PREOPERATIVE INVESTIGATION OF HIGH CARDIOVASCULAR RISK PATIENTS

The growing numbers of elderly and cardiac patients are the consequenc e of progress in the prevention of the complications of coronary arter y and valvular heart disease by surgery and revascularisation and impr oved treatment of hypertension which delays target organ complications by at least fifteen years. The elderly are particularly exposed to su rgical risk: nearly half the patients with ischaemic heart disease die of cancer; a high proportion of elderly people require orthopaedic su rgery either as an emergency (fractured femur) or as a standard proced ure (knee surgery); nearly a quarter of patients requiring peripheral vascular surgery have coronary artery disease which may be silent. A p reoperative consultation with the anaesthetist has been made compulsor y, except in emergencies, giving time for preoperative investigations. The decrees of the Court of Cassation have also affected the traditio nal relationship of trust between patients and their doctors, leading to an increase in the cost of preoperative investigations without an a ccurate assessment of their benefits with regards to postoperative com plications and the cost that they entail. Contrary to present tendenci es reflected in the literature, the screening of risks should be simpl ified : clinical history and examination and resting EGG, often comple ted by stress testing, are sufficient in the large majority of cases. More importance should be attributed to the functional status than to the lesions. When the cardiac disease is asymptomatic, the chances are that it will remain so during and after surgery... The main difficult y is not in identifying high risk patients : it is preventing cardiova scular events when surgery is unavoidable. The experience and collabor ation between the quartet of anaesthetist, surgeon, cardiologist and g eneral practitioner, are much more useful than the very incomplete bib liographical data concerning this side of the problem.