Preoperative cardiac evaluation. Assessing risk before noncardiac surgery.

Primary care physicians are often asked to evaluate a surgical candidate's cardiovascular and general health status. In some patients, history taking and physical examination provide enough information to assess risk for the proposed procedure. In others--especially those with cardiac risk factors--more extensive testing is required, such as electrocardiography, stress testing, or angiography. Once clearance for surgery has been given, primary care physicians can suggest risk-reduction strategies that may help to minimize perioperative morbidity or mortality.

Aggressive treatment of acute myocardial infarction. Management options for various settings.

Multiple lifesaving options are currently available for treatment of acute myocardial infarction as a medical emergency. Serial electrocardiography and continuous ST-segment monitoring, urgent echocardiography, rapid enzyme analysis, and cardiac catheterization may all assist in the accurate and early diagnosis of acute myocardial infarction. Both intravenous thrombolytic therapy and direct infarct percutaneous transluminal coronary angioplasty are of benefit in early treatment. The choice of therapy depends on the individual patient and the hospital capabilities. Adjunctive pharmacologic therapies can be easily administered in the community hospital setting and should be considered for every patient with suspected acute myocardial infarction. The risk of serious morbidity and hospital death in these patients has not been eliminated, and a more aggressive approach to diagnosis and treatment is sorely needed.

Value of transesophageal echocardiography during complex or high-risk coronary interventions in the cardiac catheterization laboratory.

The increasing complexity of coronary intervention and the limitations of hemodynamic and electrocardiographic monitoring have facilitated the introduction of new imaging techniques in the cardiac catheterization laboratory. Transesophageal echocardiography (TEE) has proved valuable for left ventricular (LV) monitoring during high-risk surgery, but its reported use in the cardiac catheterization laboratory has been limited. Accordingly, we assessed the feasibility and value of TEE during complex or high-risk coronary intervention in the catheterization laboratory. The TEE probe was successfully introduced in 53 of 54 (98%) attempted cases. The primary imaging goals were LV monitoring in 39 (74%), left main coronary artery (LMCA) imaging in 9 (17%) and both in 5 (9%) cases. LV monitoring was successful in 43 of the 44 (98%) attempted cases. In 25 (58%) of these, additional important observations were made by TEE that were not apparent by symptoms, or hemodynamic, electrocardiographic or radiographic monitoring. These included unexpected changes in regional myocardial function (n = 20), alteration in LV size (n = 2), exclusion of considered pericardial tamponade (n = 2) and detection of unsuspected mitral regurgitation (n = 1). Management of the interventional procedure was directly influenced by the findings of TEE in 11 of the 43 (26%) monitored cases. The LMCA was successfully visualized in 13 of the 14 (93%) attempted cases. In 11 of these, measurement of the stenotic lesion diameter by TEE correlated well with quantitative angiography both before (r = 0.83, standard error of the estimate = 0.01, p less than 0.002) and after (r = 0.80, standard error of the estimate = 0.03, p less than 0.005) intervention.(ABSTRACT TRUNCATED AT 250 WORDS)

Early hospital discharge after percutaneous transluminal coronary angioplasty.

To determine the safety and efficacy of early hospital discharge after percutaneous transluminal coronary angioplasty (PTCA), 100 patients were studied prospectively. A telemetry observation unit was established to monitor patients having uncomplicated procedures. A total of 170 lesions were dilated, with a procedural success rate of 96% and a clinical success rate of 91%. There were no deaths or patients who required emergency bypass surgery. Four patients developed abrupt vessel closure in the catheterization laboratory. No major complications developed in the telemetry observation unit or after discharge. Patients with high-risk lesion morphology, based on the American College of Cardiology/American Heart Association Task Force guidelines, tended to have a lower success rate and more procedural complications. Coronary dissections were angiographically detected in 33 patients and stratified into 6 types. To reduce possible adverse sequelae, all patients with complex dissections were triaged in the catheterization laboratory to an in-patient monitored unit for additional management. Accordingly, 20 patients were admitted to an in-patient unit for extended observation. Excluding 4 patients with myocardial infarction, 75% (12 of 16) were discharged the next day. Initial experience with early discharge suggests that under proper conditions the procedure is safe and effective. Patients with complex coronary dissections who are at high risk for abrupt vessel closure can be promptly identified after dilatation and triaged to an appropriate monitoring area. Early discharge after PTCA offers more efficient use of hospital facilities and the opportunity to reduce hospital costs.