The biggest concerns about pulmonary vein isolation are the complication rates (death in 0.05% and stroke in 0.28%). We also don’t know if this procedure will translate into long-term cures. Until we have larger studies this should not be a first-line modality for treating all patients. Quite often we find patients where neither rate nor rhythm control is a particularly attractive option, especially in regard to long-term anticoagulation. Pulmonary vein isolation provides us with a new viable option for these people as well as something to consider for carefully selected highly symptomatic patients. TH
The GOLDMAN Criteria
In 1930 Butler, et al., first described a potential association between ischemic heart disease and morbidity and mortality associated with the postoperative period. The Goldman, et al., article was a landmark in describing a formalized approach to the perioperative cardiac evaluation of patients undergoing noncardiac surgery (Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977;297:845-850)
Goldman, et al., evaluated 1,001 patients who were operated on by the general, orthopedic, and urologic surgical teams at Massachusetts General Hospital (Boston). They excluded patients who had a transurethral resection of the prostate, an endoscopic procedure, or a minor surgery requiring only local anesthesia. Goldman and his colleagues saw each patient prior to their operation, unless it was emergent that they also see the patient in the immediate postoperative period.
They performed histories and physicals tailored to detect either risk factors for cardiac disease or physical findings suggestive of such. They also reviewed each patient’s electrocardiogram along with a radiograph of the chest. Particular attention was paid to the central venous pressure as well as evidence in support of aortic stenosis and premature ventricular contractions.
All patients were seen at least once postoperatively. Those with cardiac complications were seen more frequently, and medical consultants were involved in their management. All patients charts were reviewed daily and again after discharge.
In the study, 19 patients died from postoperative cardiac deaths. Forty additional patients died from noncardiac causes. Thirty-nine patients suffered from one or more cardiac complications considered life-threatening, but they did not die from these. Using a multivariate analysis the authors found the following nine factors to be related to the development of cardiac complications:
- An S3 gallop or a jugular venous distension;
- Recent myocardial infarction;
- Rhythm other than sinus;
- Five or more premature ventricular contractions prior to surgery;
- Intraperitoneal, intrathoracic, or aortic operations;
- Age over 70 years;
- Important aortic stenosis
- Emergency surgery; and
- A poor general medical condition.
These data birthed the famous Cardiac Risk Index. These nine factors were assigned “points” that could potentially sum up to a high of 53 points. Patients were then placed into one of four classes for cardiac risk. The higher their class, the greater the patient’s risk of developing cardiac complications in the perioperative period. This became the standard for almost 20 years.
By the mid-1990s there were multiple cardiac risk indices based on Goldman’s original article. In 1996 the American College of Cardiology and the American Heart Association (ACC/AHA) put together a 12-person task force that created guidelines for the evaluation of cardiac risk in the perioperative period for those patients undergoing noncardiac surgery. In 2002 these guidelines were updated. The ACC/AHA guidelines present an eight-step algorithm to assess risk.
While these guidelines have supplanted the recommendations from Goldman’s group, there are still potential pitfalls with them. Though evidence exists in support of the ACC/AHA positions, the guidelines have not been studied in a prospective fashion. The ACC/AHA paper does not provide us with a method for considering those patients with multiple intermediate or minor risk factors. Further, as in the Goldman article, the list of risk factors remains incomplete.
More than 25 years have passed since Goldman’s findings, and we still have unanswered questions. The use of perioperative beta-blockers is addressed in this issue of The Hospitalist. (See , p. 65.) The Coronary Artery Surgery Study found that patients who underwent cardiac revascularization prior to major-risk surgery had their perioperative mortality cut in half compared with those managed medically (3.3% versus 1.7%, p<.05). The ACC/AHA guidelines state that “perioperative intervention is rarely necessary simply to lower the risk of surgery, unless such intervention is indicated irrespective of the perioperative context.”
The Coronary Artery Revascularization Prophylaxis trial, published in 2004, found that those with clinically significant though stable coronary artery disease did no better after revascularization than those medically managed for elective vascular surgeries (those with significant stenosis of the left main coronary artery, a left ventricular ejection fraction of less than 20%, and severe aortic stenosis were excluded). We also have emerging data on statins. Given their pleiotropic effects and the observational data we have now it is not surprising that well-designed trials using statins in the perioperative period to reduce cardiac complications are underway.
Goldman, et al., made a major contribution to this area of consultative medicine. Their paper has had a significant effect on the data that have emerged during the last few decades. For now it remains a challenge for the hospitalist to apply our current knowledge, with its several unanswered questions, to maximize the benefit to the patient during this important chapter in their care.