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Practice Points and Conclusions

1. Morbidity after surgery is common and not diminishing

2. The most frequent cause of perioperative morbidity is related to a cardiac event. The best evidence suggests that prophylactic revascularization is of benefit - but only for a very small subset of the patients. Therefore, for the majority of patients, medical management remains the main mode of risk reduction. This should consist of triple therapy including a antianginal (beta blocker, calcium channel blocker, alpha agonist), ASA, and a statin.

3. Beta blockers should not be withdrawn and hospitals need to adopt protocols to continue them throughout the hospital stay. If possible, longer acting agents should be used.

4. Since ASA does not appear to increase transfusion risk and withdrawal is associated with coronary syndromes, we need to adopt protocols to allow the continuation of ASA throughout the hospital stay. Patients with prior PCI are a special consideration and at the very least need to be continued on ASA. Other antiplatelet agents need to be considered on an individual case basis in concert with the cardiologist and surgeon.

5. Statins should be continued preoperatively, up to and including the day of surgery. Postoperatively, therapy should be restarted as soon as possible. Initiation of statin therapy as late as 2 days preoperatively has been shown to have a beneficial effect.

6. Overall, the liberal use of blood transfusions may increase morbidity and mortality. However, although previously normal subjects can easily tolerate a hemoglobin of 70 mg/dl, the transfusion trigger in patients with coronary artery disease needs to be higher.

7. During the perioperative period, diabetic patients should be managed with insulin to maintain tight glycemic control.


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