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Cardiac assessment prior to vascular surgery: is dipyridamole-sestamibi necessary?
C de Virgilio1, S Pak, T Arnell
1Department of Surgery, Harbor-UCLA Medical Center, Torrance, 90509, USA.
Insights
Preoperative dipyridamole-sestamibi (PMIBI) imaging is not cost-effective for identifying cardiac risks in vascular surgery patients without severe symptoms. The test has limited ability to predict cardiac complications, making it unnecessary.
Area of Science:
- Cardiology
- Vascular Surgery
- Nuclear Cardiology
Background:
- Dipyridamole-sestamibi (PMIBI) is recommended for patients undergoing vascular surgery with specific cardiac risk factors (Eagle criteria).
- Evaluating the necessity and cost-effectiveness of preoperative PMIBI is crucial for optimizing patient care and resource allocation.
Purpose of the Study:
- To assess the cardiac morbidity and mortality in patients undergoing elective major vascular procedures.
- To determine the clinical utility and cost-effectiveness of preoperative dipyridamole-sestamibi (PMIBI) imaging in this patient population.
Main Methods:
- A retrospective review of 109 consecutive patients undergoing 145 elective major vascular procedures over one year.
- Analysis of cardiac events, perioperative myocardial infarctions, and cardiac death in relation to preoperative PMIBI findings and Eagle criteria.
Main Results:
- Overall cardiac events were 4.8% with a 0.7% cardiac death rate.
- PMIBI showed low sensitivity (25%) and moderate specificity (80%) for predicting cardiac events in patients without unstable angina.
- Three of seven cardiac events occurred in patients with normal or fixed defect PMIBI scans.
Conclusions:
- Preoperative dipyridamole-sestamibi (PMIBI) has a limited ability to identify patients at risk for cardiac complications undergoing vascular surgery, especially in the absence of severe symptoms.
- Routine preoperative PMIBI is neither necessary nor cost-effective for this patient group.
Abstract:
Dipyridamole-sestamibi (PMIBI) is recommended prior to vascular surgery in patients with > or = 1 Eagle criteria (Q waves, history of ventricular ectopy, diabetes, advanced age, and/or angina). To review our cardiac morbidity and mortality and the need for preoperative PMIBI, we reviewed 109 consecutive patients with a mean age of 59 years who underwent 145 elective major vascular procedures over a 1-year period. Seventy patients (with a mean of 0.8 Eagle criteria) underwent 92 vascular procedures without preoperative PMIBI and without coronary revascularization. Thirty-one patients (with a mean of 1.1 Eagle criteria) underwent 39 procedures without coronary revascularization following PMIBI, which showed reversible ischemia in seven and a fixed defect in 10; findings were normal in 14. Preoperative coronary bypass or angioplasty was limited to eight patients (14 procedures, mean of 1.6 Eagle criteria) who had unstable angina with (2 patients) or without (6 patients) acute myocardial infarction. There were four perioperative myocardial infarctions (2.8%), seven cardiac events overall (4.8%), and one cardiac death (0.7%). Three (43%) of the seven cardiac events occurred in patients with a normal scan or fixed defect on PMIBI imaging. In the absence of unstable angina, PMIBI had a sensitivity of only 25% and a specificity of 80% for cardiac events. We conclude that among patients without severe cardiac symptoms (1) PMIBI has a very limited ability to identify patients at risk for cardiac complications, and (2) preoperative PMIBI is neither necessary nor cost-effective.