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Preoperative assessment of cardiac risk in noncardiac major vascular surgery
A Roghi1, B Palmieri, W Crivellaro
1Department of Cardiology, National Research Council, Niguarda Hospital, Milan, Italy. albertor@planet.it
Insights
A preoperative clinical algorithm effectively stratifies cardiac risk for vascular surgery patients. Routine dipyridamole thallium-201 scintigraphy is not recommended for intermediate-risk patients, improving cost-effectiveness.
Area of Science:
- Cardiology
- Vascular Surgery
- Medical Diagnostics
Background:
- Cardiac risk stratification is crucial for patients undergoing vascular surgery.
- Preoperative assessment aims to predict and mitigate adverse cardiac outcomes.
- Existing diagnostic tools require evaluation for optimal patient management.
Purpose of the Study:
- To assess a clinical algorithm for preoperative cardiac risk stratification.
- To determine the predictive value of dipyridamole thallium-201 scintigraphy and rest echocardiography for postoperative adverse cardiac events.
- To evaluate the cost-effectiveness of the proposed risk stratification algorithm.
Main Methods:
- Prospective stratification of 320 patients undergoing 338 vascular procedures into low, intermediate, and high-risk groups.
- Selective use of diagnostic tests based on risk stratification.
- Analysis of cardiac outcomes including mortality, myocardial infarction, and ischemia.
- Evaluation of dipyridamole thallium-201 scintigraphy in 99 intermediate-risk patients.
Main Results:
- Significant differences in hard and soft cardiac events were observed between risk groups (p <0.001).
- Previous pulmonary edema was a significant predictor of cardiac outcomes.
- Dipyridamole thallium-201 scintigraphy showed limited predictive value (sensitivity 38%, specificity 63%) for adverse outcomes in intermediate-risk patients.
- The algorithm demonstrated cost savings of $1,500 per patient.
Conclusions:
- The preoperative clinical algorithm provides adequate and cost-effective cardiac risk stratification.
- Routine dipyridamole thallium-201 scintigraphy screening for intermediate-risk patients is not warranted.
- Risk stratification improves patient management and resource allocation in vascular surgery.
Abstract:
We evaluated whether a preoperative clinical algorithm allows an adequate stratification in cardiac risk and the predictive value of dipyridamole thallium-201 scintigraphy and rest echocardiography for postoperative adverse cardiac outcomes. Three hundred twenty patients undergoing 338 vascular surgery procedures were prospectively stratified into low, intermediate, and high risk. The low- and intermediate-risk patients underwent surgery without further diagnostic evaluation. In 7 high-risk patients the vascular procedure was canceled (1 died of myocardial infarction at 6-month follow-up), 9 underwent presurgical myocardial revascularization (1 died of myocardial infarction), and 49 underwent vascular surgery with perioperative intensive care treatment. Hospital mortality was 3.8%. Cardiac mortality and morbidity were 1.5% and 10.4%, respectively. We observed a significant difference in "hard" (death, myocardial infarction, pulmonary edema, major arrhythmias) and "soft" (myocardial ischemia, minor arrhythmias) events between groups, p <0.001. Previous pulmonary edema was a predictive variable of cardiac outcomes (multiple logistic regression analysis). Ninety-nine of 220 intermediate-risk patients randomly underwent dipyridamole thallium-201 scintigraphy: 37 had redistribution, 10 persistent, and 52 no defects; 7 of 13 soft and hard cardiac events occurred in patients without redistribution defects. Sensitivity, specificity, and positive and negative predictive values of redistribution defects for postoperative adverse outcomes were 38%, 63%, 14%, 87%, respectively. This algorithm may provide a safe and cost-effective approach (average cost saving per patient $1,500) to cardiac risk stratification. These results suggest that routine use of dipyridamole thallium-201 scintigraphy for screening of intermediate-risk patients may not be warranted.