Coronary computed tomographic angiography for preoperative risk: improved area under curve is not enough.

Abstract

The past several years have been a tumultuous and humbling time for those of us who manage and study perioperative patients. Not long ago, preoperative cardiac testing was almost routine, and large numbers of patients were treated with prophylactic coronary revascularization and β-blockers. However, few fields in medicine have experienced the seismic shifts seen in recommendations surrounding perioperative care, as recent randomized trials and registry studies1 have prompted us to be far more cautious in thinking about how and when to test and treat preoperative patients. See Article by Hwang et al In this issue of Circulation: Cardiovascular Imaging , Hwang et al2 examined 844 consecutive patients referred for coronary computed tomographic angiography (CTA) to screen for coronary artery disease before noncardiac surgery. Included patients had >1 cardiovascular risk factor or used cardiovascular medications, whereas patients with contraindications to computed tomography or previous coronary revascularization were excluded. A clinical score, the revised cardiac risk index, was compared with the revised cardiac risk index plus coronary CTA for prediction of perioperative major cardiac events, defined as cardiac death, myocardial infarction, or pulmonary edema within 30 days. Events occurred in 25 patients (3.0%), with mortality in only 9 patients (1.0%). On receiver–operator curve analysis, the presence of significant coronary artery disease on CTA as measured …