Cardiac Algorithm - Step 6
Further testing?
With poor or unknown functional capacity, the clinician should consult
with the patient and perioperative team to determine whether further
testing will impact patient decision making (e.g., decision to perform
original surgery or willingness to undergo CABG or PCI, depending on the
results of the test) or perioperative care.
No Further Testing
- Non-emergency surgery
- No acute coronary syndrome
- Elevated Risk surgery
- Poor/unknown functional capacity
- **If no further testing elected with desire for surgery and acceptance of risk, proceed to operating room.
- **If no further testing elected with desire to avoid surgery and its risks altogether, then proceed with non-invasive non-surgical treatment of the surgical condition (e.g. radiation therapy for cancer) or palliative care.
Yes, Further Testing
Further
testing could reveal underlying coronary artery disease. Knowledge of
that underlying coronary artery disease could potentially improve
management of the patient and avoid peri/post-operative major adverse
cardiac event. However, that same knowledge of coronary disease might
lead to revascularization intervention which the patient might not
desire, and revascularization interventions all require various delays
to permit healing (see this app's review of ACC's recommendations on
timing of surgery after MI, stent, CABG), a delay which might not be
clinically permissible.
Therefore
this step asks whether further testing makes any sense. Asking this
question could prompt the patient and clinician team to accept higher
risks and proceed with surgery, it could prompt the patient and
clinician team to choose an alternative to surgery (chemo &
radiation for cancer, for example), or might prompt all concerned to
perform further coronary testing.