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Indications for Cardiology Consultation

Lustik, Stewart J. M.D.

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To the Editor:—
I applaud Dr. Park's 1 conclusion that preoperative cardiology consultations are often unnecessary if the patient is amenable to perioperative β-blockade; however, if β-blockade is contraindicated, I disagree with obtaining a consultation when the American College of Cardiology–American Heart Association algorithm 2 recommends stress testing. Anesthesiologists should be sufficiently knowledgeable to determine the indicated type of stress test. Frequently, the test may be ordered after discussion with the patient's primary care physician, as the test has long-term patient-care issues. If the test is negative for ischemia at a significant workload (e.g., achievement of 85% of maximum predicted heart rate for exercise or dobutamine echocardiography), then no consultation is indicated. If a stress test is positive for significant ischemia, the cardiologist should be asked whether more invasive testing (coronary angiography) with possible treatment (percutaneous coronary intervention or coronary artery bypass graft) is indicated.
The author also concludes that cardiac consultation is not indicated for patients with severe aortic stenosis (AS) because studies demonstrate no increased risk of surgery if the AS is recognized. However, the studies were small and did not have the power to determine increased risk (Okeefe et al.3 studied only 23 patients with general anesthesia or spinal anesthesia, and Raymer and Yang's 4 sample size was adequate to detect only a fourfold increase in risk). Patients with severe AS and any of the triad (angina, syncope, or dyspnea) should be referred for prompt valve replacement. 5 In addition, even if patients with severe AS are asymptomatic, some authors believe that certain patients with stress testing–induced symptoms will benefit from aortic valve replacement. 5 Every patient with a murmur consistent with AS should be sent for echocardiography; if the aortic valve area is less than 1.0 cm2, a cardiology consultation should be strongly considered prior to elective surgery to determine if preoperative valve replacement is indicated.
Stewart J. Lustik, M.D.
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1. Park KW: Preoperative cardiology consultation. A nesthesiology 2003; 98: 754–62

2. Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE, Fleisher LA, Froehlich JB, Gusberg RJ, Leppo JA, Ryan T, Schlant RC, Winters WL Jr: ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery. Executive Summary: A report of the ACC/AHA task force on practice guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol 2002; 39: 542–53

3. O'Keefe JH, Shub C, Rettke SR: Risk of noncardiac surgical procedures in patients with aortic stenosis. Mayo Clin Proc 1989; 64: 400–5

4. Raymer K, Yang H: Patients with aortic stenosis: Cardiac complications in non-cardiac surgery. Can J Anaesth 1998; 45: 855–9

5. Carabello BA: Aortic stenosis. N Engl J Med 2002; 346: 677–82

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