Sep 27, 2024 This Week in Cardiology Podcast

Surgical clearance, NICM assessment, dueling perspectives on PCI as first-line therapy for angina, GDMT in HFrEF are the topics John Mandrola, MD, discusses in this week’s podcast.
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-- TRANSCRIPT --
In This Week’s Podcast
For the week ending September 27, 2024, John Mandrola, MD, comments on the following news and features stories: Surgical clearance, nonischemic cardiomyopathy (NICM) assessment, dueling perspectives on percutaneous coronary intervention (PCI) as first-line therapy for angina, guideline directed medical therapy (GDMT) in patients with heart failure with reduced ejection fraction (HFrEF).
New ACC Peri-operative Guidelines Released
The Journal of the American College of Cardiology (JACC) has published a lengthy guideline document on perioperative management for non-cardiac surgery (NCS). I would like to say a few words on this because it comes up nearly every day.
We are asked to provide “surgical clearance” for one of our patients. This phrase, surgical clearance, may be the most ridiculous phrase in all of modern medicine.
I don’t write this nor do I say it, but I think to myself, only God can clear someone for surgery.
The notion inherent in the surgical clearance phrase is so preposterous that anyone who utters it ought to wear a sign saying, “I am a soft thinker.” It is as if the requester of clearance believes that a cardiologist will render the patient free of complications. Indeed, the patient may have no complications after surgery, but it is hardly due to anything the cardiologist did.
Listeners outside the United States may not have such problems of pre-op clearance, but we waste a lot of money evaluating people before surgery here in the United States.
The guideline document, like all such documents, is massive and well -referenced.
One suggestion I have would be to make a section or Table on randomized controlled trials (RCTs) in the therapeutic space. This would make it easier for a user to know when an RCT vs observational data supports a recommendation. It’s nearly all observational data.
A couple of specifics. This is a quote from the summary document:
Stress testing should be performed judiciously in patients undergoing NCS, especially those at lower risk, and only in patients in whom testing would be appropriate independent of planned surgery.
The authors only have two recommendations on stress testing. One is a 2b level of evidence B-NR (Observational study only). This is for patients with poor functional capacity and high peri-operative risk. Stress testing may be considered to evaluate for ischemia.
But the authors also write in the text that, “the goal of preoperative testing for ischemia is not to identify undiagnosed CAD (coronary artery disease) but to identify patients for whom revascularization is believed to improve clinical outcomes, specifically those with left main disease or severe multivessel disease with a reduced LVEF.”
Right after that sentence the authors cite an observational study finding that centers with high levels of stress testing before abdominal aortic aneurysm (AAA) repair had no better outcomes than centers with low stress testing.
The value of routine stress testing before AAA repair should be reconsidered, and stress testing should be used more selectively, given these findings and the associated costs of widespread testing.
Transcript in its entirety can be found by clicking here:
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