Preoperative Care, Anesthesia and Early Postoperative Care of Vascular Patients (original) (raw)

coronary syndrome, congestive heart failure, significant arrhythmias and severe heart valve diseases. Among non-cardiac surgeries associated with higher cardiac risk, the acute operations, surgery on extremely old patient, operations of the aorta, prolonged operations, operations with excessive fluid or blood loss are considered to be high-risk while carotid endarterectomy should be considered within the intermediate-risk category. The most simple clinical determining factors of cardiac risk are the age, body weight, known diabetes, congestive heart failure, angina pectoris, history of myocardial infarction and previous coronary revascularization. 2. Preoperative evaluation Preoperative examination should include the assessment of patient's functional capacity. In the presence of lower extremity peripheral vascular disease performing exercise stress test may be difficult, thus pharmacological stress test or specific upper body exercise test should be carried out. Severely impaired functional capacity further increases the cardiac risk. Diseases of the aorta are frequently associated with severe coronary artery disease.The incidence and severity of coronary artery disease are remarkably higher at the diseases of the aorta. Preoperative examination should include the following: Assessment of cardiac risk using different noninvasive examinations. Noninvasive stress testing are the following: dipyridamole myocardial perfusion scintigraphy, radionuclide ventriculography, Holter ECG monitoring, dobutamine stress echocardiography. Several authors (Eagle and collegues, Lee and coworkers) have examined the sensitivity and specificity of these methods, and have found the dobutamine stress echocardiography to be the most appropriate test to assess this group of patients. This examination not only assesses the left ventricular dysfunction but also provides other valuable information on the ground of echocardiography. However, choosing the most appropriate type of test is undoubtedly influenced by local availabilities and cost effectiveness, as well. After assessing the cardiac risk, what therapeutic options are available to decrease it? Beta-blocker therapy at high-risk vascular patient has been proven to improve not only the perioperative but also the long term survival. Manago et al. carried out a study, which covered a large number of patients on the effect of bisoprolol and atenolol on mortality and cardiovascular morbidity after non cardiac surgery. Treatment of hypertension: blood pressure fluctuation at high-risk vascular patients further increases the cardiac risk. Previous anti-hypertensive therapy should be broadened by administration of beta-blockers and the directly acting, alpha-2 agonist,clonidine. In the last few years, the American College of Cardiology Foundation/American Heart Association focused on beta-blocker therapy. Based on this update beta-blockers should be continued in patients , who are receiving them for treatment of conditions with ACCT/AHA indications (Class I) Perioperative ACE-inhibitors therapy may cause intraoperative hypotension, thus administration of them are not recommended. What further medical therapy is available to decrease the perioperative risk? Poldermans and colleagues evaluated the effectiveness of statin therapy, and they found that the perioperative statin therapy is associated with lower postoperative mortality.