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Preoperative Clinical Evaluation of the Cardiac Patient for Noncardiac Surgery
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IN RESPONSE:
I fully agree with Dr. Topf that clinical skills are fundamental to deciding when to do noncardiac surgery in patients with several illnesses. The issue of perioperative ischemia and its significance is more complex. The paradigm I propose is to divide patients having noncardiac surgery into two groups. The first group includes patients with angina on minimal exertion or a syndrome suggesting ruptured coronary plaque. In the former, myocardial blood flow, although sufficient at rest or with minimal exertion, cannot increase adequately during the added stress of noncardiac surgery. In the latter case, the added stress can cause further damage to the plaque and secondary thrombus formation. In both situations, the risk for perioperative ischemia and infarction is high; aggressive, generally invasive cardiac evaluation before noncardiac surgery is appropriate [1]. The second group comprises patients with an old myocardial infarction, stable angina, or occult disease. In my opinion, the development of perioperative ischemia as reflected by ST-T changes represents a positive stress test result. In this case, the noncardiac surgery is the stress. To avoid prolonged ischemia, which can lead to infarction, postoperative stress and pain must be aggressively managed. This is analogous to stopping the conventional exercise or pharmacologic test when ischemia occurs. If, however, the patient remains tachycardic after surgery, the ischemia may result in infarction.
Dr. Topf's last point raises an even more complex problem. Fleisher and Eagle [1] suggest using the preoperative evaluation as an opportunity to optimize management of manifest disease and to detect occult disease. This assumes not only that noninvasive testing can be used to select the patient who will benefit from prophylactic revascularization before noncardiac surgery but also that noninvasive risk stratification is a useful strategy for patients with coronary artery disease. However, numerous studies have shown consistently poor positive predictive values for noninvasive testing [2, 3].
Thus, until we have tests with higher positive predictive values or therapy associated with low mortality and morbidity, preoperative evaluation should remain focused on the question, Can this patient with this clinical picture have noncardiac surgery?
Monty M. Bodenheimer, MD
Long Island Jewish Medical Center; New Hyde Park, NY 11042
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
