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Testing Cardiac Reserve

Then & Now

Sniecinski, Roman M., MD, FASE*; Skubas, Nikolaos J., MD; London, Martin J., MD, FASE

doi: 10.1213/ANE.0b013e31825d2c09

From the *Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia; Department of Anesthesiology, Weil Cornell Medical College, New York, New York; Department of Anesthesiology, University of California, San Francisco, San Francisco, California.

In recognition of the 90th anniversary of the International Anesthesia Research Society and Anesthesia & Analgesia, we will republish summaries of our earliest articles and our current state of knowledge on the subject, highlighting how our specialty has advanced.

Funding: None.

The authors declare no conflict of interest.

Reprints will not be available from the authors.

Address correspondence to Roman Sniecinski, MD, Department of Anesthesiology, Emory University Hospital, 1364 Clifton Rd NE, Atlanta, GA 30322. Address e-mail to

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Tests for Evaluating Cardiac Reserve

No single test will classify the functional capacity of a given heart. The judgment of the physician may be assisted or confirmed by any of the many methods for estimating cardiac reserve, but his estimate must include a complex of cardiac symptoms which only his personal experience will enable him to properly appraise. Aside from the ordinary signs of cardiac decompensation there is a very simple test which will often assist in forming an estimate of cardiac reserve in a bed fast patient. If a patient cannot assume the prone position, or when lying down cannot sit up without an increase of .10 beats per minute or an increase in the rate or depth of respiration, then there is no cardiac reserve. In ambulatory cases, if walking slowly on the level produces either an increase of 20 beats or more per minute in the heart rate, or evident dyspnea, the case should be classed as one with no reserve. The “Postural Test” (Crompton’s), the “Staircase Test” or its modification, the “Chair Test,” or the “Russian Test” (holding the breath), are often helpful.

Frequent blood pressure readings are of assistance. But here also there is no rule of thumb. A proportionately high diastolic reading signifies relative myocardial incompetence, and this, with a low systolic pressure in a chronic myocarditis, is of serious import. A high systolic pressure with a normal pulse-pressure ratio points to a fair cardiac reserve. In the course of preoperative treatment, a fall in diastolic pressure and a commensurate increase in pulse-pressure is to be expected. Should this not occur, the details of care and treatment should be carefully scrutinized.

In the class of cardiacs under consideration will be found the myocardial and valvular defects of rheumatic hearts, chronic myocarditis, either infectious or toxic, syphilitic myocarditis, essential hypertension, cardio-renal sclerosis, paroxysmal tachycardia, auricular flutter and auricular fibrillation. For the purpose of preliminary treatment it is important to determine the character of the lesion but this may be disregarded in estimating the heart’s functional capacity.1

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Anesthesiologists in the early 1900s were acutely aware of the risks that anesthetic gases posed to a patient’s respiratory and circulatory systems. There was great interest in evaluating the strength of a patient’s heart to select the appropriate anesthetic technique. Dr. N. Worth Brown’s “The Disabled Heart and General Anesthesia” in the 1923 issue of this journal contains a particularly relevant passage dealing with “Tests for Evaluating Cardiac Reserve.”1 Dr. Brown suggests checking a patient’s pulse rate and respiratory effort when sitting up or walking on level ground to identify patients who might not tolerate the stress of surgery and anesthesia.

Ninety years later, we have come to rely less on simple pulse rates and more on sophisticated cardiac imaging to assess cardiac reserve. Since the landmark intraoperative guidelines were published in 1999,2 our specialty has embraced echocardiography in particular. Preoperative stress echocardiography has improved the ability to predict serious postoperative cardiac events.3 Even though the primary purpose of stress testing is to identify coronary artery disease, there is a certain amount of comfort in anesthetizing patients known to have a normal ejection fraction. If that information is not available preoperatively, it is easy to obtain via intraoperative transesophageal echocardiography, and our specialty has created guidelines for doing so.4 Risk stratification is possible by assessing left ventricular reserve, and right ventricular5 and diastolic function.6 We now have more methods of quantifying functional capacity of the heart than ever before. Our armamentarium will expand with the introduction of tissue Doppler and 3-dimensional echocardiography into the operating room.7,8

Yet one cannot help but wonder if Dr. Brown would be incredibly amazed or simply amused at our “progress” toward evaluating cardiac reserve. Millions of preoperative stress echocardiograms are ordered every year in this country, up to ¼ of them inappropriately, leading to increased cost and potential unnecessary interventions.9 A recent study suggested that preoperative echocardiography, albeit resting and not stress, may actually increase mortality and length of hospital stay.10 The bottom line is that in our quest to improve preoperative assessment, we must not forget that “Crompton’s test” and the “staircase test” are as relevant now as they were then.

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Dr. Martin London is the Section Editor for Perioperative Echocardiography and Cardiovascular Education for Anesthesia & Analgesia. This manuscript was handled by Dr. Steven L. Shafer, Editor-in-Chief, and Dr. London was not involved in any way with the editorial process or decision.

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Name: Roman M. Sniecinski, MD.

Contribution: This author helped prepare the manuscript.

Attestation: Roman Sniecinski approved the final manuscript.

Name: Nikolaos J. Skubas, MD.

Contribution: This author helped prepare the manuscript.

Attestation: Nikolaos Skubas approved the final manuscript.

Name: Martin J. London, MD.

Contribution: This author helped prepare the manuscript.

Attestation: Martin London approved the final manuscript.

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1. Brown NW.. The disabled heart and general anesthesia. Anesth Analg. 1923;2:112–6
2. Shanewise JS, Cheung AT, Aronson S, Stewart WJ, Weiss RL, Mark JB, Savage RM, Sears-Rogan P, Mathew JP, Quinones MA, Cahalan MK, Savino JS. ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg. 1999;89:870–84
3. Beattie WS, Abdelnaem E, Wijeysundera DN, Buckley DN. A meta-analytic comparison of preoperative stress echocardiography and nuclear scintigraphy imaging. Anesth Analg. 2006;102:8–16
4. Practice guidelines for perioperative transesophageal echocardiography.. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology. 2010;112:1084–96
5. Maslow AD, Regan MM, Panzica P, Heindel S, Mashikian J, Comunale ME.. Precardiopulmonary bypass right ventricular function is associated with poor outcome after coronary artery bypass grafting in patients with severe left ventricular systolic dysfunction. Anesth Analg. 2002;95:1507–18
6. Bernard F, Denault A, Babin D, Goyer C, Couture P, Couturier A, Buithieu J.. Diastolic dysfunction is predictive of difficult weaning from cardiopulmonary bypass. Anesth Analg. 2001;92:291–8
7. Skubas N.. Intraoperative Doppler tissue imaging is a valuable addition to cardiac anesthesiologists’ armamentarium: a core review. Anesth Analg. 2009;108:48–66
8. Vegas A, Meineri M.. Core review: three-dimensional transesophageal echocardiography is a major advance for intraoperative clinical management of patients undergoing cardiac surgery: a core review. Anesth Analg. 2010;110:1548–73
9. Picano E, Pasanisi E, Brown J, Marwick TH.. A gatekeeper for the gatekeeper: inappropriate referrals to stress echocardiography. Am Heart J. 2007;154:285–90
10. Wijeysundera DN, Beattie WS, Karkouti K, Neuman MD, Austin PC, Laupacis A.. Association of echocardiography before major elective non-cardiac surgery with postoperative survival and length of hospital stay: population based cohort study. BMJ. 2011;342:d3695
11. Gross H, Stein P, Buchberg AS.. Surgical anesthesia, heart disease and cardiovascular responses. Curr Res Anesth Analg. 1951;30:250–61

Both cardiac patient and physician are naturally apprehensive that the heart may not be strong enough to withstand operation.

— Harry Gross, MD11

© 2012 International Anesthesia Research Society