The suspicion of coronary artery disease (CAD) represents an important risk for patients who undergo elective noncardiac surgical procedures. 1 Because the stress of surgery and postoperative recovery can be a significant ischemic burden for patients, a critical evaluation for the presence and severity of CAD should be considered for all patients. The medical consultant must appreciate that the request for "medical clearance" for surgery is clinically incorrect and should be avoided. The real issue is to assess the patient's current medical status and make a recommendation concerning the risk of a cardiac problem over the entire perioperative and follow-up period. A combination of clinical factors and appropriate noninvasive and invasive testing should be combined with good clinical judgement to achieve an individualized assessment of cardiac risk. Therefore the overall goal of cardiac risk assessment should be a consideration of both the impending surgery and, more importantly, the long-term cardiac risk factors for the patient, 2 independent of the decision to proceed with the surgery. In this review, I will try to avoid oversimplification of the complex clinical situations. It should be apparent that all presurgical patients do not need testing and that coronary angiography and revascularization are not automatically recommended for all patients with positive test results. One clear caveat is to think through what you would do with a positive test result before you order the test, to avoid the trap of treating test results instead of patients.
Clinical History (Risk Indices):
The first step in this evaluation is to classify the type of surgery as low or high cardiac risk. The procedures generally considered high risk are vascular, intra-abdominal or thoracic, major orthopedic conditions, and any emergency procedures. 3'4 After considering the type of surgery, as well as the inherent cardiac risk of such a