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Coronary CTA works for preoperative risk stratification, but do we know when and how to use it?
  1. Márcio Sommer Bittencourt1,2,3,
  2. Danielle Menosi Gualandro4,5
  1. 1 Division of Internal Medicine, University Hospital, University of Sao Paulo, Sao Paulo, Brazil
  2. 2 Hospital Israelita Albert Einstein, Sao Paulo, Brazil
  3. 3 Diagnósticos da América (DASA), Sao Paulo, Brazil
  4. 4 Cardiology, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil
  5. 5 Cardiovascular Research Institute Basel (CRIB)Department of Cardiology, University Hospital, Basel, Switzerland
  1. Correspondence to Dr Márcio Sommer Bittencourt, Division of Internal Medicine, University Hospital, University of Sao Paulo, Sao Paulo 05412003, Brazil; msbittencourt{at}mail.harvard.edu

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More than 300 million surgeries are performed annually worldwide. Despite improvements in surgical techniques and anaesthesia, mortality related to these procedures is still higher than expected. Since cardiovascular complications are important contributors to postoperative morbidity and mortality, it is fundamental to identify patients at increased cardiovascular risk, not only to take measures to decrease risk but also to access the risk–benefit ratio of the surgery. Although the core of preoperative risk stratification are clinical risk scores, such as the Revised Cardiac Risk Index, they are known to have limited accuracy and additional tools to improve risk assessment may be needed for part of the population. Among the various cardiovascular complications commonly seen in the perioperative period, myocardial infarction/injury (PMI) are important contributors to mortality. Although in other clinical scenarios most of those episodes are mostly related to coronary plaque rupture or other acute atherosclerotic plaque instability defining a type 1 myocardial infarction (MI), in the perioperative period a significant proportion of events are also caused by oxygen supply demand mismatch, known as type 2 MI, though this is also most common in individuals with prior coronary artery disease (CAD).1 2

Despite the need to identify higher risk individuals, recommendations for routine preoperative testing have substantially decreased in the last two decades.3 This was motivated by the negative results of several randomised trials evaluating preoperative ‘prophylactic’ myocardial revascularisation, that failed to show benefit,4 5 as well as by the lack of evidence that performing preoperative testing reduces postoperative cardiac complications. In fact, unnecessary preoperative testing could result in harm by delaying surgery and compromising the prognosis of the disease leading to the indication for surgery. Yet, despite those restrictions, higher risk …

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