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Ideas and Opinions |15 April 1996

Noncardiac Surgery in the Cardiac Patient: What Is the Question?

Monty M. Bodenheimer, MD

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  • From the Long Island Jewish Medical Center, New Hyde Park, New York. For the current author address, see end of text. Acknowledgments: The author thanks Drs. Andrew Grunwald and Obi Nwasokwa for their helpful comments. Requests for Reprints: Monty M. Bodenheimer, MD, The Harris Chasanoff Heart Institute, Room 2135, Long Island Jewish Medical Center, New Hyde Park, NY 11042.
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Considerable debate surrounds the preoperative evaluation of patients scheduled for noncardiac surgery who have coronary artery disease established on the basis of typical angina pectoris or previous myocardial infarction or who have risk factors that suggest the presence of asymptomatic coronary artery disease [1-4]. The good news is that noninvasive tests are sensitive to the presence of coronary artery disease and thus help identify most of the patients who would have nonfatal myocardial infarction or die of a cardiac event [5]. The bad news is that because the likelihood of such events is less than 10%, the positive predictive value is poor, ranging from 10% to 20% [5].
Why, then, are such patients almost automatically screened? Recent editorials [1-4] strongly recommend that patients with moderate risk (defined as the presence of one or two risk factors, such as age more than 70 years or diabetes, even in the absence of angina) have preoperative noninvasive testing. This has created a scenario wherein “defensive medicine” is practiced; in my experience, any desire to avoid testing meets with resistance from the cardiologist, the anesthesiologist, and the surgeon. In addition, preoperative noninvasive or invasive testing often reflects a lack of focus on the immediate question: “Can this patient reasonably have noncardiac surgery?” Instead, the consultant's preoperative opinion often concerns a different issue [3]: “Would coronary revascularization improve the long-term prognosis from a cardiac standpoint and protect the patient from adverse events during the necessary noncardiac surgery?” By modifying the question...
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Bodenheimer MM. Noncardiac Surgery in the Cardiac Patient: What Is the Question?. Ann Intern Med. 1996;124:763–766. doi: 10.7326/0003-4819-124-8-199604150-00010

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Published: Ann Intern Med. 1996;124(8):763-766.

DOI: 10.7326/0003-4819-124-8-199604150-00010

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