LETTER
Perioperative Cardiac Risk Assessment and Management
Steven L. Cohn, MD
15 April 1998 | Volume 128 Issue 8 | Pages 693-694
TO THE EDITOR:
After reviewing the American College of Physicians' guidelines for perioperative cardiac risk assessment [1], I thought that the recommendations overly relied on Detsky and colleagues' modified cardiac risk index [2]. In contrast to the American College of Cardiology/American Heart Association guidelines [3], the College's position paper was written by two physicians, one of whom may have been biased by his own risk index. Another possible problem is that the College's guidelines do not include use of exercise capacity in risk assessment, despite the fairly widespread use of this measure. At the same time, however, the guidelines recommend ß-blockers on the basis of one study [4] that had 200 patients and showed no immediate perioperative benefit. Although Detsky and colleagues' index stressed the prior probability of the procedural risk, the new guidelines treat all nonvascular operations as a homogeneous group, which they are not. Section 3,4 of the guidelines incorrectly states that patients with angina were excluded from Goldman and coworkers' original study [5]. The Methods section of that report stated that "69 patients had classic angina by history, another 69 had chest pain not typical of angina, 72 patients had a clinical history of myocardial infarction, and another 59 had EKG criteria of an old MI [myocardial infarction]."
The algorithm published with the guidelines seems somewhat cumbersome and should be simplified to facilitate its use:
1. Step 1: Emergent surgery? If so, proceed to the operating room (without collecting any variables).
2. Step 2: Detsky and colleagues' modified cardiac risk index-If 20 points or more, consider angiography (if due largely to ischemic variables); if less than 20 points and nonvascular surgery is needed, proceed to the operating room; if less than 20 points and vascular surgery is needed, proceed to step 3.
3. Step 3: Eagle criteria-If there are 0 to 1 low-risk variables, proceed to the operating room; if there are 2 or more low-risk variables, perform noninvasive testing.
Development of guidelines is important and potentially useful; until those guidelines can be validated in large studies, however, the clinician should continue to evaluate each patient individually, exercising good clinical judgment.
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Author and Article Information
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State University of New York Health Science Center at Brooklyn; Brooklyn, NY 11203
1. American College of Physicians. Guidelines for assessing and managing the perioperative risk from coronary artery disease associated with major noncardiac surgery. Ann Intern Med. 1997; 127:309-12.
2. Detsky AS, Abrams HB, McLaughlin JR, Drucker DJ, Sasson Z, Johnston N, et al. Predicting cardiac complications in patients undergoing non-cardiac surgery. J Gen Intern Med. 1986; 1:211-9.
3. Eagle KA, Brundage BH, Chaitman BR, Ewy GA, Fleisher LA, Hertzer NR, et al. Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol. 1996; 27:910-48.
4. Mangano DT, Layug EL, Wallace A, Tateo I. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group. N Engl J Med. 1996; 335:1713-20.
5. Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977; 297:845-50.
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