ABSTRACT
Heart disease, especially coronary artery disease (CAD) is the primary health care problem
in the USA. Nearly one out of every two deaths in this country can be attributed to cardio-
vascular disease. Therefore, it is not surprising that CAD is also the major cause of morbidity
[myocardial infarction (MI), unstable angina, congestive heart failure (CHF), or serious
dysrhythmia] and mortality after surgery. In 1988, noncardiac surgical procedures were per-
formed in 25 million patients in all age groups. One million of these patients had diagnosed
CAD, and another 2-3 million were estimated to be at risk for the disease. Many of these
patients were elderly, who now constitute the fastest growing segment of our population. In
1988, 25 million (10%) were over 65 years old. The figure is projected to grow to 66 million
by the year 2055. In 1988, elderly patients comprised 25% (6 million) of the noncardiac
surgery group, and this figure is expected to grow to 35% (12 million) within 30 years
(1). The implied magnitude of the problem of CAD is enormous. In the aging surgical popu-
lation, how can the preoperative patient who is at high risk for perioperative cardiac morbid-
ity (PCM) be identified? Can the patient’s risk be reduced? For the past 35 years, clinical
studies have focused primarily on the factors involved in cardiac risk assessment, but in
recent years more emphasis has been devoted to risk reduction. This chapter provides a fra-
mework for assessing and reducing the risk of PCM in the surgical patient. It will emphasize
that directed history and physical examination are vital for evaluating risk. As will be seen in
the following discussion, the patient’s functional capacity has the same weight in estimating
risk as a history of MI.
