Lesson 2
5. Lee Goldman
 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.
 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?
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Goldman, L., et. al.
Multifactorial index of cardiac risk in noncardiac surgical procedures,
NEJM 1977
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