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Outpatient echocardiography as a predictor of perioperative cardiac morbidity after peripheral vascular surgical
K Ouriel1, R M Green, J A DeWeese
1Department of Surgery, University of Rochester, New York 14642, USA.
Insights
Outpatient echocardiography effectively identifies patients at high risk for cardiac complications before peripheral vascular surgery. This cost-efficient method offers a valuable alternative to more resource-intensive cardiac testing, improving patient safety.
Area of Science:
- Cardiology
- Vascular Surgery
- Diagnostic Imaging
Background:
- Preoperative cardiac risk assessment is crucial for patients undergoing peripheral vascular procedures.
- Traditional provocative tests like dipyridamole myocardial scintigraphy and dobutamine stress echocardiography are sensitive but costly and time-consuming.
- There is a need for more resource-efficient methods to evaluate cardiac risk.
Purpose of the Study:
- To investigate the utility of outpatient echocardiography as a cost-efficient tool for assessing cardiac risk before peripheral vascular operations.
- To compare the accuracy of echocardiography with established clinical risk indexes.
Main Methods:
- 250 consecutive patients undergoing elective peripheral vascular surgery had outpatient transthoracic echocardiography.
- Accuracy of clinical indexes (Goldman, Detsky, ASA) was assessed against cardiac complications.
- Left ventricular ejection fraction (LVEF) accuracy was determined at various thresholds.
Main Results:
- Perioperative cardiac events occurred in 9.2% of patients; 3.6% died.
- Clinical indexes showed low sensitivity for predicting cardiac complications.
- LVEF < 50% identified high-risk patients with 78% sensitivity and 81% specificity.
- Outpatient echocardiography proved more economical than dipyridamole myocardial scintigraphy or dobutamine stress echocardiography.
Conclusions:
- Outpatient echocardiography provides a cost-efficient balance between clinical assessment and provocative testing for preoperative cardiac screening.
- It is a valuable tool for identifying patients at high risk for cardiac morbidity before peripheral vascular surgery.
- This approach can optimize resource allocation in preoperative cardiac risk stratification.
Purpose:
A variety of preoperative provocative tests have been used to define the risk of cardiac morbidity and mortality after peripheral vascular procedures, including dipyridamole myocardial scintigraphy and dobutamine stress echocardiography. Although highly sensitive, these tests are time-consuming and associated with significant expense. We investigated outpatient echocardiography as a less resource-intensive means of assessing cardiac risk with operation.
Methods:
Over a 2-year period 250 consecutive patients underwent outpatient transthoracic echocardiography before elective peripheral vascular operation was performed. The accuracy of the Goldman, Detsky, and the American Society of Anesthesiologists' Physical Status Classification clinical indexes of cardiac risk were assessed with regard to the development of cardiac complications such as unstable angina, myocardial infarction, life-threatening ventricular arrhythmias, severe congestive heart failure, and cardiogenic shock. The accuracy of echocardiographically determined left ventricular ejection fraction was determined at threshold values between 20% and 60%.
Results:
Perioperative cardiac events developed in 23 (9.2%) of the patients, and nine (3.6%) of the patients died as a result of these complications. Clinical indexes lacked sensitivity in the preoperative prediction of cardiac complications. Receiver operating curve analysis defined a left ventricular ejection fraction of less than 50% as an appropriate threshold for defining patients at high risk, with a sensitivity of 78% and a specificity of 81% in the identification of patients who had cardiac morbidity. The positive predictive value was 27%, and the negative predictive value was 97%. The economic impact of outpatient echocardiography was well below that of dipyridamole myocardial scintigraphy or dobutamine stress echocardiography.
Conclusions:
Outpatient echocardiography appears to offer a cost-efficient compromise between clinical criteria alone and provocative cardiac testing such as dipyridamole myocardial scintigraphy and dobutamine stress echocardiography in the preoperative screening of patients undergoing peripheral vascular surgical procedures.