Perioperaive evaluation and management in vascular surgery especially for arteriosclerosis obliterans

Perioperative cardiac event is relatively high in vascular surgery for arteriosclerosis obliterans (ASO), which is a major cause of postoperative death. ACC/AHA guideline and revised cardiac risk index (CRI) were advocated to assess risk factor stratification and to manage risk reduction. ACC/AHA guideline categorized all vascular procedures except carotid endarterectomy as high risk. Because almost all patients with ASO were aged and/or inactive, noninvasive testing was necessary in almost all patients by the stepwise bayesian strategy. Patients with revised CRI less than 1 point dominated about three fourths of all patients, whose prevalence and incidence of ischemic heart disease (IHD) were 2.5% and 1.3%, respectively. It seemed appropriate to apply noninvasive testing only for patients with revised CRI more than 2 points, and high risk indicated coronary angiography. Electrocardigrams obtained at baseline, immediately, and on the first 2 days after surgery appear to be cost-effective to diagnose IHD. Use of cardiac biomarkers was reserved for patients at high risk and those with clinical, or ECG evidence of myocardial infarction (MI). Beta-blockers or alpha-agonists were effective to reduce incidence of perioperative IHD. Although even optimal preoperative assessment and perioperative management, some patients will have perioperative MI.     

A multicenter study of cardiac events and anesthetic management of patients with ischemic heart diseases for noncardiac surgery--a follow-up report

We have conducted a joint research project to investigate the incidence of ischemic heart disease in patients for noncardiac surgery and to define the risk of perioperative cardiac complications in these patients. From September to November 1997 we had 7288 patients scheduled to undergo noncardiac surgery in the 8 departments of anesthesiology. Of these patients, 228 (3.1%) patients had ischemic heart disease, and 30 of them (13.2%) developed perioperative cardiac events. Critical cardiac events, including perioperative myocardial ischemia and lethal arrhythmia, occurred in 7 of these patients. In our region of Japan, 3-4% of surgical patients tend to develop ischemic heart disease and 3.1% of them demonstrated severe cardiac complications perioperatively. Compared with United States we encounter fewer surgical patients with ischemic heart disease, but the risk of developing perioperative cardiac complications in such patients is almost the same for both countries.     

Nuclear cardiac ejection fraction and cardiac index in abdominal aortic surgery

Since atherosclerotic heart disease results in more than half of the perioperative deaths that follow abdominal aortic surgery, a prospective protocol was designed for preoperative evaluation and intraoperative hemodynamic monitoring. Twenty men who were prepared to undergo elective operation for aortoiliac occlusive disease (12 patients) and abdominal aortic aneurysm (eight patients) were evaluated with a cardiac scan and right heart catheterization. The night prior to operation, each patient received volume loading with crystalloid based upon ventricular performance curves. At the time of the operation, all patients were anesthetized with narcotics and nitrous oxide, and hemodynamic parameters were recorded throughout the operation. Aortic crossclamping resulted in a marked depression in CI in all patients. CI remained depressed P less than 0.05 after unclamping in the majority of patients. There were two perioperative deaths, both from myocardial infarction or failure. Both patients had ejection fractions less than 30% and initial CIs less than 2 L/M2, while the survivors' mean ejection fraction was 63% +/- 1 and their mean CI was 3.2 L/M2 +/- 0.6. We conclude that preoperative evaluation of ejection fraction can select those patients at a high risk of cardiac death from abdominal aortic operation. These patients should receive intensive preoperative monitoring with enhancement of ventricular performance.     

Multicenter study of cardiac events and anesthetic management of patients with ischemic heart diseases undergoing noncardiac surgery

We designed a joint research project to investigate the incidence of ischemic heart diseases in patients undergoing noncardiac surgery and to define the risk of perioperative cardiac complications in these patients. Of the 8358 surgical patients in the 8 departments of anesthesiology between March 1997 and June 1997, 328 (3.9%) had ischemic heart diseases. Among the 328 patients, 54 (16.4%) developed perioperative cardiac events, including myocardial infarction (3 patients) and either lethal or potentially dangerous dysrhythmias (51 patients). Preoperative cardiac assessments were performed while the anesthetic techniques including intensive monitoring and perioperative prophylactic therapy were also employed. Patients with ischemic heart diseases received various types of preoperative evaluation to identify the degree of coronary artery disease and to assess the overall cardiac function. The patients were monitored using a multilead electrocardiogram, an arterial line, a central venous catheter, a pulmonary artery catheter, and by transesophageal echocardiography intraoperatively. Therapeutically, isosorbide, nitroglycerin, beta-blockers, calcium channel blockers, and/or nicorandil were administered to prevent perioperative ischemia. So far, no generally accepted management strategies have been established in patients with cardiovascular disorders based on large-scale outcome trials in Japan. Therefore, nationwide large multicenter trials are awaited with interest in order to establish helpful guidelines to improve the perioperative management and to reduce ischemia in cardiac patients undergoing noncardiac surgery.     

Perioperative Cardiac Risk Stratification and Modification in Abdominal Aortic Aneurysm Repair

Cardiovascular complications are important causes of morbidity and mortality following vascular surgery. Adequate preoperative risk assessment and perioperative management may modify postoperative mortality and morbidity and improve long-term prognosis. The objective of this review is to examine the present day knowledge regarding the preoperative evaluation and perioperative management of patients undergoing noncardiac surgery, focusing specifically on abdominal aortic aneurysm (AAA) repair.

Clinical markers combined with ECG and surgical risk assessment can effectively divide patients in a truly low-risk, intermediate and high-risk population. Low-risk patients can probably be operated on without additional cardiac testing. Notably, due to the surgical risk, AAA patients are never low-risk patients. Intermediate-risk and high-risk patients are referred for cardiac testing to exclude extensive stress induced myocardial ischemia, as beta-blockers provide insufficient myocardial protection in this case and preoperative coronary revascularization might be considered. Whether patients at intermediate risk without ischemic heart disease should be treated with statins and/or beta-blockers is still controversial. In high-risk patients, it is strongly advised to administer beta-blockers with heart rate determined dose adjustment, while the effects of preoperative revascularization remain subject to debate.     

A surgical treatment for ischemic heart disease associated with systemic lupus erythematodes: report of a case]

We reported a case of coronary artery bypass grafting (CABG) associated with systemic lupus erythematodes (SLE). A 45-year-old male who had been treated for SLE with prednisolone for 9 years was transferred to our department for a surgical treatment due to ischemic heart disease (IHD). We successfully performed CABG resolving various perioperative complications. The intensive care is indispensable in the case of IHD with SLE.     

Myocardial ischaemia,infarction and cardiac-related death following carotid endarterectomy: risk assessment by thallium myocardial perfusion scan compared with clinical examination

Risk factors in 402 patients undergoing 447 carotid endarterectomies were reviewed to see whether the presence of coronary artery disease before operation influenced the likelihood of perioperative cardiac complications. A second aim of the study was to assess whether myocardial thallium scintigraphy was valuable for preoperative assessment. Fourteen patients developed postoperative cardiac complications, six (1.3%) of which were fatal. Four of these deaths occurred in 60 patients undergoing combined carotid-coronary revascularization (6.6%). In 387 carotid endarterectomies without simultaneous coronary revascularization, there were two deaths from myocardial infarcts (0.5%). These fatalities and other cardiac complications occurred in 204 patients with preoperative clinical or ECG evidence of coronary artery disease. In 198 patients with no preoperative evidence of coronary disease there were no fatalities and only one patient with reversible postoperative myocardial ischaemia (0.4%). It is concluded that carotid endarterectomy under general anaesthesia is unlikely to be followed by cardiac complications when there is no preoperative evidence of coronary artery disease. When coronary disease is detected before operation, postoperative cardiac complications occur after 5.6% of operations, including 0.9% fatalities. When coronary artery disease is severe enough to warrant combined carotid-coronary reconstruction, the perioperative mortality rate was 6.6%, all the deaths being cardiac-related. When myocardial thallium scintigraphy was normal, postoperative cardiac complications did not occur.     

瓣膜病变合并冠状动脉病变外科治疗及围术期管理

目的 总结瓣膜病变合并冠状动脉病变的外科治疗及围术期管理经验。方法 对66例瓣膜病变合并冠状动脉病变病人的一般临床资料、术前心功能状态、冠状动脉病变相关因素、冠脉造影情况和手术结果进行分析。结果 围手术期死亡5例，死亡率为7.6%。结论 瓣膜病变合并冠状动脉病变的特点：⑴冠心病病史不常典型，必须重视术前冠状动脉造影检查。尤其年龄在45岁以上、来自冠心病高发区、即往有高血压、高血脂、糖尿病病史者。⑵术中心肌保护采用持续逆灌加间断顺灌。⑶手术重点放在再血管化分布范围广及对室壁运动有重要影响的分支。⑷瓣膜病变合并冠心病病人围术期心功能调整的重要原则是较好的处理心率（心律）、前负荷和后负荷以及心肌收缩力之间的综合关系。同时，治疗中严密注意电解质和酸碱平衡变化，及时酌情处理。     

Perioperative cardiac risk stratification and modification in abdominal aortic aneurysm repair

Cardiovascular complications are important causes of morbidity and mortality following vascular surgery. Adequate preoperative risk assessment and perioperative management may modify postoperative mortality and morbidity and improve long-term prognosis. The objective of this review is to examine the present day knowledge regarding the preoperative evaluation and perioperative management of patients undergoing noncardiac surgery, focusing specifically on abdominal aortic aneurysm (AAA) repair. Clinical markers combined with ECG and surgical risk assessment can effectively divide patients in a truly low-risk, intermediate and high-risk population. Low-risk patients can probably be operated on without additional cardiac testing. Notably, due to the surgical risk, AAA patients are never low-risk patients. Intermediate-risk and high-risk patients are referred for cardiac testing to exclude extensive stress induced myocardial ischemia, as beta-blockers provide insufficient myocardial protection in this case and preoperative coronary revascularization might be considered. Whether patients at intermediate risk without ischemic heart disease should be treated with statins and/or beta-blockers is still controversial. In high-risk patients, it is strongly advised to administer beta-blockers with heart rate determined dose adjustment, while the effects of preoperative revascularization remain subject to debate.     

Does perioperative myocardial ischemia lead to postoperative myocardial infarction?

To determine if a relationship exists between perioperative myocardial ischemia (ST segment depression greater than or equal to 0.1 mV) and postoperative myocardial infarction (PMI), nonparticipating observers recorded all ECG, hemodynamic, and other events between arrival of patients in the operating room and onset of cardiopulmonary bypass during 1,023 elective coronary artery bypass operations (CABG). The roles of preoperative patient characteristics, quality of the operation limited by disease as rated by the surgeon and duration of ischemic cardiac arrest as risk factors for PMI also were quantified. ECG ischemia occurred in 36.9% of all patients, with almost half the episodes occurring before induction of anesthesia. PMI was almost three times as frequent in patients with ischemia (6.9% vs. 2.5%) and was independent of when ischemia occurred. Ischemia was related significantly to tachycardia but not hypertension nor hypotension and was frequent in the absence of any hemodynamic abnormalities. The anesthesiologist whose patients had the highest rate of tachycardia and ischemia had the highest rate of PMI. Although neither single nor multiple preoperative patient characteristics related to PMI, suboptimal quality of operation and prolonged ischemic cardiac arrest increased the likelihood of PMI independent of the occurrence of myocardial ischemia. The authors conclude that perioperative myocardial ischemia is common in patients undergoing CABG, occurs randomly as well as in response to hemodynamic abnormalities, and is one of three independent risk factors the authors identified as related to PMI. PMI is unrelated to preoperative patient characteristics such as ejection fraction and left main coronary artery disease, and its frequency will relate primarily to perioperative management rather than patient selection.     

Noncardiac surgery in patients with ischemic heart disease

From January 1983 to December 1988, 4679 patients with operated under general anesthesia in our institute: 161 patients involved suspected ischemic heart disease (IHD patients) by history or electrocardiogram. Eight of 161 patients (5.0%) experienced fatal or life-threatening cardiac complications. On the other hand, only two non-IHD patients (0.03%) experienced complications. IHD patients had a significantly higher incidence of complications compared with non-IHD patients. Forty-five IHD patients had not undergone coronary cineangiogram (CAG) before noncardiac operations and six of them (13.8%) experienced complications. They had a significantly higher incidence of complications compared with other IHD-patients who had received CAG. Fifty-five IHD patients who had already been treated by coronary bypass grafting (CABG) or by percutaneous transluminal angioplasty experienced only one complication. We conclude that CAG should be more actively performed for IHD patients because prior CABG or PTCA is suspected to decrease cardiac complications in IHD patients. However, IHD patients must be managed as carefully as possible.     

Myocardial ischemia revisited

Does perioperative myocardial ischemia lead to postoperative myocardial infarction? By Stephen Slogoff and Arthur S. Keats. Anesthesiology 1985; 62:107-14. Reprinted with permission. To determine if a relationship exists between perioperative myocardial ischemia (ST segment depression greater than or equal to 0.1 mV) and postoperative myocardial infarction (PMI), nonparticipating observers recorded all electrocardiographic, hemodynamic, and other events between arrival of patients in the operating room and onset of cardiopulmonary bypass during 1,023 elective coronary artery bypass operations (CABG). The roles of preoperative patient characteristics, quality of the operation limited by disease as rated by the surgeon and duration of ischemic cardiac arrest as risk factors for PMI also were quantified. Electrocardiographic ischemia occurred in 36.9% of all patients, with almost half the episodes occurring before induction of anesthesia. PMI was almost three times as frequent in patients with ischemia (6.9% vs. 2.5%) and was independent of when ischemia occurred. Ischemia was related significantly to tachycardia but not hypertension nor hypotension and was frequent in the absence of any hemodynamic abnormalities. The anesthesiologist whose patients had the highest rate of tachycardia and ischemia had the highest rate of PMI. Although neither single nor multiple preoperative patient characteristics related to PMI, suboptimal quality of operation and prolonged ischemic cardiac arrest increased the likelihood of PMI independent of the occurrence of myocardial ischemia. The authors conclude that perioperative myocardial ischemia is common in patients undergoing CABG, occurs randomly as well as in response to hemodynamic abnormalities, and is one of three independent risk factors the authors identified as related to PMI. PMI is unrelated to preoperative patient characteristics such as ejection fraction and left main coronary artery disease, and its frequency will relate primarily to perioperative management rather than patient selection.     

The value of silent myocardial ischemia monitoring in the prediction of perioperative myocardial infarction in patients undergoing peripheral vascular surgery

Real-time electrocardiographic monitoring for silent myocardial ischemia was performed on 200 patients undergoing peripheral vascular surgery to try to better define those at high risk of perioperative myocardial infarction. The patients were divided into those undergoing abdominal aortic aneurysm or lower extremity revascularization procedures (group I, n = 120) and those undergoing carotid artery endarterectomy (group II, n = 80). Silent ischemia was detected during the preoperative, intraoperative, or post-operative periods in 60.8% of group I and 67.5% of group II patients. Six group I and three group II patients suffered an acute perioperative myocardial infarction with two cardiac deaths. In both groups I and II a variety of parameters based on monitoring of silent myocardial ischemia were compared between the subgroups of patients who had myocardial infarction and those who did not. The results show that in both groups there was a significantly (p less than or equal to 0.05) greater total duration of perioperative ischemic time, total number of perioperative ischemic episodes, and total duration of perioperative ischemic time as a percent of total monitoring time in patients who suffered a perioperative myocardial infarction compared to those who did not. Multivariate logistic regression analysis of preoperative characteristics in all 200 patients showed the occurrence of preoperative silent myocardial ischemia and angina at rest to be the only significant predictors of perioperative myocardial infarction. Thus perioperative monitoring for silent myocardial ischemia might noninvasively identify those patients undergoing peripheral vascular surgery who are at increased risk for perioperative myocardial infarction, permitting implementation of timely preventive measures in selected patients.     

Relationship between symptoms of ischemic heart disease and upper abdominal digestive organ disease

We previously reported that percutaneous trans-arterial coronary angioplasty (PTCA) seemed to decrease cardiac complications in patients with ischemic heart disease (IHD) who underwent abdominal surgery. After the report, 1293 PTCAs were performed for patients with IHD in our institute. Of these 1293 patients, 6 patients underwent abdominal surgery under general anesthesia within 14–150 days after successful PTCA. We observed the relationship between symptoms of IHD and upper abdominal digestive organ disease (ADOD), which sometimes occurs concomitantly in IHD patients. In conclusion, the present study identified some features of the chief complaints and symptoms of IHD patients with concomitant upper ADOD. This information should prove useful for making a differential diagnosis and deciding treatment.An abstract of this study was presented at the annual meeting of the Japanese Society of Internal Medicine, Nagoya, Japan, 2002.     

The effect of heart rate control on myocardial ischemia among high-risk patients after vascular surgery

Patients undergoing vascular surgery have a high risk of suffering major postoperative cardiac events. Preoperative myocardial ischemia as detected by Holter monitoring identifies a high-risk subgroup whose postoperative ischemia, similarly detected, seems to herald major cardiac events. In this study, we determined whether systematic, patient-specific postoperative heart rate control with beta-adrenergic blocker therapy decreases the incidence of postoperative ischemia among high-risk vascular surgery patients. A total of 26 of 150 patients who underwent elective vascular surgery and were monitored preoperatively by 24-h Holter were found to have significant myocardial ischemia as defined by ST-segment depression. The minimal heart rate at which this ST-segment depression occurred was identified (ischemic threshold), and these 26 patients were then randomized to receive continuous i.v. beta-blockade with esmolol or placebo plus usual medical therapy, aiming to reduce the postoperative heart rate to 20% below the ischemic threshold. All patients were monitored by Holter for 48 h postoperatively. Postoperative Holter readings were analyzed for the incidence of ischemia and for the number of hours during which heart rate was controlled below the ischemia threshold. Patients had a median of two episodes of preoperative ischemia lasting a median of 30 min (range 1-155 min). A total of 15 patients were randomized to receive esmolol, and 11 were randomized to receive placebo. The two groups were comparable with respect to clinical characteristics and incidence and duration of preoperative ischemia. Ischemia persisted in the postoperative period in 8 of 11 placebo patients (73%), but only 5 of 15 esmolol patients (33%) (P < 0.05). Of the 15 esmolol patients, 9 had mean heart rates below the ischemic threshold, and all 9 had no postoperative ischemia. A total of 4 of 11 placebo patients had mean heart rates below the ischemic threshold, and 3 of the 4 had no postoperative ischemia. There were two postoperative cardiac events among patients who had postoperative ischemia (one placebo, one esmolol) and whose mean heart rates exceeded the ischemic threshold. Our data suggest that patient-specific, strict heart rate control aiming for a predefined target based on individual preoperative ischemic threshold was associated with a significant reduction and frequent elimination of postoperative myocardial ischemia among high-risk patients and provide a rationale for a larger trial to examine this strategy's effect on cardiac risk. IMPLICATIONS: Patients who undergo peripheral vascular surgery often experience transient cardiac complications and/or permanent heart damage just after surgery because of inadequate myocardial blood flow. In this study, we identified patients at high risk of cardiac complications after vascular surgery and showed that if their heart rate was carefully controlled for 48 h after surgery, myocardial ischemia, a common marker of heart injury, was markedly reduced.     

Detection of cardiac insufficiency by computer-assisted monitoring of the response of intra-cardiac hemodynamics to exercise test in patients with ischemic heart disease with similar lesions of the coronary arteries (patient selection for the aortocoronary bypass)]

Preoperative identification of cardiac insufficiency in patients with ischemic heart disease (IHD) has proved essential for the success of surgery on the coronary arteries. To provide for an objective assessment of the contractile function of the myocardium in selecting candidates for surgery among IHD patients with over 70-percent narrowing of one, two, and three coronary arteries, use was made of the central hemodynamics indices in response to the loading test during right heart catheterization with computer-assisted monitoring and mathematical analysis. Two patient groups were distinguished during the hemodynamic loading test: group I showing a high and effective chronotropic reserve (+X) and group II presenting a negative chronotropic reserve (-X). It was established that with equal numbers of narrowed coronary arteries and similar clinical manifestations, the estimates of myocardial contraction may differ which determines indications for surgery and preoperative care.     

Ischemic heart disease

Because of changing demographics, increasing numbers of patients with IHD are presenting for noncardiac surgery, and the risks of perioperative morbidity and mortality are significant. The Lee Cardiac Risk Index is applicable in defining perioperative cardiac risk: however, ACC/AHA guidelines may not be applicable comprehensively. The role of biomarkers in risk stratification still needs to be defined. Structured management protocols that help assess, diagnose, and treat patients with IHD preoperatively are likely to help decrease postoperative morbidity and mortality, but clearly are not applicable to all patients. Augmented hemodynamic control with beta-blockers or alpha-2 agonists and modulating inflammation by statins can play an important role in improving outcomes in many patients with IHD; preoperative coronary revascularization may be of limited value. Intraoperative anesthetic management that minimizes hemodynamic perturbations is important; however, the choice of a particular technique typically is not critical. Of critical importance is the postoperative management of the patient. Postoperative myocardial injury should be identified, evaluated, and managed aggressively. Secondary stresses such as sepsis, extubation, and anemia, which can increase demand on the heart, should be treated or minimized. Clearly, optimal care of the patient with IHD entails closely coordinated assessment and management throughout the preoperative, intraoperative, and postoperative phases, if one is to optimize short- and long-term outcomes.     

Cardiac arrhythmias and myocardial ischemia after thoracotomy for lung cancer.

The records of 598 patients undergoing a thoracic surgical procedure for lung cancer from 1975 through 1989 were reviewed for occurrence of cardiac arrhythmias and myocardial ischemic events. Atrial tachycardias occurred in 16% (94/598); atrial fibrillation was preponderant (87%), followed by supraventricular tachycardia and atrial flutter. Patients with recurrent episodes of dysrhythmias had a significantly higher mortality rate than those without episodes or with a single episode only (17% versus 2.4%; p less than 0.01). Transient ischemic electrocardiographic changes were documented in 23 patients (3.8%) and myocardial infarction in 7 (1.2%). An abnormal preoperative exercise test result and intraoperative hypotension were strongly associated with both dysrhythmia and ischemia (p less than 0.01). Pneumonectomy, ischemic changes on the electrocardiogram, and cardiac enlargement were also associated with arrhythmias (p less than 0.01). A weaker association (p less than 0.05) was found between postoperative arrhythmias and old myocardial infarction (greater than 6 months), arterial hypertension, and heart failure. Pulmonary function had no predictive value in this respect. A history of angina or old myocardial infarction was predictive of transient postoperative myocardial ischemia but not myocardial infarction. Despite improved anesthetic and monitoring techniques and more frequent use of the intensive care unit postoperatively in the last decade, the incidence of arrhythmias after thoracotomy has not decreased. More effective prevention is needed, particularly for patients with defined preoperative and perioperative risk factors.     

Recent trends in cardiac surgery for acquired heart disease

Some recently developed problems in cardiac surgery for acquired heart diseases, in our department, have been discussed in this paper. Ischemic heart disease (IHD): Indication for aortocoronary bypass grafting (ACBG) has been extended for the patients with poor left ventricular function. The number of the patients, who are found to have IHD before general surgery have been increased. Surgical treatments for these patients, five with malignant tumor, and two with aneurysm of the descending aorta, were performed 16 days to 4 months after ACBG without any operative death. In three patients with lesions of carotid arteries, blood flow of the carotid arteries was monitored with doppler echography, which was found useful for this purpose, during extracorporeal circulation. One hundred and four patients, over 40 years old, for valvular surgery, had coronary angiography at the cardiac catheterization between 1982-1983. Nine patients (8%) had significant IHD. They had ACBG and valvular surgery simultaneously. Valvular heart disease (VHD): Long-term results following aortic valve replacement have showed that 6 deaths were of cardiac origin. Five of them were with poor preoperative left ventricular function (ejection fraction: 0.35 or less, left ventricular endsystolic volume index: 200 ml/m2 or more) which might be indices for indication of surgical treatment for aortic regurgitation.     

Prävention perioperativer Myokardischämien – ein Update

Perioperative cardiac morbidity and mortality are a major health care challenge with important individual as well as economic aspects. Up to 30% of all perioperative complications and up to 50% of all postoperative deaths are related to cardiac causes. Perioperative myocardial ischemia, which occurs in more than 40% of patients with or at risk for coronary artery disease and undergoing noncardiac surgery, represents a dynamic predictor of postoperative cardiac complications. Long-duration myocardial ischemia and ischemic episodes associated with myocardial cell damage are particularly of prognostic relevance. In patients suffering from this type of ischemia, the incidence of adverse cardiac outcome is increased up to 20-fold. Reducing the incidence of perioperative myocardial ischemia is associated with a decrease in adverse cardiac outcome. Important issues related to perioperative myocardial ischemia are hematocrit level, body temperature, and hemodynamic variables. In contrast, the choice of anesthetic agents and techniques appears to be less important. Perioperative administration of anti-ischemic drugs in patients at risk, however, leads to a further decrease in the incidence of myocardial ischemia and to an improvement in patient outcome. Recent studies suggest that alpha 2-agonists and particularly beta-adrenoreceptor blocking agents are effective anti-ischemic drugs in the perioperative setting. Perioperative administration of beta-adrenoreceptor blocking agents in coronary risk patients undergoing noncardiac surgery is associated with a reduced rate of postoperative cardiac complications and an improvement in long-term outcome. This is particularly relevant in high risk patients with preoperative stress-induced ischemic episodes. In clinical practice, therefore, chronically administered anti-ischemic drugs should also be administered on the day of surgery and during the postoperative period. In untreated patients with or at risk for coronary artery disease and who have to undergo urgent surgical procedures without the opportunity of preoperative anti-ischemic intervention, perioperative administration of beta-adrenoreceptor blocking agents is mandatory.