Comparative prognostic value of clinical risk indexes, resting two-dimensional echocardiography, and dipyridamole stress thallium-201 myocardial imaging for perioperative cardiac events in major nonvascular surgery patients

doi:10.1016/0002-8703(93)90660-2

American Heart Journal

Volume 126, Issue 5, November 1993, Pages 1099-1106

https://doi.org/10.1016/0002-8703(93)90660-2 Get rights and content

Abstract

The relative prognostic value of widely accessible resting two-dimensional echocardiographic ventricular function data has not been compared with recognized clinical and scintigraphic risk markers in patients who are unable to exercise before major nonvascular surgery. To this end, 53 consecutive patients aged 67 ± 13 years undergoing preoperative evaluation (intraabdominal, 23%; orthopedic, 30%; thoracic, 9%; other, 38%) for known or suspected coronary artery disease were followed up to evaluate the prognostic value of these studies for the perioperative cardiac events (cardiac death [n = 4], myocardial infarction [n = 2], unstable angina [n = 3], and pulmonary edema [n = 8]) that occurred in 13 of the 53 patients (25%). Dipyridamole thallium-201 myocardial redistribution defects occurred in 15 (28%) patients. Resting echocardiographic left ventricular dysfunction was present in 21 (40%) patients. Multivariate analysis of clinical, echocardiographic, and scintigraphic risk predictors revealed that cardiac events were not predicted by clinical variables, including Goldman class or score. Cardiac events were independently predicted only by the presence of significant left ventricular dysfunction on resting two-dimensional echocardiography (p < 0.042) and dipyridamole thallium-201 defect redistribution (p < 0.026). A dipyridamole-induced reversible thallium-201 perfusion defect was predictive of subsequent cardiac death or myocardial infarction (p < 0.02), whereas left ventricular dysfunction on resting echocardiography was predictive of perioperative pulmonary edema (p < 0.023). We conclude that stress thallium-201 perfusion imaging and resting two-dimensional echocardiography provide independent prognostic information in patients undergoing major nonvascular surgery who are at significant risk for ischemic cardiac events and who are unable to perform standard exercise stress tests. Clinical risk indexes were not predictive of cardiac events in these patients when analyzed in combination with noninvasive risk assessment.

References (31)

L Goldman
Assessment of the patient with known or suspected ischemic heart disease for non-cardiac surgery
Br J Anesth
(1988)
SA Abraham et al.
Coronary risk of noncardiac surgery
Prog Cardiovasc Dis
(1991)
RC Hendel et al.
Prognostic value of dipyridamole thallium scintigraphy for evaluation of ischemic heart disease
J Am Coll Cardiol
(1990)
J Lette et al.
Multivariate clinical models and quantitative dipyridamole-thallium imaging to predict cardiac morbidity and death after vascular reconstruction
J Vasc Surg
(1991)
J Leppo et al.
Noninvasive evaluation of cardiac risk before elective vascular surgery
J Am Coll Cardiol
(1987)
PF Pasternack et al.
The value of radionuclide angiography as a predictor of perioperative myocardial infarction in patients undergoing abdominal aortic aneurysm resection
J Vasc Surg
(1984)
KA Brown et al.
Noninvasive cardiac risk stratification of diabetic and noncardiac uremic renal allograft candidates using dipyridamole-thallium-201 imaging and radionuclide ventriculography
Am J Cardiol
(1989)
LT Younis et al.
Perioperative and long-term prognostic value of intravenous dipyridamole thallium scintigraphy in patients with peripheral vascular disease
Am Heart J
(1990)
JT Lam et al.
Safety and diagnostic accuracy of dipyridamole-thallium imaging in the elderly
J Am Coll Cardiol
(1988)
CS McEnroe et al.
Comparison of ejection fraction and Goldman risk factor analysis to dipyridamole-thallium-201 studies in the evaluation of cardiac morbidity after aortic aneurysm surgery
J Vasc Surg
(1990)

L Shaw et al.

Prognostic value of dipyridamole thallium-201 imaging in elderly patients

J Am Coll Cardiol

(1992)

AD Camp et al.

Prognostic value of intravenous dipyridamole thallium imaging in patients with diabetes mellitus considered for renal transplatation

Am J Cardiol

(1990)

AF Amico et al.

Superiority of visual versus computerized echocardiographic estimation of radionuclide left ventricular ejection fraction

Am Heart J

(1989)

NH Carliner et al.

Routine peroperative exercise testing in patients undergoing major noncardiac surgery

Am J Cardiol

(1985)

CM Coley et al.

Usefulness of dipyridamole-thallium scanning for peroperative evaluation of cardiac risk for nonvascular surgery

Am J Cardiol

(1992)

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Current guidelines recommend preoperative cardiac stress echocardiography in patients with limited functional capacity who are considered to have a risk of a major cardiac event of ≥1% on the basis of clinical factors [1]. However, these guidelines do not recommend routine resting TTE for the evaluation of cardiac function before NCS, owing to conflicting results regarding the significance of a preoperative TTE at rest in patients who underwent NCS [10–12]. Moreover, all observational studies examining the effect of TTE on perioperative outcomes have focussed on left ventricular function, left venticular hypertrophy, and valvular dysfunction in patients undergoing NCS [13].
Transthoracic echocardiography is frequently ordered before non-cardiac surgery (NCS), but the impact of preoperative echocardiography on perioperative outcomes in patients undergoing NCS is unknown. The present study aimed to evaluate the predictive value of preoperative right ventricular echocardiograhic parameters for the occurrence of perioperative cardiovascular complications (PCC) in patients undergoing NCS.
We reviewed the data of 660 patients aged ≥18 years and over (mean age 66.3±15 yr) who underwent preoperative comprehensive echocardiography before elective NCS between January 2015 and February 2019. Only patients who had undergone echocardiography before NCS were included. Echocardiographic measurements of right ventricular function, including tricuspid annular plane systolic excursion (TAPSE), Tei index, right ventricular fractional area change, and pulmonary artery systolic pressure, were retrospectively evaluated. The primary outcome of the study was major PCC defined as cardiac death, non-fatal cardiac arrest, severe arrhythmias requiring treatment, acute heart failure, acute coronary syndrome, pulmonary thrombo-embolism, and cardio-embolic stroke.
Eighty (80) patients (12.1%) experienced PCC. Patients with PCC were older, and had a higher prevalence of coronary artery disease, heart failure, and diabetes mellitus. Patients with PCC had lower TAPSE (16.9±4.4 vs 20.8±4.2 mm; p<0.001) than patients without PCC. Multivariate logistic regression analysis showed that older age (odds ratio [OR], 2.35; 95% confidence interval [CI], 1.25-4.65; p<0.01), presence of diabetes (OR, 1.78; 95% CI, 0.95-3.46; p=0.03), and TAPSE <17.6mm (OR, 3.12; 95% CI, 1.12-5.46; p=0.03) were significant variables associated with PCC.
This is the first study to demonstrate that preoperative reduced right ventricular systolic function, as measured by TAPSE, is associated with increased rates of perioperative adverse cardiac events in patients undergoing NCS.
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Risk stratification of patients could potentially improve outcomes by identifying patients who might benefit from more intensive care and invasive monitoring. Numerous methods (both invasive and noninvasive) have been proposed to perform preoperative risk stratification.21-28 These investigative modalities have a very low positive predictive value (stress echocardiogram 18%, dipyridamole thallium 13.8%, and dobutamine stress echo 14%).19
Objective: Perioperative measurement of the myocardial performance index (MPI) with transesophageal echocardiography in patients undergoing elective abdominal aortic aneurysm repair and its association with outcome.
Design: A prospective observational study.
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Participants: Patients undergoing elective abdominal aortic aneurysm repair.
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Measurements: Fifty-one consecutive patients undergoing elective abdominal aortic aneurysm repair were enrolled in the study. The MPI was calculated by using pulse-wave Doppler from the midesophageal window and the deep transgastric position of the probe. In addition, diastolic function was measured as the slope of the transmitral flow propagation velocity, and ejection fraction was calculated as a measure of ventricular systolic function. Comparisons between subjects with uncomplicated versus adverse outcomes were made by using a Mann-Whitney U test. Comparison of the incidence of adverse outcome among subjects with normal and elevated MPIs was made by using a Fisher exact test. Statistical significance was set at p < 0.05.
Results: It was possible to calculate MPI in all patients with transesophageal echocardiography perioperatively. Patients with adverse postoperative outcomes had an elevated MPI as compared with those without any adverse outcome (0.50 v 0.30, p < 0.001). Also, an MPI of ≥0.36 was associated with a statistically significant higher incidence of complications (congestive heart failure/prolonged intubation) (p < 0.001).
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Often, vascular patients do not reach the target heart rates because of limb claudication, and therefore have an inadequate examination. In patients who can perform the test, studies conducted in vascular and non-vascular patients are not conclusive for its ability to predict perioperative cardiac complications.32 41 59 113 However, a recent prospective study on intermediate-risk patients confirmed that a ST-segment depression of 0.1 mV or more during exercise is an independent predictor of perioperative ischaemic events.39
The increasing number of patients with coronary artery disease undergoing major non-cardiac surgery justifies guidelines concerning preoperative evaluation, stress testing, coronary angiography, and revascularization. A review of the recent literature shows that stress testing should be limited to patients with suspicion of a myocardium at risk of ischaemia, and coronary angiography to situations where revascularization can improve long-term survival. Recent data have shown that any event in the coronary circulation, be it new ischaemia, infarction, or revascularization, induces a high-risk period of 6 weeks, and an intermediate-risk period of 3 months. A 3-month minimum delay is therefore indicated before performing non-cardiac surgery after myocardial infarction or revascularization. However, this delay may be too long if an urgent surgical procedure is requested, as for instance with rapidly spreading tumours, impending aneurysm rupture, infections requiring drainage, or bone fractures. It is then appropriate to use perioperative beta-block, which reduces the cardiac complication rate in patients with, or at risk of, coronary artery disease. The objective of this review is to offer a comprehensive algorithm to help clinicians in the preoperative assessment of patients undergoing non-cardiac surgery.

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^☆: Supported in part by the Lichtenstein Foundation.

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Comparative prognostic value of clinical risk indexes, resting two-dimensional echocardiography, and dipyridamole stress thallium-201 myocardial imaging for perioperative cardiac events in major nonvascular surgery patients☆

Abstract

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