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Physician / Resident Forums [ MD / DO ]
Anesthesiology
Positive stress test for non cardiac surgery
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<blockquote data-quote="Hork Bajir" data-source="post: 22237834" data-attributes="member: 963226"><p>I’m surprised that people would delay this case for “cardiology clearance”. This isn’t an elective THA, this is an early stage cancer operation. [USER=147516]@BLADEMDA[/USER] if you read them word for word, our guidelines suggest further testing in these patients ONLY IF IT WILL CHANGE MANAGEMENT. I see this as the question which the CARP trial addresses: would intervening on a positive stress test improve outcomes? The best evidence that we have seems to suggest that it doesn’t (despite the gut feeling that it should). So, especially for a cancer operation, I don’t think further cardiac work up would change my management at all: put in an art line, careful hemodynamics during the case, consent patient for higher risk of MACE and document as such. Patient is making an informed (and very reasonable) decision, I respect that autonomy.</p><p></p><p>I would feel very comfortable defending this decision making in court if it came to that... As a consultant I am interpreting the data and following our somewhat vague guidelines in a manner which is consistent with our best evidence, using my clinical judgement of risks vs benefits.</p><p></p><p>Now as as to whether it’s worth delaying the case I order to get him on optimal medical therapy (BB, statin, ASA, BP control)... That seems like more of a gray area. Delaying the case until he can see his PCP and get on those meds would be totally reasonable, but for me it would depend on how long we’d be delaying the surgery. Surgeon all booked up and patient could be delayed for a month plus? Personally I would hate to delay this dude’s potentially curative cancer operation, so I would probably still go ahead after having him started on all those meds for a few days (recognizing that this is a data-free decision and reflects my own risk tolerance to a greater degree)</p></blockquote><p></p>
[QUOTE="Hork Bajir, post: 22237834, member: 963226"] I’m surprised that people would delay this case for “cardiology clearance”. This isn’t an elective THA, this is an early stage cancer operation. [USER=147516]@BLADEMDA[/USER] if you read them word for word, our guidelines suggest further testing in these patients ONLY IF IT WILL CHANGE MANAGEMENT. I see this as the question which the CARP trial addresses: would intervening on a positive stress test improve outcomes? The best evidence that we have seems to suggest that it doesn’t (despite the gut feeling that it should). So, especially for a cancer operation, I don’t think further cardiac work up would change my management at all: put in an art line, careful hemodynamics during the case, consent patient for higher risk of MACE and document as such. Patient is making an informed (and very reasonable) decision, I respect that autonomy. I would feel very comfortable defending this decision making in court if it came to that... As a consultant I am interpreting the data and following our somewhat vague guidelines in a manner which is consistent with our best evidence, using my clinical judgement of risks vs benefits. Now as as to whether it’s worth delaying the case I order to get him on optimal medical therapy (BB, statin, ASA, BP control)... That seems like more of a gray area. Delaying the case until he can see his PCP and get on those meds would be totally reasonable, but for me it would depend on how long we’d be delaying the surgery. Surgeon all booked up and patient could be delayed for a month plus? Personally I would hate to delay this dude’s potentially curative cancer operation, so I would probably still go ahead after having him started on all those meds for a few days (recognizing that this is a data-free decision and reflects my own risk tolerance to a greater degree) [/QUOTE]
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Physician / Resident Forums [ MD / DO ]
Anesthesiology
Positive stress test for non cardiac surgery