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1. The long-term outcomes of coronary artery bypass graft surgery remain superior to coronary stenting for patients with left main disease and multivessel coronary artery disease in diabetic patients.

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2. Congestive heart failure is reaching epidemic proportions. Effective surgical strategies exist for these patients, ranging from valve repair to ventricular assist devices.

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3. Mitral valve repair rather than replacement affords superior long-term benefits to patients with degenerative mitral valve disease.

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4. Aortic valve replacement is routinely and safely performed in patients over 80 years old.

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Clinical Evaluation

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The importance of the history and physical examination when evaluating a patient with acquired heart disease for potential surgery cannot be overemphasized. It is imperative that the surgeon be well aware of the functional status of the patient and the clinical relevance of each symptom, because surgical decisions depend upon the accurate assessment of the significance of a particular pathologic finding. Likewise, as the number of diagnostic tests continues to increase, appropriate sequencing of the diagnostic work-up requires a clinical perspective that is obtained through the history and physical examination. Associated risk factors and coexisting conditions must be identified, as they significantly influence a patient’s operative risk for cardiac or noncardiac surgery. Furthermore, the operative strategy is affected by specific physical findings and important history, such as previous cardiac or thoracic surgery, peripheral vascular occlusive disease, or prior saphenous vein stripping. The safe surgeon is one who can integrate clinical evidence and diagnostic information to establish a scientifically based operative plan.

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Symptoms

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The classic symptoms of heart disease are fatigue, angina, dyspnea, edema, hemoptysis, palpitations, and syncope, as outlined by Braunwald.1 When a patient describes or complains of any of these symptoms, the clinical scenario leading to it must be explored in detail, including symptom intensity, duration, provocation, and conditions that lead to relief. The initial goal is to determine whether a symptom is cardiac or noncardiac in origin, as well as to determine the clinical significance of the complaint. An important feature of cardiac disease is that myocardial function or coronary blood supply that may be adequate at rest may become completely inadequate with exercise or exertion. Thus, chest pain or dyspnea that occurs primarily during exertion is frequently cardiac in origin, while symptoms that occur at rest often are not.

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In addition to evaluating the patient’s primary symptoms, the history should include a family history, past medical history [prior surgery or myocardial infarction (MI), concomitant hypertension, diabetes, and other associated diseases], personal habits (smoking, alcohol or drug use), functional capacity, and a detailed review of systems. After a careful assessment of a patient’s symptoms, appropriate diagnostic studies are ordered and interpreted. The classic symptoms are reviewed in detail below.

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Easy fatigability is a frequent but nonspecific symptom of cardiac disease that can arise from many causes. In some ...

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