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.
2. Congestive heart failure is reaching epidemic proportions.
Effective surgical strategies exist for these
patients, ranging from valve repair to ventricular
3. Mitral valve repair rather than replacement affords
superior long-term benefits to patients with degenerative
mitral valve disease.
4. Aortic valve replacement is routinely and safely performed
in patients over 80 years old.
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.
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.
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.
Easy fatigability is a frequent but nonspecific symptom of cardiac disease
that can arise from many causes. In some ...