[HSF] Too scared to touch.....

[prasannasimha]

Hal,
The reason I have shifted in my approach is after seeing the reverse 
happening too.
In fact I had teamed up many years back with a cardiologist and we used 
to implant a BMS for say a circ lesion or CABG the patient and do some 
major vascular work and found our event rate was higher and then I 
shifted to selective treatment with vascular surgery first and sos 
stenting /CABG which had a far better result.
I also had a bunch of aortic surgeries in inoperable CAD and they were 
managed very well with aggressive beta blockade , additional epidural 
for pain relief etc etc. In fact what triggered it all was a patient 
with inoperable CAD who had limb threatening ischemia and I did his 
aortobifemoral and when he started getting postop Ischemia ,I did a 
literature search and he improved dramatically with IV beta blockade and 
other measures and then this started me thinking. Obviously you have to 
be careful and every case would not qualify especially if the CAD is 
unstable but for stable CAD I really think we may be doing a disservice 
by treating the angio and not the patient.Obviously all of this requires 
good periop management, good pain relief and judicious fluid management.
Prasanna
Hgrmd at aol.com wrote:
> Ajit,
>   I invested the time it took to read all of Prasanna's  abstracts.  I'm 
> still not convinced that medical therapy with beta-blockers  is the way to go for 
> nearly every case.  Again, if a stress test in an  asymptomatic patient shows 
> a lot of myocardium with reversible ischemia, it  would be potentially 
> foolhardy not to cath that patient.  Over the years,  we've been referred lots of 
> patients with left mains or critical 3vd that were  cathed prior to an elective 
> noncardiac procedure (usually carotid, ischemic leg,  or AAA).  We did the 
> CABG, they eventually got the vascular procedure, and  they did fine.  I've yet to 
> recall "graft closure" while the subsequent  case was done.  In light of the 
> problems with DES, the cardiologists are  much more likely to use bare metal 
> stents in such scenarios.  
>   I do agree that beta blockade, possible Swan, and a competent  cardiac 
> anesthesiologist suffice for the vast majority of cardiac patients  getting 
> noncardiac surgery.  However, there are plenty of asymptomatic  cardiac time bombs 
> waiting to explode for those that never cath and treat  preemptively.
> Hal
>
>
>
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