Dr.S.Venkatesan MD

Can you  safely rule out  heart disease before  non cardiac surgery without echocardiography  ?

Yes  ,  in most situations  .  Experience suggest  If the clinical examination is normal  ,  ECG and  X ray  do not show any abnormality  , significant heart disease is ruled out 95/ 100 times.

  Please note  : ECG and X-ray can not  R/O  Coronary  artery disease by  any  degree of   specificity  .Echo cardiogram  also  miserably fails to predict future CAD. But  EST / TMT does this very efficiently!

So where does the  echo comes in the   routine  protocol  in the screening of  heart disease*  ?

“No where” to be precise.  It is only a gimmick . But  many   physicians  and anesthetists are obsessed  with  echo estimated LV EF %  They     invariably   ask for pre  operative echo  for   cardiac risk  stratification.

* On the other hand EST has a strong case for inclusion as a routine screening test before surgery.

What about diastolic dysfunction  ?

ECG and X ray will not miss  a manifest myocardial disease  . However concealed diastolic  dysfunction can not be detected  without echo. It is very common to detect early forms of diastolic relaxation abnormalities in echo . Significance of this is not clear especially  if it is grade 1 . In this situation patient’s  functional capacity comes to our rescue.  In a non functional patient any degree of diastolic dysfunction may increase  the   pulmonary capillary  wedge pressure. These patients must be  monitored and fluid administration should be  be judiciously used.

Final  message

Echocardiography   rarely  comes*  in the  routine  scheme of things in the pre -operative   cardiac risk assessment.

Summary

First question to ask   before non cardiac surgery is  about the  symptoms and functional capacity . ( Do you climb 3 floors  ? Walk 6 km /hr . lift 20kg over a flight of stairs , objectively walk 9 mts on treadmill with std Bruce)  If  he is asymptomatic and his functional capacity is good , for all practical purposes he will be fit for  surgery in cardiac point of view .

Next  , we need to look  the ECG and X ray chest . If one of them shows  some evidence for chamber enlargement / q waves etc ,an echocardiography is ordered .

If  you  really suspect CAD  one should  go for EST or doubtamine stress ECHO.

* Cardiologist lack professional freedom in new age medicine  :

In this funny medical world , a cardiologist can not do what he wants to do . I have encountered surgeons and anesthetics refusing to take a patient for surgery without knowing the  ejection fraction ! Once when  I gave a  surgical fitness without taking an echo there was a furore  from the corporate  desk  of  a  big hospital . How can you  make decision without these modern gadgets they seemed  to  ask  !  Future looks lovely for cardiology !