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(Circulation. 1998;98:823-824.)
© 1998 American Heart Association, Inc.

Correspondence

Noncardiac Surgery in CAD Patients

Enrique V. Carbajal, MD

Veterans Affairs Medical Center Fresno, Calif

To the Editor:

The article by Eagle et al¹ provides interesting data that may have important implications in the management of patients with coronary artery disease (CAD) who are scheduled for noncardiac surgery. This is an extremely interesting and complex subject, in part because of the difficulty in assessing cardiac risk in CAD patients and because of the paucity of data to guide management strategies aimed at reducing the risk of perioperative cardiac complications.

Indeed, there is an urgent need for management tactics in CAD patients to reduce or suppress perioperative coronary events (myocardial infarction [MI] or cardiac death). In this regard, the authors accomplished a superb task in summarizing data from the CASS trial.^1,2

There are, however, some issues of concern in this report. The data presented in this study¹ appear to be derived from retrospective observations in patients from the CASS registry and randomized groups³ who underwent noncardiac surgeries. In the design of CASS, a portion of patients from the registry were randomized to treatment according to specific clinical and angiographic criteria.³ Because treatment of CAD was dictated by physician and patient preference,¹ it is likely that significant bias was introduced into the various analyses of treatment outcomes. It appears unlikely that use of various statistical tools while these data are evaluated will compensate for the observational nature of the analyses.

It is interesting to note that in the high-risk noncardiac surgery groups (vascular, thoracic, and head and neck), patients without evidence of CAD had higher rates of . . . [Full Text of this Article]

Kim A. Eagle, MD; Charanjit S. Rihal, MD; Mary C. Mickel, MS; David R. Holmes, MD; Eric D. Foster, MD; ; Bernard J. Gersh, MD

University of Michigan Heart Care Program, Ann Arbor, Michigan