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Clinical Decisionmaking

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Echocardiography can help identify patients at risk of cardiac complications following major noncardiac surgery

Cardiovascular complications are the most common cause of death among patients undergoing noncardiac surgery. Transthoracic echocardiography (TTE) is frequently ordered before noncardiac surgery, although its ability to predict postoperative cardiac complications has been uncertain. Echocardiography is an imaging technique that can be used to visualize the position and motion of the heart walls or internal structures of the heart from the echo obtained by directing ultrasonic waves through the chest wall.

A recent study suggests that preoperative TTE can add helpful information to clinical criteria to better predict which patients are at risk of postoperative cardiac complications following major noncardiac surgery. However, echocardiograms are unlikely to improve management of otherwise low-risk patients based on clinical criteria or patients with a low probability of having an abnormal echocardiogram. Routine clinical data should suffice for these patients, according to the researchers.

It is premature, however, to recommend that TTE be performed routinely in patients with both a moderate or high clinical risk for postoperative cardiac complications and a high risk for abnormal echocardiographic findings, caution Lee Goldman, M.D., M.P.H., of the University of California, San Francisco, and Thomas H. Lee, M.D., M.S., of Brigham and Women's Hospital in Boston. With support from the Agency for Healthcare Research and Quality (HS06573), the researchers evaluated what additional information beyond clinical data TTE provided for predicting cardiac complications after surgery among 570 patients who underwent TTE before major noncardiac surgery at a university hospital from 1989 to 1994.

TTE preoperative systolic dysfunction was associated with about three times the odds of postoperative heart attack (odds ratio, OR 2.8) and cardiogenic pulmonary edema (OR 3.2), and it indicated double the likelihood of major cardiac complications (OR 2.4). Moderate to severe LV hypertrophy (thought to jeopardize blood supply to myocardial tissue by interfering with coronary flow reserve), moderate to severe mitral valve regurgitation, and increased aortic valve gradient also doubled the odds of major postoperative cardiac events (OR 2.3, 2.2, and 2.1, respectively). Overall, models with echocardiographic variables predicted major cardiac complications significantly better than those that included only clinical variables.

See "Usefulness of transthoracic echocardiography as a tool for risk stratification of patients undergoing major noncardiac surgery," by Luis E. Rohde, M.D., M.Sc., Carisi A. Polanczyk, M.D., M.Sc., Dr. Goldman, and others, in the March 1, 2001, American Journal of Cardiology 87, pp. 505-509.

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