Negative predictive value of dobutamine stress echocardiography for perioperative risk stratification in patients with cardiac risk factors and reduced exercise capacity undergoing non-cardiac surgery.

Abstract

Guidelines recommend functional testing for myocardial ischaemia in the perioperative setting in patients with greater than one recognised cardiac risk factor and self-reported reduced exercise capacity. To determine the clinical utility of dobutamine stress echocardiography (DSE) for perioperative risk stratification in patients undergoing major non-cardiac surgery. Data on 79 consecutive patients undergoing DSE for perioperative risk stratification at a single centre were retrospectively reviewed to determine rates of major adverse cardiac events (MACE) during the index hospitalisation and 30 days post-discharge. Echocardiography and outcome data were obtained through a folder audit and echolab database. Out of the 79 DSE performed for perioperative risk stratification, 11 (14%) were positive (DSE +ve) and 68 (86%) were negative (DSE -ve). Management in the DSE +ve group included medical optimisation without invasive intervention (n = 7(64%)), diagnostic coronary angiography (n = 3(27%)) and coronary artery bypass graft (n = 1(9%)). None of the patients underwent percutaneous coronary intervention preoperatively. Perioperative MACE in the DSE +ve group was 36% compared to 4% in the DSE-ve group (P = 0.006). DSE +ve was a powerful predictor of perioperative inpatient MACE (OR 12.4, 95% CI 2.3-67, P = 0.003). The positive predictive value of DSE +ve status was 36%, whereas the negative predictive value of DSE-ve status for perioperative MACE was 96%. DSE for perioperative risk stratification had a high clinical utility in patients undergoing major non-cardiac surgery. In particular, a normal DSE had a high negative predictive value for perioperative MACE.