Preoperative Evaluation of Patients
with Chest Pain
Ralph J. Fuchs, M.D.
Dept of Anesthesiology, University of Florida
A 69-year-old woman with a paraesophageal hernia, admitted for
increasing chest pain secondary to GERD with hiatal hernia and
esophageal spasms, was scheduled to undergo Nissen
fundoplication. She had been followed by the Anesthesia Pain
Management Clinic for neuropathic pain involving the right and
left chest, status post bilateral silicone breast implant
removal, myofascial pain syndrome over the upper back and right
chest, fibromyalgia, and post herpetic neuralgia of the right
lower extremity. Her medical history was also significant for
atypical chest pain related to her myofascial pain from multiple
breast surgeries, chronic fatigue, hypothyroidism, major
depression, irritable bowel syndrome, diverticulitis,
pancreatitis, migraine headaches, and spastic dysphonia.
The day before she was seen in the anesthesia preop clinic, she
developed very severe substernal chest pain during esophageal
manometry that was part of a preoperative surgical evaluation
for a large hiatal hernia. She identified this pain as similar
to her previous episodes of noncardiac chest pain. Three years
ago, she had undergone adenosine thallium scans, which showed no
evidence of infarct or redistribution to cause chest pain.
Patient had a cardiac catheterization in 1990 and another
adenosine thallium in 1992. She had been admitted to the
hospital several times in order to be ruled out for myocardial
infarction by serial enzymes and EKGs. All tests were
interpreted as normal. During the most recent attack of chest
pain, her blood pressure increased to approximately 220/120 mmHg
and her pulse increased to approximately 120 beats/min. An
electrocardiogram (ECG) revealed non-specific anterolateral ST-T
wave changes; specifically a biphasic T-wave in V1 and V2, with
inverted T-waves in V3 and V4. The pain spontaneously resolved
and the pressure and pulse returned rapidly to a normal range.
Her ECG was unchanged when compared to one recorded two years
ago.
Even given the patient’s previous extensive cardiac work-up and
the unchanged ECG, the patient was scheduled for another cardiac
work-up by the anesthesia service. A radionuclide study showed
coronary artery disease: abnormal stress myocardial perfusion
SPECT examination showing periapical redistribution in the
circumflex territoy. A coronary artery angiography showed a
50-70% left main coronary artery stenosis and a 20% obstruction
of the mid-section of the left anterior descending branch of the
left coronary artery. The patient was taken to the operating
room for coronary artery bypass graft surgery instead of Nissen
fundoplication.
This lecture reviews the differential diagnosis of chest pain
and the perioperative cardiovascular evaluation for non-cardiac
surgery through a case presentation.
References:
1) Kim A. Eagle et al.,JACC 1996;27:910-948
2) Dennis T. Mangano, Anesthesiology 1999;91:1521-6
3) Lee A. Fleisher, IARS 1998 Review Course Lectures, Supplement
to Anesthesia & Analgesia
