[The cardiac risk patient in anesthesia]

Perioperative cardiac morbidity is one of the main challenges to the anaesthesiologist. Because of demographic changes and the increased prevalence of coronary artery disease (CAD) in elderly patients, the number of those at risk is increasing. Special attention has to be paid to patients bearing an increased risk where CAD has not been proven preoperatively because they represent the majority. The use of the "Revised Cardiac Risk Index", which includes patient-related as well as surgery-related risk, is recommended as its predictive value is validated to be very high. Additional preoperative testing is indicated only in those patients at intermediate risk where functional status is poor or unclear. In those with clearly high risk, possibility and urgency of an intervention related to their cardiac disease must be weighed against urgency and invasiveness of planned non-cardiac surgery. Regarding prophylactic perioperative therapy, only beta-blockers can be recommended on a sufficient basis of clinical data. This treatment is of special value in patients with poor functional status and those undergoing vascular surgery. Postoperative continuation of beta blockade for five to seven days is essential to its success. The usefulness of alpha-2-blockers is not equally well-proven so far. Prevention of perioperative hypothermia can reduce cardiac risk. In addition, there is increasing evidence that thoracic epidural anaesthesia decreases cardiovascular morbidity and mortality.