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The value of dipyridamole echocardiography in risk stratification before vascular surgery. A multicenter study. The
Insights
Dipyridamole echocardiography is a safe and effective pre-operative screening tool for patients undergoing major vascular surgery. This stress echocardiography method accurately identifies patients at risk for cardiac events, boasting a high negative predictive value.
Area of Science:
- Cardiology
- Vascular Surgery
- Diagnostic Imaging
Background:
- Major vascular surgery carries a significant risk of peri-operative cardiac events.
- Pharmacological stress echocardiography is increasingly utilized for risk stratification in these patients.
Purpose of the Study:
- To evaluate the safety and efficacy of dipyridamole echocardiography for peri-operative cardiac risk stratification in patients undergoing major vascular surgery.
- To assess the predictive value of dipyridamole echocardiography in identifying patients who will experience cardiac events.
Main Methods:
- 121 patients undergoing vascular surgery were studied using dipyridamole echocardiography across six centers.
- A positive test was defined by a dipyridamole-time < 5 min and/or a peak wall motion score index > 2.
- Patients were monitored for peri-operative cardiac events.
Main Results:
- Dipyridamole echocardiography testing was safe and well-tolerated, with no major complications.
- 28% of patients had a positive test, and 8% experienced peri-operative cardiac events (deaths, myocardial infarctions, unstable angina).
- The test demonstrated high sensitivity (78%) and specificity (81%), with an excellent negative predictive value (98%).
Conclusions:
- Dipyridamole echocardiography is a safe and effective pre-operative screening tool for risk stratification in major vascular surgery patients.
- The test's high negative predictive value is particularly valuable in identifying patients unlikely to experience cardiac events.
- Stress echocardiography outperforms clinical parameters and resting echocardiographic variables in discriminating between patients with and without cardiac events.
Purpose:
Patients undergoing major vascular surgery are at relatively high risk of cardiac events, and pharmacological stress echocardiography is increasingly used for peri-operative risk stratification.
Patients And Methods:
One hundred and twenty-one patients undergoing vascular surgery (age 65 +/- 7 years) were studied by dipyridamole echocardiography testing in six different centres. Of the total 136 patients, 15 were subsequently excluded because surgery was either cancelled (n = 8) or postponed pending cardiac revascularization (n = 7) because of the presence of a 'high-risk' stress echo response (identified 'a priori' as a positive dipyridamole echocardiography testing with a dipyridamole-time < 5 min and/or a peak wall motion score index > 2, upon scoring each segment from 1 = normal to 4 = dyskinetic in an 11-segment model).
Results:
No major complications occurred during dipyridamole echocardiography testing. Technically adequate images were obtained in all patients; however, in one patient only the low dipyridamole dose (56 mg.kg-1 over 4 min) was given to limit side effects. Of the 121 patients undergoing surgery 28 (23%) had a positive test. Peri-operative events occurred in nine patients (8%): two deaths, two myocardial infarctions, five cases of unstable angina. Sensitivity and specificity of dipyridamole echocardiography testing for predicting cardiac events were 78% and 81%, respectively, with a positive predictive value of 25% and a negative predictive value of 98%. Dipyridamole echocardiography testing effectively singled out patients with, from those without, events, but neither clinical parameters, such as Detsky score, nor baseline echo parameters, such as resting wall motion score index or ejection fraction were able to distinguish between such patients.
Conclusion:
In conclusion, dipyridamole echocardiography testing is safe and well tolerated in patients undergoing major vascular surgery, and provides an effective pre-operative screening test for risk stratification of these patients mainly due to the extremely high negative predictive value. Stress echocardiography is a better discriminator than clinical and rest echocardiographic variables.
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