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The Beta Blocker and Clonidine Protocol

Lesson 2
Lesson 2 - Epidemiology

5. Lee Goldman

Groooovy!Dr. Lee Goldman did a fundamental study in the 1970's. No, it was not an investigation of the effects of disco music and polyester clothing on PCM. Dr. Goldman did a prospective epidemiologic study of 1001 patients coming in for non-cardiac surgery. He found a series of risk factors for perioperative cardiac morbidity that have been ingrained into our entire medical perspective. These risk factors were longer lasting than even disco music. What he found was that old, sick people do badly.

Do the Hustle!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. 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.

If a patient has signs of congestive heart failure (third heart sound), myocardial infarction in the last six months, five premature ventricular contractions (PVC's) per minute, arrhythmias, age over 70, a big operation, an emergency operation, aortic stenosis, or my favorite, are really, really sick, they do badly. Thanks. Now what do I do? I may joke about this list, but it is fundamental. It must be understood. Here it is bulleted for printing.

And then we have to do something about it. Most of these risk factors are fixed. There's not much you can do about a person's age. It's a risk factor and we all know it. Now what?

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

bullet Hypothesis: Preoperative factors might affect the development of cardiac complications after major noncardiac operations.
bullet Preoperative factors might affect the development of cardiac complications after major noncardiac operations
Prospective Study: 1001 patients over 40 years of age.
bullet Multivariate discriminant analysis
bullet Nine independent significant correlates of life-threatening and fatal cardiac complications
bullet Patients could be separated into four classes of significantly different risk
bullet Ten of the 19 postoperative cardiac fatalities occurred in the 18 patients at highest risk
If validated by prospective application, the multifactorial index may allow preoperative estimation of cardiac risk independent of direct surgical risk.

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