Are the current perioperative risk management strategies for myocardial infarction flawed? Current Guideline-Based Preoperative Evaluation Provides the Best Management of Patients Undergoing Noncardiac Surgery

The Problem The volume of noncardiac surgery has progressively increased over the past 2 decades2 to levels exceeding prior predictions,3 with elderly patients undergoing at least 4 million major noncardiac operations annually.4 Given the high prevalence of coronary heart disease (CHD), it is not surprising that cardiac complications are a major cause of perioperative morbidity and mortality. Cardiac complications occur in 1% to 5% of unselected patients undergoing vascular surgery.3,5 Of the 27 million patients undergoing anesthesia annually, 50 000 suffer a perioperative myocardial infarction (MI).6 The recently published universal definition of MI7 has broadened the definition of MI and will likely result in a further increase of perioperatively diagnosed MIs and affect long-term management and prognosis.8 As a result, consultations for preoperative evaluation and assistance in perioperative management are frequently requested of cardiologists, internists, and generalists by surgeons and anesthesiologists. The guidelines emphasize that the consultant should not only offer opinions regarding the operative risk and advice on perioperative management but should use this opportunity to recommend treatments that will affect long-term patient outcomes. This report will focus entirely on preoperative risk assessment and management of patients with known or potential CHD, the major cause of perioperative cardiac morbidity and mortality. Although valvular disease, cardiomyopathy, and other forms of heart disease contribute to surgical morbidity and mortality and warrant consideration in preoperative risk determination, they will not be addressed because of space constraints.