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Does routine stress-thallium cardiac scanning reduce postoperative cardiac complications?
J M Seeger1, G R Rosenthal, S B Self
1Department of Surgery, University of Florida, Gainesville.
Insights
Prophylactic cardiac revascularization before aortic reconstruction does not reduce complications or mortality. Routine stress-thallium testing and intervention are not justified due to similar outcomes and high costs.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Cardiology
Background:
- Aortic reconstruction carries risks of cardiac complications, often due to coronary artery disease.
- Stress-thallium scanning identifies ischemic myocardium, a potential risk factor.
- Previous cardiac revascularization is associated with fewer postoperative cardiac complications.
Purpose of the Study:
- To evaluate the effectiveness of prophylactic cardiac revascularization in patients undergoing aortic reconstruction.
- To determine if preoperative stress-thallium testing reduces postoperative cardiac complications and improves long-term survival.
Main Methods:
- Prospective evaluation of stress-thallium scanning in 146 patients undergoing aortic reconstruction.
- Patients with positive scans underwent coronary arteriography and revascularization.
- Comparison of outcomes with 172 patients who did not undergo stress-thallium testing.
Main Results:
- Stress-thallium testing led to higher rates of coronary arteriography and cardiac revascularization.
- Despite increased intervention, cardiac mortality and complications were similar between groups.
- Advanced age and intraoperative complications predicted adverse cardiac events, not positive stress-thallium tests.
Conclusions:
- Preoperative stress-thallium testing reveals high rates of coronary artery disease in patients undergoing aortic reconstruction.
- Prophylactic cardiac intervention does not improve operative or long-term mortality.
- Routine stress-thallium testing and subsequent revascularization are not cost-effective or clinically justified.
Objective:
Prophylactic cardiac revascularization in patients with ischemic myocardium could reduce postoperative cardiac complications after aortic reconstruction. However, the effectiveness of this approach has not been documented.
Summary Background Data:
Stress-thallium scanning can identify patients with ischemic myocardium. Morbidity and mortality after aortic reconstruction appears to be largely caused by co-existent coronary artery disease, and patients who have had recent cardiac revascularization have few postoperative cardiac complications.
Methods:
Preoperative stress-thallium scanning was evaluated prospectively in 146 patients undergoing aortic reconstruction. Patients with positive studies underwent coronary arteriography and cardiac revascularization, when appropriate. Postoperative cardiac complications and long-term survival in these patients were compared with results from 172 similar patients undergoing aortic reconstruction without stress-thallium scanning. Results also were analyzed to determine predictors of postoperative cardiac events.
Results:
Forty-one per cent of patients undergoing stress-thallium testing underwent coronary arteriography, and 11.6% had cardiac revascularization. In contrast, 14.7% of patients treated without stress-thallium testing had coronary arteriography, and 4.1% had revascularization (p < 0.01). Despite this, cardiac mortality, serious cardiac complications, and long-term cardiac mortality were similar in both groups. Only advanced age and intraoperative complications (but not a positive stress-thallium test) predicted postoperative cardiac events.
Conclusions:
Preoperative stress-thallium testing confirmed a high incidence of significant coronary artery disease in patients undergoing aortic reconstruction, but prophylactic cardiac intervention does not reduce operative or long-term mortality. Thus, the risk and expense of routine stress-thallium testing and subsequent cardiac revascularization cannot be justified.