REPLY
Risk Stratification for Noncardiac Surgery
Paul A. Grayburn, MD, and
L. David Hillis, MD
6 January 2004 | Volume 140 Issue 1 | Page W-3
IN RESPONSE:
As stated in our paper, the ultimate goal of "risk stratification" is to reduce risk. Accordingly, diagnostic tests that are used to define risk should first have likelihood ratios that accurately define risk and second should sort patients into clearly defined risk groups. Unfortunately, the diagnostic tests that are currently used in preoperative risk stratification for noncardiac surgery do not accomplish these goals, and under most circumstances, fail to add to the known clinical risk profile. Moreover, decision analytic models indicate that a strategy of routine preoperative testing followed by cardiac catheterization and revascularization in patients with abnormal test results does more harm than good (1, 2). In contrast, ß-blockers reduce the risk for perioperative complications, even in so-called high-risk patients (3). For these reasons, we believe strongly that the focus of perioperative management should be on therapy and prevention, not costly diagnostic testing with an unproven effect on outcomes. In short, we stand by our conclusion that "the era of routine noninvasive testing has ended."
Precisely which patients might benefit from preoperative noninvasive testing is unclear. Frost and Michota propose that such noninvasive testing should be reserved for those at high risk or limited functional capacity. On the basis of the data of Boersma and colleagues (4), we support the use of preoperative dobutamine echocardiography in patients with 3 or more clinical risk factors, unless they have a clear indication for coronary angiography independent of the need for noncardiac surgery. We agree with Dr. Cohn that this recommendation may not have been as clear in the algorithm as it was in the text. We also with Frost and Michota that "additional research is needed" in this field.
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Author and Article Information
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From Baylor Heart and Vascular Institute, Dallas, TX 75246; and University of Texas Southwestern Medical Center, Dallas, TX 75390.
1. Mason JJ, Owens DK, Harris RA, Cooke JP, Hlatky MA. The role of coronary angiography and coronary revascularization before noncardiac vascular surgery JAMA. 1995;273:1919-25. [PMID: 7783301].[Abstract]
2. Fleisher LA, Skolnick ED, Holroyd KJ, Lehmann HP. Coronary artery revascularization before abdominal aortic aneurysm surgery: a decision analytic approach Anesth Analg. 1994;79:661-9. [PMID: 7943772].[Abstract/Free Full Text]
3. Auerbach AD, Goldman L. ß-Blockers and reduction of cardiac events in noncardiac surgery: scientific review JAMA. 2002;287:1435-44. [PMID: 11903031].[Abstract/Free Full Text]
4. Boersma E, Poldermans D, Bax JJ, Steyerberg EW, Thomson IR, Banga JD, et al. Predictors of cardiac events after major vascular surgery: role of clinical characteristics, dobutamine echocardiography, and ß-blocker therapy JAMA. 2001;285:1865-73. [PMID: 11308400].[Abstract/Free Full Text]
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