Stress echocardiography with regadenoson for the assessment of perioperative cardiovascular risk in non-cardiac surgery

Funding Acknowledgements

Type of funding sources: None.

Introduction

The most commonly used drug in pharmacological stress echocardiography (SE) for perioperative cardiovascular (CV) risk assessment is dobutamine. Its arrhythmogenic potential and the unpredictable hypertensive response in patients with vascular pathology, makes us often resort to other less accessible and more expensive techniques such as Cardio-MRI or SPECT. Regadenoson is emerging as a safe drug in the detection of myocardial ischemia, although its use has not yet been validated in SE.

Purpose

The objective is to assess the short-medium term prognosis in patients undergoing high-risk noncardiac surgery who undergo SE with regadenoson.

Methods

A unicentric retrospective observational study. We included a subgroup of 58 patients referred for detection of ischemia prior to high-risk noncardiac surgery who underwent SE with regadenoson during the years 2017-2020. No patient has had cardiological symptoms. The test was considered positive if it presented at least one of the following: wall motion abnormalities, electrocardiographic and/or clinical changes compatible with ischemia.  Patients were followed up in the immediate postoperative period (30 days), at 12 months and at 24 months, considering the presence of CV events such as admission for heart failure (HF), chest pain, acute myocardial infarction (AMI) or CV death. It was compared the group with negative (NG) and the group with positive (PG) results.

Results

97% of the patients underwent vascular high-risk noncardiac surgery, 3% underwent other surgeries such as kidney transplantation or lung surgery considered high risk in the preanesthetic assessment. Twelve studies (21%) were positive and of these, only 2 patients underwent coronary artery bypass prior to surgery. The only CV event observed in this period was HF: in the NG 3 episodes were observed compared to 1 in the PG (p = 0.82), only in one of the events for HF was coronary angiography done that did not show coronary artery disease. The time to the NG event was a median of 90 [3-600] days versus 180 days in the PG.  The cumulative incidence (CI) of events in the NG in the immediate postoperative period (30 days post-surgery) was 2%, annual 4% and biannual 7%.

Conclusions

A SE test with negative regadenoson prior to high-risk noncardiac surgery presents a low CI of events in the immediate postoperative period and in the short-medium term. Abstract Figure.

Regadenoson stress echocardiography: a road ahead

Funding Acknowledgements

Type of funding sources: None.

Introduction

Drugs use in stress echocardiography (SE) have important limitations due to side effect and contraindications. Regadenoson (R) is emerging as a selective coronary vasodilator for pharmacological stress tests. Several studies have analyzed its diagnostic accuracy, but its prognostic value has not yet been studied.

Purpose

The objective is to assess safety and short-medium term prognosis in patients (p) who underwent SE with R.

Methods

Retrospective observational study. 126 patients were included from 2017 to 2020 and SE to study the detection of myocardial ischemia with R were performed. A positive SE test were consider if presented at least one of the follow: segmental changes in myocardial contractility, electrocardiography ischaemic changes or ischaemic symtomps. Adverse events (AE) were collected. To assess prognosis, we evaluated cardiovascular events (CV) with a median follow-up of 23 months, considering heart failure, angina, myocardial infarction (AMI) o cardiovascular death. We compare negative result SE test group (NG) with group of positive results (PG).

Results

Sixteen (13%) patients, presented AE, generally mild, with nausea in 4 patients. Two patients (1.6%) required the use of aminophylline for severe AE type bronchospasm.

Nineteen studies (15%) were positive: 17 (89%) showed echocardiographically positive results, 5 of them also had clinical or electrocardiographic positivity, one (5%) was considered positive only by electrocardiographic criteria and another by clinical criteria.

 There were no CV deaths at follow-up. In the NG, 6 events were observed versus 2 in the PG (6 vs 11%). Time to event of the NG was a median of 90 [3-600] days versus 110 [40-180] days in the PG. The most frequent event was HF (4 NG vs 1 PG), coronary angiography was performed in only 2 patients with HF of the NG and did not show significant lesions. In the NG there were 2 IAM (2 vs 0), one had severe stenosis in the right coronary artery and the other several moderate diffuse stenosis. There was no events for angina in the NG (0 vs 1). The annual cumulative incidence was 11% in the PG compared to 4% in the NG.

Conclusions

Stress echocardiography with regadenoson is a safe test with a low serious adverse events rate. As concern as prognosis, In our sample, NG presented a lower proportion of events with a lower annual cumulative incidence than PG and also in a 23-month follow-up. Abstract Figure.