(Circulation. 1998;98:379-380.)
© 1998 American Heart Association, Inc.
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
trials1 2 3 that suggest, on average, that
patients who have successfully undergone coronary angioplasty
without untoward complications are at relatively low risk for cardiac
events after noncardiac surgery. However, these studies had no
comparison group, and it is impossible to gauge whether any protection
was conferred as a result of the angioplasty. Contrariwise, the
evidence that suggests that prior successful coronary artery
bypass surgery reduces the cardiac risk of noncardiac surgery is
somewhat more compelling,4 but again no
randomized trial is available with this specific question in mind.
Since the management of patients with coronary heart disease
with medical, interventional, and surgical treatments is rapidly
evolving, it is difficult to know which strategy or strategies will be
most effective for reducing perioperative complications
without prospective studies.
Because of these uncertainties, the recently published guideline on the
evaluation and management of the patient with cardiac disease
undergoing noncardiac surgery indicated that the justification to
perform coronary artery angioplasty or coronary bypass
surgery in such patients should be identical to the indications for
these procedures in general.4 At this point,
there is no compelling evidence that one should create special
indications for these procedures in individuals just because they are
being considered for noncardiac surgery. However, it certainly is true
that the presentation for noncardiac surgery may
represent the first opportunity to identify a patient in need
of further therapy, and a noncardiac procedure may influence the timing
surrounding a decision to perform coronary intervention or
bypass surgery for appropriate indications.
It was not the intent of our article on the CASS
database5 to promote routine preoperative testing
and indiscriminate coronary interventions in patients being
considered for noncardiac surgery. In fact, the national guideline on
this topic specifically argues for a very selected use of noninvasive
testing and interventional procedures in subsets of patients where
current evidence supports their value.
References
1.
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.
2.
Elmore JR, Hallett JW Jr, Gibbons RJ, Naessens JM,
Bower TC, Cherry KJ, Gloviczki P, Pairolero PC. Myocardial
revascularization before abdominal aortic
aneurysmorrhaphy: effect of coronary angioplasty.
Mayo Clin Proc. 1993;68:637–641.[Medline]
[Order article via Infotrieve]
3.
Allen JR, Helling TS, Hartzler GO. Operative
procedures not involving the heart after percutaneous
transluminal coronary angioplasty. Surg Gynecol
Obstet. 1991;173:285–288.[Medline]
[Order article via Infotrieve]
4.
Eagle KA, Brundage BH, Chaitman BR, Ewy GA, Fleischer
LA, Hertzer NR, Leppo JA, Ryan T, Schlant RC, Spencer WH 3rd, Spittell
JA Jr, Twiss RD, Ritchie JL, Cheitlin MD, Gardner TJ, Garson A Jr,
Lewis RP, Gibbons RJ, O'Rourke RA, Ryan TJ. 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.
Circulation. 1996;93:1278–1317.
5.
Eagle KA, Rihal CS, Mickel MC, Holmes DR, Foster ER,
Gersh BJ, for the CASS Investigators. Cardiac risk of noncardiac
surgery: influence of coronary disease and type of surgery in
3368 operations. Circulation. 1997;96:1882–1887.
