Anesthesia for non-cardiac surgery in patients at high cardiac risk

Anaesthesia of patients with cardiovascular diseases for cardiac as well as for non-cardiac procedures is a daily challenge for anaesthesiologists. On top of the routine screeningspecific tests have been proposed to identify the patient at risk and to allow a prediction of postoperative outcome. In particular stress tests using either exercise or pharmacological stimulation of the cardiovascular system have been employed. However, the predictive value of these tests is still a matter of discussion. Factors that have been suggested to influence postoperative outcome are the type of operation and the type of anaesthesia, however, only the type of surgery has been demonstrated to possess predictive value. Furthermore, perioperative myocardial ischaemia may be influencing the postoperative outcome. Perioperative monitoring of myocardial ischaemia is performed by ECG, transoesophageal echocardiography (TEE), and pulmonary artery catheter. The ECG is the predominant monitoring method since it is readily available in most operating theatres and possesses a high sensitivity for detection of myocardial ischaemia particularly in combination with continuous ST-trend analyses. Besides other therapie new strategies for treatment of perioperative myocardial ischaemia are the administration of acadesine or alpha(2)-adrenoceptor agonists such as clonidine, mivazerol and dexmedetomidine. The effects of these drugs on postoperative outcome are currently being determined in large multicentre trials.