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Screening for Cardiac Disease in Patients Having Noncardiac Surgery

Lee A. Fleisher, MD; and Kim A. Eagle, MD
[+] Article and Author Information

From Johns Hopkins University School of Medicine, Baltimore, Maryland, and the University of Michigan Medical Center, Ann Arbor, Michigan. Grant Support: In part by the Richard S. Ross Clinician Scientist Award of the Johns Hopkins University School of Medicine. Requests for Reprints: Lee A. Fleisher, MD, Johns Hopkins Hospital, Department of Anesthesiology, 600 North Wolfe Street, Carnegie 442, Baltimore, MD 21287. Current Author Addresses: Dr. Fleisher: Johns Hopkins Hospital, Department of Anesthesiology, 600 North Wolfe Street, Carnegie 442, Baltimore, MD 21287.


Ann Intern Med. 1996;124(8):767-772. doi:10.7326/0003-4819-124-8-199604150-00011
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The preoperative evaluation of the cardiac patient having noncardiac surgery offers an opportunity to identify occult and further define known cardiovascular disease to modify both perioperative and long-term care. The baseline probability of cardiovascular disease should initially be assessed using clinical variables and identifying unstable symptoms, including unstable angina and congestive heart failure. The decision about whether to obtain noninvasive testing to further define cardiovascular status should be made on the basis of the testing's potential to modify perioperative care, the prior probability of advanced coronary disease based on clinical history, and the magnitude of the surgical procedure. Noninvasive testing is best done in selected patients who are at moderate clinical risk. Otherwise, testing loses its predictive value because of a high incidence of false-negative and false-positive results. Quantitative imaging can also be used to identify those patients in whom coronary angiography is indicated. The value of coronary revascularization before noncardiac surgery has not been studied in a randomized, prospective manner, but several cohort studies have suggested that patients who survive coronary artery bypass grafting have decreased risk during subsequent noncardiac surgery. Given the potential short-term increase in morbidity from two surgical procedures, it is prudent to reserve coronary revascularization before noncardiac surgery for those patients in whom it is associated with improved long-term survival. If coronary revascularization is reserved for these patients, then the overall evaluation should prove cost-effective from the perspective of both perioperative and long-term cardiovascular care.

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Figure 1.
Clinical algorithm developed using clinical variables and dipyridamole thallium results sequentially to stratify risk in 1081 patients having vascular surgery.[14]

Events are perioperative death or myocardial infarction. Clinical variables include advanced age (> 70 years); history of angina, myocardial infarction, diabetes, or congestive heart failure; and previous coronary bypass grafting. Dipyridamole thallium variables were ischemic electrocardiographic changes, fixed defects, and reversible defects. The algorithm shows the Bayesian concept that clinical markers only may substantially alter the probability of disease, eliminating the need for further testing. Testing can therefore be reserved for those patients in whom it would further modify the probability of disease and change management. Adapted with permission from the Journal of the American College of Cardiology .

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