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Preoperative cardiac assessment of the thoracic surgical patient
1Department of Anesthesia, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Insights
Preoperative cardiac assessment for noncardiac surgery, including thoracic procedures, requires careful evaluation for coronary artery disease (CAD). Meticulous CAD assessment is often unnecessary, even for high-risk patients, due to imprecise risk stratification.
Area of Science:
- Cardiology
- Thoracic Surgery
- Anesthesiology
Background:
- Preoperative cardiac assessment for noncardiac surgery is crucial.
- Thoracic surgical patients share many assessment similarities with general noncardiac surgical patients.
- Specific considerations for coronary artery disease (CAD) in these patients warrant focused evaluation.
Purpose of the Study:
- To outline the purposes, methods, and limitations of cardiac risk assessment in noncardiac surgical patients with suspected CAD.
- To address the specific needs of thoracic surgical patients within this context.
- To clarify when meticulous preoperative evaluation for CAD is and is not warranted.
Main Methods:
- Review of existing literature and guidelines on preoperative cardiac risk assessment.
- Discussion of the pathophysiology of CAD relevant to surgical risk.
- Explanation of statistical principles influencing risk assessment interpretation.
Main Results:
- Risk assessment for CAD in noncardiac surgical patients is often imprecise.
- Indications for invasive coronary procedures before noncardiac surgery are generally consistent across patient populations.
- Meticulous preoperative CAD evaluation is frequently not indicated, even in high-risk scenarios.
Conclusions:
- Preoperative CAD risk assessment requires a nuanced approach, balancing potential benefits against the limitations of current methods.
- Cardiology consultant utilization should be guided by a clear understanding of risk stratification principles.
- Focus should be on appropriate patient selection for invasive procedures rather than universal meticulous evaluation.
Abstract:
The preoperative cardiac assessment of the thoracic patient differs very little from the assessment of any patient for noncardiac surgery, aside from a few special issues. Therefore, rather than reviewing the general issue of evaluation for noncardiac surgery, which is a topic that has been reviewed many times in the recent past, this article focuses on the purposes, methods, and limitations of risk assessment in the noncardiac surgical patient with suspected coronary artery disease (CAD), including thoracic surgical patients. Because risk assessment is imprecise and the main indications for invasive coronary procedures prior to noncardiac surgery are the same for any person for whom life-expectancy is expected to be prolonged, meticulous preoperative evaluation for CAD is not usually warranted, even for patients undergoing high-risk surgery or with multiple risk factors for CAD. To help understand this point of view and to utilize cardiology consultants appropriately, implications of basic pathophysiology as well as statistical principles are also discussed.