Preface

The problem of cardiac complications following anesthesia and surgery has taxed clinicians for many decades. Indeed, the death of Hannah Greener under anesthesia in 1848 is attributed to a cardiac cause. The 15-year-old girl was given chloroform for an operation to remove her toenail and probably died from a cardiac arrhythmia induced by chloroform. In 1929, Sprague described a series of 170 patients with cardiac disease who underwent anesthesia and surgery. Forty-two of them (25%) died during or following surgery. With the steady advances that have taken place in anesthesia, surgery, and the management of heart disease, the risk of cardiac complications in the perioperative period has steadily fallen. The risk of death following elective aortic aneurysm surgery is now of the order of 7%. However, this decline in individual risk has been offset by a number of other factors. More people than ever before survive into old age and extreme old age. Cardiac disease is common in old people and, as the population ages, the population burden of cardiac disease is steadily increasing. Improvements in medical technology and care are such that elderly patients who, even a decade ago, would not have been considered candidates for the operating theater can now be offered surgery.

This book is aimed at anesthetists, physicians, surgeons, and intensivists who care for patients at risk of perioperative myocardial injury and infarction. It provides, in one volume, an account of the current state of knowledge about the epidemiology, pathophysiology, and management of this problem.

Perioperative cardiac complications are a major public health issue. The size of the problem is made clear in Chapter 1. The first half of this chapter provides an account of the epidemiology of perioperative myocardial injury and its implications for the individual patient and the population as a whole. In the second half of the chapter, cardiac risk prediction for the individual patient and for the population as a whole are discussed. The strengths and limitations of the various cardiac risk scores, from the Goldman Multifactorial Risk Index to the Revised Cardiac Risk Index of Lee and Colleagues to the Customized Probability Index for vascular surgery, are examined.

The management of ischemic heart disease in the surgical setting rests on our current understanding of the pathophysiology and medical management of this disease. Chapters 2 and 3 provide the non-specialist with an overview of these rapidly advancing fields.

The mechanisms underlying perioperative myocardial infarction are still a subject of debate; is it due to myocardial oxygen supply/demand imbalance or coronary artery plaque rupture? In Chapter 4, Hans Priebe gives an account of our current understanding of the mechanisms of perioperative myocardial infarction and the extent to which pathophysiological mechanisms in the general cardiological population can be extrapolated to the surgical population. Priebe suggests a model that would unify these two mechanisms.

In the following chapter, Foëx and Biccard describe myocardial stunning and hibernation, concepts that are particularly important in light of recent findings concerning the myocardial protective effects of volatile anesthetic agents.