November 3rd, 2009
Does coronary revascularization make noncardiac surgery safer?
Richard A. Lange, MD, MBA
Does coronary revascularization make noncardiac surgery safer? If so, when?
On the cardiology consult service today, we evaluated a man who needs a “low risk” gastrointestinal surgical procedure urgently. He presented to hospital admission with a prolonged hypotensive episode associated with anterior ST depression and mildly elevated troponin levels and without chest pain. He had a 3-vessel CABG in 2004 and has been chest pain-free since.
The anesthesiologist and surgeon ordered a persantine thallium test (results pending) and a cardiology consult. Regardless of what the nuclear perfusion test shows, the anesthesiologist and surgeon are “uncomfortable” with performing surgery without defining his coronary anatomy and graft patency (i.e., “What harm is there in looking at his coronaries?”)
Two studies (McFalls et al, NEJM 2004;351:2795-804 and Poldermans et al, J Am Coll Cardiol 2007:49:1763-9) show that preoperative revascularization does not reduce the risk of death or nonfatal MI following noncardiac surgery.
Is cardiac catheterization in this patient simply defensive medicine? Do the data support such an approach? Are the previous studies of revascularization prior to non cardiac surgery relevant to our practice today?
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