To the Editor:—

We read with interest the Clinical Concepts and Commentary article by Dr. Mangano entitled “Assessment of the Patient with Cardiac Disease.”1It is a complete review of the subject by one of the preeminent authorities, and it discusses everything from preoperative workup to specialized testing. Dr. Mangano’s view of the anesthesiologist as the primary medical caregiver fits with the new role of anesthesiologists as perioperative physicians. At our preadmission test center, the anesthesiologist examines the patient. Based on physical examination, history of cardiac disease, risk factors for cardiac disease, and functional status, the anesthesiologist makes a decision about whether the patient needs further workup by the primary care physician or a specialist. However, what Dr. Mangano fails to mention is the role that the type of surgery plays in this workup. The American College of Cardiology/American Heart Association guidelines for perioperative cardiovascular evaluation for noncardiac surgery state that other factors, including type of surgery, can help determine cardiac risks. 2For example, major surgery, such as repair of an abdominal aortic aneurysm, is associated with more hemodynamic change than minor surgery, such as cataract surgery. A recent New England Journal of Medicine  article showed that routine medical testing before cataract surgery did not cause a decrease in mortality or morbidity, even when stratified according to coexisting disease, regardless of severity. 3In an accompanying article, Roizen equates modern anesthesia for low-risk procedures in otherwise well-managed patients with getting a haircut. 4 

In summary, we believe that not only history, physical examination, and functional capacity but also type of surgery should guide the anesthesiologist in ordering preoperative tests and consults.

Mangano DT: Assessment of the patient with cardiac disease: An anesthesiologist’s paradigm. A nesthesiology 1999; 91:1521–6
Eagle KA, Brundage BH, Chaitman BR, Ewy GA, Fleisher LA, Hertzer NR, Leppo JA, Ryan T, Schlant RC, Spencer WH III, Spittell JA Jr, Twiss RD, Ritchie JL, Cheitlin MD, Gardner TJ, Garson A Jr, Lewis RP, Gibbons RJ, O’Rourke RA, Ryan TJ: Guidelines for perioperative cardiovascular evaluation for noncardiac surgery: Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol 1996; 27:910–48
Schein OD, Katz J, Bass EB, Tielsch JM, Lubomski LH, Feldman MA, Petty BG, Steinberg EP, for the Study of Medical Testing for Cataract Surgery: The value of routine preoperative medical testing before cataract surgery. N Engl J Med 2000; 342:168–75
Roizen MF: More preoperative assessment by physicians and less by laboratory tests. N Engl J Med 2000; 342:204–5