Elsevier

Cardiovascular Surgery

Volume 5, Issue 1, February 1997, Pages 54-64
Cardiovascular Surgery

Cardiac risk assessment before vascular surgery: a prospective study comparing clinical evaluation, dobutamine stress echocardiography, and dobutamine Tc-99m sestamibi tomoscintigraphy

https://doi.org/10.1016/S0967-2109(96)00089-0Get rights and content

Abstract

Preoperative evaluation for cardiac risk assessment before peripheral vascular surgery remains controversial. Between January and June 1994, a prospective open study was carried out in 156 patients scheduled for elective vascular procedures (63 carotid endarterectomies, 34 abdominal aortic aneurysms, 29 aortoiliac and 30 infrainguinal reconstructions) to compare the ability of clinical data, dobutamine stress echocardiography, and dobutamine Tc-99m sestamibi tomoscintigraphy to predict postoperative cardiac events. Pharmacological stress testing consisted of incremental dobutamine infusion (±1 mg atropine to achieve 85% of age-predicted maximal heart rate, with continuous echocardiographic monitoring, and injection of Tc-99m sestamibi after dobutamine infusion). Dobutamine echocardiography was abnormal in 36 patients (worsening resting wall motion abnormality in 11; new induced wall motion abnormality in 25). Dobutamine Tc-99m sestamibi tomoscintigraphy revealed a reversible perfusion defect in 34 patients, indicating the presence of myocardial ischaemia. As a result, eight patients underwent myocardial revascularization (n = 5) or the proposed operation was cancelled (n = 3). In the remaining 142 vascular procedures, there were eight (5.6%) adverse cardiac events: three myocardial infarctions (two fatal), three prolonged myocardial ischaemia, one acute congestive heart failure and one sustained ventricular arrhythmia in the post operative period. Univariate analysis selected unstable angina (relative risk (RR) 11.6), previous congestive heart failure (RR 6.4), Detsky's score of ≥ 15 (RR 3.0), positive dobutamine stress echocardiography (RR 3.7), and positive dobutamine tomoscintigraphy (RR 7.4) as significant predictors of postoperative cardiac events. In patients without clinical markers of coronary artery disease (n = 66), non-invasive cardiac testing did not predict cardiac complications (n = 2; one prolonged myocardial ischaemia; one infarction). In the subset of 76 patients with definite clinical or electrocardiographic evidence of ischaemic heart disease, dobutamine stress testing provided additional information, and optimized risk stratification: five of six patients who suffered a cardiac complication had a pathologic dobutamine stress test. Furthermore, a negative dobutamine stress test was characterized by a high negative predictive value (0.96 for echocardiography; 0.97 for tomoscintigraphy). The study further demonstrated that the cardiac response (ischaemic versus non-ischaemic) to dobutamine stress was concordantly classified by echocardiographic and tomoscintigraphic techniques in 96% of cases. It is concluded that complementary non-invasive cardiac stress testing by dobutamine is indicated only in patients with clinically apparent coronary artery disease. © 1997 The International Society for Cardiovascular Surgery.

Introduction

The prevalence of coronary artery disease, whether or not clinically apparent, approaches 75% in vascular surgery candidates, irrespective of the underlying vascular diagnosis 1, 2, 3. The detrimental influence of pre-existing clinical coronary artery disease on operative outcome as well as on late survival has been widely recognized. Concomitant ischaemic heart disease is the main cause of postoperative morbidity and mortality in patients undergoing major vascular procedures. Therefore, many investigators have attempted to evaluate preoperatively the cardiac risk for patients scheduled for elective vascular surgery. Knowledge of the cardiac risk is important for the selection of precautions to be applied in order to minimize the cardiac complication rate or to consider cancelling or postponing the operation, or to change it for an alternative low-risk procedure.

Initially, clinical factors were analysed and extrapolated in a multifactorial cardiac risk index 4, 5. Subsequently, routine coronary angiography evidenced the high prevalence of concomitant coronary artery disease in patients with peripheral vascular disease 1, 6. In the Cleveland experience (1978–1983) [1], severe coronary lesions were documented in 60% of the vascular patients and 22% were submitted to prophylactic myocardial revascularization, before the vascular procedure. Since routine coronary angiography is not reasonable, cardiac risk evaluation by means of non-invasive testing gained in interest. Initial reports on dipyridamole thallium-201 scintigraphy 7, 8, 9 and dobutamine stress echocardiography 10, 11 have been particularly encouraging and have indicated a high accuracy in predicting adverse cardiac outcome after surgery. This was, however, contested in later reports 12, 13, 14, 15.

Given the controversy about the value of routine cardiac testing in patients requiring vascular surgery and the inconsistent results of papers reporting on the predictive value of non-invasive cardiac tests, the authors designed a prospective, unblinded study to compare cardiac risk assessment by clinical risk profile (medical history, physical examination, rest electrocardiogram), dobutamine stress echocardiography and dobutamine Tc-99m sestamibi (methoxy-ixobutyl-isonitrile) tomoscintigraphy before elective vascular surgical procedures.

Section snippets

Patients

Between January and June 1994, 156 consecutive patients scheduled for elective major vascular surgery were prospectively investigated for cardiac risk assessment. There were 63 carotid endarterectomies, 34 abdominal aortic aneurysms, 29 aortoiliac reconstructions, and 30 infrainguinal revascularizations. Detailed data were collected concerning the preoperative status, including demographics, risk factors (smoking, diabetes, hypertension, cholesterolaemia), patient's past cardiac history (prior

Patient characteristics

The clinical characteristics of the 150 patients with interpretable dobutamine echocardiography and tomoscintigraphy are listed in Table 1. The basic data were similar for the patients scheduled for different types of vascular surgical reconstruction (61 carotid endarterectomies, 60 aortoiliac and 29 femoropopliteal bypass grafts), with the exception of more females (33%) and a lower rate of prior infarction (26%) in the subgroup of carotid surgery candidates. Past cardiac history was analysed

Discussion

This prospective, unblinded study on cardiac risk stratification in 156 consecutive patients scheduled for elective reconstructive vascular surgery evaluated the impact of an abnormal cardiac history and a positive dobutamine stress test on postoperative outcome. Identification of patients at increased cardiac risk was obtained by detailed clinical history, and this with the same accuracy as by routine cardiac testing (Table 3). The highest risk patients presented with signs or symptoms of

Acknowledgements

The authors thank Mr Celentano for providing technical assistance and Mrs Delcour and Mrs Dehousse for secretarial work.

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