What do you think about “medical clearance”? You know, that’s where a surgeon sends you a patient before surgery so you can give your blessing that the surgery is safe for that patient and the patient can likely tolerate the surgery. To be honest, most primary care physicians know very little about the mechanics and stresses involved in surgery and anesthesia. So the pre-op “medical clearance” evaluation often consists of reflexly ordering a bunch of tests that clearly add to the cost of medical care but often add little to patient safety or quality outcomes. The American College of Cardiology and American Heart Association have issued Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery but these are often not followed.
Two recent papers help put those guidelines in context and suggest we need more restraint in pre-op cardiac testing. Writing in the Annals of Internal Medicine in November 2009, Chopra et al suggest it is time to throttle back on testing. The suggest that perioperative tests and treatments improve cardiac outcomes only when targeted to clearly defined patient subsets and that clinical trials have shown no additional benefit of cardiac testing in patients at low to moderate risk for perioperative cardiovascular events.
Furthermore, perioperative coronary revascularization can cause harm and does not improve clinical outcomes, even in high-risk patients. Though the role of perioperative beta blockers is still evolving, perioperative β-blockers at doses titrated to heart rate and blood pressure can reduce risk in high-risk patients. They suggest that implementing the American College of Cardiology/American Heart Association perioperative guidelines can improve clinical outcomes and reduce perioperative costs.
The second paper (Wijeysundera et al 2010) was a retrospective cohort study done in Canada. They found that noninvasive stress testing before major non-cardiac surgery was associated with improved one-year survival and shorter mean hospital length of stay. However, when patients were stratified by cardiac risk, the mortality benefit was primarily in those with high risk (Revised Cardiac Risk Index 3-6 points) and to a much lesser degree in those at intermediate risk (RCRI 1-2 points). Furthermore, such testing in those at low risk actually caused harm.
Basically, both papers support the current ACA/AHA guidelines. Not everyone needs pre-op cardiac testing and you can actually harm some patients by doing it. Keep in mind that there are other things you could be doing as part of that “medical clearance”. You could be doing simple tests to identify patients at risk for post-op delirium and suggesting strategies to minimize that possibility.
Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, et al; ACC/AHA Task Force Members. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation. 2007; 116: e418-e500 http://circ.ahajournals.org/cgi/content/full/116/17/e418
Chopra V, Flanders SA, Froelich JB, Lau WC, Eagle KA. Perioperative Practice: Time to Throttle Back. Annals of Internal Medicine 2009. Published online before print November 30, 2009
Duminda N Wijeysundera, W Scott Beattie, Peter C Austin, Janet E Hux, Andreas Laupacis
Non-invasive cardiac stress testing before elective major non-cardiac surgery: population based cohort study
BMJ 2010;340:b5526 (Published )