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INTRODUCTION

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Cardiovascular disease is the leading cause of death in the United States. Of the 27 million patients who undergo non-cardiac surgery in the United States each year, approximately 8 million have coronary artery disease or risk factors for cardiovascular disease and 1 million have perioperative cardiac complications.1 Cardiovascular perioperative risk assessment has become a vital tool for evaluating patients prior to surgery to optimize their cardiovascular safety and initiate lifestyle modifications that coupled together provide short- and long-term benefits. The American College of Cardiology/American Heart Association (ACC/AHA) task force committee created guidelines for the perioperative risk assessment of cardiovascular disease for non-cardiac surgery to address this growing problem. Over the last 5 years new evidence has emerged resulting in an update of these guidelines in 2007.2

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Goals of Preoperative Evaluation

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As a physician evaluates a patient prior to non-cardiac surgery, several goals should be kept in mind:

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  1. Identify patients who are at risk for perioperative cardiac events.

  2. Identify the risk of the proposed surgery (Table 16-1).

  3. Identify active cardiovascular disease and clinical risk factors (Tables 16-2 and 16-3).

  4. Identify patients at risk to develop cardiac events after discharge from the hospital.

  5. Intervene to reduce perioperative morbidity and mortality or cancel the planned procedure.

  6. Intervene to reduce long-term cardiovascular morbidity and mortality.

  7. Follow-up with the patient postoperatively, when most perioperative cardiac events occur.

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Table 16-1Surgery-specific Cardiac Risk
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Table 16-2Active Cardiac Conditions
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Table 16-3Clinical Risk Factors
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CLINICAL EVALUATION

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History

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The preoperative evaluation begins with a thorough history with special emphasis on the need to identify clinical markers that increase perioperative risk as well as assess functional capacity:

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  1. Identify clinical markers that increase perioperative risk:

    1. In the previous ACC/AHA guidelines from 2002, risk factors were separated into major, intermediate, and minor risk factors. The guidelines have recently been updated in 2007 with some ...

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