Risk reduction strategies: perioperative management of cardiovascular medication Chapters

The perioperative period is associated with various physiological stressors that can predispose patients to major cardiovascular events. Clinically significant hypotension and major bleeding are also common during and after surgery and can further increase the risk of myocardial events, stroke, and mortality. The decision to continue or withhold antithrombotic therapy around the time of surgery should take into consideration the patient’s thrombotic risk and the increased risk of bleeding associated with antiplatelet therapy; in most cases, the bleeding risk outweighs the benefits and such agents should be withheld in the perioperative period. Continuing statins around the time of surgery may be beneficial, but further evidence is required to confirm this finding. Perioperative beta blockade has been shown to prevent myocardial infarction but at the expense of increasing mortality, stroke, hypotension, and bradycardia. Alpha-2 blockers have also been evaluated in a large non-cardiac surgery trial, and their initiation in the perioperative setting has failed to show benefit in preventing cardiovascular events. Moreover, similar to beta blockers, perioperative alpha-2 agonist administration increased the risk of significant hypotension. Although the evidence is more limited for calcium channel blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers, their administration around the time of surgery appears to increase the risk of intraoperative hypotension without any apparent benefit. Given the increased risk of mortality and stroke among patients developing clinically important hypotension in the perioperative setting, the current evidence does not support the initiation of such agents to prevent perioperative cardiovascular events.