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Cardiac screening tests prior to lower extremity revascularization: routine versus selective application
T F Kresowik1, J J Hoballah, W J Sharp
1Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City 52242-1086, USA.
Insights
Routine cardiac screening for peripheral vascular operations is not recommended. Patient selection for screening should focus on potential benefits of coronary revascularization, not just comorbidity presence.
Area of Science:
- Cardiology
- Vascular Surgery
- Diagnostic Imaging
Background:
- Coronary artery disease (CAD) is a significant comorbidity in patients with peripheral vascular disease (PVD).
- Optimal cardiac evaluation strategies for PVD patients undergoing surgery remain debated.
- Routine cardiac screening methods have been employed in this patient population.
Purpose of the Study:
- To evaluate the utility of routine cardiac screening using dipyridamole thallium scintigraphy (DTS) and radionuclide ventriculography in patients undergoing peripheral vascular operations.
- To determine if screening alters surgical decisions or improves outcomes.
Main Methods:
- Utilized dipyridamole thallium scintigraphy (DTS) and radionuclide ventriculography for cardiac screening.
- Compared incidence of reversible ischemia and severe CAD in patients with and without a prior CAD history.
- Analyzed overall risks and benefits of routine screening.
Main Results:
- Incidence of reversible ischemia and severe CAD was similar in patients with and without a history of CAD.
- Routine screening did not demonstrate a clear benefit in overall risk-benefit analysis.
- Identification of unsuspected CAD may alter surgical decisions in select cases.
Conclusions:
- Routine cardiac screening for peripheral vascular operations is not supported by current data.
- Patient selection for screening should be individualized based on the potential benefits of coronary revascularization.
- Screening may be beneficial for younger patients or those with claudication, but not typically for older patients with limb-threatening ischemia requiring infrainguinal bypass.
Abstract:
Coronary artery disease (CAD) is the most important comorbidity associated with peripheral vascular disease. Consensus on the optimal approach to the cardiac evaluation of patients presenting for peripheral vascular operations has not been achieved. We developed a large experience with routine cardiac screening using dipyridamole thallium scintigraphy (DTS) and radionuclide ventriculography. The incidence of reversible ischemia on DTS and the subsequent documentation of severe CAD on coronary angiography was similar in vascular patients with a history of CAD (angina or myocardial infarction) and those with a negative CAD history. However, the analysis of overall risks and benefits does not support a recommendation for routine screening. We suggest that selection of patients for screening should be based on the estimated benefit of coronary revascularization for the individual patient considering both perioperative and long-term survival. In addition, screening is also considered if identification of unsuspected CAD will alter the decision to perform the proposed peripheral vascular operation. Thus, the older patient who requires an infrainguinal bypass for limb-threatening ischemia is unlikely to benefit from cardiac screening. Documentation of the extent of CAD with screening studies may be beneficial in younger patients or in patients with claudication.