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  1. Patients are likely to be anxious. Reassurance during the preoperative visit has been shown to be useful in decreasing anxiety. Anxiolytics may blunt rises in sympathetic tone and may be invaluable.
  2. Cardiac medications are usually continued perioperatively. Possible exceptions include angiotensin-converting enzyme inhibitors (due to proposed prolonged vasodilation), sustained-release or long-acting medications, and diuretics.
    1. β-blockers. While the evidence for initiating β-blockers in the perioperative period is mixed, there is a consensus that patients already taking β-blockers should continue them in the perioperative period. Initiating β-blocker therapy in the perioperative period has been associated with an increased incidence of MACEs such as nonfatal stroke and MI. In patients with moderate to high risk of perioperative myocardial ischemia or with three or more Revised Cardiac Risk Index (RCRI) risk factors (eg, diabetes mellitus, HF, CAD, renal insufficiency, cerebrovascular accident), it may be reasonable to start β-blockers before surgery. When possible, β-blockers should be started days to weeks before elective surgery and titrated cautiously. They should not be started on the day of surgery; starting β-blockers within 1 day or less of surgery increases the risk of stroke, death, hypotension, and bradycardia.
    2. Statins. Patients taking statins should continue to receive statins perioperatively. Preoperative initiation of statin therapy is reasonable in patients undergoing vascular surgery as well as in patients with standard clinical indications for statin therapy who are undergoing elevated-risk procedures.
    3. Aspirin. The efficacy of aspirin for the secondary prevention of MI in patients with ischemic heart disease has been well documented. Data on the risk of discontinuing antiplatelet therapy in patients with coronary stents have strongly suggested continuing aspirin in the perioperative period. The data on continuing aspirin in patients undergoing elective noncardiac, noncarotid surgery who have not had previous coronary stenting, however, are controversial. Some publications recommend that aspirin should not be stopped routinely in the perioperative period at all, while a recent systematic review and metanalysis suggests that aspirin has no significant effect on overall survival, cardiovascular mortality, or arterial ischemic events, while reducing venous thromboembolic events at the expense of increased risk of major bleeding.
  3. Timing of elective surgery in the setting of previous PCI presents a special challenge. Management decisions should be made in consultation with the patient’s cardiologist and surgeon.
    1. Balloon angioplasty without stent placement. The ACC/AHA recommend that elective noncardiac surgery should be delayed 14 days after balloon angioplasty. Aspirin therapy should be continued in the perioperative period.
    2. Bare-metal coronary stents (BMS). Current recommendations are to delay elective noncardiac surgery for 30 days following PCI with BMS. This time period allows for the completion of thienopyridine therapy and the endothelialization of the stent. The risk of ischemic events is greatest within 30 days of PCI, significantly lower at 30 to 90 days, and lowest after 90 days. Aspirin therapy should be continued perioperatively.
    3. Drug-eluting stents (DES). Thrombosis of DES can occur months after placement and is often related to the omission of dual antiplatelet therapy (DAPT) perioperatively. The current consensus recommendation is to defer elective surgery for at least 3 months, and optimally 6 months, following placement. Aspirin therapy should be continued perioperatively. Elective noncardiac surgery after DES implantation may be considered after 3 to 6 months if the risk of further delay is greater than the expected risks of ischemia and stent thrombosis.
    4. Should a noncardiac surgical procedure be required within the time frame recommended for DAPT following PCI, consider continuing the therapy throughout the perioperative period. If bleeding risk necessitates the discontinuation of thienopyridine therapy, continue aspirin therapy and restart thienopyridines as soon as possible.
  4. Supplemental oxygen should be provided to all patients who have a significant risk of ischemia.
  5. Monitoring is discussed in Chapter 15.
  6. Anesthetic technique. There are no convincing data to support the superiority of one particular anesthetic technique over another in the management of patients at risk for perioperative cardiac events; the anesthetic technique should be decided upon based on patient and surgical factors. The use of MAC, local, or neuraxial combination can be more hemodynamically stable compared to general anesthesia but presents challenges with regard to anticoagulation status, level of consciousness, and pain control (tachycardia and hypertension). For major open abdominal aortic surgery, it has been shown that epidural anesthesia with general anesthesia improved pain control while reducing postoperative respiratory failure and MI; however, there was no observed difference in mortality.