Preoperative assessment and optimization

Perioperative cardiovascular complications (including myocardial ischaemia and myocardial infarction) are the predominant cause of morbidity and mortality in patients undergoing non-cardiac surgery. The pathophysiology of perioperative myocardial infarction is complex. Prolonged myocardial ischaemia due to the stress of surgery in the presence of a haemodynamically significant coronary lesion, leading to subendocardial ischaemia, and acute coronary artery occlusion after plaque rupture and thrombus formation contribute equally to these devastating events. Perioperative management aims at optimizing the patient’s condition by identification and modification of underlying cardiac risk factors and diseases. The first part of this chapter covers current knowledge on preoperative risk assessment. Current risk indices, the value of additional testing, and new preoperative cardiac risk makers are investigated. During recent decades there has been a shift from the assessment and treatment of the underlying culprit coronary lesion towards a systemic medical therapy aiming at prevention of myocardial oxygen supply–demand mismatch and coronary plaque stabilization. In the second part of this chapter, risk-reduction strategies are discussed, including β‎-blocker therapy, statins, and aspirins. A central theme in this chapter will focus on long-term cardiovascular risk reduction. Patients who undergo non-cardiac (vascular) surgery are particularly prone to long-term adverse cardiac outcomes. The goal of perioperative cardiovascular risk identification and modification should not be limited to the perioperative period, but should extend well into the postoperative period.