Revascularization

Because most episodes of perioperative myocardial ischemia and infarction are related to the presence of one or more preexisting fixed coronary stenoses, the performance of coronary revascularization before surgery traditionally has been looked upon as a potential means to limit the occurrence of ischemic events during and after surgery. Recent data, however, have cast doubts on the utility of routine coronary revascularization before noncardiac surgery, although many clinicians remain convinced that certain higher-risk individuals may benefit from such an approach. Whereas coronary revascularization is typically performed preoperatively with the intention of decreasing the likelihood of subsequent adverse cardiac events, it must be remembered that coronary revascularization itself is associated with risks that are separate from (and additive to) those of surgery. Therefore, for a strategy of PCI or CABG followed by noncardiac surgery to be fruitful, the coronary revas-cularization procedure must decrease the risks of the subsequent surgery by a degree sufficient to overcome the increased cumulative risk inherent in performing two procedures instead of one.

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