Does the clinical evaluation of the cardiac status predict outcome in patients with abdominal aortic aneurysms?

Electrophysiological, hemodynamic, and metabolic response to open procedure or endovascular repair of infrarenal aortic aneurysms

BACKGROUND

The occurrence of cardiovascular diseases in the group of patients undergoing vascular surgery because of abdominal aorta aneurysm is very high. Endovascular procedures are regarded as hemodynamically safer for the patients. The aim of this study was to compare the changes in electrophysiological, hemodynamic, and metabolic parameters depending on the type of operation, using invasive hemodynamic monitoring and Holter electrocardiography recording.

METHODS

A prospective, observational, nonrandomized study was conducted to compare dynamic changes of electrophysiological parameters (dominant rhythm, arrhythmia, corrected QT interval (QTc), invasive blood pressure, electrolytes, and acid-base balance in defined points during perioperative time in 2 groups: vascular prosthesis implantation group (91 patients) and stent-graft implantation group (83 patients).

RESULTS

The study group comprised 174 consecutive adult Caucasian patients (mean age 64.4 ± 8.9 years in stent-graft group and 70.0 ± 7.5 years in vascular prosthesis implantation group). Although patients in the stent-graft implantation group were younger, they were diagnosed with lower limbs vascular atherosclerosis, type 2 diabetes mellitus, and a lower left ventricle ejection fraction more often than patients in the open procedure group. During the open procedure, higher blood pressure amplitudes (P = 0.00009), higher decrease in pH (P = 0.049), increase in the arterial lactate level (P = 0.00002), prolonged QTc values (P = 0.001), more frequent ventricular extrasystoles (P = 0.005), and cardiovascular deaths were observed, when compared with those observed during the endovascular aneurysm repair.

CONCLUSIONS

When compared with the chosen techniques, the one for infrarenal abdominal aneurysm was found to be associated with significant differences in electrophysiological, hemodynamic, and metabolic parameters.

A Case of Simultaneous Endovascular Aneurysmal Repair (EVAR) and Coronary Artery Bypass Grafting (CABG)

A male patient with abdominal aortic aneurysm (AAA) and coronary artery disease was referred to our hospital. Coronary angiography showed multiple coronary lesions including the left main trunk. Computed tomography revealed a large AAA measuring 78 mm. To prevent aneurysmal rupture after coronary artery bypass grafting or cardiac complications after AAA repair, we performed simultaneous endovascular aneurysmal repair and coronary artery bypass grafting. The postoperative course was uneventful. Endovascular therapy and beating coronary artery bypass grafting is less invasive and may offer another promising option for the treatment of complicated case of AAA with severe coronary artery disease.

An appraisal of different cardiac risk reduction strategies in vascular surgery patients

OBJECTIVES

to summarize existing evidence regarding the benefits and the risks of all available interventional and medical means aimed at cardiac risk reduction in patients undergoing vascular surgery.

DESIGN

review of the literature.

MATERIALS AND METHODS

a critical review of all studies examining the impact of various prophylactic cardiac maneuvers on perioperative outcome following vascular surgery was performed. Overall mortality, cardiac mortality and myocardial infarction rate were used as the outcome measures.

RESULTS

coronary artery bypass grafting is associated with a 60% decrease in perioperative mortality in patients undergoing vascular surgery, but in most of the cases this decrease does not outweigh the combined risk of the cardiac and the subsequent noncardiac vascular procedure. Data supporting the cardioprotective effect of percutaneous transluminal angioplasty in the perioperative setting are insufficient. beta-blockade has been shown to decrease perioperative mortality and cardiac morbidity in both high-risk (strong evidence) and low-risk (weak evidence) patients.

CONCLUSIONS

coronary revascularization is rarely indicated to simply get the patient through vascular surgery and should be reserved for patients who would need it irrespective of the scheduled vascular procedure. Among all available pharmacological agents, including beta-blockers, alpha-agonists, calcium channel blockers and nitrates, only beta-blockers have been proven to reduce the cardiac risk of vascular surgery.

Abdominal aortic aneurysm repair

Newer, minimally invasive catheter-based endovascular technology utilizing stent grafts are currently being evaluated for abdominal aortic aneurysm (AAA) repair. A retrospective review of all (3 years) consecutive, non-ruptured elective AAA repairs was undertaken to document the results of AAA surgical repair in a modern cohort of patients to allow a contemporary comparison with the evolving endoluminal data. One hundred twenty-one AAAs were identified in a male veteran population. Mean age was 68.5 +/-7.7 years. Medical history review showed hypertension in 55%, heart disease in 73.5%, peripheral vascular disease in 21%, stroke and transient ischemic attacks in 22%, diabetes mellitus in 7%, renal insufficiency in 10%, and smoking history in 80%. The AAA size was documented with ultrasound (5.2 +/-1.3 cm, n=40) and computed tomography (5.6 +/-1.3 cm, n=100). Fifty-nine percent had angiography. Intraoperative end points included an operative time of 165 +/-6.3 minutes from incision to dressing placement. A Dacron tube graft was used in 78%, the remaining were Dacron bifurcated grafts. A suprarenal clamp was used in 8% for proximal aortic control with juxtarenal aneurysms. A pulmonary-artery catheter was placed in 69%. A transverse incision was used in 69% of patients and a midline incision was used in the rest. Estimated blood loss was 1505 +/-103 mL; cell saver blood returned 754 +/-53 mL; crystalloid/Hespan 4771 +/-176 mL; banked packed red blood cells 0.75 +/-0.11 U. Time to extubation was, in the operating room (78.5%), on the day of the operation (5.0%), postoperative day (POD) 1 (12.4%), POD2 (1.7%), POD3 (0.8%), and one case was performed with epidural anesthesia only. Postoperative end points included a 30-day mortality rate of 1.6% (two patients). Postoperative morbidity included wound dehiscence 0.8%; sepsis, urinary tract infection, wound infection, leg ischemia, ischemic colitis, and stroke each had an incidence of 1.6%; myocardial infarction, congestive heart failure, pneumonia, re-operation for suspected bleeding, and ileus or bowel obstruction occurred with an incidence of 3.3%. No significant increase in serum creatinine levels was noted. Time to enteral fluids/nutrition was 3.5 +/-0.08 days. Patients were out of bed to a chair or walking by 1.3 +/-0.06 days postoperatively. The length of stay in the intensive care unit (ICU) was 2.0 +/-0.12 days and postoperative hospital stay was 6.6 +/- 0.33 days. Transfusion requirement for the hospital stay was 1.6 +/-0.2 U per patient. This review highlights a cohort of male veteran patients with significant cardiac co-morbidity who have undergone repair with a conventional open technique and low mortality and morbidity rates. This group had rapid extubation, time to oral intake, and ambulation. In addition, ICU and hospital stays were relatively short.

Repair of large abdominal aortic aneurysm should be performed early after coronary artery bypass surgery

PURPOSE

The surgical repair (coronary artery bypass grafting [CABG]) of symptomatic coronary artery disease (CAD) in patients with co-existent large abdominal aortic aneurysm (AAA) may result in an increased rate of AAA rupture after operation. Simultaneous CABG/AAA repair has been recommended by some surgeons, but with a somewhat higher mortality rate than staged repair. We reviewed the outcome of staged AAA repair that was performed early after CABG in patients with symptomatic coronary disease and AAA.

METHODS

The records of all the patients with symptomatic CAD that required CABG with large AAA (greater than 5 cm) were reviewed. In most patients, CABG was performed first, followed by AAA repair within 2 weeks. Patient demographics, severity of coronary disease, AAA size, interprocedure duration, and perioperative morbidity and mortality rates were examined.

RESULTS

Between 1991 and 1998, 1105 AAA repairs were performed. Within this group, 30 patients with AAA underwent CABG for symptomatic CAD. Mean AAA size was 6.6 cm (range, 5.0-10.0 cm). The median interprocedure interval between CABG and AAA repair was 11.5 days. There was no in-hospital AAA rupture during this interval. The patient group was comprised of 24 men and 6 women with a mean age of 71 years. There was no operative death after such staged AAA repair, and nonfatal complications occurred in seven patients (23%). During this period, seven patients had AAA rupture when they were sent home after CABG for recovery and intended AAA repair at a later date.

CONCLUSION

Staged elective AAA repair may be performed safely and effectively after CABG. Performance of these procedures with a short interprocedure interval may be preferable to the higher complication rate observed after combined procedures.

Correlates of in-hospital cost among patients undergoing abdominal aortic aneurysm repair

BACKGROUND

Surgical repair of abdominal aortic aneurysms (AAA) is increasingly being performed, but little is known about the correlates of in-hospital cost associated with this procedure.

METHODS AND RESULTS

Baseline clinical characteristics, in-hospital outcomes, and total in-hospital costs were examined among a retrospective cohort of 71 patients who underwent AAA repair. Median age was 68 years, and 75% of the patients were men. High-risk characteristics for perioperative complications were common and included hypertension (73%), documented coronary artery disease (66%), smoking (60%), previous myocardial infarction (47%), history of congestive heart failure (12%), urgent or emergent AAA repair (16%), and diabetes mellitus (11%). Perioperative complications included congestive heart failure (13%), myocardial infarction (11 %), and death (1 %). Median length of stay in the surgical intensive care unit (SICU) was 2 days (range 0 to 28), and median in-hospital stay was 9 days (range 5 to 39). In-hospital cost for the 71 patients ranged from $13,766 to $82,435 (mean $25,931, median $21,633). Univariate and multiple linear regression analyses demonstrated that among the potential correlates investigated, number of SICU days (P= .007) and total length of stay (P< .0001) were the most closely associated with in-hospital cost.

CONCLUSIONS

Among patients undergoing AAA repair, the major correlates of in-hospital cost are the number of days spent in the SICU and the total number of days spent in the hospital. These results suggest that any intervention that reduces length of stay may significantly reduce the total in-hospital cost associated with AAA repair.

Vectorcardiographic changes as predictors of cardiac complications during major vascular surgery

OBJECTIVE

To elucidate the relation of changes in computerized vectorcardiographic trend parameters indicating perioperative myocardial ischemia with perioperative cardiac complications.

DESIGN

Prospective clinical study.

SETTING

A single university hospital.

PARTICIPANTS

Thirty-eight patients undergoing elective abdominal aortic surgery.

INTERVENTIONS

Computerized vectorcardiography recorded during surgery and for 48 hours postoperatively.

MEASUREMENTS AND MAIN RESULTS

Vectorcardiographic spatial alterations in the QRS complex (QRS-VD) and absolute (ST-VM) and spatial (STC-VM) ST-segment changes, previously used indicators of myocardial ischemia, were analyzed and related to the cardiac events detected clinically. In five patients with clearly ischemic (cardiac death, myocardial infarction, recurrent ischemia) and eight patients with possibly ischemic (congestive heart failure, arrhythmia) perioperative cardiac events, ST-VM and STC-VM were significantly increased intraoperatively. Postoperatively, these differences remained, but QRS-VD were also significantly increased. Intraoperative and postoperative changes indicating ischemia were strongly related (r = 0.83). The signs of ischemia were most pronounced during the postoperative 12 to 36 hours. The presence of 60 minutes of signs of ischemia during 2 hours revealed high sensitivity (85%), specificity (80%), and positive (69%) and negative (91%) predictive values for subsequent cardiac events. Traditional vector loop analysis showed signs of non-Q-wave infarctions in six patients, whereas only three of these were detected using standard clinical methods.

CONCLUSIONS

Vectorcardiographic signs of myocardial ischemia were significantly increased intraoperatively, but most pronounced postoperatively in the patients subsequently suffering cardiac events. The changes could be related to the individual cardiac morbidity with acceptable precision. Thus, continuous vectorcardiographic monitoring may be beneficial for patients at risk of developing perioperative ischemia.

The utility of dobutamine echocardiography in preoperative evaluation for elective aortic surgery

BACKGROUND

Preoperative cardiac evaluations have been advocated prior to major vascular procedures to reduce the incidence of postoperative cardiac complications. This study was undertaken to evaluate the efficacy and predictive value of routine dobutamine echocardiography (DE) in the screening of patients undergoing elective aortic surgery.

METHODS

Dobutamine echocardiography was performed preoperatively on all patients having elective aortic procedures by our university surgical group from June 1995 to August 1996. The cardiac morbidity and mortality from this group were compared with that of a similar group undergoing elective aortic procedures from June 1993 to May 1995 with no dobutamine echocardiography (NDE).

RESULTS

Although there was no statistically significant difference in either overall mortality (4.4% in NDE vs. 2.3% in DE) or cardiac mortality (2.9% in NDE vs. 0% in DE) between the two groups, cardiac events occurred only in those patients with previous coronary artery disease. In addition, dobutamine echocardiography had a negative predictive value of 97%

CONCLUSIONS

Although routine screening is not necessary, selective screening of patients using dobutamine stress echocardiography is justified because of its high negative predictive value.

Clinical, electrocardiographic, and echocardiographic features in patients with asymptomatic aortic abdominal aneurysm

Cardiac involvement in peripheral vascular diseases can present interesting patho-physiological aspects and can influence the prognosis. The authors evaluated the cardiac condition of patients with asymptomatic aortic abdominal aneurysm (AAAA) by using clinical, electrocardiographic, and echocardiographic techniques. Seventy-eight patients were studied, 74 men and 4 women, with ages ranging from fifty-five to eighty-one years (mean 69.5 +/- 6.4). All patients were submitted to a complete clinical examination, usual blood tests, a 12-lead resting electrocardiogram, and an echo-Doppler evaluation. Forty-eight subjects (61.5%) were affected by hypertension, 53 (67.9%) were smokers, 25 (32.1%) were alcohol abusers, 39 (50%) had a history of angina pectoris, 20 (25.6%) had had previous myocardial infarction, and 30 (38.5%) were receiving active cardiovascular treatment. All patients except 2, who had chronic atrial fibrillation, manifested sinus rhythm. Electrocardiographic signs of left ventricular (LV) hypertrophy were present in 20 cases (25.6%), intraventricular conduction disturbances in 19 (24.4%), pathological Q waves in 20 (25.6%), and primary repolarization abnormalities in 25 (32.1%). Echocardiography showed a slight increase in left atrial diameter and intraventricular septum thickness (41.5 +/- 4.3 and 12.3 +/- 2 mm respectively). A clearer increase was found in LV mass index (159 +/- 44 g/m2). In 31 patients one or more LV asynergic segments were found. In our patients with AAAA the prevalence of major risk factors for atherosclerosis and ischemic heart disease including previous myocardial infarction was high. Echo-derived LV myocardial mass index was higher than normal even though electrocardiographic criteria for LV hypertrophy did not match echocardiographic data in all subjects. Finally a moderate prevalence of intraventricular conduction disturbances was recorded.

Influence of gender on cardiac risk and survival in patients with infrarenal aortic aneurysms

PURPOSE

To determine whether gender distinction influence the cardiac risk or survival rates associated with surgical treatment of infrarenal abdominal aortic aneurysms (AAAs).

METHODS

From 1983 to 1988, graft replacement of intact AAAs was performed in 490 men (84%) and in 92 women (16%) who had no history of myocardial revascularization before the discovery of their AAAs. Patients of both genders were comparable with respect to mean age (68 years) and the prevalence of coronary artery disease (CAD) by standard clinical criteria (men, 73%; women, 65%). Preoperative coronary angiography was obtained in 471 of the 582 patients (men, 81%; women, 80%) during this particular study period. Preliminary coronary bypass was warranted on the basis of existing indications in 111 (24%) of these 471 patients (men, 25%; women, 18%), including 104 (31%) of the 337 who had clinical indications of CAD (men, 32%; women, 26%) but only 7 (5.2%) of the 134 who did not (men, 6%; women, 4%). Follow-up data were collected during a mean interval of 53 months (men, 54 months; women, 48 months) and were analyzed by Kaplan-Meier survival analysis and Cox proportional hazards models.

RESULTS

Twenty-nine perioperative deaths (5.0%) occurred in conjunction with AAA repair (men, 5.1%; women, 4.3%), and 126 early and late deaths have occurred (men, 22%; women, 22%). Survival rates for the series were found to correlate with age (p < 0.001), the serum creatinine level (p < 0.001), and the coronary angiographic classification (p < 0.001). No significant differences were identified between the gender cohorts. The cardiac mortality rate for AAA resection was only 1.8% in the 111 patients who had preliminary coronary bypass, but five additional perioperative deaths (4.5%) related to renal failure or sepsis occurred in this group. However, 5-year survival rates for patients receiving preliminary bypass (men, 82%; women, 75%) were closely comparable with those for patients found to have only mild to moderate CAD by angiography (men, 86%; women, 82%).

CONCLUSION

We conclude that men and women with AAAs have similar cardiac risks and survival rates associated with surgical treatment. Our results also illustrate that the potential benefit of coronary intervention for severe CAD in patients of either gender must be considered in the context of long-term outcome and the early mortality rate of AAA repair.

Meta-analysis of intravenous dipyridamole-thallium-201 imaging (1985 to 1994) and dobutamine echocardiography (1991 to 1994) for risk stratification before vascular surgery

OBJECTIVES

This study evaluated the prognostic value of abnormal test results with pharmacologic stress with regard to perioperative and long-term outcomes in a large population of candidates for vascular surgery.

BACKGROUND

Although numerous studies have demonstrated the prognostic value of dipyridamole-thallium-201 myocardial perfusion and dobutamine echocardiography in vascular surgery candidates, a synopsis of predictive estimates is difficult because of individual study variability in pretest clinical risk, sample size and study design.

METHODS

A systematic review of published reports on preoperative pharmacologic stress risk stratification from the MEDLINE data base (1985 to 1994) identified 10 reports on dipyridamole-thallium-201 myocardial perfusion (1,994 patients) and 5 on dobutamine stress echocardiography (446 patients). Random effects models were used to calculate summary odds ratios and 95% confidence intervals.

RESULTS

Summary odds ratios for death or myocardial infarction and secondary cardiac end points were greater for dobutamine echocardiographic dyssynergy (14- to 27-fold) than for dipyridamole-thallium-201 redistribution (4-fold); wider confidence intervals were noted with dobutamine echocardiography. Pretest coronary disease probability was correlated with the positive predictive value of a reversible thallium-201 defect (r=0.70), increasing sixfold from low to high risk patient subsets. Cardiac event rates were low in patients without a history of coronary artery disease (1% in 176 patients) compared with patients with coronary disease and a normal or fixed-defect pattern (4.8% in 83 patients) and one or more thallium-201 redistribution abnormality (18.6% in 97 patients, p=0.0001).

CONCLUSIONS

Meta-analysis of 15 studies demonstrated that the prognostic value of noninvasive stress imaging abnormalities for perioperative ischemic events is comparable between available techniques but that the accuracy varies with coronary artery disease prevalence.

Operative mortality rates after elective infrarenal aortic reconstructions

PURPOSE

This study was designed to test the hypothesis that cardiac complications (myocardial infarction, congestive heart failure, fatal arrhythmias) are no longer the leading cause of death after elective aortic reconstructions.

METHODS

The medical records of all elective infrarenal aortic reconstructions performed between January 1982 and June 1994 were retrospectively reviewed. All perioperative deaths were analyzed to determine the cause of death and were compared with a subset of 266 survivors to identify any associated preoperative or intraoperative factors.

RESULTS

Seven hundred twenty-two aortic reconstructions were performed for aneurysmal or occlusive disease, and there were 44 deaths (overall mortality rate of 6.1%). The mortality rate after aortic reconstruction alone was 4.9% and increased with the addition of renal (8.9%, p = 0.16) or lower extremity vascular procedures (15.8%, p = 0.01). Multisystem organ failure (MSOF) was the cause of death in 56.8%, of the patients (3.5% overall mortality rate) followed by cardiac events in 25% (1.5% overall mortality rate). Visceral organ dysfunction was the most common cause of MSOF leading to death in 14 patients (56.0%), and postoperative pneumonia was responsible for the fatal MSOF in nine patients (36.0%). Patient age, history of myocardial infarction/congestive heart failure, ejection fraction less than 50%, duration of operative time, and performance of additional procedures were associated with increased operative mortality rates by multivariate analysis.

CONCLUSIONS

MSOF, predominantly from visceral organ dysfunction, was the leading cause of death after elective infrarenal aortic reconstruction. The risk of MSOF and operative death increases with the complexity of the procedure and the number of comorbid conditions.

Comparative early and late cardiac morbidity among patients requiring different vascular surgery procedures

PURPOSE

The evaluation of coronary artery disease (CAD) in patients undergoing vascular surgery can provide information with respect to perioperative and long-term risk for CAD-related events. However, the extent to which the required surgical procedure itself imparts additional risk beyond that dictated by the presence of CAD determinants remains in question. The purpose of this study was to quantify the relative contributions of specific vascular procedures and CAD markers on perioperative and long-term cardiac risk.

METHODS

The study cohort comprised 547 patients undergoing vascular surgery from two medical centers who underwent clinical evaluation, dipyridamole thallium testing, and either aortic (n = 321), infrainguinal (n = 177), or carotid (n = 49) vascular surgery between 1984 and 1991. Perioperative and late cardiac risk of fatal or nonfatal myocardial infarction (MI) was compared for the three procedures before and after adjustment for the influence of comorbid factors. These adjusted estimates may be regarded as the component of risk because of type of surgery.

RESULTS

Perioperative MI occurred in 6% of patients undergoing aortic and carotid artery surgery, and in 13% of patients undergoing infrainguinal procedures (p = 0.019). Significant (p < 0.05) predictors of MI were history of angina, fixed and reversible dipyridamole thallium defects, and ischemic ST depression during testing. Although patients undergoing infrainguinal procedures exhibited more than twice the risk for perioperative MI compared with patients undergoing aortic surgery (relative risk: 2.4[1.2 to 4.5, p = 0.008]), this value was reduced to insignificant levels (1.6[0.8 to 3.2, p = 0.189]) after adjustment for comorbid factors. There was little change in comparative risk between carotid artery and aortic procedures before (1.0[0.3 to 3.6, p = 0.95]) or after (0.6[0.2 to 2.3, p = 0.4]) covariate adjustment. The 4-year cumulative event-free survival rate was 90% +/- 2% for aortic, 74% +/- 5% for infrainguinal, and 78% +/- 7% for carotid artery procedures (p = 0.0001). Predictors of late MI included history of angina, congestive heart failure, diabetes, fixed dipyridamole thallium defects, and perioperative MI. Patients undergoing infrainguinal procedures exhibited a threefold greater risk for late events compared with patients undergoing aortic procedures (relative risk: 3.0[1.8 to 5.1, p = 0.005]), but this value was reduced to 1.3(0.8 to 2.3, p = 0.32) after adjustment. Long-term risk among patients undergoing carotid artery surgery was less dramatically altered by risk factor adjustment.

CONCLUSION

In current practice, among patients referred for dipyridamole testing before operation, observed differences in cardiac risk of vascular surgery procedures may be primarily attributable to readily identifiable CAD risk factors rather than to the specific type of vascular surgery. Thus the cardiac and diabetic status of patients should be given careful consideration whenever possible, regardless of surgical procedure to be performed.

Operative mortality and long-term relative survival of patients operated on for asymptomatic abdominal aortic aneurysm

OBJECTIVE

Assessment of mortality and long-term relative survival following repair of asymptomatic abdominal aortic aneurysms.

DESIGN

Retrospective review.

SETTING

University Hospital.

MATERIALS

Three hundred and twenty seven patients with a median age of 68 years and male to female proportion of 10:1.

CHIEF OUTCOME MEASURES

Operative mortality and long-term mortality obtained from Norwegian Registrar's Office. Demographically matched expected survival calculated from death rate tables published by the Norwegian Central Bureau of Statistics.

MAIN RESULTS

The overall operative mortality was 5.2%. Ten-year survival rate for all the patients was 38% compared to the expected of 52%. The standard mortality rate was 1.30, indicating a 30% higher mortality compared to a demographically matched population. Older patients and patients with known cardiac disease had significantly increased operative mortality. These patients also had the lowest long-term survival. Patients with cardiac disease suffered a postoperative mortality more than two times expected.

CONCLUSIONS

Further studies are needed to define subgroups unsuitable for elective surgery.

An assessment of the positive predictive value and cost-effectiveness of dipyridamole myocardial scintigraphy in patients undergoing vascular surgery

PURPOSE

The approach to cardiac risk stratification of patients undergoing vascular surgery continues to be controversial. The success of algorithms that use clinical risk factors to determine cardiac risk have been inconsistent. Dipyridamole myocardial scintigraphy (DMS) has been accepted as a sensitive, noninvasive approach to risk stratification with excellent negative predictive value. Low positive predictive value (PPV) of abnormal DMS scans is a shortcoming that contributes to extensive preoperative cardiac evaluation and intervention with associated morbidity, mortality, and cost in most patients who undergo uncomplicated vascular procedures, regardless of DMS results.

METHODS

Over 6 years, 237 patients underwent DMS before surgical management of infrarenal aortic aneurysm, aortoiliac, or infrainguinal occlusive disease. The value of multiple clinical factors and DMS were assessed retrospectively for the prediction of perioperative myocardial infarction (MI), heart-related death, or preoperative selection for myocardial revascularization. Only congestive heart failure and two or more reversible defects on DMS were statistically significant on logistic regression analysis.

RESULTS

The PPV of DMS was 19% for all patients with reversible defects, 12% for patients with one reversible defect, and 36.7% for patients with two or more reversible defects. The rates of cardiac death and MI were 1.3% and 5.9%, respectively. Perioperative echocardiography revealed unchanged postinfarction ejection fraction in most patients who experienced MI. Cost-effectiveness of DMS screening was evaluated.

CONCLUSIONS

The costs per MI and cardiac death averted suggest a decline in cost-effectiveness of screening with DMS over time, assuming improving cardioprotective strategies of patient care. Clinical risk factors were minimally useful in the prediction of perioperative MI, heart-related death, or need for myocardial revascularization. The PPV of DMS is low, and the majority of MIs may be clinically insignificant. The cost-effectiveness of cardiac screening with DMS may not be justifiable given current trends of health care reform.