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The Beta Blocker and Clonidine Protocol

Lesson 2
Lesson 2 - Epidemiology

6. More Lee Goldman

Let me say one more thing about Lee Goldman's study. Many people have done epidemiologic studies of patients coming for non-cardiac surgery. They always find that old, sick people, do poorly. The specific risk factor, such as the duration of time since the myocardial infarction, may change a bit or not be significant. The absence of a specific risk factor in an epidemiologic study does not mean that the risk factor is no longer important. In an epidemiologic study, there may not be enough patients, or more likely, no one is stupid enough to anesthetize a lot of patients with critical aortic stenosis, an MI last week, in CHF, for elective breast augmentation.

More reasons not to smoke!

Individual risk factors can change over time if doctors change who they operate on. It doesn't mean that it is OK to do elective cases in patients who are acutely ill with a recent MI, CHF, or critical aortic stenosis. Old sick people still do poorly.

Goldman, L., et. al. Multifactorial index of cardiac risk in noncardiac surgical procedures, NEJM 1977

bullet preoperative third heart sound or jugular venous distention
bullet myocardial infarction in the preceding six months
more than five premature ventricular contractions per minute documented at any time before operation
bullet rhythm other than sinus or presence of premature atrial
bullet contractions on preoperative electrocardiogram
bullet age over 70 years
bullet intraperitoneal, intrathoracic or aortic operation
emergency operation
bullet important valvular aortic stenosis
bullet poor general medical condition

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