The Section of Hospital Medicine at The Cleveland Clinic

Physicians in the Section of Hospital Medicine

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See the list of the physicians who work in the section.

There are three areas of service staffed by members of the Section of Hospital Medicine:

- Inpatient Care at the Main Campus of the Cleveland Clinic

- IMPACT Center (Internal Medicine Perioperative Assessment, Consultation and Treatment)

- Cleveland Clinic Center for Rehabilitation (subacute unit)

In addition to the direct patient care, the hospitalists are actively involved in research projects and the education of residents from the Cleveland Clinic and medical students from Cleveland Clinic Lerner College of Medicine.

We strive to fulfill the four ideals expressed in the Cleveland Clinic logo - the four squares represent each of the major areas of the Foundation: Inpatient care, Outpatient care, Research, and Education.

Our goal is provide the best care to our patients because we believe that Every Life Deserves World Class Care.

Perioperative Medicine Summit

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This year Perioperative Medicine Summit will take place September 17-19, 2006 at Intercontinental Hotel & MBNA Conference Center, The Cleveland Clinic, Cleveland, Ohio.

Click here for more information.

Last year summit, conducted in September 2005 included more than 200 physicians, and was a resounding success.

Summit directors were Dr. Jaffer and Dr. Michota. Several members of the hospitalist team presented lectures and case discussions during the two-day event.

Proceedings of the Perioperative Medicine Summit were published in a special supplement of the Cleveland Clinic Journal of Medicine.

Procedure Guides Step-by-Step

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Central line placement. See also Central Line Placement with Ultrasound Guidance.

Thoracentesis (pleural tap)

Paracentesis (ascites tap)

Arthrocentesis (joint tap)

Arterial line placement is illustrated in The Internet Journal of Health.

Lumbar puncture. This is an illustrated guide with brief video clips by the University of Newcastle, UK; eMedicine also has a Lumbar Puncture procedure guide.

More links

Imaging - EKG, CXR, CT scans

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EKG
ECG Wave-Maven by the Harvard Medical School is a fully-fledged ECG-trainer. You can browse through typical or not so typical EKGs here. Check out the arrhythmia simulator - you can play, pause and quiz yourself. Just click "start" on the welcome screen, you do not need a user name/password. ECG Palm Brain is the best free reference for PDAs. It works on both Pocket PC and Palm, iSilo ($ 19) is required.

CXR and CT scans
University of Virginia has a comprehensive website dedicated to CXR and CT scans. Compare what you see on the screen to the CT scans of your patient. ICU CXR is another very useful website from the University of Virginia.

Physical Examination Videos

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Vocal vs. tactile fremitus? Percussion of the spleen? If you need to brush up your physical exam skills, review the medical videos offered by some leading medical schools.

Hospital Medicine Fellowship Program

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The Cleveland Clinic Foundation Hospital Medicine Fellowship aims to train future leaders in Hospital Medicine, including clinical hospitalists, hospitalist-educators, and hospitalist-investigators. Fellows may participate for 1-2 years, depending on research interests.

ELIGIBILITY

Applicants must have completed an internal medicine residency prior to beginning fellowship, and are required to obtain permanent licensure in Ohio.

PROGRAM DESCRIPTION

CLINICAL TRAINING

Fellows serve as a junior attending under the supervision of hospitalist faculty on the teaching service. Fellows gain expertise in perioperative care through rotations in the Internal Medicine Preoperative Assessment, Consultation, & Treatment (IMPACT) Center and on the inpatient medical consultation service . They serve as co-attending physician for pre-operative medical evaluations, direct appropriate pre-operative diagnostic testing, manage perioperative medications, and collaborate with surgeons and anesthesiologists to ensure optimal medical and surgical care. Rotations in medical intensive care, palliative care, and skilled care settings provide fellows with a diversity of inpatient experiences critical to hospitalist practice.

TEACHING

As co-attending, fellows direct and supervise housestaff during patient care on the assigned teams and have primary responsibility for teaching residents and medical students during attending rounds. Fellows also present a topic at departmental Grand Rounds as a CME-accredited activity.

RESEARCH

Fellows are provided with protected time and basic training in Epidemiology, Biostatics and Research Methods from faculty in the Lerner Research Institute and the Department of Quantitative Health Sciences in preparation for the completion of a scholarly research project under the guidance of Hospitalist faculty and mentoring via Cleveland Clinic experts.
Fellows maintain a portfolio of scholarly and clinical activity that is reviewed quarterly by the program directors. Fellows are expected to submit a research proposal to the internal review board, collect and analyze data, prepare presentations of research and/or case vignette(s) for submission to regional/national meeting(s) and peer-reviewed journals.

THE ENVIRONMENT

The Cleveland Clinic Foundation is a multi-specialty tertiary care academic medical center that is consistently ranked as one of the top five hospitals in America by US News and World Report, and is world-renowned for quality of care and for numerous medical breakthroughs. World-class resources for clinical care, research, and education are available for trainees in all fields.

PROGRAM DIRECTORS

Christopher, M. Whinney, M.D.
Christopher Phillips, M.D., M.P.H.
Franklin Michota, M.D.

For more information, please contact:

Ms. Mary Ritley
Education Coordinator
General Internal Medicine / E 13
The Cleveland Clinic Foundation
9500 Euclid Avenue
Cleveland, Ohio 44195
Phone : 216/444-0895; 800/223-2273 (ask for extension 40895)
Fax: 216/445-4473
E-mail: ritleym@ccf.org

References:
A list of hospitalist fellowships. Society of Hospital Medicine.

News and Events

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2006 SHM Annual Meeting
May 3-5, 2006
Hilton Washington, Washington, DC

Submit an Abstract to the 2006 Research, Innovations, and Clinical Vignettes (RIV) Competition
May 4-5, 2006

View abstract submission guidelines (PDF file)

2006 Perioperative Medicine Summit at the Cleveland Clinic

This year Perioperative Medicine Summit will take place September 17-19, 2006 at Intercontinental Hotel & MBNA Conference Center, The Cleveland Clinic, Cleveland, Ohio.

Click here for more information.

Last year summit, conducted in September 2005 included more than 200 physicians, and was a resounding success.

Summit directors were Dr. Jaffer and Dr. Michota. Several members of the hospitalist team presented lectures and case discussions during the two-day event.

Proceedings of the Perioperative Medicine Summit were published in a special supplement of the Cleveland Clinic Journal of Medicine.

Flomax (tamsulosin ) Associated with Intraoperative Floppy Iris Syndrome (IFIS) During Phacoemulsification Cataract Surgery

The original study was published in J Cataract Refract Surg, Apr 2005: Intraoperative floppy iris syndrome associated with tamsulosin (intranet link to full text). The study was also mentioned on the American Academy of Ophthalmology website - Beware Floppy Iris During Phaco.

FDA requested the drug manufacturer Boehringer Ingelheim to send a letter informing medical professionals about the association between Flomax and IFIS.

Pending further studies, the current advice is to ask patients before cataract surgery if they are taking Flomax, and discontinue the drug for one to two weeks before surgery.

Research Projects at the Section of Hospital Medicine

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Perioperative & Periprocedural Management of Warfarin (PPMW) study.
A prospective Multicenter observational study looking at perioperative patterns of anticoagulation management and incidence of events (thromboembolic and hemorrhagic). IRB# 5766.

Perioperative Beta Blockade, Heart Rate Control and Cardiovascular Events Involving Noncardiac Surgeries. IRB# 7825.

Risk of Hemorrhage in Patients on Combination Antithrombotic Therapy with Warfarin and Clopidogrel. IRB # 7731.

Risk factors for acute venous thromboembolism in hospitalized patients. IRB # 7910.

Improving Perioperative Cardiac Risk Assessment and beta-blocker Use for Non-cardiac Surgery (INCREASE): The INCREASE Quality Improvement Project. IRB# 8655.

Perioperative risk stratification of patients with sleep apnea undergoing non-cardiac surgery. RPC # 2005-1037.

Incidence and Predictors of Post-operative Myocardial Infarction, Stent Thrombosis and Bleeding Outcomes of Patients with Drug Eluting Stent Undergoing Non-Cardiac Surgery (DES and NCS Study). IRB # 8280.

Does an IMPACT Evaluation make a difference in Post-operative Outcomes? (DIRECT Study). IRB # 8502.

Predictors of Acute Renal Failure after Non-Cardiac Surgery (ARF and NCS Study). IRB # pending.

Intranet Shortcuts

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Most of these links are accessible only from the Cleveland Clinic campus or with a CCF remote access

Hospitalist Signout on Sharepoint

UpToDate

CCF Library with full-text journals

Guidelines for Antibiotic Use

COMET Online Learning

HIPAA Online Learning

Register for Grand Rounds CME

Photos of the CCF Internal Medicine Residents

Journal Articles to Discuss

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Beta Blockers in Perioperative Medicine

Beta blockers for patients at risk of cardiac events during non-cardiac surgery
BMJ Editorial, 2005;331:919-920 (22 October)

POBBLE Trial
(enter "POBBLE" in the search field on the ScienceDirect website)
Perioperative β-blockade (Pobble) for patients undergoing infrarenal vascular surgery: Results of a randomized double-blind controlled trial.
Journal of Vascular Surgery Volume 41, Issue 4 , April 2005, Pages 602-609

DIPOM Trial
The diabetic postoperative mortality and morbidity (DIPOM) trial: rationale and design of a multicenter, randomized, placebo-controlled, clinical trial of metoprolol for patients with diabetes mellitus who are undergoing major noncardiac surgery.
American Heart Journal Volume 147, Issue 4, Pages 677-683 (April 2004)

CARP Trial
Coronary-Artery Revascularization before Elective Major Vascular Surgery.
NEJM Volume 351:2795-2804, December 30, 2004, Number 27

MaVS Trial
Metoprolol After Vascular Surgery(MaVS)
Canadian Journal of Anesthesia 51:A7 (2004)

Perioperative Beta-Blocker Therapy and Mortality after Major Noncardiac Surgery
NEJM Volume 353:349-361, July 28, 2005, Number 4

How strong is the evidence for the use of perioperative blockers in non-cardiac surgery?
Systematic review and meta-analysis of randomised controlled trials
BMJ 2005;331:313-321 (6 August)

Beta-Blockers and Reduction of Cardiac Events in Noncardiac Surgery Scientific Review
JAMA. 2002;287:1435-1444

Future Discussions

Patient Safety Concerns Arising from Test Results That Return after Hospital Discharge
Ann of Int Med 19 July 2005 | Volume 143 Issue 2 | Pages 121-128

Efficacy of lispro sq vs. continuous regular insulin IV for the treatment of patients with DKA
Am J Med. 2004 Sep 1;117(5):291-6

Coding and Billing Advice

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Is Your Documentation Vanilla? Or Spicy?
Source: DCBA Inc., Documentation Coding and Billing Accuracy

Medical Journal Articles

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Recent Articles Published by the Members of the Section of Hospital Medicine

In addition to the direct patient care, the hospitalists are actively involved in research projects which result in multiple publications in leading medical journals.

Suggested Reading

A selection of essential articles for the every day practice of the academic hospitalist.

Journal Articles to Discuss

The consensus comes in discussion. Members of the Section of Hospital Medicine regularly meet to discuss the latest advances in clinical medicine.

Hospitalists at the Cleveland Clinic Department of General Internal Medicine

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Franklin Michota, Jr, M.D. - Section Head

Dr. Michota is head of the Section of Hospital Medicine at The Cleveland Clinic Foundation in Ohio, and serves as an Associate program director for the Internal Medicine Residency Program. Dr. Michota also holds the rank of Associate Professor of Medicine at the Cleveland Clinic Lerner College of Medicine.

CV and Publications

Amir K. Jaffer, M.D. - Director of IMPACT

Dr. Jaffer, M.D. is the Medical Director of the IMPACT (Internal Medicine Preoperative Assessment Consultation and Treatment) Center and the Anticoagulation Clinic within the Section of Hospital Medicine in the Dept. of General Internal Medicine at the Cleveland Clinic Foundation in Cleveland, Ohio.

CV and Publications

In alphabetical order:

Ashish Aneja, M.D.

(photo not available)
Krista Andersen-Harris, M.D.

(photo not available)
Kristin Carlin, D.O.

(photo not available)
Olivia Cai, M.D.
Dr. Cai completed medical school at Tongji Medical University and her postgraduate education at New Hanover Regional Medical Center, Wake Forest University Baptist Medical Center and the Cleveland Clinic. She has special interest in hospital medicine and heart failure management.

(photo not available)
Thadeo Catacutan

Vesselin Dimov, M.D.

Dr. Dimov is a staff physician in The Section of Hospital Medicine. He is the creator of ClinicalCases.org, an online case-based curriculum of clinical medicine, which receives thousands of page views daily and was featured in the BMJ and Medscape. His research interests include prevention of acute renal failure and perioperative medicine.

CV and Publications

Wassim Fares, M.D.

Michael E. Felver, M.D. - Director of the Cleveland Clinic Center for Rehabilitation

David V. Gugliotti, M.D.

Brian J. Harte, M.D.

(photo not available)
Rammath Hebbar, M.D.

Roop K. Kaw, M.D.

Dr. Kaw is a staff in the Section of Hospital Medicine and Assistant Professor of Medicine at The Cleveland Clinic Lerner College of Medicine. His research interests include perioperative research methodologies, perioperative pulmonary complications and outcomes. He is an active reviewer for several journals and also serves on the Advisory Board of Gerson Lehermans Council of Health Care Advisors.

CV and Publications

(photo not available)
Arthur Kendig, M.D.

Collin D. Kroen, M.D.

Ajay Kumar, M.D.

Saira Noor, M.D.

Robert Patrick, M.D., M.B.A.

Christopher Phillips, M.D., M.P.H. - Director of the Hospitalist Fellowship Program

(photo not available)
Mohammed Qadeer, M.D.

Anitha Rajamanickam, M.D.

Vaishali M. Singh, M.D., M.B.A., M.P.H.

(photo not available)
Priyanka Sharma, M.D.

Sanjeev Suri, M.D.

(photo not available)
Katherina Tillan-Martinez

Christopher, M. Whinney, M.D. - Director of the Hospitalist Fellowship Program

Ali Usmani, M.D.

Medical Grand Rounds

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Grand Rounds Schedule

Check the Department of General Internal Medicine (GIM) Grand Rounds Schedule

Register for CME

The CCF Center for CME designates this educational activity for a maximum of 1-hour in Category-1 credit towards the AMA Physician's Recognition Award.

Web Videos - Watch the Grand Rounds Presentations Online

Free webcasts available from the Cleveland Clinic center for CME.

Cleveland Clinic Center for Rehabilitation

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The Cleveland Clinic Center for Rehabilitation is a fifty-nine bed skilled nursing care facility located on the downtown campus of the Cleveland Clinic.

Patients requiring additional medical and rehabilitation care following a surgical procedure or hospital admission, stay for an average of two weeks.

Dr. Michael Felver, a member of the Section of Hospital Medicine, is the medical director of the facility. He and others from the Section attend the patients during their stay. They are joined by specialists from Physical Medicine and other areas who supervise a highly trained nursing staff.

Together, we provide expert care, rehabilitation, and instruction following joint and spine reconstruction, organ transplantation, open-heart surgery, colorectal surgery, esophagectomy, limb amputation, stroke, serious infections, and complicated medical illnesses.

Directions:

The Cleveland Clinic Center for Rehabilitation is located between E. 87th and 89th streets just off Euclid Avenue. This is the U/Mellen Center building on the map below.

Schedules

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A password is required to access the files, email the webmaster if you do not have one. Click here to access the Schedules Download page. The content is listed below.

Schedules of The Section of Hospital Medicine

Schedule 2006-2007 - New !!!

Schedule 2005-2006

Weekend Coverage Schedule

SICU On Call Schedule (central line placement)

Kimball A & B Schedule

Recent Articles Published by the Members of the Section of Hospital Medicine

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Renal Impairment and Outcomes in Heart Failure: Systematic Review and Meta-Analysis
Grace L. Smith, Judith H. Lichtman, Michael B. Bracken, Michael G. Shlipak, Christopher O. Phillips, Paul DiCapua, and Harlan M. Krumholz
J Am Coll Cardiol 2006 47: 1987-1996.

Lupus-Related Hepatitis: Complication of Lupus or Autoimmune Association? Case Report and Review of the Literature
Digestive Diseases and Sciences. Issue: Volume 51, Number 4, Date: April 2006 (813 - 818).
Roop Kaw, Carmen Gota, Ana Bennett, David Barnes, Leonard Calabrese

Does Acid Suppressive Therapy Reduce the Risk of Laryngeal Cancer Recurrence?
Laryngoscope. 115(10):1877-1881, October 2005. Pubmed link.
Qadeer, Mohammed A. MD; Lopez, Rocio MPH, MS; Wood, Benjamin G. MD; Esclamado, Ramon MD; Strome, Marshall MD; Vaezi, Michael F. MD, PhD, MSepi

Preventing and Treating Thromboembolism in the 21st Century
Cleveland Clinic Journal of Medicine, Suppl. 1 to Vol. 72, April 2005
Amir Jaffer, MD; Daniel Brotman, MD, FACP; Alpesh Amin, MD, MBA

Do Hip Fractures Need To Be Repaired Within 24 hours of Injury?
Cleve Clin J Med 2005; 72(3): 250-252.
Whinney, CM.

A 48-year-old woman with nausea, vomiting, early satiety, and weight loss
Cleve Clin J Med. 2004 Sep;71(9):693-4, 696-7, 702. Pubmed link.
Qadeer MA, Burke CA.

Tutorials

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Epic Discharge Note Tutorial

IMPACT UPA Tutorial

These are PowerPoint Viewer files. If you do not have PowerPoint installed on your computer, a free download from Microsoft is required to view the presentations.

Web 2.0 in Medicine

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Vesselin Dimov, M.D.

Web 2.0 is a collection of free services that make the internet more useful and interactive. There is nothing to download because they all work in your browser.

Image source: Dion Hinchcliffe's Web 2.0 Blog

Suggested Online Services

1. RSS Feeds and Bloglines

RSS feeds are updates that are delivered by the websites when something new is published.

Its inventor, Dave Winer likens RSS to "a sushi bar where the sushi comes around in boats. When you see something you like, you grab it and eat it." The same is true with RSS content that feeds you news aggregator.

"It's like having a personal assistant who goes through every publication and blog that could possibly interest you and picks out stories to bring to your attention.", writes PC Magazine.

Bloglines is probably the best choice among the online RSS readers (aggregators). It helps you to collect the information you want in one place. Instead of visiting 20 websites per day, let them send the information to you. Subscribe to specific searches on Pubmed or any search engine and collect them in one place. Subscribe to the major medical journals RSS feeds. You can publish the updates to a private blog to make a portfolio entry.

See the tutorial "How to Subscribe to Medical RSS Feeds on Bloglines" (PDF, 590 kb).

2. Write Your Documents Online at Writely.com

Writely is a secure online word processor. It is ideal for 2-3 authors who are collaborating on an article. Writely allows you to see all the revisions in real time. No more emailing Word documents back and forth between the authors. The service has an easy export to MS Word and you can monitor the changes to your article by subscribing to the RSS feed in Bloglines. Other alternatives to Microsoft Office are NumSum (a simple Excel "replacement") and gOffice.

3. Online Favorites are Del.icio.us

You can collect your favorite websites online on Del.icio.us and make the list accessible from any computer. Add multiple tags (labels) to describe the content. This bookmarks/favorites list is easily searchable. Yahoo MyWeb2.0 takes the online bookmarking even further by letting you to save pages and images on their servers for free.

4. Blogs

Start a website in 5 minutes. You can publish your thoughts, collection of interesting cases or use it to make portfolio entries. The best overall service is provided by Google on Blogger.com. Read about the other options in Choose a Free Blogging Platform - Check Out Opera Blogs.

References:
What Is Web 2.0 - Tim O'Reilly
RSS: The Web at Your Fingertips - PC Magazine
Innovative Web-based software challenges Windows - USA Today
Other RSS tutorials:
Bloglines: How to use Bloglines - Honeywell.com, Adding RSS feed to Bloglines - University of California Berkeley, Using Bloglines - preetamrai.com
Google Reader - How to use Google Reader - a Flash tutorial by Andy Wibbels
Sergey Brin in conversation with John Battelle about Web 2.0 - ITconversations.com
Microsoft plays catch-up - CNN/Fortune

Useful Software Programs

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Lookout
A search engine for Outlook. There is another download link here.

OrgPlus
This is an add-in to Microsoft Word for making flow charts. The inbuilt system from Microsft is not very user-friendly. This simple program makes drawing any flow chart a breeze.

Free Medical Programs for Windows Mobile / Pocket PC
The best PDA programs.

Cleveland Clinic Hospitalists Areas of Service

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Main Campus Inpatient Care

IMPACT Center (Internal Medicine Perioperative Assessment, Consultation and Treatment)
Link

Cleveland Clinic Center for Rehabilitation

The Cleveland Clinic Center for Rehabilitation is a fifty-nine bed skilled nursing care facility located on the downtown campus of the Cleveland Clinic.

Patients requiring additional medical and rehabilitation care following a surgical procedure or hospital admission, stay for an average of two weeks.

Dr. Michael Felver, a member of the Section of Hospital Medicine, is the medical director of the facility. He and others from the Section attend the patients during their stay. They are joined by specialists from Physical Medicine and other areas who supervise a highly trained nursing staff.

Together, we provide expert care, rehabilitation, and instruction following joint and spine reconstruction, organ transplantation, open-heart surgery, colorectal surgery, esophagectomy, limb amputation, stroke, serious infections, and complicated medical illnesses.

Presentations

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Perioperative Use of Statins
Paul Grant, MD
Hospitalist Fellow, Section of Hospital Medicine
Fellows' Conference 11/05

Diogenes Syndrome
William Popovich, MD
PGY-2 Internal Medicine
Geriatrics Conference 10/05

Weight Loss and Body Mass Index in Patients with Alzheimer Dementia
Mihir Bakhru, MD
PGY-2 Internal Medicine
Geriatrics Conference 9/05

Internal Medicine Preoperative Assessment Consultation and Treatment (IMPACT) Center

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The IMPACT Center

Internal Medicine Preoperative Assessment Consultation and Treatment (IMPACT) Center at the Cleveland Clinic is a state-of-the art preoperative center in its 9th year of operation.

It is staffed by the hospitalists from the Section of Hospital Medicine and directed by Amir K. Jaffer, M.D., the Associate Section Head for Hospital Medicine. Over 13,500 patients were seen in 2005. Patients are referred from surgeons in over 10 different surgical departments at the Cleveland Clinic, ranging from Colorectal surgery to Vascular Surgery.

IMPACT Achieves Better Outcomes

In an era where outcomes are important, the IMPACT Center staff evaluate patients undergoing non-cardiac surgery and outline the perioperative risks, optimize the chronic conditions and make evidence-based recommendations for patients, the anesthesiologists and the surgical team. This systematic approach results in safe and quality care for patients at the Cleveland Clinic. A recent study in the Journal of Clinical Outcomes showed that the IMPACT Center evaluation resulted in a low rate of postoperative pulmonary complications compared to nationally reported numbers.

Annual Perioperative Medicine Summit: Improving Quality, Safety and Outcomes.

We hold formal visitation programs for faculty from other institutions and an annual CME event in its second year called: The Perioperative Medicine Summit: Improving Quality, Safety and Outcomes. Click to download the Summit brochure in PDF format.

Proceedings of the 2005 Perioperative Medicine Summit were published in a special supplement of the Cleveland Clinic Journal of Medicine.

More information about the IMPACT Center.

Perioperative Evaluation for Noncardiac Surgery

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AHA/ACC Guidelines

The most authoritative guidelines are from the AHA/ACC and they have a very useful website aimed at educating physicians. Check out the following features:

- The guidelines are available online or as a PDF file

- Teaching slides - you can view them online or download the PowerPoint file

- Download the Pocket PC version

You can check out the other guidelines available from AHA/ACC here. All files are free downloads.

Perioperative Guidelines for PDA

You have to download the Pocket PC (or Palm) version from Skyscape. The downloaded file is the standard installer, used by the other Skyscape applications, like Archimedes.

The universal algorithm makes the preoperative evaluation a breeze. It guides you step-by-step, using a simple question and answer approach, simplifying the process. You can bookmark the most commonly used parts of the guidelines like:

- conditions-predictors of cardiovascular risk in different patients - high, intermediate and low risk

- calculating the METs (metabolic equivalents, i.e. energy requirement for various activities)

- levels of risks for different surgical procedures - high, intermediate and low

- the main step-by-step algorithm

"PASS" the Preoperative Evaluation

There are 4 variables in the preoperative evaluation, remembered by the mnemonic PASS:

Patient risk
Activity level - measured in METs
Surgical risk
Select the tests to perform

1. Patient risk - a patient with CAD S/P CABG with CHF is clearly at a higher risk than a patient who has only HTN.

2. How well is the patient prepared for surgery? What is his activity level (measured in METs)? The most useful question is "do you have stairs in your house?". If yes, "can you climb a flight of stairs without SOB or CP?" Going up and down stairs will give the patient a MET of 4, which is the dividing point in the algorithm to consider cardiac testing. Just remember "stairs = MET 4".

3. Surgical risk - a high risk procedure, like AAA repair vs. a low risk procedure, like breast biopsy.

4. Select the tests to perform. EKG is almost always indicated. Follow the algorithm to decide which patient needs a stress test.

After you look into these 4 variables (PASS), you have to follow the AHA/ACC algorithm. Of course, there are many other things to address, like when to stop and restart certain medications, etc. This is the basic approach which is the backbone of the perioperative evaluation.

Three Stress Tests

Choose one of the 3 stress test modalities. The mnemonic is EDD:

- Exercise stress testing - without imaging or pharmacologic induction (both are used in the other 2 stress tests below)
- Dipyridamole-thallium imaging (DTI)
- Dobutamine stress echo (DSE)

Exercise stress testing limitations:
- OA patient who is unable to exercise
- Resting EKG abnormalities

DTI prognostic accuracy is 81%.

DSE has the additional advantage of showing the systolic function, the accuracy is similar to DTI.

Cut-off Numbers in the Algorithm

Remember the cut-off numbers 2-4-5 in the algorithm:
- 2 years of the last catheterization or a stress test - safe to proceed with surgery, if no symptoms
- 4 METs
- 5 years of the last coronary revascularization - safe to proceed with surgery, if no symptoms

Take the "HIP" Shortcut

The majority of patients have intermediate or minor clinical predictors, and you can use the following shortcut to determine who needs a stress test.

The shortcut to noninvasive testing is remembered by the mnemonic HIP:

- High risk surgery - vascular surgery
- Intermediate clinical predictors - old MI, DM 2
- Poor functional class

Note: The "HIP" shortcut is valid for patients who are scheduled to have high risk or intermediate risk surgery. Patients scheduled for low risk surgery can usually proceed with the operation without the need to have a stress test first.

The Cleveland Clinic Perioperaive Medicine Summit

The summit, conducted on September 22-23, 2005 included more than 200 physicians, and was a resounding success.

Summit directors were Dr. Jaffer and Dr. Michota. Several members of the hospitalist team presented lectures and case discussions during the two-day event.

Lectures will be published in a special supplement of the Cleveland Clinic Journal of Medicine.

Reference:
AHA/ACC Clinical Statements/Guidelines
Online Calculator - MedCalc: Perioperative Cardiac Evaluation
Image source: Wikipedia, CCF (used with permission)