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ACC/AHA
Guideline Update for Perioperative Cardiovascular Evaluation
for Noncardiac Surgery
A
Report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines
(Committee to Update the 1996 Guidelines on Perioperative
Cardiovascular Evaluation for Noncardiac Surgery)
VI.
Implications of Risk Assessment Strategies for Costs
The
decision to recommend further noninvasive or invasive
testing for the individual patient being considered
for noncardiac surgery ultimately becomes a balancing
act between the estimated probabilities of effectiveness
vs. risk. The proposed benefit, of course, is the possibility
of identifying advanced but relatively unsuspected CAD
that might result in significant cardiac morbidity or
mortality either perioperatively or in the long term.
In the process of further screening and treatment, the
risks from the tests and treatments themselves may offset
or even exceed the potential benefit of evaluation.
Furthermore, the cost of screening and treatment strategies
must be considered. Although physicians should be concerned
with improving the clinical outcome of their patients,
cost is an appropriate consideration when different
evaluation and treatment strategies are available that
cannot be distinguished from one another in terms of
clinical outcome.
Formal
decision and cost-effectiveness analyses of this particular
question have been done and have yielded highly varied
results (134,167-169).
Because the exact amount of risk reduction from coronary
revascularization in the clinical populations differs
so much from center to center, it is difficult to determine
the exact risks of aggressive screening and treatments
vs. the benefits in terms of risk reduction. Additionally,
the models all demonstrate that optimal strategy depends
on the mortality rates for both cardiac procedures and
noncardiac surgeries in the clinically relevant range.
One recent model, which did not support a strategy incorporating
coronary angiography and revascularization, used lower
mortality rates than those used or reported in the other
studies (91,168,169).
Therefore, use of any decision and cost-effectiveness
model in a specific situation depends on the comparability
of local mortality rates to those of the model.
One
report suggested that the cost of a selected coronary
screening approach, as described in these guidelines,
was as low as $214 per patient (245).
Several recent publications have shown a cost per year
of life saved for this selected screening strategy of
less than $45,000 when applied to patients undergoing
vascular surgery (244,246).
However, none of these studies included a strategy of
selected screening followed by aggressive beta-blocker
treatment in high-risk individuals, as recently described
by Poldermans and colleagues (252).
It is likely that this approach will be preferred over
more aggressive coronary assessment/treatment strategies
except perhaps among very high-risk subsets of patients
(293).
Prophylactic beta blockade represents an excellent strategy
in patients for whom coronary revascularization for
long-term benefit is not a serious consideration.
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