PREOPERATIVE ASSESSMENT OF CORONARY CIRCU LATION

To define a strategy for coronary circulation assessment is a difficul t task as most of the studies have been carried out in vascular surger y, as some of them are controversial, and as no test has a 100% sensit ivity and specificity. However patients with high perioperative risk o f cardiac events have to be identified, in order to intensify medical treatment or to consider myocardial revascularisation. A first evaluat ion is based on history, physical examination and simple tests, such a s rest electrocardiogram and thorax X-Ray, Additional tests are not re quired when surgery does not elicit a major activity of the cardiocirc ulatory system. Postoperative cardiac risk is low when none of the nin e risk factors defined by Goldman and/or coronary insufficiency (resid ual angina elicited by minor physical activity, unstable angina, myoca rdial infarction) are present. The problem remains in patients with Go ldman risk factors and/or at risk of coronary artery disease because o f diabetes mellitus, heavy smoking, hypercholesterolaemia, arterial hy pertension, undergoing major abdominal, thoracic or vascular surgery. Preoperative electrocardiographic Hotter monitoring is still of value, especially in patients with known or supposed ischaemic heart disease and unable to make a physical effort. A poor exercise capacity and ch anges in electrocardiographic stress testing are factors of poor progn osis. The dobutamine stress echocardiography has a good sensitivity an d specifity when an effort test cannot be performed. The value of dipy ridamole-thallium 201 scintigraphy could be improved by a quantitative analysis of the number of affected segments and territories. Patients with angina or ischaemic episodes on continuous electrocardiogram, or with dobutamine echocardiography kinetic disturbances and with stress myocardic scintigraphy or stress exercise testing abnormalities could undergo a coronarography, in order to consider myocardic revasculariz ation prior to surgery.