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Each year in the United States, approximately 27 million patients undergo noncardiac surgery.1 Of these, approximately 50,000 experience perioperative myocardial infarction (MI), and more than half of the 40,000 perioperative deaths are caused by cardiac events.2,3 As the population of the United States continues to age over the next several decades, both the total number and the percentage of patients who are older than 65 years of age will increase. These patients represent the largest group in whom surgeries are performed, a group in which approximately 25% of surgeries are associated with significant risk of cardiac morbidity and death and a group at increased risk for the presence of cardiac disease. As such, the number of patients with significant perioperative risk undergoing noncardiac surgery can be expected to increase.

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Most perioperative cardiac morbidity and deaths are related to myocardial ischemia, congestive heart failure, or arrhythmias. Therefore, preoperative evaluation and perioperative management to reduce morbidity and mortality rates emphasize the detection, characterization, and treatment of coronary artery disease (CAD), left ventricular (LV) systolic dysfunction, and significant arrhythmias. However, not all patients with underlying cardiac disease are at significantly increased perioperative risk of a morbid cardiac event. The purpose of preoperative evaluation is not to clear patients for surgery but to assess their medical status, cardiac risks posed by the surgery planned, and recommend strategies to reduce risk. Evaluation must be tailored to the circumstances that have prompted the consultation and to the nature of the surgical illness. There are two goals of the preoperative evaluation: (1) to identify patients at increased risk of an adverse perioperative cardiac event and (2) to identify patients with a poor long-term prognosis because of cardiovascular disease who come to medical attention only because of the problem requiring noncardiac surgery. In this sense, the preoperative evaluation represents an opportunity to identify and treat patients, thereby affecting long-term prognosis, even though their risk at the time of noncardiac surgery may not be prohibitive.

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Preoperative evaluation can identify many patients at increased risk of an adverse cardiac event, and appropriate perioperative management can reduce that risk. Internists and cardiologists play vital roles in the evaluation and management of patients before, during, and after noncardiac surgery. This chapter reviews available data and recommendations for the preoperative evaluation and perioperative management of patients with known or suspected cardiovascular disease undergoing noncardiac surgery. The nature of preoperative evaluation and perioperative management should be individualized to the patient and the clinical scenario surrounding surgery. Patients presenting with an acute surgical emergency require only a rapid preoperative assessment, with subsequent management directed at preventing or minimizing cardiac morbidity and death. Among such patients, a more thorough evaluation can often be performed after surgery. In contrast, patients undergoing elective procedures with no surgical urgency can undergo a more thorough preoperative evaluation. Among patients presenting for cardiac evaluation before "same-day" elective surgery, perioperative risk to the patient must be weighed against the impact ...

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