Which of the factors listed below will adversely affect the risk of perioperative cardiac complications and reinfarction in the patient described above?

a. Greater than five premature ventricular beats per minute on EKG rhythm strip

c. Withdrawal of medical therapy with beta blockers and topical nitrates

e. Known three vessel coronary artery disease

The incidence of reinfarction is increased in patients undergoing intrathoracic or intra-abdominal procedures lasting longer than three hours. The site of surgery or anesthetic technique have not been shown to change the incidence of reinfarction if the procedure is less than three hours in duration. Patients with known three-vessel or left main coronary artery disease are at increased risk, while those who have undergone prior coronary artery bypass grafting are of substantially decreased risk of reinfarction. Prophylactic therapy with beta blockers, calcium channel agents, and nitrates has not been proven beneficial; however, withdrawal of these agents has been associated with perioperative ischemia, myocardial infarction, and death. CHF is the single most important factor predicting postoperative cardiac morbidity. Rhythm disturbances, particularly frequent premature ventricular beats, more than five beats/minute, are also independently associated with an increased risk of perioperative cardiac complications.