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Risk Stratification for Noncardiac Surgery
- Paul A. Grayburn, MD; and
- L. David Hillis, MD
- From Baylor Heart and Vascular Institute, Dallas, TX 75246; and University of Texas Southwestern Medical Center, Dallas, TX 75390.
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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, β-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.
Paul A. Grayburn, MD
Baylor Heart and Vascular Institute; Dallas, TX 75246
L. David Hillis, MD
University of Texas Southwestern Medical Center; Dallas, TX 75390
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
