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From the Departments of Medicine and of Clinical Epidemiology and Biostatistics (Devereaux, Guyatt, Yusuf) and the Population Health Research Institute (Yusuf), McMaster University, Hamilton, Ont., the Department of Medicine, University of California, San Francisco, San Francisco, Calif. (Goldman), the Department of Medicine, University of Western Ontario, London, Ont. (Gilbert), the Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, and the Department of Pharmacology, University of Melbourne, Melbourne, Australia (Leslie)
Abstract
THIS IS THE SECOND OF 2 ARTICLES EVALUATING cardiac events in patients undergoing noncardiac surgery. Unrecognized myocardial infarctions (MIs) are common, and up to 50% of perioperative MIs may go unrecognized if physicians rely only on clinical signs or symptoms. In this article, we summarize the evidence regarding monitoring strategies for perioperative MI in patients undergoing noncardiac surgery. Perioperative troponin measurements and 12-lead electrocardiograms can detect clinically silent MIs and provide independent prognostic information. Currently, there are no standard diagnostic criteria for perioperative MIs in patients undergoing noncardiac surgery. We propose diagnostic criteria that reflect the unique features of perioperative MIs. Finally, we review the evidence for perioperative prophylactic cardiac interventions. There is encouraging evidence that some perioperative interventions (e.g., ß-blockers, 
2-adrenergic agonists, statins) may prevent major cardiac ischemic events, but firm conclusions await the results of large definitive trials. The best evidence does not support a management strategy of preoperative coronary revascularization before noncardiac surgery.
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