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Thompson A, Fleischmann KE, Smilowitz NR, de Las Fuentes L, Mukherjee D, Aggarwal NR, Ahmad FS, Allen RB, Altin SE, Auerbach A, Berger JS, Chow B, Dakik HA, Eisenstein EL, Gerhard-Herman M, Ghadimi K, Kachulis B, Leclerc J, Lee CS, Macaulay TE, Mates G, Merli GJ, Parwani P, Poole JE, Rich MW, Ruetzler K, Stain SC, Sweitzer B, Talbot AW, Vallabhajosyula S, Whittle J, Williams KA. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024:S0735-1097(24)07611-3. [PMID: 39320289 DOI: 10.1016/j.jacc.2024.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2024]
Abstract
AIM The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery. METHODS A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.
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Bae MI, Kim TH, Yoon HJ, Song SW, Min N, Lee J, Ham SY. Myocardial Injury after Non-Cardiac Surgery in Patients Who Underwent Open Repair for Abdominal Aortic Aneurysm: A Retrospective Study. J Clin Med 2024; 13:959. [PMID: 38398272 PMCID: PMC10888606 DOI: 10.3390/jcm13040959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Myocardial injury after non-cardiac surgery (MINS) has been known to be associated with mortality in various surgical patients; however, its prognostic role in abdominal aortic aneurysm (AAA) open repair remains underexplored. This study aimed to investigate the role of MINS as a predictor of mortality in patients who underwent AAA open repair. METHODS This retrospective study investigated 352 patients who underwent open repair for non-ruptured AAA. The predictors of 30-day and 1-year mortalities were investigated using logistic regression analysis. RESULTS MINS was diagnosed in 41% of the patients after AAA open repair in this study. MINS was an independent risk factor of 30-day mortality (odds ratio [OR]: 10.440, 95% confidence interval [CI]: 1.278-85.274, p = 0.029) and 1-year mortality (OR: 5.189, 95% CI: 1.357-19.844, p = 0.016). Kaplan-Meier survival curves demonstrated significantly lower overall survival rates in patients with MINS compared to those without MINS (p = 0.003). CONCLUSION This study revealed that MINS is a common complication after AAA open repair and is an independent risk factor of 30-day and 1-year mortalities. Patients with MINS have lower overall survival rates than those without MINS.
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Affiliation(s)
- Myung Il Bae
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (M.I.B.); (H.J.Y.); (N.M.); (J.L.)
| | - Tae-Hoon Kim
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul 03722, Republic of Korea;
| | - Hei Jin Yoon
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (M.I.B.); (H.J.Y.); (N.M.); (J.L.)
| | - Suk-Won Song
- Department of Cardiovascular Surgery, Ewha Womans University Aorta and Vascular Hospital, Seoul 07804, Republic of Korea
| | - Narhyun Min
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (M.I.B.); (H.J.Y.); (N.M.); (J.L.)
| | - Jongyun Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (M.I.B.); (H.J.Y.); (N.M.); (J.L.)
| | - Sung Yeon Ham
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (M.I.B.); (H.J.Y.); (N.M.); (J.L.)
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
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Tereshina OV, Griaznova DA, Vachev AN. [Preoperative stress testing in patients prior to vascular surgery]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:159-164. [PMID: 34528601 DOI: 10.33529/angid2021320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Myocardial infarction is the leading cause of mortality during peripheral artery surgery. The review summarizes the data on cardiac event risk stratification in angiosurgical patients by preoperative stress testing. The prognostic value of positive and negative results is described. Stress testing with physical activity or pharmacological agents is rarely indicated in patients at low risk of major adverse cardiovascular events. Stress testing may be used in patients at increased risk of myocardial infarction (functional activity less than <4 metabolic equivalents), and if the test results should change the approaches to perioperative therapy, anesthesia or the volume of surgical intervention and, in rare situations, to perform coronary revascularization.
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Affiliation(s)
- O V Tereshina
- Department of Faculty Surgery, Samara State Medical University of the RF Ministry of Public Health, Samara, Russia
| | - D A Griaznova
- Department of Faculty Surgery, Samara State Medical University of the RF Ministry of Public Health, Samara, Russia
| | - A N Vachev
- Department of Faculty Surgery, Samara State Medical University of the RF Ministry of Public Health, Samara, Russia
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Sawada SG. A Reappraisal of Dobutamine Echocardiography for Risk Stratification before Noncardiac Surgery. J Am Soc Echocardiogr 2020; 33:433-437. [PMID: 32111538 DOI: 10.1016/j.echo.2020.01.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 01/24/2020] [Accepted: 01/25/2020] [Indexed: 01/13/2023]
Affiliation(s)
- Stephen G Sawada
- Krannert Institute of Cardiology, Indiana University School of Medicine, IU Health, Indianapolis, Indiana.
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Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol 2014; 64:e77-137. [PMID: 25091544 DOI: 10.1016/j.jacc.2014.07.944] [Citation(s) in RCA: 823] [Impact Index Per Article: 82.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:e278-333. [PMID: 25085961 DOI: 10.1161/cir.0000000000000106] [Citation(s) in RCA: 209] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Shizukuda Y, Plummer SL, Harrelson A. Customized exercise echocardiography: beyond detection of coronary artery disease. Echocardiography 2010; 27:186-94. [PMID: 20380677 DOI: 10.1111/j.1540-8175.2009.01086.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Exercise echocardiography has been established as a reliable diagnostic tool for assessment of myocardial ischemia. However, more recent advances in its technique have expanded its routine clinical use to include quantification of exercise-induced diastolic dysfunction, exercise-induced pulmonary hypertension, and dynamic assessment of mitral and aortic valve function. The indications for exercise echocardiography have increased to include cardiac symptoms such as exertional dyspnea, fatigue, and limited exercise capacity. In light of its expanded capability for evaluating cardiovascular function, we believe that exercise echocardiography should be utilized in a new paradigm of personalized cardiology, in which we regularly investigate individual patient symptoms for endpoints beyond critical myocardial ischemia, for example, exercise-induced pulmonary hypertension. We refer to this refocused use of exercise echocardiography as "customized exercise echocardiography." In this review article, we present current scientific evidence to support our proposed role and discuss the logistical requirements for proper test performance of customized exercise echocardiography.
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Affiliation(s)
- Yukitaka Shizukuda
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio 45267, USA.
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol 2009; 54:e13-e118. [PMID: 19926002 DOI: 10.1016/j.jacc.2009.07.010] [Citation(s) in RCA: 232] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF. 2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. Circulation 2009; 120:e169-276. [PMID: 19884473 DOI: 10.1161/circulationaha.109.192690] [Citation(s) in RCA: 209] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol 2007; 50:e159-241. [PMID: 17950159 DOI: 10.1016/j.jacc.2007.09.003] [Citation(s) in RCA: 257] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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12
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Tarkington LG, Yancy CW. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. Circulation 2007; 116:e418-99. [PMID: 17901357 DOI: 10.1161/circulationaha.107.185699] [Citation(s) in RCA: 377] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Raux M, Godet G, Isnard R, Mergoni P, Goarin JP, Bertrand M, Fleron M, Coriat P, Riou B. Low negative predictive value of dobutamine stress echocardiography before abdominal aortic surgery. Br J Anaesth 2006; 97:770-6. [PMID: 16973646 DOI: 10.1093/bja/ael246] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND According to previous studies, a negative dobutamine stress echocardiography (DSE) test before major vascular surgery indicates that postoperative myocardial necrosis is very unlikely. We believe that the use of new cardiac troponin assays which can detect small amounts of myocardial necrosis results in a lower DSE negative predictive value for myocardial necrosis. METHODS A total of 418 consecutive patients were screened using the ACC/AHA Guideline for Perioperative Cardiovascular Evaluation for Noncardiac Surgery before scheduled abdominal aortic surgery. Of these 143 met ACC/AHA criteria for non-invasive testing and underwent DSE. Patients with a negative DSE were deemed to be fit for surgery. A positive DSE led to a coronary angiogram. DSE was negative in 110 (77%) and positive in 33 (23%) patients. Myocardial necrosis was monitored up to the third postoperative day by daily cardiac troponin I (cTnI) measurement and a daily 12-lead ECG. RESULTS Coronary angiography showed artery stenosis in 27 (84%) of 32 patients with a positive DSE. The negative predictive value of DSE for cTnI elevation was 92.7% (95% CI 86.2-96.8%). This was significantly lower than the lowest value of negative predictive value for myocardial necrosis assessed in previous studies. CONCLUSION A negative DSE prescribed before scheduled aortic surgery according to ACC/AHA guidelines does not rule out postoperative myocardial necrosis.
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Affiliation(s)
- M Raux
- Department of Anesthesiology and Critical Care, Centre Hospitalo-Universitaire Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie-Paris 6, Paris, France.
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14
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Raux M, Godet G, Fine E, Isnard R. [Preoperative cardiac assessment using dobutamine stress echocardiography]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2006; 25:386-96. [PMID: 16458477 DOI: 10.1016/j.annfar.2005.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2005] [Accepted: 11/29/2005] [Indexed: 05/06/2023]
Abstract
Postoperative myocardial ischaemia is the leading cause of life expectancy impairment after high cardiac risk surgical procedures. Preoperative identification of patients at high risk for such complication helps reducing its postoperative incidence through therapeutic adjustments. The former relies upon preoperative selection of patients who are candidates for cardiac testing using dobutamine stress echocardiography, according to ACC/AHA guidelines. This exam evaluates echographic myocardial response to a pharmacological stress induced by dobutamine infusion. Its aim is to reproduce part of the stress the myocardium will undergo during surgical procedure. A stress induced myocardial ischaemia suggests such a complication could occur postoperatively. A positive dobutamine stress echocardiography justifies to prescribe preoperative anti-ischaemic treatment in order to reduce the cardiac risk of the further surgical procedure. Moreover, it justifies clear definition of perioperative haemodynamic objectives. Whatever the result of the dobutamine stress echocardiography, cardiac ischaemia should be monitored up to the third postoperative day on the basis of a daily 12-lead electrocardiogram recording and daily plasmatic troponin Ic measurement.
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Affiliation(s)
- M Raux
- Département d'anesthésie-réanimation, groupe hospitalier Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France.
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15
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Beattie WS, Abdelnaem E, Wijeysundera DN, Buckley DN. A Meta-Analytic Comparison of Preoperative Stress Echocardiography and Nuclear Scintigraphy Imaging. Anesth Analg 2006; 102:8-16. [PMID: 16368798 DOI: 10.1213/01.ane.0000189614.98906.43] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In this meta-analysis we compared thallium imaging (TI) and stress echocardiography (SE) in patients at risk for myocardial infarction (MI) scheduled for elective noncardiac surgery. Two searches of published articles were used to identify relevant articles. We included all studies that stated the criteria for a positive test and detailed the frequency of postoperative MI and in-hospital death. Data were abstracted by two authors and captured preoperative patient characteristics, study design, blinding, and outcome adjudication. We defined a positive test as a test with a reversible defect and, where possible, quantified the size of the defects in each study. MI and/or death were the only postoperative outcomes of interest. We calculated the sensitivity, specificity, and likelihood ratio (LR) and, where possible, the Receiver Operating Characteristic (ROC) curve of a cardiac event in each study. The LR and ROC were combined by meta-analyses using the random effects model. Heterogeneity was assessed using the I2 test. The search revealed 68 studies of 10,049 patients. There were 25 SE studies and 50 TI studies. There were 7 studies with a direct comparison of the two methodologies. The quality of studies differed; routine screening for MI was used more frequently in SE studies (47.8% versus 21.2%; P = 0.008) and screening dictated treatment more often after TI (72.1%) than after SE (46.3%) (P = 0.027). The LR for SE was more indicative of a postoperative cardiac event than TI (LR, 4.09; 95% CI, 3.21-6.56 versus 1.83; 1.59-2.10; P = 0.001). This difference was attributable to fewer false-negative SEs. There was no difference in the cumulative ROC curves from qualitative studies (SE, 0.80; 95% CI, 0.76-.84 versus TI, 0.75; 95% CI, 0.70-081). Again, the LR for a negative SE was less (0.23; 95% CI, 0.17-0.32 versus 0.44; 95% CI, 0.36-0.54). A moderate-to-large defect, seen in 14% of patients, by either method predicts a postoperative cardiac event (LR, 8.35; 95% CI, 5.6-12.45). This meta-analysis possesses the statistical power to demonstrate that SE has better negative predicative characteristics than TI. A moderate-to-large perfusion defect by either SE or TI predicts postoperative MI and death. We conclude the SE is superior to TI in predicting postoperative cardiac events.
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Affiliation(s)
- W Scott Beattie
- Department of Anesthesia and Pain Management University Health Network (Toronto General Hospital), University of Toronto, Toronto, Ontario.
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Kertai MD, Poldermans D. The utility of dobutamine stress echocardiography for perioperative and long-term cardiac risk assessment. J Cardiothorac Vasc Anesth 2005; 19:520-8. [PMID: 16085263 DOI: 10.1053/j.jvca.2005.05.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Miklos D Kertai
- Department of Cardiovascular Surgery, Semmelweis University, Varosmajor Str. 68, 1122 Budapest, Hungary.
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Ghansah JN, Murphy JT. Complications of major aortic and lower extremity vascular surgery. Semin Cardiothorac Vasc Anesth 2005; 8:335-61. [PMID: 15583793 DOI: 10.1177/108925320400800406] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Atheromatous disease and invasive intervention of the aortoiliac and distal arteries are common. Morbidity and mortality have been reduced through understanding and management of patient risk factors. Complications of this form of treatment affect all organ systems; mortality is most frequently caused by a cardiovascular complication (eg, myocardial infarction). Infection, leading to aortoenteric fistula is a dreaded complication, and paraplegia, though rare, is a devastating outcome. Multiorgan failure and death may result from a systemic inflammatory response syndrome. Vascular surgery for infrainguinal disease also has a significant cardiovascular complication rate. Resulting complications may affect all organs; loss of an extremity may occur. The first part of this article reviews perioperative and postoperative complications of open aortic repair and lower-extremity revascularization and addresses the issue of regional anesthesia for major vascular surgery. The second part reviews endovascular aortic repair (EVAR). EVAR is a new intervention that combines surgery and radiology. Complications of EVAR are similar to open repair, but early results suggest they may be less frequent. New technology leads to new complications; endoleaks, migration of the endoprosthesis, and surgical conversion are unique to EVAR. The benefits of EVAR may be less blood loss, shorter hospitalization, and less cardiovascular stress; the risks may be aneurysm recurrence, prolonged surveillance and repeated secondary procedures. The development of EVAR, the complications, and the anesthesia-related concerns of EVAR, including its use in management of acute abdominal aortic aneurysm are reviewed.
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Affiliation(s)
- J Nana Ghansah
- Department of Anesthesiology, University of Kentucky, College of Medicine, H A Chandler Medical Center, Lexington, KY 40536-0293, USA
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Chitilian HV, Isselbacher EM, Fitzsimons MG. Preoperative Cardiac Evaluation for Vascular Surgery. Int Anesthesiol Clin 2005; 43:1-14. [PMID: 15632514 DOI: 10.1097/01.aia.0000148884.78733.22] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Hovig V Chitilian
- Department of Anesthesia and Critical Care, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02214, USA
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Sicari R. Perioperative risk stratification in non cardiac surgery: role of pharmacological stress echocardiography. Cardiovasc Ultrasound 2004; 2:4. [PMID: 15140258 PMCID: PMC419977 DOI: 10.1186/1476-7120-2-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2004] [Accepted: 05/12/2004] [Indexed: 11/30/2022] Open
Abstract
Perioperative ischemia is a frequent event in patients undergoing major non-cardiac vascular or general surgery. This is in agreement with clinical, pathophysiological, and epidemiological evidence and constitutes an additional diagnostic therapeutic factor in the assessment of these patients. Form a clinical standpoint, it is well known that multidistrict disease, especially at the coronary level, is a severe aggravation of the operative risk. From a pathophysiological point of view, however, surgery creates conditions able to unmask coronary artery disease. Prolonged hypotension, hemorrhages, and haemodynamic stresses caused by aortic clamping and unclamping during major vascular surgery are the most relevant factors endangering the coronary circulation with critical stenoses. From the epidemiological standpoint, coronary disease is known to be the leading cause of perioperative mortality and morbidity following vascular and general surgery: The diagnostic therapeutic corollary of these considerations is that coronary artery disease - and therefore the perioperative risk - in these patients has to be identified in an effective way preoperatively.
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Affiliation(s)
- Rosa Sicari
- CNR Institute of Clinical Physiology, Via G, Moruzzi, 1 56124 Pisa, Italy.
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Abstract
Guidelines on perioperative cardiovascular evaluation for noncardiac surgery have been published. The integration of clinical risk factors, surgery-specific risk,and functional capacity should be used to determine the need for further diagnostic evaluation. The use of beta-adrenergic blockade in high-risk patients,particularly those with documented myocardium at risk undergoing vascular surgery, has been shown to reduce perioperative risk and may obviate the need for more invasive procedures. Coronary intervention should be reserved for those patients who warrant intervention independent of the noncardiac surgery.
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Affiliation(s)
- Lee A Fleisher
- Department of Anesthesia, University of Pennsylvania School of Medicine, 3400 Spruce Street, Dulles 680, Philadelphia, PA 19104, USA.
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Falcone RA, Nass C, Jermyn R, Hale CM, Stierer T, Jones CE, Walters GK, Fleisher LA. The value of preoperative pharmacologic stress testing before vascular surgery using ACC/AHA guidelines: a prospective, randomized trial. J Cardiothorac Vasc Anesth 2003; 17:694-8. [PMID: 14689407 DOI: 10.1053/j.jvca.2003.09.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the validity of preoperative cardiac stress testing using clinical predictors from the American College of Cardiology/American Heart Association Guidelines on Perioperative Evaluation before Noncardiac Surgery in patients undergoing vascular surgery. DESIGN Prospective, randomized pilot study. SETTING Academic medical center. PARTICIPANTS Patients undergoing elective abdominal aortic, infrainguinal, and carotid vascular surgery. INTERVENTIONS After stratification by American College of Cardiology/American Heart Association (ACC/AHA) Guideline parameters, 99 patients were randomized to preoperative cardiac stress testing or to no stress testing and followed for up to 12 months postoperatively for adverse cardiac outcomes. MEASUREMENTS AND MAIN RESULTS Before hospital discharge of 46 patients who underwent preoperative stress testing, 7 (15%) had inducible ischemia with no adverse postoperative cardiac outcomes, whereas only 1 (3%) of 39 patients (85%) with no ischemia had a nonfatal adverse cardiac outcome (p = not significant). Of 53 patients without preoperative stress testing, only 2 (4%) had a nonfatal adverse postoperative cardiac outcome. There were no cardiac deaths. At 12-month follow-up in 79 (80%) patients, there was 1 nonfatal adverse cardiac outcome (no stress test) and 1 cardiac death (abnormal stress test), reflecting a 1% 12-month cardiac morbidity and mortality. CONCLUSION In this small prospective, randomized study evaluating the validity of preoperative cardiac stress testing using ACC/AHA Guidelines before major vascular surgery, preoperative cardiac stress testing offered no incremental value for determining postoperative adverse cardiac outcomes. Larger randomized clinical trials are needed to confirm these findings.
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Affiliation(s)
- Rita A Falcone
- Division of Cardiology, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA.
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Abstract
The purpose of this chapter is to provide a brief overview of the current place of open surgical repair for abdominal aortic aneurysms with respect to the factors influencing clinical decision-making, the operative techniques most frequently used, and some of the complications commonly encountered in the postoperative period.
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Affiliation(s)
- Murray L Shames
- Section of Vascular Surgery, Washington University School of Medicine, 9901 Wohl Hospital, 4960 Children's Place, St. Louis, MO 63110, USA
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Kertai MD, Boersma E, Sicari R, L'Italien GJ, Bax JJ, Roelandt JRTC, van Urk H, Poldermans D. Which stress test is superior for perioperative cardiac risk stratification in patients undergoing major vascular surgery? Eur J Vasc Endovasc Surg 2002; 24:222-9. [PMID: 12217283 DOI: 10.1053/ejvs.2002.1704] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE to compare the additional prognostic value of Dobutamine Stress Echocardiography (DSE), Dipyridamole Stress Echocardiography (DiSE) and Perfusion Scintigraphy (DTS) on clinical risk factors in patients undergoing major vascular surgery. DESIGN retrospective analysis. MATERIALS 2204 consecutive patients who underwent DSE (n=1093), DiSE (n=394), or DTS (n=717) testing before major vascular surgery were studied. METHODS primary endpoint was a composite of cardiac death and non-fatal myocardial infarction (MI). Logistic regression analysis was performed to evaluate the relation between cardiac risk factors, stress test results and the incidence of the composite endpoint. RESULTS there were 138 patients (6.3%) with cardiac death or MI. Patients with 0, 1-2, and 3 or more risk factors experienced respectively 3.0, 5.7 and 17.4% cardiac events. We found no statistically significant difference in the predictive value of a positive test result for DiSE and DSE (Odds ratio (OR) of 37.1 [95% CI, 8.1-170.1] vs 9.6 [95% CI, 4.9-18.4]; p=0.12), whereas a positive test result for DTS had significantly lower prognostic value (OR=1.95 [95% CI, 1.2-3.2]). CONCLUSION a result of stress echocardiography effectively stratified patients into low- and high-risk groups for cardiac complications, irrespective of clinical risk profile. In contrast, the prognostic value of DTS results was more likely to be dependent on patients' clinical risk profile.
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Affiliation(s)
- M D Kertai
- Departments of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands
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24
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Sicari R, Ripoli A, Picano E, Pulignano G, Minardi G, Rossi E, Matskeplishvili S. Long-term prognostic value of dipyridamole echocardiography in vascular surgery: a large-scale multicenter study. Coron Artery Dis 2002; 13:49-55. [PMID: 11917199 DOI: 10.1097/00019501-200202000-00007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Late cardiac events after non-cardiac major vascular surgery are an important cause of morbidity and mortality. The aim of the present study was to assess the value of a preoperative dipyridamole echocardiography test (up to 0.84 mg/kg over 10 min) in predicting late cardiac events in survivors of major non-cardiac vascular surgery. DESIGN Large-scale, multicenter, prospective, observational study design. METHODS Two hundred and seventy-six patients (mean age 66 +/- 9 years) were studied prior to vascular surgery by dipyridamole stress echocardiography in four different centres. All patients underwent preoperative clinical risk assessment according to the American Heart Association guidelines. All underwent dipyridamole stress echocardiography according to standard high-dose protocol. RESULTS No major complications occurred during dipyridamole stress echocardiography. Sixty-three patients (23%) had a positive test. Patients were followed up for a median of 20 months. Cardiac events occurred in 43 patients (16%): five deaths, 18 myocardial infarctions and 20 cases of unstable angina. The difference between wall-motion score index (WMSI) at rest and peak stress (delta WMSI), using multivariate analysis, was an independent predictor of late cardiac death. CONCLUSION Dipyridamole stress echocardiography performed before major vascular surgery identifies patients at high risk for late cardiac events. Stress echocardiographic parameters outperformed clinical variables in the long-term risk stratification in this set of patients.
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Affiliation(s)
- Rosa Sicari
- Institute of Clinical Physiology, Via G. Moruzzi, Pisa.
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25
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Henein MY, O'Sullivan C, Das SK, Khir AW, Anagnostopoulos C, Underwood RS, Gibson DG, Khir A. Assessment of cardiac risk before peripheral vascular surgery: a comparison of myocardial perfusion imaging and long axis echocardiography at rest. Int J Cardiol 2001; 80:125-32; discussion 132-3. [PMID: 11578704 DOI: 10.1016/s0167-5273(01)00512-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare resting long axis echocardiography with adenosine thallium-201 emission tomography in detecting myocardial ischaemic abnormalities and surgical related risk in patients before peripheral vascular surgery. DESIGN A prospective and blinded pre-operative examination of resting left ventricular minor and long axes and myocardial perfusion during adenosine vasodilation using thallium-201 emission tomography. SETTING A tertiary referral centre for cardiac and vascular disease equipped with invasive, non-invasive and surgical facilities. SUBJECTS 65 patients (40 male) with significant peripheral vascular disease, mean age 63+/-10 (S.D.) years, and 21 normal subjects of similar age. RESULTS Thallium-201 myocardial perfusion tomography was abnormal in 50/65 patients; 27 had fixed, 23 reversible abnormalities (19 of whom had both). Long axis was considered abnormal if one or more of two systolic long axis disturbances, reduced extent of total excursion <1 cm at any of the three (left, septal and posterior left ventricular) sites or prolonged shortening >1 mm after A2, and two diastolic abnormalities, delayed onset of lengthening >80 ms after A2 or reduced peak lengthening velocity <4.5 cm/s, was present. Long axis score (maximum 12) was based on the presence or absence of these four disturbances at each of the three sites. Myocardial perfusion imaging with thallium-201 classified the patients into three different groups according to their liability to low, moderate or high surgical risk (summed stress perfusion score of 36). Thirteen of 50 patients were identified as subjects at high surgical risk, with a perfusion score of 22/36 and below. Twelve of these demonstrated significantly greater impairment of systolic and diastolic long axis function, compared to those at low surgical risk, with a total long axis echo score of 6/12 or more. Seventeen of 18 patients identified as being at low surgical risk, with a perfusion score of 32/36 and above, had total long axis score of less than 6/12. The remaining 19 moderate risk patients had a wide range of long axis scores. In the 65 patients studied there were two post-operative deaths, one post-discharge death due to cerebrovascular accident, and one due to renal failure. CONCLUSION The combination of both systolic and diastolic long axis disturbances in patients with peripheral vascular disease can be used to predict the thallium assessment of surgical risk. Long axis echocardiography may thus have value as a screening test before non-cardiac surgery as well as providing a means of monitoring myocardial perfusion.
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Affiliation(s)
- M Y Henein
- Department of Cardiology, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College, Sydney Street, SW3 6NP London, UK.
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Chugh A, Bossone E, Mehta RH. Cardiac risk assessment for noncardiac surgery: current concepts. COMPREHENSIVE THERAPY 2001; 27:47-55. [PMID: 11280855 DOI: 10.1007/s12019-001-0007-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Strategies for perioperative risk assessment in patients undergoing noncardiac surgery vary among physicians and are aimed to estimate the risk and minimize complications. We propose simplistic guidelines for assessing and modifying risk for patients undergoing a wide variety of procedures.
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Affiliation(s)
- A Chugh
- Division of Cardiology, University of Michigan, and Ann Arbor Veterans Affairs Health System, Ann Arbor, Mich., USA
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27
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Brooks MJ, Mayet J, Glenville B, Foale R, Wolfe JH. Cardiac Investigation and Intervention Prior to Thoraco-abdominal Aneurysm Repair: Coronary Angiography in 35 Patients. Eur J Vasc Endovasc Surg 2001; 21:437-44. [PMID: 11352520 DOI: 10.1053/ejvs.2001.1310] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE retrospective studies indicate a high risk of cardiac events in patients undergoing thoraco-abdominal aneurysm repair. We aimed to determine the prevalence of coronary disease in these patients, define the role of non-invasive cardiac testing and assess the short-term outcome of coronary re-vascularisation. DESIGN a prospective cohort study of consecutive patients referred to a single surgeon. MATERIALS AND METHODS forty patients recruited over 16 months (Type I, 6; II, 11; III, 8; IV, 15). Dobutamine stress echocardiography, coronary angiography and coronary re-vascularisation (PTCA or CABG) were performed according to a pragmatic protocol. Main outcome measures were the prevalence of coronary artery disease, sensitivity and specificity of clinical assessment and non-invasive cardiac testing, and adverse events associated with coronary investigation and intervention. RESULTS seven patients (17.5%) were stratified as having high perioperative cardiac risk. The majority of patients (23, 57.5%) had no cardiac risk factor other than the operation type. Five patients (12.5%) had inducible ischaemia on non-invasive testing. Fourteen patients (40%) had haemodynamically significant coronary artery stenoses, of whom 12 (34%) underwent coronary revascularisation. Dobutamine stress echocardiography demonstrated 100% specificity and 71% sensitivity for the detection of significant coronary artery lesions. Coronary re-vascularisation by three-vessel bypass grafting was complicated by non-fatal stroke in one patient. Thirty-five patients (87.5%) proceeded to aneurysm repair. No patient who had been adequately investigated suffered a cardiac complication. CONCLUSIONS the 40% prevalence of coronary artery disease in these patients is comparable to that of other patients undergoing arterial surgery. Non-invasive testing proved beneficial, both in screening low-risk patients and planning intervention in patients at higher risk. An aggressive approach to intervention was associated with an acceptable complication rate and favourable short-term outcome.
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Affiliation(s)
- M J Brooks
- Regional Vascular Unit, St Mary's Hospital, London, UK
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28
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Brown KA, Rosman DR, Dave RM. Stress nuclear myocardial perfusion imaging versus stress echocardiography: prognostic comparisons. Prog Cardiovasc Dis 2000; 43:231-44. [PMID: 11153510 DOI: 10.1053/pcad.2000.19314] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The use of noninvasive stress cardiac imaging for stratifying risk in patients with known or suspected coronary artery disease is growing as a tool for identification of the subgroup most likely to benefit from the expense and risk of more invasive procedures, including cardiac catheterization and coronary revascularization. In this setting, it is especially important that a test be able to identify patients with sufficiently low risk that clinicians are comfortable in deferring such interventions, especially in those with other markers of increased risk. Previous data have shown that cardiac risk is most closely related to the presence and extent of jeopardized viable myocardium on noninvasive stress cardiac imaging. Although stress echocardiography may have comparable ability to detect coronary artery disease, current data suggest that stress echocardiography detects significantly less jeopardized viable myocardium than stress nuclear myocardial perfusion imaging and consequently fewer patients at risk for cardiac events. Stress nuclear myocardial perfusion imaging may therefore have important advantages for risk stratification and the direction of future care of patients with known or suspected coronary artery disease.
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Affiliation(s)
- K A Brown
- Department of Medicine, University of Vermont College of Medicine, Burlington, USA
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29
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Pillet JC, Chaillou P, Bizouarn P, Pittaluga P, Patra P, Chabbert C, Sellier E. Influence of respiratory disease on perioperative cardiac risk in patients undergoing elective surgery for abdominal aortic aneurysm. Ann Vasc Surg 2000; 14:490-5. [PMID: 10990560 DOI: 10.1007/s100169910060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
We retrospectively reviewed perioperative cardiac complications in a series of 214 patients who underwent surgical treatment for infrarenal aortic aneurysm between 1992 and 1996. There were 192 men and 22 women, with a mean age of 68.3 years. Cardiac risk factors included angina in 28% of patients and previous myocardial infarction in 25%. Resting electrocardiography was normal in 80 patients (37.5%). Depending on clinical findings, thallium-201 scintigraphy was undertaken in 76 patients (35.5%) and led to elective coronary arteriography in 22 patients (10%). Results of coronary arteriography revealed lesions in 14 patients. Aortic reconstruction was performed by the transperitoneal route in all patients. Procedures consisted of aortoaortic bypass (63%), aortobiiliac bypass (27.5%), or aortobifemoral bypass (9.5%). Nine patients (4.2%) died within the first 30 postoperative days. The cause of death was myocardial infarction (MI) in two patients (1%), colonic necrosis in two (1%), acute pancreatitis in one (0.5%), acute renal insufficiency in three (1.4%), and multiple organ failure in one patient (0.5%). Nonfatal cardiac complications were observed in 15 patients (7%). Statistical analysis of risk factors revealed two predictors of perioperative cardiac complications, i.e., history of chronic bronchitis and reoperation. On review of the literature, we cannot propose a routine preoperative work-up. Prospective multicentric studies are needed to determine the predictive value of current preoperative screening methods.
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Affiliation(s)
- J C Pillet
- Department of Vascular Surgery, Hôpital GR Laennec, Nantes, France
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30
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Abstract
Unidentified coronary artery disease remains a significant cause of premature death and morbidity during the prime of life. The availability of effective interventions for the management of ischemia has provoked new interest in screening for this condition in asymptomatic patients, in the hope of reducing the burden of this condition. Although widespread use of stress testing is ineffective, the use of imaging techniques may offer better accuracy for detection of ischemia. Other tests that identify evidence of atheroma in the peripheral or coronary circulation may be useful to identify patients at risk.
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Affiliation(s)
- T H Marwick
- Department of Medicine, University of Queensland, Australia.
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31
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Verani MS. Stress myocardial perfusion imaging versus echocardiography for the diagnosis and risk stratification of patients with known or suspected coronary artery disease. Semin Nucl Med 1999; 29:319-29. [PMID: 10534234 DOI: 10.1016/s0001-2998(99)80019-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Stress perfusion imaging and stress echocardiography (ECHO) are both very useful for assessment of diagnosis and risk stratification of patients with coronary artery disease (CAD). Both techniques have been well validated during exercise and inotropic stress, but coronary vasodilation stress is better used in combination with perfusion imaging. The overall sensitivity for detection of CAD is slightly higher by single photon emission computed tomography (SPECT) than by two-dimensional (2D) ECHO during all stress modalities, whereas the specificity is slightly higher by ECHO, although the differences in general are not statistically significant. SPECT, however, appears to be superior to ECHO in the diagnosis of isolated circumflex stenosis, as well as for the correct identification of multivessel CAD. A substantially greater amount of information is available regarding risk stratification with SPECT than with 2D ECHO. Although the data suggest that both techniques are very useful for risk stratification of patients with stable CAD, after myocardial infarction, and for preoperative risk stratification, the risk for cardiac events is lower in the presence of a normal stress SPECT study than of a normal stress ECHO.
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Affiliation(s)
- M S Verani
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
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Bossone E, Martinez FJ, Whyte RI, Iannettoni MD, Armstrong WF, Bach DS. Dobutamine stress echocardiography for the preoperative evaluation of patients undergoing lung volume reduction surgery. J Thorac Cardiovasc Surg 1999; 118:542-6. [PMID: 10469973 DOI: 10.1016/s0022-5223(99)70194-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lung volume reduction surgery has been proposed as a bridge to lung transplantation and as definitive therapy for advanced chronic obstructive lung disease. However, patient selection criteria and optimal preoperative assessment have not been clearly defined. OBJECTIVE We investigated the feasibility, safety, and value of dobutamine stress echocardiography as a predictor of major early cardiac events in patients who underwent lung volume reduction surgery. METHODS The study population consisted of 46 patients (21 men and 25 women, mean age 59 +/- 9 years) who underwent dobutamine stress echocardiography (maximum dose 40 microg. kg(-1). min(-1) plus atropine if needed) 180 days or less before lung volume reduction surgery. Adverse cardiac events were prospectively defined and tabulated during hospitalization after the operation and at subsequent outpatient visits. RESULTS Dobutamine stress echocardiography was interpretable in 45 of 46 (98%) patients. There were no adverse events during testing. The studies revealed normal left ventricular systolic function at rest in all patients and normal right ventricular function in all patients but one. Thirteen patients had right ventricular enlargement. Estimated right ventricular systolic pressure was mildly elevated (>40 mm Hg) in 5 patients. Four patients (9%) had stress tests positive for ischemia. There were no perioperative deaths. Follow-up was available for 44 of 45 patients at a duration of 20.0 +/- 7.0 months. Two major adverse cardiac events occurred in the same patient in whom the results of dobutamine stress echocardiography were positive for ischemia (positive predictive value 25%, 95% confidence interval 0% to 83%; negative predictive value 100%, 95% confidence interval 90 to 100%). CONCLUSION Despite end-stage chronic obstructive lung disease and poor ultrasound windows, dobutamine stress echocardiography is feasible and safe in patients undergoing evaluation for lung volume reduction surgery. It yields important information on right and left ventricular function and has an excellent negative predictive value for early and late adverse cardiac events.
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Affiliation(s)
- E Bossone
- Department of Internal Medicine, University of Michigan, Ann Arbor 48109-0273, USA
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33
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Abstract
Pharmacologic stress testing is an important noninvasive method for evaluating patients with known or suspected coronary artery disease who are unable to adequately exercise. Pharmacologic stress echocardiography using dobutamine has been developed over the last 10 to 15 years as an alternative to vasodilator stress testing using nuclear perfusion imaging. As experience has grown, digital subtraction echocardiogram has been shown to be a safe, convenient, and reliable method for stress testing in a variety of patient populations. Digital subtraction echocardiogram has comparable sensitivity, specificity, and accuracy when compared to other stress testing methods which employ cardiac imaging and is superior to the exercise echocardiogram. It has certain advantages over nuclear perfusion imaging in terms of cost and convenience. The recent addition of arbutamine echocardiography (which has been shown to be comparable to digital subtraction echocardiogram) provides another alternative method for pharmacologic stress testing. Continued improvement in echocardiographic image quality and the development of new technologies such as tissue harmonic imaging and contrast echocardiography will hopefully improve the echocardiographic evaluation of wall motion therefore increasing the diagnostic accuracy of echocardiographic stress testing.
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Affiliation(s)
- D A Orsinelli
- Department of Internal Medicine, Ohio State University College of Medicine and Public Health, Columbus, USA
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34
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Abstract
Stress echocardiography is composed of a family of examinations in which various forms of cardiovascular stress are combined with echocardiographic imaging to assist in the diagnosis of coronary artery disease. Exercise cardiography has evolved over the past 20 years into a routinely available clinical tool employed in both university and community hospital settings. This article discusses advantages and disadvantages of using exercise echocardiography.
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Affiliation(s)
- E Bossone
- Cardiorespiratory Department, II University of Naples, Italy
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35
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Krivokapich J, Child JS, Walter DO, Garfinkel A. Prognostic value of dobutamine stress echocardiography in predicting cardiac events in patients with known or suspected coronary artery disease. J Am Coll Cardiol 1999; 33:708-16. [PMID: 10080472 DOI: 10.1016/s0735-1097(98)00632-9] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The study sought to determine the utility of dobutamine stress echocardiography (DSE) in predicting cardiac events in the year after testing. BACKGROUND Increasingly, DSE has been applied to risk stratification of patients. METHODS Medical records of 1,183 consecutive patients who underwent DSE were reviewed. The cardiac events that occurred during the 12 months after DSE were tabulated: myocardial infarction (MI), cardiac death, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass surgery (CABG). Patient exclusions included organ transplant receipt or evaluation, recent PTCA, noncardiac death, and lack of follow-up. A positive stress echocardiogram (SE) was defined as new or worsened wall-motion abnormalities (WMAs) consistent with ischemia during DSE. Classification and regression tree (CART) analysis identified variables that best predicted future cardiac events. RESULTS The average age was 68+/-12 years, with 338 women and 220 men. The overall cardiac event rate was 34% if SE was positive, and 10% if it was negative. The event rates for MI and death were 10% and 8%, respectively, if SE was positive, and 3% and 3%, respectively, if SE was negative. If an ischemic electrocardiogram (ECG) and a positive SE were present, the overall event rate was 42%, versus a 7% rate when ECG and SE were negative for ischemia. Rest WMA was the most useful variable in predicting future cardiac events using CART: 25% of patients with and 6% without a rest WMA had an event. Other important variables were a dobutamine EF <52.5%, a positive SE, an ischemic ECG response, history of hypertension and age. CONCLUSIONS A positive SE provides useful prognostic information that is enhanced by also considering rest-wall motion, stress ECG response, and dobutamine EF.
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Affiliation(s)
- J Krivokapich
- Department of Medicine, UCLA School of Medicine, Los Angeles, California 90095-1679, USA.
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36
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Kloehn GC, O'Rourke RA. Perioperative Risk Stratification in Patients Undergoing Noncardiac Surgery. J Intensive Care Med 1999. [DOI: 10.1177/088506669901400205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Adverse cardiac events during noncardiac surgery are a major cause of morbidity and mortality. As the population ages, greater numbers of patients (including the elderly) are undergoing noncardiac surgical procedures; additional emphasis must therefore be placed on effective preoperative risk assessment. On a national level, the estimated annual expenditure for this process is already $3.7 billion. There is a need for both the specialist and primary care provider to execute a safe, methodical, and cost efficient screening plan. This process should identify both the patients at highest risk and also those at lowest risk. Subsequently, the emphasis should attempt to minimize the overall risk of perioperative complications. The cornerstone of risk assessment requires meticulous history taking, a thorough physical examination, and usually a chest radiograph and an ECG. Five subsequent (basic) steps for the evaluation of patients for noncardiac surgery are outlined here in assessment of clinical markers and the pa- tient's functional capacity, risk of the surgical procedure, the need for noninvasive testing, and when appropriate, the indications for invasive testing. The AHA/ACC Practice Guidelines Committee has outlined a clinical algorithm which provides a stepwise approach to guide the clinician during the decision making process. The purpose of preoperative evaluation is not to "give medical clearance" per se, but rather to evaluate the patient's current medical status, detect stress-induced ischemia in a cost effective manner, and to make recommendations about patient management throughout the entire perioperative period.
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Bigatel DA, Franklin DP, Elmore JR, Nassef LA, Youkey JR. Dobutamine stress echocardiography prior to aortic surgery: long-term cardiac outcome. Ann Vasc Surg 1999; 13:17-22. [PMID: 9878652 DOI: 10.1007/s100169900215] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study was undertaken to evaluate the efficacy of dobutamine stress echocardiography (DSE) in predicting not only perioperative but also long-term cardiac events. One hundred fifty-nine patients who were evaluated for elective abdominal aortic surgery were screened preoperatively with DSE from January 1, 1992 to December 31, 1993. We concluded that DSE is useful for preoperative assessment of cardiac risk prior to elective aortic surgery to minimize the need for cardiac intervention and still maintain acceptable perioperative MI and death rates. A selective approach for coronary revascularization is justified by the higher mortality in the subgroup requiring sequential procedures. DSE also allowed us to identify those high-risk patients who are best excluded from aortic surgery. Patients with abnormal DSE results are at higher risk for late cardiac events, require cardiology follow-up, and may require late coronary intervention.
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Affiliation(s)
- D A Bigatel
- Section of Vascular Surgery, Geisinger Medical Center, Penn State Geisinger Health System, Danville, PA 17822-2150, USA
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38
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Abstract
Perioperative cardiac events are the largest cause of morbidity and mortality for patients undergoing elective surgery. As a result, numerous recent studies have focused on attempts to identify patients at increased risk for perioperative events. These have delineated testing modalities capable of identifying high-risk patients, and clinical markers which further stratify patients facing elective surgery into high-, medium-, and low-risk subgroups. In this article, the authors review the evidence supporting the use of clinical markers of risk to evaluate patients before elective surgery. The role of preoperative clinical assessment in identifying patients most likely to benefit from further testing or intervention, (ie, those at significant risk for short- and long-term cardiac events) is stressed. Assessment and intervention for risk factors of long-term cardiac disease is also stressed, as the preoperative evaluation represents an opportunity for improvement in the short- and long-term cardiac risk profile. Finally, the algorithm for preoperative cardiovascular evaluation published jointly by the ACC/AHA joint taskforce on practice guidelines is reviewed. This algorithm is a synthesis of the current literature, into a cost effective and efficient approach to patient evaluation.
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Affiliation(s)
- J B Froehlich
- Department of Internal Medicine, University of Michigan Hospital, Ann Arbor 48109-0273, USA
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39
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Abstract
Consultation represents the act of providing advice regarding diagnosis and/or management and may comprise a major component of a cardiologist's practice. A frequent cause for cardiac consultation is preoperative risk assessment. With steadily decreasing morbidity and mortality related to noncardiac surgery, cardiovascular management strategies that are known to improve long-term outcomes should guide decision making in the perioperative setting. The preoperative cardiac consultation may represent an opportunity to initiate or modify cardiac care including primary and secondary preventive measures. A stepwise approach to perioperative cardiac risk assessment, as set forth by joint American College of Cardiology and American Heart Association guidelines, should be employed. The hallmark of successful preoperative cardiology consultation is effective communication with referring physicians. A consultant's good clinical judgement will only impact a patient's care if recommendations are communicated effectively. There is no substitution for direct, verbal contact. Recommendations should be kept to less than five when possible, be brief and specific. The consultant should provide contingency plans and follow-up. Good consultative technique increases compliance with recommendations and facilitates efficient patient care.
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Affiliation(s)
- M C Cohen
- Department of Medicine, Maine Medical Center, Portland, USA
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40
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Abstract
Prognostic risk stratification to identify perioperative and long-term cardiac risk in selected patients undergoing noncardiac surgery is part of good clinical practice. Exercise variables associated with significant increased risk include poor functional capacity (eg, <4 metabolic equivalents), marked exercise-induced ST segment shift or angina at low workloads, and inability to increase or actually decrease systolic blood pressure with progressive exercise. Approximately 40% of patients tested before peripheral vascular surgery will have an abnormal exercise electrocardiogram (ECG). The predictive value for a perioperative event, ie, death or myocardial infarction, ranges from 5% to 25% for a positive test and 90% to 95% for a negative test. Whereas exercise cardiac imaging is the modality of choice in patients with a noninterpretable exercise ECG, pharmacological stress imaging should be used in the 30% to 50% of patients who require perioperative noninvasive risk stratification and are unable to perform an adequate level of exercise to test cardiac reserve. Myocardial perfusion variables predictive of increased cardiac events include severity of the perfusion defect, number of reversible defects, extent of fixed and reversible defects, increased lung uptake of thallium-201, and marked ST segment changes associated with angina during the test. The reported sensitivity and specificity of dobutamine-induced echocardiographic wall motion abnormalities in patients with peripheral vascular disease is similar to myocardial perfusion scintigraphy, but the confidence limits are wider due to the smaller sample size in these more recent studies. In conclusion, noninvasive cardiac testing should be used selectively in patients undergoing noncardiac surgery; the results provide useful estimates of short- and long-term risk of cardiac events, and the magnitude of abnormal response on noninvasive testing should be used to formulate decisions regarding the need for coronary angiography and subsequent revascularization.
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Affiliation(s)
- B R Chaitman
- Department of Internal Medicine, St Louis University School of Medicine, MO, USA
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41
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Abstract
Cardiac risk assessment is a crucial aspect of perioperative evaluation because it is estimated that 1 million people, regardless of gender, will have perioperative cardiac complications at a cost of 20 billion dollars. Unfortunately, establishment of optimal guidelines for selected patient subgroups, particularly women, are lacking. More prospective studies are needed to help evaluate the most cost-effective, yet accurate way to noninvasively assess the presence of coronary artery disease in women.
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Affiliation(s)
- L L Liu
- Department of Anesthesia, University of California School of Medicine, San Francisco, USA
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42
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Shafritz R, Ciocca RG, Gosin JS, Shindler DM, Doshi M, Graham AM. The utility of dobutamine echocardiography in preoperative evaluation for elective aortic surgery. Am J Surg 1997; 174:121-5. [PMID: 9293826 DOI: 10.1016/s0002-9610(97)00068-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- R Shafritz
- Department of Surgery, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick 08903, USA
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43
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Rubin DN, Ballal RS, Marwick TH. Outcomes and cost implications of a clinical-based algorithm to guide the discriminate use of stress imaging before noncardiac surgery. Am Heart J 1997; 134:83-92. [PMID: 9266787 DOI: 10.1016/s0002-8703(97)70110-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Approximately 8 million patients at risk for coronary artery disease undergo noncardiac surgery annually in the United States. This study defined the appropriateness and cost of evaluating these patients with stress imaging tests. Before noncardiac surgery, 178 consecutive patients were prospectively studied by stress imaging. Pretest cardiac risk (low, intermediate, high) was established by interviewing the referring physician and separately by a cardiologist on the basis of the nature of noncardiac surgery and Eagle's clinical criteria. Patients were followed-up for alterations in management and perioperative events until hospital discharge. Referring physicians and cardiologists identified low risk in 24% and 54% of patients, respectively (p < 0.0001). Of 96 patients identified as low risk by cardiologists, 75 had minor surgery and 21 had major surgery, but no clinical risk factors. In the remaining 82 patients with major surgery, ischemia and other severe abnormalities were detected in 19 (23%) patients. At follow-up, no perioperative complications occurred in minor surgery; one patient with major surgery but no clinical risk factors died from complications related to hypertrophic cardiomyopathy. Patients with at least one clinical risk factor undergoing major surgery but who did not have ischemia on stress testing (n = 63) had two complications (infarction and unstable angina). Intervention (revascularization and surgical cancellation) was probably the explanation for the absence of events in 19 patients with ischemia. With a weighted mean Medicare reimbursement ($386), the use of a simple selection algorithm based on noncardiac surgery and clinical risk to avoid testing low-risk patients would have an average cost of $214 per patient, representing a 45% savings.
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Affiliation(s)
- D N Rubin
- Cardiovascular Imaging Section, Cleveland Clinic Foundation, Ohio 44195, USA
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D'Angelo AJ, Puppala D, Farber A, Murphy AE, Faust GR, Cohen JR. Is preoperative cardiac evaluation for abdominal aortic aneurysm repair necessary? J Vasc Surg 1997; 25:152-6. [PMID: 9013919 DOI: 10.1016/s0741-5214(97)70332-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE It is reported that 25% to 50% of patients with abdominal aortic aneurysms (AAA) have severe coronary artery disease (CAD) and should undergo an aggressive cardiac workup before AAA repair. In contrast, it has been our policy that patients referred for AAA repairs undergo no cardiac testing before surgery. METHODS This report reviews the last 113 consecutive patients who underwent elective AAA repair by the senior author using this policy. Seventy-four patients (group A) had only an electrocardiogram before surgery. The remaining 39 patients (group B) were referred having already had additional testing that included a thallium stress test (n = 20), echocardiogram (n = 18), multiple gated acquisition (MUGA) scan (n = 3), cardiac catheterization (n = 8), or some combination of these. RESULTS There was no statistical difference between group A and group B with regard to age, sex, tobacco use or history of coronary artery disease, diabetes mellitus, stroke (CVA), hypertension, peripheral vascular disease, or chronic obstructive pulmonary disease. Group B more commonly had a history of myocardial infarction (41% vs 19%, p < 0.03) and congestive heart failure (23% vs 7%, p < 0.03). During surgery there was no significant differences in blood loss, transfusion requirements, or operative times. There were no myocardial infarctions in group A and two (5.1%) in group B, which was not significantly different. Other complications, such as CVA, renal failure, pulmonary failure, pneumonia, wound infection, and hemorrhage, were not significantly different between the two groups. Postoperative hospital stay was not significantly different. There were three deaths in the entire series (2.7%), and only one in group B was cardiac-related in a patient with known end-stage cardiac disease and a symptomatic 8 cm AAA. CONCLUSIONS These data indicate that most patients with AAA can safely undergo repair with no cardiac workup and that cardiac workup before AAA repair contributes little information that impacts on treatment or final clinical outcome. We conclude that cardiac testing in preparation for AAA repair is not usually necessary and that intraoperative hemodynamic management may be the most important variable in determining outcome.
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Affiliation(s)
- A J D'Angelo
- Department of Surgery, Long Island Jewish Medical Center, New Hyde Park, NY 11040, USA
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45
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Hultman J. Pre-anaesthetic evaluation and management of patients with cardiovascular disease. Acta Anaesthesiol Scand 1996; 40:996-1003. [PMID: 8908214 DOI: 10.1111/j.1399-6576.1996.tb05618.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- J Hultman
- Department of Cardiothoracic Anaesthesia, University Hospital, Uppsala, Sweden
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46
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ACC/AHA task force report. Special report: guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Cardiothorac Vasc Anesth 1996; 10:540-52. [PMID: 8776655 DOI: 10.1016/s1053-0770(05)80022-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Starr JE, Hertzer NR, Mascha EJ, O'Hara PJ, Krajewski LP, Sullivan TM, Beven EG. Influence of gender on cardiac risk and survival in patients with infrarenal aortic aneurysms. J Vasc Surg 1996; 23:870-80. [PMID: 8667509 DOI: 10.1016/s0741-5214(96)70250-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- J E Starr
- Department of Vascular Surgery, Cleveland Clinic Foundation, OH 44195, USA
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Aronson S, Han LK. Stress echocardiography, contrast echocardiography, and tissue characterization: applications for the future. Crit Care Clin 1996; 12:429-50. [PMID: 8860848 DOI: 10.1016/s0749-0704(05)70254-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
During the last three decades the application of ultrasonography has expanded rapidly. The information available to the clinician from ultrasound imaging today is vastly more significant than it was in the early years of the development of this technology. In addition to automatic information, there is an increasing potential to provide functional, dynamic perfusion and even cellular information about the heart. This article attempts to summarize briefly the advances in these areas.
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Affiliation(s)
- S Aronson
- Department of Anesthesia and Critical Care, University of Chicago, Illinois, USA
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Shaw LJ, Eagle KA, Gersh BJ, Miller DD. Meta-analysis of intravenous dipyridamole-thallium-201 imaging (1985 to 1994) and dobutamine echocardiography (1991 to 1994) for risk stratification before vascular surgery. J Am Coll Cardiol 1996; 27:787-98. [PMID: 8613604 DOI: 10.1016/0735-1097(95)00549-8] [Citation(s) in RCA: 197] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- L J Shaw
- Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina, USA
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50
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Eagle KA, Brundage BH, Chaitman BR, Ewy GA, Fleisher LA, Hertzer NR, Leppo JA, Ryan T, Schlant RC, Spencer WH, Spittell JA, Twiss RD, Ritchie JL, Cheitlin MD, Gardner TJ, Garson A, Lewis RP, Gibbons RJ, O'Rourke RA, Ryan TJ. Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol 1996; 27:910-48. [PMID: 8613622 DOI: 10.1016/0735-1097(95)99999-x] [Citation(s) in RCA: 210] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- K A Eagle
- Educational Services, American College of Cardiology, Bethesda, Maryland 20814-1699, USA
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