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[Preoperative management of patients with high-risk cardiovascular conditions]
J P Broustet1, H Douard, L Labbé
1Département des épreuves d'effort et de la réadaptation des cardiaques, Hôpital cardiologique du Haut-Lévêque. jean-paul.broustet@pu.u-bordeaux2.fr
Insights
Elderly patients undergoing surgery face risks, but simplified preoperative cardiac screening focusing on functional status is often sufficient. Collaboration among medical professionals is key to preventing cardiovascular events.
Area of Science:
- Cardiology
- Geriatrics
- Anesthesiology
Context:
- Increasing numbers of elderly and cardiac patients due to medical advancements.
- Elderly patients face higher surgical risks, including silent coronary artery disease.
- Legal changes impact patient-doctor relationships and preoperative testing costs.
Purpose:
- To advocate for simplified preoperative cardiac risk assessment in elderly surgical patients.
- To emphasize functional status over lesion identification for risk evaluation.
- To highlight the importance of interdisciplinary collaboration in preventing perioperative cardiovascular events.
Summary:
- Preoperative screening for elderly surgical patients should prioritize clinical history, examination, and resting ECG, potentially with stress testing.
- Focusing on functional status is more critical than identifying specific cardiac lesions.
- Asymptomatic cardiac disease in this population is unlikely to worsen during or after surgery.
Impact:
- Streamlined preoperative evaluations can reduce unnecessary costs and improve patient care.
- Enhanced collaboration between anesthesiologists, surgeons, cardiologists, and general practitioners is crucial.
- Effective prevention of cardiovascular events in unavoidable surgeries is a primary goal.
Abstract:
The growing numbers of elderly and cardiac patients are the consequence of progress in the prevention of the complications of coronary artery and valvular heart disease by surgery and revascularisation and improved treatment of hypertension which delays target organ complications by at least fifteen years. The elderly are particularly exposed to surgical risk: nearly half the patients with ischaemic heart disease die of cancer; a high proportion of elderly people require orthopaedic surgery either as an emergency (fractured femur) or as a standard procedure (knee surgery); nearly a quarter of patients requiring peripheral vascular surgery have coronary artery disease which may be silent. A preoperative consultation with the anaesthetist has been made compulsory, except in emergencies, giving time for preoperative investigations. The decrees of the Court of Cassation have also affected the traditional relationship of trust between patients and their doctors, leading to an increase in the cost of preoperative investigations without an accurate assessment of their benefits with regards to postoperative complications and the cost that they entail. Contrary to present tendencies reflected in the literature, the screening of risks should be simplified: clinical history and examination and resting ECG, often completed by stress testing, are sufficient in the large majority of cases. More importance should be attributed to the functional status than to the lesions. When the cardiac disease is asymptomatic, the chances are that it will remain so during and after surgery.... The main difficulty is not in identifying high risk patients: it is preventing cardiovascular events when surgery is unavoidable. The experience and collaboration between the quartet of anaesthetist, surgeon, cardiologist and general practitioner, are much more useful than the very incomplete bibliographical data concerning this side of the problem.