To the Editor:—
We read with great interest the review article by Park. 1
We appreciate the importance the author attributes to the necessity for the anesthesiologist and the cardiologist to work as a team and to the guidelines.
However, we disagree with the author about the risks of percutaneous transluminal coronary angioplasty during the acute phase of myocardial infarction (AMI). When feasible, percutaneous transluminal coronary angioplasty remains the treatment of choice during AMI, resulting in an approximately 85% success rate. 2
During AMI, it appears that it is always useful to “open” the occluded coronary artery, even when the patient is in cardiogenic shock. In this setting, coronary angioplasty seems to be the best treatment. 3,4
The trend is to perform intravenous thrombolysis as soon as possible, and then coronary angioplasty when the patient can be managed in a center where this technique is available.
The important issue of the patient with AMI who needs noncardiac surgery must be addressed. In any case, AMI should be managed first. Especially when the patient with AMI needs urgent noncardiac surgery, establishing the best strategy will rely on an emergency coronary assessment in a center experienced with primary angioplasty.
If the occluded artery is a large vessel with a large myocardial territory involved, angioplasty and stenting must not be delayed, and any urgent surgery must be done under antiplatelet therapy while considering the increased risk of bleeding. If the occluded artery is a small vessel with few myocardial tissues at risk, angioplasty is not necessary, avoiding the need for antiplatelet treatment and the risk of subsequent bleeding. Close collaboration between the anesthetist and cardiologist is warranted during the perioperative period.
Pierre Lena, M.D.*
Alain Mihoubi, M.D.
Claude-Jean Mariottini, M.D.
Pierre Meyer, M.D.
1. Park KW: Preoperative cardiology consultation. A nesthesiology 2003; 98: 754–62
2. Herrmann HC, Moliterno DJ, Ohman EM, Stebbins AL, Bode C, Betriu A, Forycki F, Miklin JS, Bachinsky WB, Lincoff AM, Califf RM, Topol EJ: Facilitation of early percutaneous coronary intervention after reteplase with or without abciximab in acute myocardial infarction: Results from the SPEED (GUSTO-4 Pilot) Trial. J Am Coll Cardiol 2000; 36: 1489–96
3. Garcia E, Elizaga J, Perez-Castellano N, Serrano JA, Soriano J, Abeytua M, Botas J, Rubio R, Lopez de Sa E, Lopez-Sendon JL, Delcan JL: Primary angioplasty versus systemic thrombolysis in anterior myocardial infarction. J Am Coll Cardiol 1999; 33: 605–11
4. Grines CL, Cox DA, Stone GW, Garcia E, Mattos LA, Giambartolomei A, Brodie BR, Madonna O, Eijgelshoven M, Lansky AJ, O'Neill WW, Morice MC: Coronary angioplasty with or without stent implantation for acute myocardial infarction: Stent Primary Angioplasty in Myocardial Infarction Study Group. N Engl J Med 1999; 341: 1949–56
© 2003 American Society of Anesthesiologists, Inc.