Craig R Narins

KEY POINTS

■ Perioperative myocardial infarction (MI) can result from coronary plaque rupture or from a myocardial oxygen supply-demand mismatch related to a preexisting coronary stenosis.

■ Perioperative MI, even if clinically silent, is a powerful predictor of future adverse cardiac events.

■ The indications for performing preoperative coronary angiography are typically the same as those in the nonoperative setting.

■ Perioperative P-blocker therapy has been associated with reduced cardiac event rates among patients at risk for complications during noncardiac surgery.

■ The benefit of using coronary revascularization to "get the patient through" noncardiac surgery is unproven.

■ Because no prospective trial to date has demonstrated short- or long-term benefits from a strategy of routine preoperative percutaneous coronary intervention (PCI) among patients with coronary disease, the indications for preoperative PCI at this time remain limited and uncertain.

■ The procedural risks of PCI are increased among patients with comorbidities requiring impending surgery, especially peripheral vascular disease.

■ Noncardiac surgery performed within 6 weeks after coronary stent implantation is associated with very high rates of stent thrombosis and major cardiac events.

■ The risk-benefit decision regarding whether to perform preoperative PCI is typically complex and requires multi-disciplinary input from the cardiologist, surgeon, and other involved subspecialists.

Of the more than 30 million surgical procedures requiring the use of general anesthesia performed annually in the United States, approximately one third involve patients who are at risk for or have known coronary artery disease. Given the physiologic stresses that accompany surgery, the perioperative period represents a time of substantially heightened risk for adverse cardiac events among these individuals. A variety of algorithms have been developed to assist practitioners in predicting which patients are at elevated risk for perioperative cardiac events, but in clinical practice there remains a great deal of physician-to-physician variability in the approach to preoperative risk assessment. Even more so, among patients documented to have significant coronary disease, controversy persists as to whether and when preoperative coronary revascularization may have a beneficial role in reducing the likelihood of subsequent cardiac events.

Despite these uncertainties, preoperative assessment remains a common indication for coronary angiography in clinical practice. Among individuals who do ultimately undergo percutaneous coronary intervention (PCI) before noncardiac surgery, various technical issues exist that are unique to the preopera-tive setting. This chapter provides a clinically oriented review of preoperative PCI, including the indications for coronary angiography before upcoming surgery, the utility of various medical and inter-ventional strategies to reduce perioperative risk among patients with known or suspected coronary disease, and the technical aspects of performing angioplasty and stenting before noncardiac surgery.

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