Of the 23 million Americans anesthetized annually, it has been estimated that approximately 1 to 2 million have known ischemic heart disease, and an additional 6 million have major risk factors.<sup>46 Mangano D.T. Perioperative cardiac morbidity Anesthesiology 1990 ;  72 : 153  [cross-ref]

Cliquez ici pour aller à la section Références</sup> In addition, the population is continuing to age and cardiovascular disease is associated with less mortality, leading to a higher percentage of patients presenting with some degree of ischemic heart disease. This article focuses on the management of these patients.

Unlike patients undergoing cardiac surgery, the literature, with respect to the patient with ischemic heart disease undergoing noncardiac surgery, is not as extensive and suffers from a lack of randomized clinical trials and well-defined outcomes. Cardiovascular death is the ultimate bad outcome; however, many series have demonstrated a reduction in mortality over the previous two decades. The increasing safety of the perioperative period is a major contributor to the lack of randomized trials. It is very difficult to identify factors that influence mortality except in extremely large cohorts. Therefore, most studies include a perioperative myocardial infarction (MI) as major morbidity. In studies during the 1970s and 1980s, approximately 50% of patients who sustained perioperative MIs died<sup>56 Rao T.K., Jacobs K.H., El-Etr A.A. Reinfarction following anesthesia in patients with myocardial infarction Anesthesiology 1983 ;  59 : 499  [cross-ref]

Cliquez ici pour aller à la section Références, 66 Tarhan S., Moffitt E.A., Taylor W.F. , et al. Myocardial infarction after general anesthesia JAMA 1972 ;  220 : 1451

Cliquez ici pour aller à la section Références</sup>; this is not the case in the 1990s.<sup>22 Fleisher L.A., Nelson A.H., Rosenbaum S.H. Postoperative myocardial ischemia: Etiology of cardiac morbidity or manifestation of underlying disease J Clin Anesth 1995 ;  7 : 97  [cross-ref]

Cliquez ici pour aller à la section Références, 40 Landesberg G., Luria M.H., Cotev S. , et al. Importance of long-duration postoperative ST-segment depression in cardiac morbidity after vascular surgery Lancet 1993 ;  341 : 715  [cross-ref]

Cliquez ici pour aller à la section Références</sup> One possibility is improved care of these patients, although it is also possible that the use of sensitive means of detecting a perioperative MI have led to identification of smaller infarcts. As discussed later in this article, the meaning of a small perioperative MI diagnosed primarily by cardiac enzymes remains to be determined. In many trials, unstable angina and congestive heart failure are included among the end points. A diagnosis of unstable angina in the perioperative period may in fact be the normal angina pattern in an ambulatory patient and may not result in increasing morbidity. The cause of perioperative congestive heart failure is complex, and it may only lead to increased use of resources, but not any irreversible effects. Therefore, in determining the goals of perioperative management and interpreting any randomized clinical trial or cohort study, the type of outcome assessed is an important variable.