No mysticism today, but a meditation nonetheless. I have in mind the once-again confused state of matters for the patient with cardiac disease presenting for non-cardiac surgery. When I left off in my thinking, snug (and smug) in my self-assurance, it was January 2005. Life was good! Eagle and Fleischer (and all the rest..) had published, in 2002, a lovely practice guide stratifying risk by extent of procedure, severity of risk factors, and had even published a sexy little flow chart suggesting how to proceed. To make matters even better, intervening publications highlighted the protective effects of Beta-blockers, statins (who knew they had an acute protective effect?), and the interesting observation that many post-op MI's smolder (elevated i-troponins for hours or days) before they burst forth. (At least, that's one of the off-hypothesis impressions I took from this data.) McFalls et al did their remarkable study (CARP) in the VA system (where else in America could such a thing be done?) where they took a bunch of veterans with known coronary artery disease of sufficient severity to warrant intervention (CABG or PCI), and randomized them to either have their hearts fixed before abdominal or thoracic aneurysm surgery, or after. No kidding-you can look it up! Here. No differences in outcomes! No differences!(They eliminated critical aortic stenotics (Duh!) and Left mains (hmmm.) Lots of letter-to-the-editor chatter about this study, as befits a work of this breathtaking hypothesis and conclusion. You'll have to read them yourself...
Then, ashes-ashes-we-all-fall-down! Coated stents, the salvation of all mankind, apparently come with a lifetime annuity for Bristol-Meyers in the form of P-cubed; perpetual-plavix-prescription. Oh, you can probably stop after a year, but they won't promise your stent won't clog like a toilet after your 4-year old flushes three rolls of toilet paper. So, what are we to do? Play "plavix-roulette" with or without heparin drip, like a mechanical valve? Wait 4 to 6 months? Just to highlight the predicament, a note appears on our practice's "can you believe it?" bulletin board regarding a $10,000,000 jury award against some hapless cardiologist, who, poor sap that he was, probably read the literature, and knew he didn't have to cath that poor guy with the stable angina who was having his colon resected. (Time for a disclaimer; I saw this six months ago, and now can't find any reference anywhere to it online; can anybody help?)
So, here we are. Now, the cardiologist is back in whack-a-mole mode; and, if he finds a lesion, persuade him that he shouldn't use "the best" technology immediately, but should rather wait two weeks so that some gas-passer can take the patient on a roller-coaster ride through surgery-land. As they say, "don't try this at home;" I don't mind using judgment. But it's pretty hard when we have three-way distributed judgment (surgeon-cadiologist-anesthesiologist) not to mention the poor patient, who is frequently left to make a choice of how she wants to proceed based upon a hopelessly muddled set of risk-benefit variables.
I know a few courageous cardiologists who, finding amenable pre-op lesions, will plasty rather than stent, temporizing until a couple of weeks after surgery. But who can blame the guy who feels the need to fix what he sees? I usually try to schedule a three-way between myself, the surgeon, and the cardiologist prior to cath, if that's the way we are going. I want the cardiologist to hear the surgeon's assessment of the relative acute need for surgery in these "in-betweeners." I call them "in-betweeners" because they are the patients who are not true emergencies (bowel obstruction) in whom we just go, and the fully electives (the takedown colostomies, for instance). This includes cases such as colectomy for adenocarcinoma, thoracic biopsies of lung nodules, peripheral vascular and the like. Once the cardiologist is in her lab, she's going to do what her judgment dictates, but I want to ensure that her judgment is "informed" by the overall clinical situation.
Actually, none of this is bad news; it's just messy. So we have to wade in and organize care for the patient. Of course, we can always just "pass gas" and let the others decide for us; all we have to do is cancel the patient for "cardiac clearance," and wait for the patient to come back someday... But that wouldn't be "The Ether Way", now would it?