Showing papers by "Kim A. Eagle published in 1997"

Cardiac Risk of Noncardiac Surgery Influence of Coronary Disease and Type of Surgery in 3368 Operations

Abstract: Background The influence of prior coronary artery bypass surgery (CABG) versus medical therapy for reducing the risk of postoperative cardiac complications after noncardiac surgery continues to be debated. To further clarify this controversy we studied 24 959 participants in the Coronary Artery Surgery Study (CASS) database with suspected coronary disease by identifying those who required noncardiac surgery during more than 10 years of follow-up. Methods and Results CASS registry enrollees were either treated with CABG or medical therapy after initial entry. During follow-up, patients who required noncardiac operations were evaluated for hospital death or out-of-hospital death within 30 days of noncardiac surgery and nonfatal postoperative myocardial infarction (MI). At a mean follow-up of 4.1 years, 3368 patients underwent noncardiac surgery, with abdominal (36%), urologic (21%), orthopedic (15%), and vascular being most common. Abdominal, vascular, thoracic, and head and neck surgery each had a combined MI/death rate among patients with nonrevascularized coronary disease >4%. Among 1961 patients undergoing higher-risk surgery, prior CABG was associated with fewer postoperative deaths (1.7% versus 3.3%, P =.03) and MIs (0.8% versus 2.7%, P =.002) compared with medically managed coronary disease. Contrariwise, 1297 patients undergoing urologic, orthopedic, breast, and skin operations had mortality of Conclusions In patients with known coronary artery disease, noncardiac surgeries involving the thorax, abdomen, vasculature, and head and neck are associated with the highest cardiac risk, which is reduced among patients with prior CABG.

Dobutamine stress echocardiography. Stressing the indications for preoperative testing.

Abstract: In the current issue of Circulation, Poldermans et al1 report on the long-term prognostic value of dobutamine stress echocardiography in patients undergoing major vascular surgery. Their findings add to the growing literature on the use of exercise and dobutamine stress echocardiography as adjuncts in the assessment of prognosis among patients with known or suspected coronary artery disease. To date, the published experience with dobutamine stress echocardiography for assessment of prognosis and perioperative risk is relatively small compared with that using nuclear perfusion imaging techniques. Stress echocardiography is a more recently developed technique to detect coronary artery disease and myocardial ischemia, and all studies related to prognosis have been published since 1991. However, stress echocardiography is of increasing importance because of the increasing availability these techniques and because ofseveral advantages it offers over nuclear perfusion imaging. In addition to providing apparently equivalent data with respect to the presence and extent of coronary artery disease and myocardium at risk, dobutamine stress echocardiography allows assessment of valvular anatomy and function as well as resting and stress ventricular systolic function. This allows a more complete assessment of overall cardiac function, pertinent especially among patients with a history of congestive heart failure or cardiac murmur. Finally, stress echocardiographic techniques appear to have lower associated costs than the equivalent nuclear perfusion imaging counterparts, which may become increasingly important as the healthcare environment requires the delivery of cost-effective medical care. Poldermans et al2 and others3 4 have previously published reports on the utility of dobutamine stress echocardiography in the assessment of prognosis in a general population4 and for the identification of patients at increased perioperative risk during major vascular surgery.2 3 The report in the current issue of Circulation is important in that it describes the long-term prognostic data afforded by preoperative …

Surgical patients with heart disease: summary of the ACC/AHA guidelines. American College of Cardiology/American Heart Association.

Abstract: The evaluation and management of heart disease in patients about to undergo noncardiac surgery begins with a careful history and physical examination, including an assessment of clinical risk for perioperative myocardial infarction and/or death. Patients can be categorized into major, intermediate, minor or low clinical risk groups, based on clinical markers such as past myocardial infarction, congestive heart failure, angina or diabetes. Additional evaluation includes estimation of surgery-specific risk, prior coronary evaluation and/or revascularization, and level of functional capacity. Based on these parameters, physicians can decide to engage in further noninvasive testing to assess left ventricular function and/or risk of perioperative ischemia in a small, selected group of patients. Rarely, patients may meet criteria for perioperative coronary revascularization followed by noncardiac surgery. Perioperative medical therapy relies heavily on the use of beta blockers. Postoperative cardiac surveillance must be tailored to the individual patient. The use of pulmonary arterial catheters, the type of anesthesia and the assessment of long-term cardiac risk are also discussed in this summary of the ACC/AHA Guidelines.

Gender Differences in Presentation, Management, and Cardiac Event-Free Survival in Patients With Syncope

Abstract: In a MEDLINE search of published English studies (1966 to 1996), no prior study was identified that examined gender-based differences in the management and prognosis of patients admitted with syncope. We studied 109 consecutive patients (48 women) admitted with syncope at the Massachusetts General Hospital (1989 to 1990). All patients underwent Holter monitoring, signal-averaged electrocardiography, and echocardiography according to study protocol. Follow-up was 100% complete (10 ± 4 months). Women were older (74 ± 2 vs 66 ± 2 years, p 3 times as frequent for men compared with women (20% of men vs 6% of women, p

Expert opinion regarding indications for coronary angiography before noncardiac surgery

Abstract: Whether to perform coronary angiography on the basis of preoperative noninvasive cardiac testing remains a difficult decision. We hypothesized that there are noninvasive test results for which experts have general agreement about the indication for preoperative coronary angiography. We asked 30 experts (24 in specific diagnostic tests and six in clinical cardiology) to comment on statements regarding hypothetical noninvasive test results. There was agreement that catheterization should be performed for (1) exercise electrocardiographic ischemia with a blood pressure drop >10 mm Hg, (2) stress perfusion scan reversibility in one half or more of single-photon emission computed tomographic slices, and (3) stress echo ischemia in more than five segments, two or more coronary artery zones, or four left anterior descending coronary artery segments. Therefore coronary angiography should be performed for results of noninvasive tests that indicate large zones of myocardial ischemia and not for limited ischemia or test abnormalities without other significant findings.