Training general surgery residents to avoid postoperative cardiac events
Thomas R. McLean, M.D., J.D.*, Jennifer McGoldrick, P.A., Sheryl Fox,
Chris C. Haller, M.D., Jane Arevalo, R.N.
VA Eastern Kansas Health Care System, Dwight D. Eisenhower VA Medical Center, 4104 S. Fourth St. Trafﬁcway, Leavenworth, KS 66048, USA
Manuscript received May 16, 2007; revised manuscript July 30, 2007
Presented at the 31st Annual Surgical Symposium of the Association of VA Surgeons, Little Rock, AR, May 10 –12, 2007
Background: Expertise in cardiac risk assessment takes years to acquire, but unnecessary cardiology
consultation delays treatment and consumes scarce resources.
Methods: A retrospective review was performed of the cardiac work-up and postoperative events during
1 year on a general surgery service. Postgraduate year 1–3 general surgery residents were instructed to
obtain a cardiology consult if a patient had any of the following: (1) had undergone coronary artery
intervention more than 2 years in the past; (2) was taking an anti-anginal medication (nitroglycerine, Ca
-blocker); or (3) was symptomatic or had an abnormal electrocardiogram. Whether a patient
was symptomatic was to be tempered by the nature of the planned procedure.
Results: Supervised residents screened 720 unique patients for surgery. Cardiology consultation was
obtained in 37. All but 1 (97%) patient referred to cardiology met at least 1 of the earlier-described criteria;
with 8 (22%) meeting all 3 criteria. On average, patients referred to the cardiologists were taking 1.4
anti-anginal medications; and 1 patient sustained a fatal myocardial infarction after referral. Cardiac
imaging (stress test or catheterization) was performed on 24 (65%) referred patients and was positive in
8 (33%). After minimizing cardiac risk by medication or intervention, the surgery service declined to offer
the planned procedure to 11 (30%) of the referred patients and an additional 5 (15%) patients declined
surgery. The overall surgical mortality was 2%. None of the patients in this series sustained a postoperative
myocardial infarction or cardiac death. Postoperative supraventricular tachycardia was not inﬂuenced
signiﬁcantly by cardiology consultation (5% referred patients vs 1% nonreferred).
Conclusions: Our criteria for obtaining cardiology consultation in general surgery patients appears to
appropriately select patients in need of further work-up. Information obtained from a cardiac consulta-
tion frequently leads to a re-evaluation of the risks and beneﬁts of surgery by both surgeons and
patients. © 2007 Excerpta Medica Inc. All rights reserved.
Keywords: Cardiac risk; General surgery; Resident training
Cardiac events after noncardiac surgery can be avoided by
appropriately identifying patients in need of coronary artery
intervention before surgery. However, selecting patients
who would beneﬁt from undergoing either coronary artery
bypass grafting (CABG) or percutaneous coronary interven-
tion (PCI) before general surgery is complex. For example,
the updated guidelines published by the American College
of Cardiology/American Heart Association (ACC/AHA)
recommend that a general surgeon should screen patients
for cardiac risk by using a comprehensive 8-step evaluation
. Based on this process the surgeon then determines the
likelihood (low, intermediate, and high) that a patient will
have a postoperative cardiac event. Patients in the low-risk
group may proceed to surgery without further cardiac eval-
uation; patients in the intermediate-risk group are to be
selectively referred to cardiology depending on the scope of
the planned surgery; and the high-risk group of patients
should be referred to a cardiologist even when the scope of
planned surgery is modest.
From a practical point of view, training general surgery
residents in the art of formally assessing cardiac risk can be
difﬁcult for a number of reasons. For example, when a
patient complains of having chest pain, is that pain some-
* Corresponding author. Tel.: ϩ1-913-682-2000, ext. 5-2714; fax: ϩ1-
E-mail address: Thomas.McLean@med.va.gov
The American Journal of Surgery 194 (2007) 633– 638
0002-9610/07/$ – see front matter © 2007 Excerpta Medica Inc. All rights reserved.