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Ask the doctor: What heart tests do I need before surgery for something else?

Ask the doctor

What heart tests do I need before surgery for something else?

Q. I have chest pain about once a month. Since it happens so infrequently and has been going on for years, my doctor says I don’t need anything other than medicine to keep it under control. Now I need to have two operations, one to fix my cataracts and another to remove part of my colon. Should I start worrying about these heart pains?

A. Your question — Do I need to have my heart checked before having surgery for something else? — is extremely common. It is also a difficult one for cardiologists and internists to answer.

Virtually every operation can affect the heart. That’s even true for those that don’t go anywhere near the chest, such as cosmetic surgery or hip replacement. The odds that noncardiac surgery will affect the heart are generally quite small. But they aren’t zero, even for the healthiest individual, and they creep upward with a variety of conditions.

The big ones that increase the chances of heart problems during or immediately after surgery are heart failure, serious problems with the heart’s rhythm or valves, a prior heart attack or stroke, kidney disease, and diabetes.

Doctors also consider how someone is doing overall. If you walk four miles a day and rarely, if ever, have symptoms suggesting heart disease, your risk is probably low. On the other hand, if you have chest pain (angina) once a month and you aren’t very active, a little extra stress on your heart from surgery could lead to a problem, particularly in the first days of recovery when pain and other stresses make the heart work harder.

Another consideration is the type of surgery. Cataract surgery can usually be tolerated even by people with serious heart disease, because the risk of bleeding is low and the anesthesia is by local injection. In contrast, having part of your colon removed requires general anesthesia, more extensive surgery, some bleeding, and a longer recovery time. This isn’t as tough on your heart as having an operation on your aorta — or your heart — but it is certainly riskier than cataract removal.

Balancing your cardiovascular status with the risk of the operation requires judgment and experience. So I recommend that you talk with your cardiologist about your cardiac health and the planned operations. (Your surgeons or anesthesiologists will almost surely insist on this, too.)

The point of this conference isn’t just to “clear you” for surgery. Instead, it helps all the doctors who will work with you know what to expect and how to best manage your surgery and recovery.

Don’t be surprised if your cardiologist wants you to have some blood tests and an electrocardiogram, exercise stress test, echocardiogram, and/or perhaps even a coronary angiogram to check your heart. Then again, he or she may say you don’t need any of these if you’ve had a thorough cardiovascular evaluation in the last couple of years and haven’t experienced any changes in symptoms since then.

If you really want to read up on this, the American Heart Association and the American College of Cardiology published a 58-page report that aims to help doctors determine who needs what before noncardiac surgery. You can get a copy by calling the American College of Cardiology at 800-253-4636 (toll free). It is also available for free on the Internet at www.americanheart.org/presenter.jhtml?identifier=3000370.

— Richard T. Lee, M.D. Associate Editor, Harvard Heart Letter

Last updated:	August 21, 2006