Dipyridamole technetium 99m sestamibi myocardial tomography for preoperative cardiac risk stratification before major or minor nonvascular surgery

Abstract

The value of dipyridamole technetium 99m sestamibi (MIBI) tomography for preoperative cardiac risk stratification was assessed in 285 consecutive patients being considered for nonvascular surgery. A “major” ( n = 140) or “minor” ( n = 89) nonvascular procedure was later done in 229 of these patients ≤4 months after dipyridamole testing. Perioperative cardiac events (unstable angina, acute ischemic pulmonary edema, nonfatal myocardial infarction, or cardiac death) occurred in 11 (8%) patients undergoing major nonvascular surgery and 1 (1%) undergoing a minor procedure. The only clinical or scintigraphic variables associated with significantly increased perioperative cardiac risk in patients having major surgery were Goldman class ≥II, an abnormal MIBI scan, and a fixed perfusion defect. In these patients, cardiac events occurred in 1% of those who had a normal MIBI study, 14% of those with an abnormal scan ( p < 0.01), 12% with a reversible MIBI defect ( p = 0.29), and 17% with a fixed MIBI defect ( p < 0.01). In the 60 patients whose Goldman class was ≥II, only an abnormal MIBI study and a fixed perfusion defect were associated with incremental risk of a perioperative cardiac event. The incidence of perioperative cardiac events in these patients was 4% with a normal MIBI scan, 27% with an abnormal study ( p < 0.05), 24% with a reversible MIBI defect ( p = 0.45), and 37% with a fixed defect ( p < 0.01). Event rates were low in patients having minor nonvascular surgery; none of the 25 with a normal MIBI study and only 1 of the 64 with an abnormal scan had a perioperative cardiac event ( p = not significant (NS). We conclude that dipyridamole MIBI tomography can provide important prognostic information in patients having major nonvascular surgery. A normal MIBI study indicates a low risk of perioperative cardiac events, whereas an abnormal study in patients with Goldman class ≥II undergoing major surgery is associated with significantly increased risk. The prognostic value of MIBI tomography in patients at low clinical risk undergoing minor surgery is limited.