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18 March 2003 | Volume 138 Issue 6 | Pages 506-511
Internists and cardiologists are often asked to estimate the risk for perioperative myocardial infarction or cardiac death in patients being considered for noncardiac surgery. Estimating this risk in an individual patient is difficult and complex. Although noninvasive imaging tests are often used for this purpose, a review of the literature reveals that the positive predictive value of noninvasive imaging tests is uniformly low and that they do not provide information beyond that obtained by assessing simple clinical risk variables. Moreover, no evidence exists that noninvasive imaging tests lead to a therapeutic strategy that reduces the risk for perioperative myocardial infarction or cardiac death. Since the publication of guidelines for preoperative risk stratification by the American College of Cardiology/American Heart Association in 1996 and the American College of Physicians in 1997, three clinical trials have shown that ß-blocker therapy reduces the risk for perioperative cardiac events. This paper focuses on the relationship between risk stratification and subsequent therapy to minimize or eliminate risk. In short, the paradigm is shifting from predicting which patient is at high risk for having a perioperative cardiac event to minimizing the likelihood of such an event with specific perioperative pharmacologic therapy.
Author and Article Information
From the University of Texas Southwestern Medical Center and Veterans Affairs Medical Center, Dallas, Texas.
Grant Support: Dr. Grayburn is supported by a Mid-Career Investigator in Patient-Oriented Research Award (K24-HL03980) from the National Heart, Lung, and Blood Institute.
Requests for Single Reprints: Paul A. Grayburn, MD, Baylor Heart and Vascular Institute, 3500 Gaston Avenue, Dallas, TX 75246.
Current Author Addresses: Dr. Grayburn: Baylor Heart and Vascular Institute, 3500 Gaston Avenue, Dallas, TX 75246.
Dr. Hillis: Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9030. PERSPECTIVE
Cardiac Events in Patients Undergoing Noncardiac Surgery: Shifting the Paradigm from Noninvasive Risk Stratification to Therapy
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