Dobutamine stress echocardiography for assessment of perioperative cardiac risk in patients undergoing major vascular surgery.

Abstract

The purpose of this study was to determine the predictive value of dobutamine stress echocardiography for perioperative cardiac events in patients scheduled for elective major noncardiac vascular surgery. Patients (n = 136; mean age, 68 years) unable to exercise underwent a dobutamine stress test before surgery (incremental dobutamine infusion [10-40 micrograms.kg-1.min-1] continued with atropine [0.25-1 mg i.v.] if necessary to achieve 85% of the age-predicted maximal heart rate without symptoms or signs of ischemia). The clinical risk profile was evaluated by Detsky's modification of Goldman's risk factor analysis. Echocardiographic images were evaluated by two observers blinded to the clinical data of the patients, and results of the test were not used for clinical decision making. Technically adequate images were obtained in 134 of 136 patients, one major complication occurred (ventricular fibrillation), and three tests were discontinued prematurely because of side effects. Finally, data from 131 patients were analyzed with univariate and multivariate methods. The dobutamine stress test was positive (new or worsened wall motion abnormality) in 35 of 131 patients. In the postoperative period, five patients died of myocardial infarction, nine patients had unstable angina, and one patient developed pulmonary edema. All patients with cardiac complications (15 patients) had a positive dobutamine stress test. No cardiac events occurred in patients with negative tests. Five patients with a technically inadequate or prematurely stopped test were operated on without complications. By multivariate analysis (logistic regression), only age > 70 years and new wall motion abnormalities during the dobutamine test were significant predictors of perioperative cardiac events. Dobutamine stress echocardiography is a feasible, safe, and useful method for identifying patients at high or low risk of perioperative cardiac events. The test yields additional information, beyond that provided by clinical variables, in patients who are scheduled for major noncardiac vascular surgery.