Udho Thadani, MD

The United States spends more money on health care than any other industrialized country; and in return, it is expected that patients receive the most sophisticated, state-of-the-art diagnostic procedures and treatment.

Perioperative MI and its subsequent consequences remain a dreaded complication after noncardiac vascular surgery. In the 1970s, recommendations were to avoid the perioperative use of beta-blockers due to possible harm secondary to beta-blocker–induced bradycardia and hypotension. However, subsequent data showed that there was a dose-related reduction in the incidence of MI after beta-blocker therapy.

Patients with established coronary heart disease (myocardial infarction, stable angina and documented coronary artery disease) and patients with diabetes or peripheral, cerebral and carotid vascular disease, or hypertension, are at high risk for developing myocardial infarction, stroke, sudden ischemic death, and unstable angina.

Patients with non-ST elevation acute coronary syndrome can be risk stratified into low- and high-risk groups at initial presentation. Identification of patients in the high-risk group is considered essential in the current ACC/AHA and ESC guidelines in order to institute measures to improve the prognosis. A history of accelerating tempo of ischemic symptoms in the proceeding 48 hours, prolonged ongoing (>20 minute) rest pain, pulmonary edema, older age (>65 years), transient ST-segment changes and elevated cardiac biomarkers, especially troponin T or I, characterize high-risk patients.