Cardiac evaluation in patients with vascular disease — Overview: A practical approach

Abstract

Since the seminal work of Hertzer et al).2 in the early 1980s, vascular surgeons have accepted the fact that patients with peripheral vascular disease frequently have concomitant coronary artery disease. Some studies, however, have suggested that despite the presence of coronary artery disease, vascular reconstructive surgery can be undertaken with low morbidity and mortality, and that routine coronary angiography and prophylactic revascularization is unnecessary and, indeed, unjustified. 3'4 In these latter studies, we noted that the cardiac-related mortality rate after major aortic reconstruction in patients who had no history of coronary artery disease by clinical assessment alone was only 0.8%. In addition, even those patients who had clinical evidence of coronary artery disease on the basis of symptomatology or electrocardiographic (ECG) changes underwent aortic reconstruction, with a cardiac-related mortality rate of less than 3%? ,4 Since these early reports, however, accurate noninvasive means of functional cardiac assessment have gained widespread use. Previously, exercise electrocardiography was the mainstay of functional assessment of the myocardium. Clearly, this had limited applicability in elderly patients whose frailty or clandication status limited their ability to exercise to a satisfactory level. Multigated radionuclide scans, although useful in determining left ventricular ejection fraction (LVEF), could not really provide an adequate assessment of the extent of myocardium at risk from possible occlusive lesions; we still do use these scans to evaluate LVEF in selected patients, particularly those with a history of congestive failure. Currently dipyridamole-thallium scans have gained increasing acceptance as a valuable and reliable noninvasive technique to assess the functional significance of coronary artery stenoses, s-9 Boucher et al.~