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Training general surgery residents to avoid postoperative cardiac events
Thomas R McLean1, Jennifer McGoldrick, Sheryl Fox
1VA Eastern Kansas Health Care System, Dwight D. Eisenhower VA Medical Center, 4104 S. Fourth St. Trafficway, Leavenworth, KS 66048, USA. Thomas.McLean@med.va.gov
Insights
General surgery residents can effectively identify patients needing cardiology consultation using clear criteria. This approach streamlines care, ensuring appropriate cardiac risk assessment and optimizing surgical decisions.
Area of Science:
- Cardiology
- General Surgery
- Medical Decision Making
Background:
- Acquiring expertise in cardiac risk assessment is time-consuming.
- Unnecessary cardiology consultations can delay patient treatment and strain healthcare resources.
Purpose of the Study:
- To evaluate the effectiveness of specific criteria for general surgery residents in obtaining cardiology consultations.
- To determine if these criteria appropriately select patients requiring further cardiac work-up before surgery.
Main Methods:
- Retrospective review of cardiac work-up and postoperative events for general surgery patients over one year.
- General surgery residents (Postgraduate years 1-3) used defined criteria to request cardiology consultations.
- Criteria included: coronary intervention >2 years prior, current anti-anginal medication use, or symptomatic status/abnormal ECG, tempered by planned procedure.
Main Results:
- Of 720 screened patients, 37 (5%) received cardiology consultations; 97% met at least one criterion.
- Cardiac imaging was performed on 65% of referred patients, with 33% showing positive results.
- Thirty percent of referred patients did not proceed with surgery after risk minimization, and 15% declined; overall surgical mortality was 2% with no postoperative myocardial infarctions or cardiac deaths.
Conclusions:
- The established criteria effectively identify general surgery patients who require further cardiac evaluation.
- Cardiology consultations often lead to revised surgical risk-benefit assessments by surgeons and patients.
Background:
Expertise in cardiac risk assessment takes years to acquire, but unnecessary cardiology consultation delays treatment and consumes scarce resources.
Methods:
A retrospective review was performed of the cardiac work-up and postoperative events during 1 year on a general surgery service. Postgraduate year 1-3 general surgery residents were instructed to obtain a cardiology consult if a patient had any of the following: (1) had undergone coronary artery intervention more than 2 years in the past; (2) was taking an anti-anginal medication (nitroglycerine, Ca channel, or beta-blocker); or (3) was symptomatic or had an abnormal electrocardiogram. Whether a patient was symptomatic was to be tempered by the nature of the planned procedure.
Results:
Supervised residents screened 720 unique patients for surgery. Cardiology consultation was obtained in 37. All but 1 (97%) patient referred to cardiology met at least 1 of the earlier-described criteria; with 8 (22%) meeting all 3 criteria. On average, patients referred to the cardiologists were taking 1.4 anti-anginal medications; and 1 patient sustained a fatal myocardial infarction after referral. Cardiac imaging (stress test or catheterization) was performed on 24 (65%) referred patients and was positive in 8 (33%). After minimizing cardiac risk by medication or intervention, the surgery service declined to offer the planned procedure to 11 (30%) of the referred patients and an additional 5 (15%) patients declined surgery. The overall surgical mortality was 2%. None of the patients in this series sustained a postoperative myocardial infarction or cardiac death. Postoperative supraventricular tachycardia was not influenced significantly by cardiology consultation (5% referred patients vs 1% nonreferred).
Conclusions:
Our criteria for obtaining cardiology consultation in general surgery patients appears to appropriately select patients in need of further work-up. Information obtained from a cardiac consultation frequently leads to a re-evaluation of the risks and benefits of surgery by both surgeons and patients.
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