Cleveland Clinic journal of medicine
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The American College of Cardiology and American Heart Association updated their joint guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery in 2007. The guidelines recommend preoperative cardiac testing only when the results may influence patient management. ⋯ In most instances, coronary revascularization before noncardiac surgery has not been shown to reduce morbidity and mortality, except in patients with left main disease. The timing of surgery following percutaneous coronary intervention (PCI) depends on whether a stent was used, the type of stent, and the antiplatelet regimen.
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Postoperative pulmonary complications are common, serious, and expensive. Important predictors of risk are advanced age, poor health as assessed by American Society of Anesthesiologists class, and surgery near the diaphragm. Effective strategies to reduce risk include postoperative lung expansion techniques, preoperative intensive inspiratory muscle training, postoperative thoracic epidural analgesia, selective rather than routine use of nasogastric tubes, and laparoscopic rather than open bariatric surgery.
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Perioperative management of patients on warfarin or antiplatelet therapy involves assessing and balancing individual risks for thromboembolism and bleeding. Discontinuing anticoagulant and antiplatelet therapy is usually necessary for major surgery but increases the risk of thrombotic events. ⋯ The timing of warfarin withdrawal and timing of the preoperative and postoperative components of bridge therapy are critical to balancing these risks. Perioperative management of antiplatelet therapy requires special care in patients with coronary stents; the timing of surgery relative to stent placement dictates management in these patients.
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Guidelines on perioperative management of patients undergoing noncardiac surgery recommend the use of prophylactic perioperative beta-blockers in high-risk patients who are not already taking them, and their continuance in patients on chronic beta-blockade prior to surgery. These recommendations were challenged recently by results of the Perioperative Ischemic Evaluation (POISE), a large randomized trial of extended-release metoprolol succinate started immediately before noncardiac surgery in patients at high risk for atherosclerotic disease. While metoprolol significantly reduced myocardial infarctions relative to placebo in POISE, it also was associated with significant excesses of both stroke and mortality. ⋯ P. J. Devereaux (co-principal investigator of POISE).