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The cardiac consult
The cardiac consult for patients undergoing non-cardiac surgery
  1. Steven L Cohn
  1. Correspondence to Dr Steven L Cohn, Department of Medicine, University of Miami Miller School of Medicine, 1120 NW 14th St—CRB 1140, Miami, FL 33136, USA; scohn{at}med.miami.edu

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Learning objectives

  • To perform a preoperative cardiac risk assessment in patients undergoing non-cardiac surgery.

  • To decide whether or not further cardiac testing or subspecialty consultation is indicated.

  • To optimise the patient's medical condition prior to non-cardiac surgery using a multidisciplinary approach to reduce postoperative cardiovascular complications.

Introduction

The goal of the preoperative cardiac consultation is to assess the patient’s perioperative risk, to determine the need for additional testing or changes in management and to optimise the patient's medical condition prior to surgery (which may occasionally involve cancelling a case or switching to a lower-risk procedure). Risk assessment is dependent upon patient factors including functional capacity, cardiac conditions and surgery-specific risk. Optimal preoperative evaluation and perioperative management requires multidisciplinary team communication among all parties providing medical care as well as with the patient and family members. Because there are no evidence-based criteria mandating when a consultation is required and by whom, these decisions are often left to the discretion of the surgeon or anaesthesiologist. There are multidisciplinary preoperative assessment clinics that use their own criteria to determine how patients should be evaluated and by whom, but again any decision for specific cardiac consultation depends on the evaluating physician's experience, knowledge and comfort level. However, patients deemed to be at high risk should be discussed with all team members, and all options with their risks and benefits should then be discussed with the patient. This article will provide a clinical state-of-the-art review of perioperative cardiac risk assessment and management, focusing on the latest American College of Cardiology (ACC)1 and European Society of Cardiology (ESC) perioperative guidelines,2 which provide a framework and tools to assist the physician in risk assessment and decision-making.

Note: The scientific integrity of the DECREASE trials from the Poldermans group has been questioned.3 As part of the ACC …

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