About cardiovascular risk in non-cardiac surgery.

ated by the American College of Cardiology and the American Heart Association (ACC/AHA) first met the need of systematizing the bulk of studies carried out so far, and then tried to draw a perioperative management algorithm considering not only the patient’s risk factors and his/her clinical history, but also the type of surgery the patient was to undergo. That was also done in order to reduce the costs related to non-essential instrumental investigation and the risks deriving from unnecessary invasive procedures. Rather soon, however, these guidelines showed their limitations and contradictions. On the one hand, they extensively describe the advisability of performing procedures and provocative tests for the definition of the cardiologic risk in some groups of patients, and on the other, they do not provide any element to differentiate the clinical-therapeutic procedures, in the light of the results of the above-mentioned tests. In fact, according to the same guidelines, once the cardiovascular evaluation has been performed, the indication to myocardial revascularization is independent of the concomitant necessity for non-cardiac surgery. Moreover, there is still lack of data showing the actual protective role of revascularization through angioplasty or coronary artery bypass grafting against adverse perioperative cardiac events. Finally, according to some authors, the publication of the study of Poldermans et al.1 (although carried out on a limited sample of patients) heralded a “new era” in the preoperative management of cardiac patients; the extensive use of beta-blockers and a customized anti-ischemic therapy are indeed able to modify the incidence of early postoperative primary events and improve the long-term prognosis. Scuola di Specializzazione in Medicina Interna II (Direttore: Prof. Emilio D’Erasmo), Dipartimento di Scienze Cliniche, Universita degli Studi “La Sapienza” di Roma © 2004 CEPI Srl The perioperative management of patients at risk for cardiovascular diseases who undergo noncardiac surgery has been subject of debate over the past few decades and is still of great interest. An adequate perioperative management may modify postoperative mortality and morbidity and may improve the long-term prognosis. The purpose of this review is to examine the present day knowledge regarding the preoperative evaluation and perioperative and postoperative management. In spite of the available guidelines (the American College of Cardiology and the American Heart Association of 1996) and of several studies on this subject, many controversies still persist. The main questions are: 1) the preoperative cardiovascular evaluation through noninvasive tests (and the true predictive value of the increased cardiovascular risk) and 2) the real benefit of coronary revascularization before non-cardiac surgery. The last part of this review highlights many recent clinical observations and experimental studies regarding the efficacy of the extensive use of beta-adrenergic receptor blockers and optimized anti-ischemic pharmacological therapy in reducing the cardiovascular risk of non-cardiac surgery and in improving the long-term prognosis. (Ann Ital Med Int 2004; 19: 262-268)