Preoperative Cardiology Consultation: How Helpful Is It?
Kleinman, Bruce M.D.
To the Editor:—
Dr. Park does us all a service in his review of preoperative cardiology consultation by clarifying the state of the art of preoperative cardiologic interventions and their associated outcomes. 1
At the same time, however, Park's review perpetuates a common myth: that anesthesiologists need to request, or consider, preoperative cardiology consultation in the many patients who present for elective noncardiac surgery who also have moderate or severe concomitant heart disease. Park's very own analysis of the perioperative interventional outcome data in fact proves what an exercise in wasted time, money, and effort most preoperative cardiology consultations are. Specifically, he clearly points out the lack of definitive data demonstrating the efficacy of preoperative cardiologic interventions (percutaneous transluminal coronary angioplasty, coronary artery bypass graft surgery) in improving outcomes for patients undergoing noncardiac surgery who have concomitant ischemic heart disease. 1
Indeed, he presents data which strongly suggest that some preoperative interventions, such as percutaneous transluminal coronary angioplasty with stent deployment, can be harmful. 1
In the case of valvular heart disease, Park presents convincing data to suggest that patients with aortic stenosis may undergo elective surgery safely. 1
Fourteen years ago, we found that the major preoperative problem generating a cardiology consultation was ischemic heart disease. 2
I suspect that is still true at present. We also suggested that the major reason for obtaining a consultation could only be that the consultant possesses a singular level of expertise over and beyond that of the requesting physician (in most cases, the anesthesiologist). 2
In the case of our cardiology colleagues, that level of expertise is related to the immediate treatment of acute coronary syndromes in which the intervention required clearly is outside the expertise and skills of an anesthesiologist. Furthermore, the possible medical treatment of unstable coronary syndromes—potent anticoagulants—in and of themselves automatically precludes most elective noncardiac procedures. But let's be clear, in terms of quantifying perioperative risk and managing that risk, anesthesiologists do not need a cardiologist. Perioperative risk assessment and management is not just within the purview or expertise of our cardiology colleagues; rather, it has a long and honored history within our discipline. Historically, anesthesiologists were one of the first groups of physicians to study perioperative risk and outcomes. 3–6
How exactly, then, is the singular expertise of a cardiologist obtained during a preoperative cardiology consultation supposed to “make things better” for the patient or the anesthesiologist? What hidden pearls of wisdom does the cardiologist possess that the anesthesiologist does not? And what pearls of wisdom are going to unequivocally improve perioperative outcome? In the one generally accepted efficacious intervention—the use of perioperative β-blockade—clearly, an anesthesiologist does not need the expertise of a cardiology consultant to initiate this therapy. After all, the idea that preoperative β-blockade might be efficacious was originally proposed by anesthesiologists. 7,8
Anesthesiologists now claim to be perioperative physicians, but being a perioperative physician demands more than just a name change. It demands a behavioral change as well.
In my opinion, what Park's review has clearly shown is that in terms of perioperative management—other than the management of perioperative acute coronary syndromes—the cardiology consultant has little to add. Given what we know about altering perioperative outcomes, there are very few instances when a preoperative cardiology consultant will prove useful to the anesthesia-surgical care team. If the overriding principle of preoperative cardiology consultation is “in general, indications for further cardiac testing and treatments [in the perioperative setting] are the same as those in the nonoperative setting,”1,p 755
then might I suggest that most cardiology consultations are best obtained after the patient has had elective surgery. It is in that setting where our patient's long-term diagnostic and therapeutic needs are best addressed. As the situation stands currently, there is still much confusion. I am left scratching my head in disbelief at the number of times the response from the cardiology consultant is, “Patient cleared for surgery, high-risk, use Swan-Ganz catheter!” Indeed, the emperor has no clothes!
Bruce Kleinman, M.D.
1. Park KW: Preoperative cardiology consultation: A nesthesiology 2003; 98: 754–62
2. Kleinman B, Czinn E, Shah K, Sobotka PA, Rao TK: The value to the anesthesia-surgical care team of the preoperative cardiac consultation. J Cardiothor Anesth 1989; 3: 682–7
3. Dripps RD, Lamont A, Eckenhoff JE: The role of anesthesia in surgicial mortality. JAMA 1961; 178: 261–6
4. Steen PA, Tinker JH, Tarhan S: Myocardial reinfarction after anesthesia and surgery. JAMA 1978; 239: 2566–70
5. Marx GF, Mateo CV, Orkin LR: Computer analysis of post-anesthetic deaths. A nesthesiology 1973; 39: 54–8
6. Vacanti CJ, Van Houten RJ, Hue RC: A statistical analysis of the relationship of physical status to postoperative mortality in 68,388 cases. Anesth Analg 1970; 49: 564–6
7. Stone JG, Foex P, Sear JW, Johnson LL, Khambatta HJ, Triner L: Myocardial ischemia in untreated hypertensive patients: Effect of a single small dose of a beta-adrenergic blocking agent. A nesthesiology 1988; 68: 495–500
8. Mangano DT, Layug EI, Wallace A, Tateo I: Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. N Engl J Med 1996; 335: 1713–20
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