[HSF] Too scared to touch.....
Ajit Damle
damle at cableone.net
Tue May 1 05:54:45 EDT 2007
Great posting, Prasanna!
I know medical practice is based (somewhat loosely) on science, but I wish
our practices were a tad more rigorous.
We commonly form our opinions from our own personal experiences. Of course,
life in trenches is a little different, but still.....
Perhaps medical societies could take lead in this. I fantasize about a day
when all the patient parameters are inputed in a computer and the treatment
options are displayed with scientific validity of each, at least what class
of evidence is their for each treatment.
The best way , I think, would be to try and figure out how this can be done,
rather than think of all the (currently good) reasons why it can not.
Am I just dreaming?
Ajit Damle
-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of prasannasimha
Sent: Sunday, April 29, 2007 8:55 PM
To: OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] Too scared to touch.....
Hal,
Assumptions about certain things does not often mean we are right.
The articles after 2004 have shifted and this is specifically after the 2002
recommendations of maximal beta blockade peri-surgery
which caused a paradigm shift in perioperative outcomes after noncardiac
surgery in IHD patients.
Here are some references. In fact the new AHA guidelines (for what they are
worth) have shifted recommendations from revascularization
to beta blockade since that actually has given a better outcome than both
PCI and CABG. Just because we do these does not mean
we are actually reducing the event rate !! Most periop MI's in recently
revascularized patients have been due to enhanced mortality
due to stent/ graft closure produced by a combination of withdrawal of
platelets inhibitors, hemodynamic perturberations that have actually
increased graft closure (compared to native coronary disease) and new
events in non revascularized areas.
As far as current practice in US that you speak of ,see the heterogeneity
of practice in ref 5 !!
Prasanna
1: Acta Chir Belg. 2006 Jul-Aug;106(4):361-6.
Perioperative cardiac risk stratification and modification in abdominal
aortic
aneurysm repair.
Dunkelgrun M, Schouten O, Feringa HH, Noordzij PG, Hoeks S, Boersma E, Bax
JJ,
Poldermans D.
Vascular Surgery, Erasmus Medical Center, Rotterdam, The Netherlands.
Cardiovascular complications are important causes of morbidity and mortality
following vascular surgery. Adequate preoperative risk assessment and
perioperative management may modify postoperative mortality and morbidity
and
improve long-term prognosis. The objective of this review is to examine the
present day knowledge regarding the preoperative evaluation and
perioperative
management of patients undergoing noncardiac surgery, focusing specifically
on
abdominal aortic aneurysm (AAA) repair. Clinical markers combined with ECG
and
surgical risk assessment can effectively divide patients in a truly
low-risk,
intermediate and high-risk population. Low-risk patients can probably be
operated on without additional cardiac testing. Notably, due to the surgical
risk, AAA patients are never low-risk patients. Intermediate-risk and
high-risk
patients are referred for cardiac testing to exclude extensive stress
induced
myocardial ischemia, as beta-blockers provide insufficient myocardial
protection
in this case and preoperative coronary revascularization might be
considered.
Whether patients at intermediate risk without ischemic heart disease should
be
treated with statins and/or beta-blockers is still controversial._* In
high-risk
patients, it is strongly advised to administer beta-blockers with heart rate
determined dose adjustment, while the effects of preoperative
revascularization
remain subject to debate.*_
Publication Types:
Review
PMID: 17017685 [PubMed - indexed for MEDLINE]
2: Curr Treat Options Cardiovasc Med. 2006 Feb;8(1):59-66.
Preoperative evaluation and treatment of stable CAD in patients scheduled
for
major elective vascular surgery.
Kelly RF, McFalls EO.
Division of Cardiology, VA Medical Center, University of Minnesota, 1
Veterans
Drive, 111C, Minneapolis, MN 55414, USA.
One of the most controversial topics in clinical cardiology is the extent of
preoperative studies that is required among patients scheduled for major
elective noncardiac operations. Patients in need of an elective operation
for
either an expanding aortic aneurysm or lower limb ischemia have the highest
risk
of postoperative cardiac complications because of the high prevalence of
coronary artery disease and the hemodynamic stresses associated with the
vascular procedures. The decision to perform preoperative coronary
angiography
should be reserved for only those patients who are deemed clinically
unstable or
are functionally limited by cardiac symptoms. _*Among patients with minimal
symptoms, preoperative coronary artery revascularization with either
coronary
artery bypass graft surgery or percutaneous coronary interventions delays
the
needed operation and does not improve short-term outcomes or long-term
survival.
*_
PMID: 16401384 [PubMed]
3: CMAJ. 2005 Sep 27;173(7):779-88.
Surveillance and prevention of major perioperative ischemic cardiac events
in
patients undergoing noncardiac surgery: a review.
Devereaux PJ, Goldman L, Yusuf S, Gilbert K, Leslie K, Guyatt GH.
Department of Medicine, McMaster University, Hamilton, Ont.
philipj at mcmaster.ca
This is the second of 2 articles evaluating cardiac events in patients
undergoing noncardiac surgery. Unrecognized myocardial infarctions (MIs) are
common, and up to 50% of perioperative MIs may go unrecognized if physicians
rely only on clinical signs or symptoms. In this article, we summarize the
evidence regarding monitoring strategies for perioperative MI in patients
undergoing noncardiac surgery. Perioperative troponin measurements and
12-lead
electrocardiograms can detect clinically silent MIs and provide independent
prognostic information. Currently, there are no standard diagnostic criteria
for
perioperative MIs in patients undergoing noncardiac surgery. We propose
diagnostic criteria that reflect the unique features of perioperative MIs.
Finally, we review the evidence for perioperative prophylactic cardiac
interventions. There is encouraging evidence that some perioperative
interventions (e.g., beta-blockers, alpha2-adrenergic agonists, statins) may
prevent major cardiac ischemic events, but firm conclusions await the
results of
large definitive trials./* */_*/The best evidence /does not support a
management
strategy of preoperative coronary revascularization before noncardiac
surgery.*_
Publication Types:
Research Support, Non-U.S. Gov't
Review
PMID: 16186585 [PubMed - indexed for MEDLINE]
4: Mt Sinai J Med. 2005 May;72(3):185-92.
Preoperative cardiovascular evaluation for noncardiac surgery.
Maddox TM.
Zena and Michael A. Wiener Cardiovascular Institute, Box 1030, Mount Sinai
School of Medicine, One East 100th Street, New York, NY 10029-6574, USA.
tmaddox at alumni.rice.edu
Cardiovascular complications following noncardiac surgery constitute an
enormous
burden of perioperative morbidity and mortality. Annually, more than one
million
operations are complicated by adverse cardiovascular events, such as
perioperative myocardial infarction or death from cardiac causes. In order
to
combat this problem, cardiac evaluation prior to noncardiac surgery should
ask
two questions about the patient: What is the risk of cardiac complications
during and after surgery? How can that risk be reduced or eliminated? Risk
assessment evaluates patients' co-morbidities and exercise tolerance, as
well as
the type of surgery to be performed, to determine the overall risk of
perioperative cardiac complications. Previous or current cardiac disease,
diabetes and renal insufficiency all confer higher risks for perioperative
cardiac complications. Poor exercise tolerance and high-risk surgical
procedures
(e.g., vascular, prolonged thoracic or abdominal operations) also predict
worse
perioperative outcomes. Noninvasive stress testing is widely used to help
predict risk of perioperative complications, but the poor predictive power
of
these tests hampers their usefulness. After estimating the risk of cardiac
complications, one should take measures to reduce it. Beta blockade has
shown
clear benefits in risk reduction. At this time, there are no data suggesting
benefits of percutaneous coronary intervention or coronary artery bypass
grafting in reducing noncardiac surgical risk. In addition, angioplasty with
stenting and its attendant need for anticoagulation can expose patients to
increased risk of perioperative bleeding. Thus, the use of coronary
revascularization prior to noncardiac surgery should be reserved for those
patients with an independent cardiac need for the procedure, such as
unstable
angina or stable angina refractory to medical therapy. In summary, patients
with
low clinical risk factors and good functional status, undergoing a low or
intermediate risk surgery, have an excellent prognosis and may proceed to
surgery without further delay. In addition, stable patients who have
previously
undergone coronary revascularization may also safely undergo surgery.
Patients
requiring urgent surgery should proceed immediately, since the consequences
of
delay usually outweigh the benefits of preoperative risk assessment.
However,
elective surgery should be indefinitely deferred for those patients with
unstable coronary syndromes, since consequences of the cardiac disease
usually
negate the benefits of surgery. Controversy involves the intermediate or
high
clinical risk patient considering high-risk, but elective, surgery.
Noninvasive
testing offers only limited assistance in estimating risk for these
patients.
_*The best risk reduction strategy for these patients is perioperative beta
blockade use. The role of coronary revascularization specifically to reduce
perioperative cardiac complications remains unproven.*_
Publication Types:
Review
PMID: 15915313 [PubMed - indexed for MEDLINE]
5: Am J Cardiol. 2004 Nov 1;94(9):1124-8.
Disparate opinions regarding indications for coronary artery
revascularization
before elective vascular surgery.
Pierpont GL, Moritz TE, Goldman S, Krupski WC, Littooy F, Ward HB, McFalls
EO;
Current Opinion On Revascularization Study Investigators.
Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota 55417,
USA.
pierp002 at umn.edu
Despite consensus guidelines, the optimal strategy for preoperative cardiac
risk
management among patients scheduled for major noncardiac surgery remains
controversial. This study assesses current opinion about the role of
preoperative coronary revascularization for patients with coronary artery
disease scheduled for elective vascular surgery. Thirty-one practicing
cardiologists recruited from 4 different regions reviewed case records,
imaging
tests, and coronary angiograms of 12 patients with coronary artery disease
participating in the Coronary Artery Revascularization Prophylaxis (CARP)
trial.
The need for preoperative coronary revascularization was determined and
results
summarized using 3 categories: favoring conservative management, neutral, or
recommending revascularization (either by percutaneous intervention or
bypass
surgery). We found recommendations were frequently disparate and often
deviated
from published guidelines (40% of the time). The likelihood of discordance
between 2 cardiologists was 54%, with a 26% chance that recommendations for
revascularization would be directly contradictory. Opinions were more often
conservative (43%) or aggressive (40%) than neutral (17%). Similar
inconsistency
was found as to the preferred method of revascularization, with only 1
patient
having complete agreement. _*Thus, this study reveals substantial
differences of
opinion among cardiologists across the country about the role of
preoperative
coronary artery revascularization for patients scheduled for elective
vascular
operations. Deviations from published guidelines are common, suggesting that
current consensus statements need additional data to support their
recommendations.*_
Publication Types:
Clinical Trial
Comparative Study
Randomized Controlled Trial
Research Support, U.S. Gov't, Non-P.H.S.
PMID: 15518605 [PubMed - indexed for MEDLINE]
6: J Vasc Surg. 2004 Oct;40(4):752-60.
Long-term survival after vascular surgery: specific influence of cardiac
factors
and implications for preoperative evaluation.
Back MR, Leo F, Cuthbertson D, Johnson BL, Shamesmd ML, Bandyk DF.
Division of Vascular & Endovascular Surgery, University of South Florida
College
of Medicine, the Surgical Service, James A. Haley Veterans Hospital, Tampa,
FL,
USA. mback at hsc.usf.edu
OBJECTIVE: We sought to identify specific determinants of long-term cardiac
events and survival in patients undergoing major arterial operations after
preoperative cardiac risk stratification by American College of
Cardiology/American Heart Association guidelines. A secondary goal was to
define
the potential long-term protective effect of previous coronary
revascularization
(coronary artery bypass grafting [CABG] or percutaneous coronary
intervention
[PCI]) in patients with vascular disease. METHODS: Four hundred fifty-nine
patients underwent risk stratification (high, intermediate, low) before 534
consecutive elective or urgent (<24 hours after presentation) open
cerebrovascular, aortic, or lower limb reconstruction procedures between
August
1996 and January 2000. Long-term follow-up (mean, 56 +/- 14 months) was
possible
in 97% of patients. The Kaplan-Meier method was used for survival data.
Long-term prognostic variables were identified with the multivariate Cox
proportional hazards model and contingency table analysis censoring early
(<30
days) perioperative deaths. RESULTS: While 5-year survival was 72% for the
overall cohort, cardiac causes accounted for only 24% of all deaths, and new
cardiac events (myocardial infarction, congestive heart failure, arrhythmia,
unstable angina, new coronary angiography, new CABG or PCI, cardiac death)
affected only 4.6% of patients per year during follow-up. High cardiac risk
stratification level (hazards ratio [HR], 2.2, 95% confidence interval [CI],
1.4-3.4), adverse perioperative cardiac events (myocardial infarction,
congestive heart failure, ventricular arrhythmia; HR, 2.2; 95% CI, 1.2-4.1),
and
age (HR, 0.33; 95% CI, 0.2-0.6) were independently prognostic for
latemortality.
Preoperative cardiac risk levels also correlated with new cardiac event
rates (
P < .01) and late cardiac mortality ( P = .02). Modestly improved survival
in
patients who had undergone CABG or PCI less than 5 years before vascular
operations compared with those who had undergone revascularization 5 or more
years previously and those at high risk without previous coronary
intervention
(73% vs 58% vs 62% 5-year survival; P = .02) could be demonstrated with
univariate testing, but not with multivariate analysis. Type of operation,
urgency, noncardiac complications, and presence of diabetes did not affect
long-term survival. CONCLUSION: Despite cardiac events being a less common
cause
of late mortality after vascular surgery, perioperative cardiac factors
(age,
preoperative risk level, early cardiac complications) are the primary
determinants of patient longevity._/* Patients undergoing more recent (<5
years)
CABG or PCI before vascular surgery do not have an obvious survival
advantage
compared with patients at high cardiac risk without previous coronary*/_
/_*interventions.*_/
Publication Types:
Comparative Study
PMID: 15472605 [PubMed - indexed for MEDLINE]
Hgrmd at aol.com wrote:
> Ben,
> You seem to be mixing apples and oranges a bit. I thought we were
> discussing whether coronary revascularization makes noncardiac surgery
less risky,
> not whether Mike's patient should get a CABG. Not withstanding the 2002
> Circulation article reportedly showing no benefit of CABG and PCI in
lowering the
> risk of noncardiac surgery, go ahead and repair an AAA on a patient with
a
> critical left main. See how they do, and see how long it takes you to
end up
> in court. I can tell you that patients and families get pretty upset
when the
> patient has a perioperative MI. Furthermore, I don't know of any
reputable
> general, orthopedic, or vascular surgeon, or anesthesiologist for that
> matter, who will take a patient to surgery with a stress test showing a
lot of
> myocardium at risk.
> Hal
>
>
>
> ************************************** See what's free at
http://www.aol.com.
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