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Preoperative assessment of the patient with cardiac disease
1University of California, San Francisco, USA.
Insights
Assessing cardiovascular disease patients before surgery is complex. This review examines preoperative testing methods, highlighting the need for trials on new strategies to improve patient outcomes and reduce costs.
Area of Science:
- Cardiology
- Perioperative Medicine
- Medical Diagnostics
Background:
- Perioperative cardiac morbidity impacts over 1.5 million US patients annually, costing over $20 billion.
- Traditional risk assessment relies on clinical evaluations and indices.
- Non-routine preoperative cardiovascular testing is increasingly recommended.
Purpose of the Study:
- To review current preoperative cardiovascular testing methods for surgical patients.
- To discuss the strengths and limitations of various diagnostic tests.
- To present paradigms for assessing high-risk surgical patients.
Main Methods:
- Review of existing literature on preoperative cardiovascular assessment.
- Discussion of diagnostic tests including exercise ECG, Holter, radionuclide ventriculography, stress echocardiography, and dipyridamole thallium scintigraphy.
- Presentation of assessment paradigms based on coronary disease and functional status.
Main Results:
- Various non-routine tests have strengths and limitations.
- Current diagnostic and therapeutic approaches for high-risk patients remain challenging.
- Evidence for the cost-effectiveness of new strategies is limited.
Conclusions:
- Preoperative assessment of cardiovascular disease patients undergoing surgery is challenging.
- Further large-scale clinical trials are needed to evaluate new assessment strategies.
- Evaluating therapeutic and cost-effectiveness is crucial for future guidelines.
Abstract:
Assessment of the patient with cardiovascular disease is a challenging problem, especially for the subset of patients undergoing surgery. Perioperative cardiac morbidity affects more than 1.5 million people annually in the United States, and consumes more than +20 billion per year in health care resources. Solution of the problem initially had been addressed using routine historical and clinical evaluations and risk indices. More recently, nonroutine preoperative cardiovascular testing has been recommended, including exercise and Holter electrocardiography, radionuclide ventriculography, stress echocardiography, and dipyridamole thallium scintigraphy. Each of these tests has strengths and limitations that are addressed in this review. Paradigms for preoperative assessment of high-risk patients, based on the presence of coronary disease and the functional status of the patient, are presented and discussed. Diagnostic and therapeutic approaches for patients at high risk remain challenging; the mandate is for large-scale clinical trials to evaluate both the therapeutic and cost effectiveness of new preoperative assessment strategies.
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