Heart Patients’ Guidelines for Having Other Surgery

By LAWRENCE K. ALTMAN
The nation’s two leading heart groups issued new guidelines yesterday about what should be done for patients with heart disease before they undergo surgery on other parts of the body.
The aim is to reduce a heart patient’s risk of complications during and after an operation. The recommendations were based on a critical review of studies, particularly those published since the two groups’ last guidelines, in 2002.
A panel of experts from the American College of Cardiology and the American Heart Association wrote the guidelines, which affect the quality and cost of care.
The guidelines, 82 pages long, cover a number of wide-ranging medical issues. One is whether to stop taking certain prescribed drugs before an operation. Another is whether to implant stents or perform coronary bypass surgery before conducting other types of elective surgery.
The decisions depend on the urgency of the operation, its type and risk, a patient’s general ability to function, and the hospital where the surgery is performed, the panel said.
Although the safety of surgery for heart patients has improved in recent years, problems affecting the heart and blood vessels are the most common and treatable complications of nonheart operations. For example, patients have a 40 percent to 70 percent increased risk of dying if they have a painful heart attack after surgery, the panelists wrote.
If heart patients need emergency nonheart surgery, doctors should forgo heart testing and send a patient straight to an operating room, said the panel’s chairman, Dr. Lee A. Fleisher, chairman of anesthesiology and critical care at the University of Pennsylvania School of Medicine.
But many people with heart disease can safely undergo non-emergency operations without first undergoing the extensive testing that is common practice.
Doctors often do many screening tests and then repair the heart problem to prepare the patient for noncardiac surgery. For example, doctors often perform an artery-opening procedure and implant a stent or do a coronary bypass operation.
The panel said that such interventions are rarely necessary to lower the risk of nonheart surgery unless a patient needed the intervention in any case.
The guidelines recommend that patients undergo evaluation and treatment before noncardiac surgery only for active heart problems like severe angina, late-stage heart failure, serious heart rhythm abnormalities (arrhythmias) and severe heart valve disease.
The guidelines also say new studies show that patients should not stop taking the cholesterol-lowering drugs called statins before surgery, an issue not addressed in earlier versions.
Another recommendation concerns the use of anticlotting drugs that patients take after they have received a stent. In the past, such patients were advised to stop taking such drugs before surgery because of the risk of bleeding.
Newer information shows that anticlotting drug treatment is important after stent placement, and the guidelines urge patients to stop taking such drugs for as short a time as possible.
The panel said that for many people the need for nonheart surgery is their first chance to receive evaluation for the risk for heart disease.
In analyzing the published studies, the panel found that most were too small to provide meaningful statistical results, increasing the difficulty of making recommendations. “A lot of the studies should never have been started or published,” Dr. Fleisher said in an interview.
The panel also urged researchers to conduct sufficiently large clinical trials to clarify areas where data is lacking. Among them are the safety and effectiveness of starting and stopping drugs like aspirin, statins and beta blockers before surgery.
The guidelines will be published in the Oct. 23 issue of the heart association’s journal, Circulation.