To the Editor:—
We read with great interest the review article by Park. 1We appreciate the importance the author attributes to the necessity for the anesthesiologist and the cardiologist to work as a team and to the guidelines.
However, we disagree with the author about the risks of percutaneous transluminal coronary angioplasty during the acute phase of myocardial infarction (AMI). When feasible, percutaneous transluminal coronary angioplasty remains the treatment of choice during AMI, resulting in an approximately 85% success rate. 2During AMI, it appears that it is always useful to “open” the occluded coronary artery, even when the patient is in cardiogenic shock. In this setting, coronary angioplasty seems to be the best treatment. 3,4The trend is to perform intravenous thrombolysis as soon as possible, and then coronary angioplasty when the patient can be managed in a center where this technique is available.
The important issue of the patient with AMI who needs noncardiac surgery must be addressed. In any case, AMI should be managed first. Especially when the patient with AMI needs urgent noncardiac surgery, establishing the best strategy will rely on an emergency coronary assessment in a center experienced with primary angioplasty.
If the occluded artery is a large vessel with a large myocardial territory involved, angioplasty and stenting must not be delayed, and any urgent surgery must be done under antiplatelet therapy while considering the increased risk of bleeding. If the occluded artery is a small vessel with few myocardial tissues at risk, angioplasty is not necessary, avoiding the need for antiplatelet treatment and the risk of subsequent bleeding. Close collaboration between the anesthetist and cardiologist is warranted during the perioperative period.
