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(Circulation. 1998;98:379-380.)
© 1998 American Heart Association, Inc.

Correspondence

Cardiac Risk of Noncardiac Surgery

Gregory L. Miller, MD, FACC

Grand River Cardiology p.c., Grand Rapids, Mich

To the Editor:

I would like to compliment Dr Eagle and colleagues on an excellent article regarding cardiovascular risk of patients with coronary artery disease undergoing noncardiac surgery, published recently in Circulation.¹ I do take issue, however, with the general statement that coronary revascularization done before the planned procedure is effective in reducing the risk of postoperative myocardial infarction and/or death.

Although retrospective studies, including the CASS registry patients used in Dr Eagle's study, have shown a low mortality rate after noncardiac surgical procedures in patients who have undergone coronary bypass surgery, I do not believe that percutaneous revascularization procedures have been shown to be similarly effective. Again, retrospective studies have been done, such as the one by Huber et al² from Mayo Clinic, that have not clearly shown whether PTCA is also "protective".

It has been my perception that many angioplasty procedures are being performed, especially now with the widespread use of stenting, on patients who have been found by intensive preoperative testing and screening to have obstructive coronary disease, with the belief that the risk of surgery will be reduced. The article by Eagle et al may unintentionally foster behavior that is possibly inappropriate by not making a more clear distinction between surgical and percutaneous revascularization.

References

1. Eagle KA, Rihal CS, Mickel MC, Holmes DR, Foster ED, Gersh BJ, for the CASS Investigators and University of Michigan Heart Care Program. Cardiac risk of noncardiac surgery: influence of coronary disease and type of surgery in 3368 operations. Circulation. 1997;96:1882–1887.[Abstract/Free Full Text]

2. Huber KC, Evans MA, Bresnahan JF, Gibbons RJ, Holmes DR Jr. Outcome of noncardiac operations in patients with severe coronary artery disease successfully treated preoperatively with coronary angioplasty. Mayo Clin Proc. 1992;67:15–21.[Medline] [Order article via Infotrieve]

Response

Kim A. Eagle, MD

Albion Walter Hewlett Professor of Internal Medicine and Senior Associate Chair Department of Internal Medicine, Chief of Clinical Cardiology, Division of Cardiology, University of Michigan, Ann Arbor, Mich

As Dr Miller points out, the prophylactic application of coronary angiography and related procedures for the expressed purpose of lowering coronary risk for noncardiac surgery remains ill defined. There have been at least 3 nonrandomized trials^{1 2 3} that suggest, on average, that patients . . . [Full Text of this Article]