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Cardiac risk assessment, morbidity prediction, and outcome in the vascular intensive care unit
Mary Dover1, Wael Tawfick, Niamh Hynes
11Western Vascular Institute, Department of Vascular and Endovascular Surgery, Galway University Hospital, Newcastle Road, Galway, Ireland.
Insights
The revised cardiac risk index (RCRI) has low predictive value for vascular ICU patients. Optimal medical therapy alone did not prevent acute myocardial infarction (AMI) in patients without prior cardiac intervention.
Area of Science:
- Cardiology
- Vascular Surgery
- Intensive Care Medicine
Background:
- The Lee revised cardiac risk index (RCRI) is commonly used for cardiac risk assessment.
- Optimal medical therapy (OMT) is standard for patients undergoing vascular procedures.
- The predictive value of RCRI and the impact of prior interventions in vascular ICU populations require further investigation.
Purpose of the Study:
- To evaluate the predictive capability of the RCRI in a vascular ICU setting.
- To assess the utility of transthoracic echocardiography.
- To determine the influence of prior coronary artery disease (CAD) and revascularization on patient outcomes.
Main Methods:
- Retrospective review of prospectively maintained Vascubase and ICU data from 363 vascular ICU admissions.
- Calculation of RCRI and correlation with patient outcomes.
- Analysis of echocardiography findings, including ejection fraction, left ventricular hypertrophy (LVH), and valvular dysfunction.
Main Results:
- RCRI showed poor discrimination (AUC = .621) for predicting outcomes.
- Left ventricular hypertrophy (LVH) was associated with significantly increased mortality (14.9% vs 6.5%).
- Patients receiving OMT without prior intervention had the highest rate of acute myocardial infarction (AMI) (41.22%).
Conclusions:
- The RCRI has limited discriminatory power for assessing cardiac risk in vascular intervention patients.
- Prior coronary artery disease (CAD) and revascularization influence outcomes.
- Protocols are needed to identify patients requiring cardiac intervention before vascular procedures to reduce AMI rates.
Objectives:
The aim of this study is to examine the predictive value of the Lee revised cardiac risk index (RCRI) for a standard vascular intensive care unit (ICU) population as well as assessing the utility of transthoracic echocardiography and the impact of prior coronary artery disease (CAD) and coronary revascularization on patient outcome.
Design:
This is a retrospective review of prospectively maintained Vascubase and prospectively collected ICU data.
Materials And Methods:
Data from 363 consecutive vascular ICU admissions were collected. Findings were used to calculate the RCRI, which was then correlated with patient outcomes. All patients were on optimal medical therapy (OMT) in the form of cardioselective β-blocker, aspirin, statin, and folic acid.
Results:
There was no relationship found between a reduced ejection fraction and patient outcome. Mortality was significantly increased for patients with left ventricular hypertrophy (LVH) as identified on echo (14.9% vs 6.5%, P = .028). The overall complication rates were significantly elevated for patients with valvular dysfunction. Discrimination for the RCRI on receiver-operating characteristic analysis was poor, with an area under the receiver-operating characteristic curve of .621. Model calibration was reasonable with an Hosmer-Lemeshow Ĉ statistic of 2.726 (P = .256). Of those with known CAD, 41.22% of the patients receiving best medical treatment developed acute myocardial infarction (AMI) compared to 35.3% of those who previously underwent percutaneous cardiac intervention and 23.5% of those who had undergone coronary artery bypass grafting. There was 3-fold increase in major adverse clinical events in patients with troponin rise and LVH.
Conclusions:
The RCRI's discriminatory capacity is low, and this raises difficulties in assessing cardiac risk in patients undergoing vascular intervention. The AMI is highest in the OMT group without prior cardiac intervention, which mandates protocols to identify patients requiring cardiac intervention prior to vascular procedures.
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