Physicians' recommendations for patients who undergo noncardiac surgery

Abstract

Objective: To investigate how consulting physicians attempt to modify perioperative cardiac risk for patients who undergo noncardiac surgery by comparing the preoperative cardiac recommendations of consulting physicians in 2 university centres.

Design: Retrospective cross-sectional analysis.

Setting: Five hospitals affiliated with 2 Canadian universities.

Patients: Three hundred and eight preoperative consultations were evaluated in 297 patients who were 40 years of age or older and scheduled for noncardiac surgery.

Outcome measures: Cardiac drug recommendations at the preoperative consultation [corrected]; overall recommendations and practice variation between the 2 centres.

Results: The greatest changes in drug management suggested by consultants were the initiation of nitrates in 13% of the patients and a decrease in acetylsalicylic acid administration from 27% to 17%. Centre A physicians recommended adding an angiotensin-converting enzyme inhibitor 11% of the time, whereas centre B physicians recommended such an inhibitor in only 1% of the patients (p = 0.001). In patients taking acetylsalicylic acid at the preoperative consultation, Centres A and B physicians recommended withholding the drug 47% and 22% of the time, respectively (p = 0.03). These differences persisted between the 2 centres after controlling for physician estimates of risk.

Conclusions: Consultants frequently recommended perioperative changes in the use of cardiac medications, and there were differences in practice patterns between the 2 centres. These differences may be affecting patient outcomes and highlight the need for randomized clinical trials to determine the impact of perioperative drug administration on bleeding, myocardial infarction and death.