloping and horizontal ST depression are of greater specificity for ischemia than up-sloping depression. New ST-segment elevations are rare during noncardiac surgery and are indicative of severe ischemia, vasospasm, or infarction.
  • Image not available.The principal hemodynamic goals in managing mitral stenosis are to maintain a sinus rhythm (if present preoperatively) and to avoid tachycardia, large increases in cardiac output, and both hypovolemia and fluid overload by judicious fluid therapy.
  • Image not available.Anesthetic management should be tailored to the severity of mitral regurgitation as well as the underlying left ventricular function. Factors that exacerbate the regurgitation, such as slow heart rates (long systole) and acute increases in afterload, should be avoided. Excessive volume expansion can also worsen the regurgitation by dilating the left ventricle.
  • Image not available.Maintenance of normal sinus rhythm, heart rate, and intravascular volume is critical in patients with aortic stenosis. Loss of a normally timed atrial systole often leads to rapid deterioration, particularly when associated with tachycardia. Spinal and epidural anesthesia are contraindicated in patients with severe aortic stenosis.
  • Image not available.Bradycardia and increase in systemic vascular resistance (SVR) increase the regurgitant volume in patients with aortic regurgitation, whereas tachycardia can contribute to myocardial ischemia. Excessive myocardial depression should also be avoided. The ...

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