What is included in preoperative and intraoperative cardiac management?

Answer

The stress of surgery results in the release of catecholamines. Increasing the rate-pressure product may predispose the patient to a cardiac event. In 1996, Mangano et al evaluated the role of atenolol perioperatively in reducing long-term cardiac morbidity and mortality.^[9]Patients received a beta-blocker if they had known coronary artery disease or met 2 of the following criteria: older than 65 years, hypertension, total cholesterol level higher than 6.2 mmol/L, smoking history, or diabetes mellitus.

Atenolol produced a 15% absolute risk reduction in the end points of MI, unstable angina, CHF requiring hospitalization, or death at 6 months and reduced mortality at 6 months and 2 years in noncardiac surgery.

Similarly, another randomized controlled trial evaluating the cardioprotective effects of bisoprolol in high-risk patients undergoing vascular surgery was performed. The study was stopped early because of the dramatic results. In 1999, Poldermans et al screened 1351 patients awaiting vascular surgery and included those who had one or more cardiac risk factors and positive results on a dobutamine echocardiography study.^[10]The 112 patients remaining were randomized to receive either standard care or standard care plus bisoprolol. Bisoprolol, at a dose of 10 mg PO qd given 1 week preoperatively and continued for 1 month postoperatively, reduced the incidence of perioperative death from cardiac causes and nonfatal MI. Consequently, when possible, beta-blockers should be started 1 week before elective surgery, with the dose titrated to a resting heart rate of 50-60. As for the use of nitrates, digitalis, and calciumblockers, no studies have evaluated their use in the perioperative state.

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Media Gallery

Perioperative cardiac management. Algorithm for preoperative cardiac assessment.
Perioperative cardiac management. The transthoracic echocardiogram illustrates a parasternal long axis view of the left ventricle with preserved cardiac function.
Perioperative cardiac management. The sestamibi perfusion scan illustrates reversible ischemia in the anterior wall of the myocardium, comparing rest and stress images.
Perioperative cardiac management. Coronary angiogram revealing severe left circumflex and left anterior descending disease.

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Author

Davinder Jassal, MD Academic Clinical Scientist, Cardiac Sciences Division, St Boniface Hospital Research; Assistant Professor of Cardiology and Radiology, Afffiliated Scientist of the Institute of Biodiagnostics at the National Research Council of Canada; Principal Investigator of the Cardiovascular Imaging Laboratory, Institute of Cardiovascular Sciences

Davinder Jassal, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians-American Society of Internal Medicine, American Heart Association, Canadian Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Sat Sharma, MD, FRCPC Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba Faculty of Medicine; Site Director, Respiratory Medicine, St Boniface General Hospital, Canada

Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, World Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Donna Leco Mercado, MD, MD

Donna Leco Mercado, MD, MD is a member of the following medical societies: Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

William A Schwer, MD Professor, Department of Family Medicine, Rush Medical College; Chairman, Department of Family Medicine, Rush-Presbyterian-St Luke's Medical Center

William A Schwer, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Additional Contributors

George A Stouffer, III, MD Ernest and Hazel Craige Distinguished Professor of Medicine and Cardiology, Chief of Cardiology, University of North Carolina Medical Center

George A Stouffer, III, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, Phi Beta Kappa, Society for Cardiovascular Angiography and Interventions

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Tomas G Neilan, MD, to the development and writing of this article.

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