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Improved cardiac risk stratification in major vascular surgery with dobutamine-atropine stress echocardiography
D Poldermans1, M Arnese, P M Fioretti
1Thoraxcentre, Erasmus University, Rotterdam, The Netherlands.
Insights
Combining clinical assessment and dobutamine-atropine stress echocardiography effectively stratifies cardiac risk in vascular surgery patients. This approach identifies low-risk individuals and those needing further evaluation, optimizing clinical decisions and resource allocation.
Area of Science:
- Cardiology
- Vascular Surgery
- Echocardiography
Background:
- Dobutamine-atropine stress echocardiography (DASE) predicts perioperative cardiac risk in vascular surgery.
- Previous studies used DASE based on regional left ventricular wall motion abnormalities.
Purpose of the Study:
- To optimize preoperative cardiac risk stratification in vascular surgery candidates.
- To combine clinical risk assessment with semiquantitative DASE.
Main Methods:
- 302 consecutive vascular surgery patients underwent clinical assessment and DASE.
- Assessed extent, severity, and heart rate of stress-induced wall motion abnormalities.
Main Results:
- Absence of clinical risk factors identified 33% of patients at very low risk (1% cardiac event rate).
- DASE identified 72 patients with positive findings; 27 experienced perioperative cardiac events (38% positive predictive value, 100% negative predictive value).
- Heart rate at ischemia onset stratified risk: low ischemic threshold (53% events), high ischemic threshold (21% events).
Conclusions:
- Clinical variables identify a low-risk group (33%) where further testing is unnecessary.
- DASE is crucial for risk stratification in other candidates, identifying intermediate and very high-risk groups.
- Combined assessment aids clinical decision-making and conserves resources.
Objectives:
This study sought to optimize preoperative cardiac risk stratification in a large group of consecutive candidates for vascular surgery by combining clinical risk assessment and semiquantitative dobutamine-atropine stress echocardiography.
Background:
Dobutamine-atropine stress echocardiography has been used for the prediction of perioperative cardiac risk in a small group of patients scheduled for elective major vascular surgery on the basis of the presence or absence of stress-induced regional left ventricular wall motion abnormalities.
Methods:
Clinical risk assessment and dobutamine-atropine stress echocardiography were performed in 302 consecutive patients presenting for major vascular surgery. The extent and severity of stress wall motion abnormalities and the heart rate at which they occurred, in addition to the presence of wall motion abnormalities at rest, were assessed.
Results:
The absence of clinical risk factors (angina, diabetes, Q waves on the electrocardiogram, symptomatic ventricular tachyarrhythmias, age > 70 years) identified a low risk group of 100 patients with a 1% cardiac event rate (unstable angina). Dobutamine-atropine stress echocardiographic findings were positive in 72 patients. Twenty-seven patients had a perioperative cardiac event (cardiac death in 5, nonfatal infarction in 12, unstable angina pectoris in 10); all 27 patients had positive stress test results (positive predictive value 38%, negative predictive value 100%). The semiquantitative assessment of the extent and severity of ischemia did not provide additional prognostic information in patients with positive test results. In contrast, the heart rate at which ischemia occurred defined a high risk group with a low ischemic threshold (38 patients with 20 events [53%]) and an intermediate risk group with a high ischemic threshold (34 patients with 7 events [21%]). All 5 patients with a fatal outcome and 8 of 12 with a nonfatal myocardial infarction were in the high risk group with a low ischemic threshold.
Conclusions:
Clinical variables identify 33% of patients at very low risk for perioperative complications of vascular surgery in whom further testing is redundant. In all other candidates, dobutamine-atropine stress echocardiography is a powerful tool that identifies those patients at intermediate risk and a small group at very high risk. Risk stratification with a combination of clinical assessment and pharmacologic stress echocardiography has the potential to facilitate clinical decision making and conserve resources.