Noncardiac surgery in the cardiac patient: what is the question?

Before having major noncardiac surgery, patients with known or suspected coronary artery disease frequently have noninvasive cardiac testing to better define their cardiac risk. The rationale for this approach is that prophylactic coronary revascularization will significantly reduce the number of adverse cardiac events. No randomized studies support this conclusion. Furthermore, recent studies have suggested that adverse cardiac events result from postoperative stress and excess catecholamine levels, which cause an imbalance between myocardial oxygen supply and demand. Plaque rupture in this setting, if it occurs, is secondary and not primary, in contrast to its pivotal role in spontaneous myocardial infarction. Therefore, improved clinical outcomes are more likely to result from preventing excess oxygen demand after surgery rather than from deciding which tests optimally predict adverse events. The exception is the patient with a clinical syndrome consistent with existing plaque rupture who requires active therapy for the cardiac disease independent of the need for noncardiac surgery. Otherwise, the tests should be skipped and the patient cleared.