Jonathan B. Shammash, MD
Assistant Professor of Medicine,
Director of General Medical Consultation Service,
Department of Medicine,
Weill Medical College of Cornell University,
New York, NY, USA.

Julie M. Gold, BA
Weill Medical College of Cornell University,
New York, NY, USA.

Overview
Cardiovascular complications are the leading cause of morbidity and mortality in patients undergoing major noncardiac surgeries. It is estimated that 20-40% of patients at risk for cardiac events will experience perioperative cardiac ischemia, conferring a nine-fold increase in risk of perioperative cardiac death, myocardial infarction or unstable angina. This is a serious concern in North America. In the United States, about 1.5 of the 30 million patients undergoing noncardiac surgery each year will experience cardiovascular morbidity.¹ Since many of these patients have identifiable risk factors for cardiac ischemia, research efforts have been channeled toward finding modifiable risk factors and introducing pharmacological interventions that may offer cardiovascular protection during the perioperative period. Several small clinical trials have examined the perioperative use of nitrates² and calcium channel blockers,³ but these did not show a significant reduction in the incidence of cardiac ischemic events.

Laurie G. Jacobs, MD
Head, Unified Division of Geriatrics,
Albert Einstein College of Medicine & Montefiore Medical Center,
Bronx, NY, USA.

Introduction
Increasingly, older adults are undergoing invasive procedures and surgery. Surgery in the elderly has been associated with a greater morbidity and mortality than in younger patients due to the physiologic changes of aging, concurrent medical conditions and an increased rate of emergency procedures. Age alone is often a determining factor in whether a procedure or surgery should even be undertaken. Preoperative evaluation and perioperative care of the elderly patient requires evaluating the risk of complications, maximizing functional and physiologic parameters, instituting preventative measures, and focused management to assess potential risk and benefit for an individual patient.

Surgical Stress and Operative Risk
Noncardiac surgery in adults is associated with an incidence of postoperative myocardial infarction of 1-2%. Those with known heart disease, advanced age and serious comorbid conditions have a significantly greater risk for MI and other serious complications. Cardiovascular complications represent 50% of the causes of postoperative morbidity and mortality. In older adults, pulmonary, renal, infectious and cognitive adverse events are also extremely common.