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Risk stratification of patients undergoing peripheral vascular revascularization by combined resting and dipyridamole
E Rossi1, F Citterio, M F Vescio
1Institute of Cardiology, Catholic University, Rome, Italy.
Insights
Echocardiography effectively predicts cardiac events in patients undergoing limb revascularization. This cardiac risk assessment tool is superior to clinical evaluation for identifying low-risk patients.
Area of Science:
- Cardiology
- Vascular Surgery
- Diagnostic Imaging
Background:
- Patients with peripheral vascular disease face high cardiac risks.
- Limb revascularization procedures carry significant perioperative and long-term cardiac event potential.
Purpose of the Study:
- To evaluate rest and stress echocardiography's predictive value for cardiac events in patients undergoing limb revascularization.
- To compare echocardiography with clinical assessment for cardiac risk stratification.
Main Methods:
- 110 patients with peripheral vascular disease underwent preoperative clinical and echocardiographic assessments, including dipyridamole stress testing.
- Cardiac events were monitored perioperatively and during a 1-year follow-up.
- High-risk patients were identified by clinical markers, low ejection fraction, or positive stress tests.
Main Results:
- Echocardiography was the strongest predictor of both early (p <0.00003) and late (p <0.0003) cardiac complications.
- No cardiac events occurred in patients with negative stress tests and good ejection fraction.
- Clinical evaluation predicted late events (p <0.0002) but was less sensitive for perioperative events.
Conclusions:
- Echocardiographic assessment of resting function and dipyridamole-induced ischemia reliably predicts perioperative cardiac risk.
- Echocardiography surpasses clinical data in identifying patients at low risk for cardiac complications during limb revascularization.
- This imaging modality aids in safely selecting patients for surgical procedures.
Abstract:
Patients with advanced peripheral vascular disease have an increased cardiac morbidity and mortality. The aim of this study was to assess the predictive value of rest and stress echocardiography for perioperative and late cardiac events in 110 patients undergoing limb revascularization. All patients underwent preoperative clinical and echocardiographic evaluation at rest and by dipyridamole stress testing to assess cardiac risk. Patients with > or =3 clinical Eagle markers, low left ventricular ejection fraction at rest, or positive dipyridamole stress test results were considered at high cardiac risk. To record adverse cardiac events, all patients were monitored during and after surgery, and followed for at least 1 year after hospital discharge. Cardiac complications occurred in 10 patients (9.7%) perioperatively (2 fatal myocardial infarctions), and in 13 (13%) at 1-year follow-up (7 fatal myocardial infarctions). Echocardiographic evaluation was the best predictor of early (p <0.00003) and late (p <0.0003) cardiac complications. No patient with a negative dipyridamole stress test result and good left ventricular ejection fraction had cardiac complications, either postoperatively or during follow-up. Clinical evaluation does not appear sufficiently sensitive for predicting perioperative cardiac events, but was valuable in predicting late cardiac complications (p <0.0002). Our data show that echocardiographic evaluation of resting dysfunction and of the ischemic response to dipyridamole is a good predictor of perioperative cardiac risk, and is superior to generally available clinical data. Echocardiographic evaluation is useful in defining a low-risk group of patients who can safely undergo limb revascularization, whichever surgical procedure is proposed.