Preoperative cardiac risk stratification: Ritual or requirement?

Abstract

IS THERE ANY real benefit to doing preoperative cardiac evaluation and risk stratification tests in a stable patient? Most physicians would intuitively maintain that there is benefit in identifying the subset of patients at high risk of perioperative myocardial ischemia before surgery. 1 Eagle KA Brundage BH Chaitman BR et al. ACC/AHA Task Force Report: Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Circulation. 1996; 93: 1278-1317 PubMed Google Scholar Notably, patients with evidence of ongoing plaque rupture and thrombosis causing an acute unstable coronary syndrome should have cardiac intervention before noncardiac surgery. However, in all patients without evidence of an acute unstable coronary syndrome, several peer-reviewed publications advocate proceeding directly to surgery. 2 Bodenheimer MM Noncardiac surgery in the cardiac patient: What is the question?. Ann Intern Med. 1996; 124: 763-766 Crossref PubMed Scopus (43) Google Scholar , 3 D'Angelo AJ Puppala D Farber A et al. Is preoperative cardiac evaluation for abdominal aortic aneurysm repair necessary?. J Vasc Surg. 1997; 25: 152-156 Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar , 4 Lee TH Reducing cardiac risk in noncardiac surgery. N Engl J Med. 1999; 341: 1838-1840 Crossref PubMed Scopus (75) Google Scholar , 5 Rosenfeld BA Breslow MJ Dorman T Postoperative management strategies may obviate the need for most preoperative cardiac testing. Anesthesiology. 1996; 84 (letter): 1267-1268 Crossref Scopus (6) Google Scholar Other authors state the decision to pursue perioperative cardiac risk stratification tests and possible coronary revascularization should be the same as in the nonoperative setting. 6 Palda VA Detsky AS Guidelines for assessing and managing the perioperative risk from coronary artery disease associated with major noncardiac surgery. Ann Intern Med. 1997; 127: 309-312 Crossref PubMed Google Scholar , 7 Palda VA Detsky AS Perioperative assessment and management of risk from coronary artery disease. Ann Intern Med. 1997; 127: 313-328 Crossref PubMed Scopus (193) Google Scholar