Progress in cardiovascular diseases
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Perioperative cardiac events are the largest cause of morbidity and mortality for patients undergoing elective surgery. As a result, numerous recent studies have focused on attempts to identify patients at increased risk for perioperative events. These have delineated testing modalities capable of identifying high-risk patients, and clinical markers which further stratify patients facing elective surgery into high-, medium-, and low-risk subgroups. ⋯ Assessment and intervention for risk factors of long-term cardiac disease is also stressed, as the preoperative evaluation represents an opportunity for improvement in the short- and long-term cardiac risk profile. Finally, the algorithm for preoperative cardiovascular evaluation published jointly by the ACC/AHA joint taskforce on practice guidelines is reviewed. This algorithm is a synthesis of the current literature, into a cost effective and efficient approach to patient evaluation.
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Prog Cardiovasc Dis · Mar 1998
ReviewSurgery-specific considerations in the cardiac patient undergoing noncardiac surgery.
Myocardial infarction after noncardiac surgery in patients with coronary artery disease results from the interplay of patient-specific, anesthetic-specific, and surgery-specific factors. Surgery-specific factors include the stress response to injury, both neurohormonal and hemostatic alterations, and clinically-significant operative parameters such as urgency, duration, blood loss, body core temperature, fluid shifts, and location of surgery. ⋯ Overall, the morbidity and mortality of surgery is minimal even in high-risk patients, and the contribution of surgery-specific factors to operative risk is subtle compared with that of patient specific-factors such as severity of coronary disease and other comorbid conditions. Nonetheless, the optimal surgical management of patients with coronary disease requires the collaborative effort of the anesthesiologist, cardiologist, and surgeon.
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The intraoperative management of the high-risk patient has received a great deal of attention and research during the past decade. Based on the available evidence, there appears to be no one best anesthetic technique or agent. ⋯ Perioperative pharmacological treatment with alpha-2 agonists and beta-adrenergic blocking agents are associated with a reduced incidence of perioperative myocardial ischemia and improved long-term survival, respectively. Future research will be required to determine whether prophylactic therapy or early treatment of perioperative myocardial ischemia will lead to improved outcome.
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Prog Cardiovasc Dis · Jan 1998
ReviewRight ventricular function in congenital heart disease: pressure and volume overload lesions.
The right ventricle is often subject to both pressure and volume overload in congenital heart disease. Evaluating right ventricular function in both the native lesion and after surgery in light of these loading conditions, presents a unique challenge for investigators studying these misshapen hearts. The purpose of this article is to briefly delineate what is generally known about right ventricular function in congenital heart disease and to touch on some noninvasive imaging modalities which have helped shed some light on this matter.
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Prog Cardiovasc Dis · Nov 1997
ReviewThrombosis, antithrombotic agents, and the antithrombotic approach in cardiac disease.
To develop a rational approach to antithrombotic therapy, in cardiac disease, a sound understanding is required (1) of the hemostatic processes leading to thrombosis, (2) of the various antithrombotic agents, and (3) of the relative risks of thrombosis and thromboembolism in the various cardiac disease entities. With the understanding of pathogenesis and risk of thrombus formation, a rational approach to the use of antiplatelet and anticoagulant agents can be formulated. ⋯ Patients at low risk of thrombus formation should not receive antithrombotics. Such rational approach to antithrombotic therapy serves as the basis of this article.