Perioperative assessment and management of risk from coronary artery disease.

摘要: PURPOSE To summarize available evidence on preoperative cardiac risk stratification so that the internist may 1) use clinical and electrocardiographic findings to stratify a patient's perioperative for myocardial infarction death; 2) decide which tests provide useful additional risk-related information; 3) understand benefits, risks, surrounding decision undertake coronary revascularization before elective noncardiac surgery. DATA SOURCES A MEDLINE search review of reference lists identified articles. Sensitivities, specificities, likelihood ratios diagnostic were calculated, quality rating study methods was applied. EXTRACTION Myocardial mortality major outcomes considered, SYNTHESIS Clinical findings, organized by multivariate prediction indices, accurately identify patients as having low, intermediate, or high death. Pharmacologic stress imaging with thallium echocardiography probably improves intermediate-risk vascular These have not been shown be effective prognostic indicators nonvascular No studies angiography reported. Decision analyses retrospective series suggest risks incurred doing surgery outweigh benefits. Prospective, controlled are lacking. Evidence from randomized, trial has survival benefit beta-blockers in at artery disease. CONCLUSIONS Evaluation all surgical indices is recommended. Low-risk need no further evaluation High-risk optimal management their high-risk problems, including (if appropriate) beta-blocker use, procedures canceled. Intermediate-risk noninvasive testing, especially if they Further trials needed most areas concern.