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Erich
Fogg, PA-C, MMSc, DEPARTMENT EDITOR
John Bradford,
MPAS, PA-C
The author is a staff physician assistant in primary care at the VA Medical Center in Salt Lake City, Utah, and a clinical associate for the University of Utah Physician Assistant Program. He has indicated no relationships to disclose relating to the content of this article. Erich Fogg is Assistant Professor in and Program Director of the Physician Assistant Program at the College of Health Professions, University of New England, Portland, Me.
Case
The patient is a 72-year-old man who was referred
for a preoperative evaluation before surgery to remove a melanoma on his back. An
ECG performed at the surgeon’s office showed nonspecific ST-segment changes.
The patient denied any history of coronary artery disease (CAD), MI, chest pain,
or shortness of breath. His medical history was significant for hypertension, and
his current medications consisted only of aspirin. The patient said he felt very
well, was active, tried to follow a healthy diet, and had never experienced any
significant medical problems.  The patient’s cardiac risk factors
included age, gender, and a positive family history for premature CAD. He was a
nonsmoker. Laboratory studies disclosed the following values: LDL cholesterol, 153
mg/dL; total cholesterol level, 222 mg/dL; triglyceride level, 69 mg/dL; and HDL
cholesterol level, 55 mg/dL. The non-HDL cholesterol level was 167 mg/dL. The 10-year
Framingham risk score was 20%. An ECG done on the day of the clinic visit showed
normal sinus rhythm with left axis deviation, and nonspecific T wave abnormalities
in the anterolateral leads (see Figure 1). The patient’s BP in clinic was 175/93
mm Hg.
What is the next step?
- Proceed with surgery because the procedure is minor and can be performed under a local anesthetic
- Obtain a stress test to further delineate any disease
- Optimize medical management of risk factors, including hypertension and presumed coronary disease,
and proceed with surgery
Discussion
The 2003 American College of Cardiology/American
Heart Association (ACC/AHA) guidelines promote a stepwise approach to the preoperative
assessment of risk in coronary patients.1 After careful clinical assessment,
major, intermediate, or minor clinical predictors should be used to categorize the
patient. The type of surgery to be performed and the degree of hemodynamic stress
that will be encountered should be considered, and the patient’s functional
capacity (FC) should be assessed. Additionally, intangibles such as the effectiveness
of the surgeon—for instance, is the surgeon known for long operating times
or large blood loss in patients?—cannot be ignored.
Outcome This patient had several
minor clinical predictors and an excellent FC. Minor clinical predictors include
age, ECG changes, a low FC (in the absence of other indicators), uncontrolled hypertension,
a history of stroke, or any arrhythmia other than sinus arrhythmia. The patient
was initially sent home with hydrochlorothiazide for BP control and instructed to
take a baby aspirin daily. The surgical procedure was minor, and under the ACC/AHA
guidelines, it could be assumed to be safe to proceed. However, the surgeon wanted
to use a general anesthetic and more than one minor predictor was evident, so a
stress test was requested to further delineate any underlying disease. This showed
evidence of a moderately sized area of ischemia at the apex and septum. The patient
was started on a ß-blocker and referred for catheterization. The results showed
severe multivessel disease, including 100% occlusion of the left anterior descending
and right coronary arteries. The circumflex artery was also severely stenosed in
several places. Because of the severity of the distal disease, the patient was a
poor risk for revascularization and opted for medical management. He was started
on a statin and an ACE inhibitor, and the dosage of his ß-blocker was optimized.
He was also started on clopidogrel. As for his melanoma, this was excised under
a local anesthetic.
Comment Clinical guidelines
such as those from the ACC/AHA provide excellent criteria for evaluating a patient.
Nevertheless, guidelines are not laws, and good clinical judgment must be used when
determining a course of action. In this case, proceeding with the surgery as indicated
by the guidelines may have resulted in a poor outcome for the patient.
REFERENCE
1. Eagle KA,
Berger PB, Calkins H, et al. ACC/AHA guideline update for perioperative cardiovascular
evaluation for noncardiac surgery—executive summary: a report of the American
College of Cardiology/American Heart Association Task Force on Practice Guidelines
(Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation
for Noncardiac Surgery). J Am Coll Cardiol. 2002;39:542-553.
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