Preoperative Dobutamine Stress Echocardiography Research Articles

Utility of dobutamine stress echocardiography in aortic valve regurgitation and reduced left ventricular function.

Predictors for post-operative reverse remodeling in patients with severe aortic regurgitation (AR) and reduced left ventricular ejection fraction (LVEF) are unknown. We performed low-dose dobutamine stress echocardiography (DSE) in patients with severe AR and reduced LVEF to evaluate the relationship between contractile reserve (CR) and reverse remodeling after surgery. In 31 patients with chronic severe AR and reduced LVEF (LVEF<50%), we performed pre-operative DSE, assessed CR, and examined whether changes in preoperative DSE were associated with improvement of post-operative LVEF after aortic valve surgery. The pre-operative echocardiographic findings were as follows: left ventricular (LV) end-diastolic dimension: 67 ± 10mm, LV end-systolic dimension: 52 ± 13mm, and LVEF: 42 ± 8%. All patients underwent aortic valve surgery. Patients with pre-operative LVEF of ≥45% exhibited a significant increase in LVEF; however, patients with pre-operative LVEF of <45% showed no significant change. When we examined the results of DSE performed in patients with pre-operative LVEF of <45%, ΔLVEF of ≥6% (with CR) during DSE was related to an improvement in post-operative LVEF; ΔLVEF of ≥6% during DSE predicted an improvement in post-operative LVEF, with sensitivity 100%; specificity 78%; and area under curve (AUC) .92. DSE might be a helpful tool for predicting post-operative reverse remodeling in patients with severe AR and moderately reduced LVEF.

Clinical implications of inducible left ventricular outflow tract obstruction among patients undergoing liver transplant evaluation

IntroductionPatients with end stage liver disease (ESLD) have a hyperdynamic state due to decreased systemic vascular resistance and increased cardiac output. Preoperative evaluation with dobutamine stress echocardiography (DSE) is used to risk-stratify patients prior to liver transplant. We sought to identify the impact of inducible left ventricular outflow tract obstruction (LVOTO) on DSE on post-operative liver transplant outcomes. MethodsPatients with ESLD who underwent liver transplant at Cleveland Clinic between January 2007 and August 2016 were identified. Pre-operative DSE data, and post-operative intensive care unit (ICU) data were extracted. Patients with inducible LVOTO were compared to those without LVOTO. ResultsOf the 515 patients identified who underwent DSE prior to liver transplant, 165 (30%) were female, and 95 (18%) had LVOTO. There were no major differences in baseline characteristics between the two groups. In the LVOTO group, rest gradients were 10.8 ± 3 mm Hg while peak gradients were 90 ± 48.2 mm Hg. No significant differences in ICU length of stay or duration of mechanical ventilation between both groups were noted. There were 21 deaths at 30 days. There were 2 (2.1%) deaths in the LVOTO group, versus 19 (4.5%) deaths in the non LVOTO group (p = 0.28). Higher Model for End Stage Liver Disease (MELD) scores predicted longer duration of mechanical ventilation and ICU length of stay. ConclusionInducible LVOTO on DSE does not adversely affect the short-term outcomes post liver transplant. Presence of inducible LVOTO should not be the mere reason to deny liver transplant among patients with ESLD.

Preoperative Dobutamine Stress Echocardiography and Clinical Factors for Assessment of Cardiac Risk after Noncardiac Surgery

The role of dobutamine stress echocardiography (DSE) in the risk stratification of patients undergoing noncardiac surgery in the current era is unclear. The aim of this study was to evaluate the yield of DSE and the additive role of DSE to clinical criteria for preoperative risk stratification of patients undergoing noncardiac surgery. The study included 4,494 patients undergoing DSE ≤90days before noncardiac surgery. The primary outcome was a composite of postoperative myocardial infarction, cardiac arrest, and all-cause mortality ≤30days after noncardiac surgery. The overall 30-day postoperative cardiac event rate was 2.3%. The mortality rate was 0.9% overall and 0.7% and 1.3% after normal and abnormal results on DSE, respectively. Among clinical variables, the modified Revised Cardiac Risk Index score demonstrated the strongest association with postoperative risk (P<.001). Patients with Revised Cardiac Risk Index scores of ≥3 had an event rate of 7.5%. The event rates for patients with wall motion score index ≥1.7 at baseline, left ventricular ejection fractions <40% at peak stress, or ischemic thresholds <70% of age-predicted maximal heart rate were 7.1%, 8.6%, and 7.9%, respectively. After adjusting for clinical variables, the overall result of DSE (P<.001), baseline and peak-stress wall motion score index (P<.001 and P=.014, respectively), peak-stress left ventricular ejection fraction (P<.001), and the number of ischemic segments (P=.027) were all associated with postoperative cardiac events. Incremental multivariate analysis demonstrated that an overall abnormal result on DSE, added to clinical variables, was associated with an increased risk for postoperative cardiac events (odds ratio, 2.07; 95% CI, 1.35-3.17; P<.001). Baseline and peak-stress findings on preoperative DSE add to the prognostic utility of clinical variables for stratifying cardiac risk after noncardiac surgery.

Preoperative dobutamine stress echocardiography in patients undergoing orthotopic liver transplantation.

Coronary artery disease (CAD) is associated with increased mortality in patients who undergo orthotopic liver transplantation (OLT). Chronic vasodilatory state and poor exercise tolerance in patients with end-stage liver disease make dobutamine stress echocardiography (DSE) preferred for preoperative evaluation of CAD prior to OLT. We studied the incidence of positive DSE results and the association between DSE results and perioperative and longer-term events. DSE results pre-OLT will predict short and long term outcomes. We studied 460 patients who underwent DSE within 1 year prior to OLT between 2004 and 2011. Primary events included death and MI at 30 days post-OLT. We also recorded longer-term deaths. Four patients (0.9%) had an ischemic response to DSE, 360 (78%) were normal, and 96 (21%) were nondiagnostic. Fourteen patients (3%) had a primary event at 30 days following OLT (13 deaths and 1 NSTEMI), and there were 108 (24%) deaths at 4.6±2 years of follow-up. No patient with ischemia on DSE had a 30-day event. The accuracy, sensitivity, specificity, and positive and negative predictive values of DSE that was not normal (ie, ischemic or nondiagnostic response) to predict 30-day post-OLT events were 76%, 14%, 78%, 2%, and 97%, respectively. On Cox survival analysis, only baseline left ventricular ejection fraction (HR: 0.90, 95% CI: 0.85-0.96, P < 0.001) was associated with longer-term deaths. Patients undergoing pre-OLT DSE have very low incidence of an ischemic response on DSE, and it has no association with 30-day events.

Cardiac Events after Noncardiac Surgery in Patients Undergoing Preoperative Dobutamine Stress Echocardiography: Findings From the Mayo Poce-DSE Investigators

BackgroundCurrent guidelines support the use of dobutamine stress echocardiography (DSE) prior to noncardiac surgery in higher-risk patients who are unable to perform at least 4 metabolic equivalents of physical activity. We evaluated postoperative outcomes of patients in different operative risk categories after preoperative DSE. MethodsWe collected data from the medical record on 4494 patients from January 1, 2006 to December 31, 2011 who had DSE up to 90 days prior to a noncardiac surgery. Patients were divided into low, intermediate, and high preoperative surgery-specific risk. Baseline demographic data and risk factors were abstracted from the medical record, as were postoperative cardiac events including myocardial infarction, cardiac arrest, and mortality within 30 days after surgery. ResultsThere were 103 cardiac outcomes (2.3%), which included myocardial infarction (n = 57, 1.3%), resuscitated cardiac arrest (n = 26, 0.6%), and all-cause mortality (n = 40, 0.9%). Cardiac event rates were 0.0% (95% confidence interval [CI], 0.0%-3.9%) in the low-surgical-risk group, 2.1% (95% CI, 1.6%-2.5%) in the intermediate-surgical-risk group, and 3.4% (95% CI, 2.0%-4.4%) in the high-risk group. Thirty-day postoperative mortality rates were 0%, 0.9%, and 0.8% for the low-risk, intermediate-risk, and high-risk surgical groups, respectively, and were not statistically different. ConclusionsThese findings demonstrate low cardiac event rates in patients who underwent a DSE prior to noncardiac surgery. The previously accepted construct of low-, intermediate-, and high-risk surgeries based on postoperative events of <1%, 1%-5%, and >5% overestimates the actual risk in contemporary settings.

Formation de préthrombus lors d’une échocardiographie de stress à la dobutamine

Although generally regarded as a safe stress modality, dobutamine stress echocardiography (DSE) has been associated with several well described complications. However, to our knowledge, acute constitution of thrombi during the stress test has never been described. In this report, we present the case of a 64 year-old man with a history of ischemic heart disease who underwent a preoperative DSE; during the test, we witnessed a striking acute constitution of an intense prethrombotic state with almost a formation of a highly mobile massive thrombus adjacent to the infero-apical segment spontaneously resolving few minutes after the end of the test.

A Preoperative Echocardiographic Predictive Model for Assessment of Cardiovascular Outcome after Renal Transplantation

Major adverse cardiac events (MACE) frequently determine the outcome of renal transplantation (RT). Stress testing is advocated for preoperative risk assessment, but limited information is available on the prognostic value of these tests. We aimed to retrospectively assess the value of preoperative dobutamine stress echocardiography (DSE) in predicting MACE in patients undergoing RT. A total of 185 patients (age 56 +/- 11 years, 64% were men, creatinine level of 7.3 +/- 2.9 mg/d, 27% were smokers, 86% had hypertension, 54% had diabetes, 57% were dyslipidemic) with end-stage renal disease (ESRD) underwent DSE before RT. A standard DSE protocol was used with the administration of 5-50 mug/kg/min incremental doses in 3-minute intervals and up to 1 mg of atropine if needed to reach prespecified end points. Regional left ventricular wall motion abnormality (WMA) at rest (fixed), with stress (inducible), or both were present in 54, 35, and 18 patients, respectively. In 38 patients who underwent coronary angiography, the sensitivity, specificity, and positive and negative predictive values of inducible WMA for predicting angiographic coronary artery disease (> or = 70% luminal diameter reduction) were 88%, 62%, 65%, and 87%, respectively. Cox regression analysis identified the presence of combined fixed and inducible WMA (ie, resting WMA that did not change during DSE, accompanied by new WMA evident during DSE; hazard ratio [HR] 5.6, P = .012), left atrial enlargement (HR 4.2, P = .002), and aortic valve sclerosis (HR 3.9, P = .013) as independent predictors of 48-month MACE (cardiac death, nonfatal acute myocardial infarction, and coronary revascularization after RT). Patients with all 3 predictors had a 48-month MACE of 60% compared with 5% in those with none (P = .007). Compared with those without WMA, patients with both fixed and inducible WMA had a higher rate of MACE at 48 months (7% vs 33%, P = .004). In RT candidates, DSE can effectively identify those at low and high risk of MACE.

Not All Perioperative Myocardial Infarctions Can Be Prevented with Preoperative Revascularization

Not All Perioperative Myocardial Infarctions Can Be Prevented with Preoperative Revascularization

The prevalence and prognosis of unrecognized myocardial infarction and silent myocardial ischemia in patients undergoing major vascular surgery

The aim of this study is to determine the prevalence and prognosis of unrecognized myocardial infarction (MI) and silent myocardial ischemia in vascular surgery patients. In a cohort of 1092 patients undergoing preoperative dobutamine stress echocardiography and noncardiac vascular surgery, unrecognized MI was determined by rest wall motion abnormalities in the absence of a history of MI. Silent myocardial ischemia was determined by stress-induced wall motion abnormalities in the absence of angina pectoris. Beta blockers and statins were noted at baseline. During follow-up (mean: 6+/-4 years), all-cause mortality and major cardiac events (cardiac death or nonfatal MI) were noted. The prevalence of unrecognized MI and silent myocardial ischemia was 23 and 28%, respectively. Both diabetes and heart failure were important predictors of unrecognized MI and silent myocardial ischemia. During follow-up, all-cause mortality occurred in 45% and major cardiac events in 23% of patients. In multivariate analysis, unrecognized MI and silent myocardial ischemia were significantly associated with increased risk of mortality [hazard ratio (HR), 1.86; 95% confidence interval (CI), 1.53-2.25 and HR, 1.74; 95% CI, 1.46-2.06, respectively] and major cardiac events (HR, 2.15; 95% CI, 1.59-2.92 and HR, 1.86; 95% CI, 1.43-2.41, respectively). In patients with unrecognized MI, beta-blockers and statins were significantly associated with improved survival. Statins improved survival in patients with silent myocardial ischemia. In patients undergoing major vascular surgery, unrecognized MI and silent myocardial ischemia are highly prevalent (23 and 28%) and associated with increased long-term mortality and major cardiac events.

Myocardial Damage in High-risk Patients Undergoing Elective Endovascular or Open Infrarenal Abdominal Aortic Aneurysm Repair

Objective Dobutamine stress echocardiography (DSE) provides an objective assessment of the presence and extent of coronary artery disease. Therefore we compared cardiac outcome in patients at high-cardiac risk undergoing open or endovascular repair of infrarenal AAA using preoperative DSE results. Methods Consecutive patients with ≥3 cardiac risk factors (age >70 years, angina pectoris, myocardial infarction, heart failure, stroke, renal failure, and diabetes mellitus) undergoing infrarenal AAA repair were reviewed retrospectively. All underwent cardiac stress testing using DSE. Postoperatively data on troponin release and ECG were collected on day 1, 3, 7, before discharge, and on day 30. The main outcome measures were perioperative myocardial damage and myocardial infarction or cardiovascular death. Results All 77 patients (39 endovascular, 38 open) had a history of cardiac disease. The number and type of cardiac risk factors were similar in both groups. Also DSE results were similar: 55 vs 56%, 24 vs 28%, and 21 vs 18% had no, limited, or extensive stress induced myocardial ischemia respectively. The incidence of perioperative myocardial damage (47% vs 13%, p=0.001) and the combination of myocardial infarction or cardiovascular death (13% vs 0%, p=0.02) was significantly lower in patients receiving endovascular repair. Conclusion In patients with similar high cardiac risk, endovascular repair of infrarenal aortic aneurysms is associated with a reduced incidence of perioperative myocardial damage.

Pro: Beta-Blockers Are Indicated for Patients at Risk for Cardiac Complications Undergoing Noncardiac Surgery

Pro: Beta-Blockers Are Indicated for Patients at Risk for Cardiac Complications Undergoing Noncardiac Surgery

Myocardial Damage in High-risk Patients Undergoing Elective Endovascular or Open Infrarenal Abdominal Aortic Aneurysm Repair

Dobutamine stress echocardiography (DSE) provides an objective assessment of the presence and extent of coronary artery disease. Therefore we compared cardiac outcome in patients at high-cardiac risk undergoing open or endovascular repair of infrarenal AAA using preoperative DSE results. Consecutive patients with >or=3 cardiac risk factors (age >70 years, angina pectoris, myocardial infarction, heart failure, stroke, renal failure, and diabetes mellitus) undergoing infrarenal AAA repair were reviewed retrospectively. All underwent cardiac stress testing using DSE. Postoperatively data on troponin release and ECG were collected on day 1, 3, 7, before discharge, and on day 30. The main outcome measures were perioperative myocardial damage and myocardial infarction or cardiovascular death. All 77 patients (39 endovascular, 38 open) had a history of cardiac disease. The number and type of cardiac risk factors were similar in both groups. Also DSE results were similar: 55 vs 56%, 24 vs 28%, and 21 vs 18% had no, limited, or extensive stress induced myocardial ischemia respectively. The incidence of perioperative myocardial damage (47% vs 13%, p=0.001) and the combination of myocardial infarction or cardiovascular death (13% vs 0%, p=0.02) was significantly lower in patients receiving endovascular repair. In patients with similar high cardiac risk, endovascular repair of infrarenal aortic aneurysms is associated with a reduced incidence of perioperative myocardial damage.

Protecting the Heart with Cardiac Medication in Patients with Left Ventricular Dysfunction Undergoing Major Noncardiac Vascular Surgery

Patients with left ventricular dysfunction who are undergoing major noncardiac vascular surgery are at increased risk of adverse postoperative events. We sought to evaluate whether perioperative medication use, including angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, statins, and aspirin, was associated with a reduced incidence of postoperative in-hospital mortality in these high-risk patients. The study enrolled 511 patients with left ventricular dysfunction (left ventricular ejection fraction <30%) who were undergoing major noncardiac vascular surgery. Cardiac risk factors and medication use were noted before surgery. Preoperative dobutamine stress echocardiography (DSE) was performed to identify patients with stress-induced myocardial ischemia. The end point was postoperative in-hospital mortality. Univariate and multivariate logistic regression analyses were performed to evaluate the relation between perioperative medication use and mortality. The mean age of the study population was 64 +/- 11 years, and 75% were men. Perioperative use of ACE inhibitors, beta-blockers, statins, and aspirin was recorded in 215 (48%), 139 (27%), 107 (21%), and 125 patients (24%), respectively. Stress-induced myocardial ischemia occurred in 82 patients (16%). Sixty-four patients (13%) died. Perioperative use of ACE inhibitors (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.12-0.91), beta-blockers (OR, 0.03; 95% CI, 0.01-0.26), statins (OR, 0.06; 95% CI, 0.01-0.53), and aspirin (OR, 0.13; 95% CI, 0.03-0.55), was significantly associated with a reduced incidence of mortality, after adjusting for cardiac risk factors and DSE results. In conclusion, the present study showed that the perioperative use of ACE inhibitors, beta-blockers, statins, and aspirin is independently associated with a reduced incidence of in-hospital mortality in patients with left ventricular dysfunction who are undergoing major noncardiac vascular surgery.

Long-term cardiovascular risk in the orthotopic liver transplant population

In theoperative and peri-operative period, these events in-clude life-threatening arrhythmias at the time of donorliver reperfusion, myocardial ischemia or myocardialinfarction (MI) or congestive heart failure. In long termOLTx survivors, CV events include unstable angina, MIor death. Therefore, assessing short and long term CVrisk is an important aspect of the ESLD pretransplantevaluation.Currently, there is no widely accepted algorithm toidentify patients that are at high risk of perioperativetransplant CV events from the hemodynamic stress ofsurgery. Contrary to data in the vascular surgery pop-ulation

Preoperative Dobutamine Stress Echocardiography, Intraoperative Events, and Intraoperative Myocardial Injury in Liver Transplantation

Introduction The appropriate method of screening for coronary artery disease in patients who present for liver transplantation is currently uncertain. Methods We assessed the utility of a screening protocol using dobutamine stress echocardiography (DSE) in 119 patients who underwent liver transplantation. Patients with cardiac risk factors had DSE performed, and those with positive results were referred for coronary angiography. Outcome was myocardial injury during liver transplantation determined by an elevation of cardiac troponin T measured after transplantation. Results Seventy-three patients had DSE performed; eight were reported as positive for inducible ischemia. Seven of these patients underwent coronary angiography, and one had significant coronary artery disease. Postoperative troponin elevation occurred in 14 patients. There was no significant difference in the prevalence of troponin elevation in those patients with positive DSE versus those with negative DSE. No significant difference was identified in the prevalence of troponin elevation when comparing those patients with cardiac risk factors who underwent DSE with those patients with no risk factors and no DSE performed. DSE had a sensitivity of 0.2 and a specificity of 0.9 for myocardial injury. The prevalence of intraoperative hemodynamic instability was significantly higher in patients who had evidence of myocardial injury, but hemodynamic instability was no more common in patients who had a positive DSE. Conclusion When used in accordance with our protocol a positive DSE does not reliably identify patients at high cardiac risk during liver transplantation, but a negative DSE is strongly predictive of no myocardial injury.

Cardiac events in patients with negative maximal versus negative submaximal dobutamine echocardiograms undergoing noncardiac surgery: Importance of resting wall motion abnormalities

ObjectivesThis study sought to evaluate the negative predictive value (NPV) of preoperative dobutamine stress echocardiography (DSE) in patients who fail to achieve target heart rate (HR) and assess the influence of resting wall motion abnormalities (WMAs) without demonstrable ischemia on perioperative events. BackgroundThe prognostic value of a negative-submaximal DSE study before noncardiac surgery is unknown. MethodsConsecutive patients (n = 429) who underwent surgery over a three-year period, preceded by DSE, were included. We compared perioperative event rates among those without inducible ischemia according to whether or not 85% age-adjusted maximum HR was achieved, and whether WMAs were present at rest. ResultsOf 397 negative DSEs, peak HR was <85% maximum predicted in 62 (16%). Most were receiving beta-blockers (77%). The average dobutamine and atropine doses were 48 μg/kg/min and 1.2 mg, respectively. Average HR was 115 beats/min (74% maximum predicted). Perioperative myocardial infarctions occurred more frequently in patients with positive tests (3 of 32 [9.4%] vs. 7 of 397 [1.8%]; p = 0.03), but with similar frequency among the negative-maximal and negative-submaximal groups (6 of 335, 1.8% vs. 1 of 62, 1.6%, respectively). Accordingly, the NPV was 98% in both subgroups. Events occurred exclusively in patients with WMAs at rest: 7 of 100 (7%) versus 0 of 297 (0%) (p < 0.0001). ConclusionsIn patients undergoing preoperative DSE, failure to achieve target HR is not uncommon despite an aggressive DSE regimen. A negative DSE without resting WMAs has excellent NPV regardless of the HR achieved. Patients with resting WMAs appear to be at increased risk for perioperative events even without provokable ischemia.

Les limites de lèchocardiographie d’effort préopératoire avec dobutamine dans l’identification d’une sténose du tronc de l’artère coronaire gauche : observation de deux cas et brève revue

Using case illustrations, to elucidate factors which increase the likelihood of false negative preoperative dobutamine stress echocardiography (DSE) studies in patients with severe left main coronary artery stenosis, and to provide criteria which must be met in order to ensure the accurate interpretation of these tests. Two patients presented for elective abdominal aortic aneurysm repair within a one-month period of time. Both patients had DSE as part of their preoperative assessment, which were interpreted as normal. Nevertheless, both suffered major coronary events in the perioperative period, and both proved to have severe left main coronary artery stenosis on postoperative angiography. A narrative review is presented based on a selection of the current literature, and local experience with the technique. Some pitfalls in the interpretation of these tests are presented, along with modalities to increase their sensitivity and specificity. DSE is an important and useful modality in the preoperative cardiac evaluation of patients who are unable to exercise. However the reliable interpretation of the test depends on an understanding of the limitations of the procedure.

Optimizing long-term cardiac management after major vascular surgery: Role of beta-blocker therapy, clinical characteristics, and dobutamine stress echocardiography to optimize long-term cardiac management after major vascular surgery.

Survivors of major vascular surgery are at increased risk of late cardiac complications. To examine the cardioprotective effect of beta-blockers. A follow-up study was conducted in 1286 patients who survived surgery for at least 30 days. Patients were screened for cardiac risk factors and dobutamine stress echocardiography (DSE) results; 1034 patients (80%) underwent preoperative DSE, and 370 (29%) received beta-blockers. The main outcome measure was late cardiac death or myocardial infarction. Seventy-four patients (5.8%) had late cardiac events. Cardiac event rates in patients with 0, 1 to 2, and 3 or more risk factors were 1.6%, 4.7%, and 19.2%, respectively. In patients without risk factors, beta-blockers were associated with improved event-free survival (2.8% vs 0%), and DSE had no additional prognostic value. In patients with 1 to 2 risk factors, the presence of ischemia during DSE increased cardiac events from 3.9% to 9.8%. However, if patients with ischemia were treated with beta-blockers, the risk decreased to 7.2%. In patients with 3 or more risk factors, DSE and beta-blockers stratified patients into intermediate- and high-risk groups. In patients without ischemia, beta-blockers reduced the cardiac event rate from 15.1% to 9.5%, whereas the cardioprotective effect was limited in patients with 3 or more risk factors and positive DSE findings. Long-term beta-blocker use is associated with a reduction in the cardiac event rate, except for patients with 3 or more risk factors and positive findings on DSE.

Preoperative cardiology consultation.

In a 1998 survey of New York metropolitan area anesthesiologists, surgeons, and cardiologists, the three specialties were in general agreement that important purposes of a cardiology consultation are to treat an inadequately treated cardiac condition before surgery (e.g., unstable angina or congestive heart failure [CHF]), to provide data to use in anesthesia management (e.g., ischemic threshold of tachycardia on stress test or left ventricular ejection fraction), and possibly to diagnose a medical condition before surgery (e.g., the cause of a new-onset atrial fibrillation). The yield of a cardiology consultation, in terms of new therapy or significant effect on patient management strategy prior to surgery, has, however, been reported to vary widely from 10% to more than 70%. The reasons why the consultation process often falls short of ideal are probably multifold, but may often originate from vague understanding of the consultation process. The physician initiating the consultation, whether an anesthesiologist or a surgeon, may not make it clear to the cardiologist why the consultation is being sought. In a retrospective review of 202 cardiology consultations at a university hospital, it was found that 108 just asked for an “evaluation,” 79 asked for a “clearance,” and 9 did not specifically request anything. Only six posed a specific question. As a result, the consultant often makes broadly inclusive, general remarks about perioperative management of the patient and may recommend preoperative diagnostic work-up that does not influence the patient’s outcome but prolongs the hospital stay. In this review are presented (1) the indications for cardiology consultations as implied in the American College of Cardiology–American Heart Association (ACC–AHA) guidelines on preoperative cardiac evaluation, and (2) suggestions on how the ACC–AHA guidelines may be critically applied to, and improve, the consultation process. Preoperative Cardiac Consultation Based on the ACC–AHA Guidelines The ACC–AHA guidelines on preoperative cardiac evaluation were published initially in 1996 and were also endorsed by the Society of Cardiovascular Anesthesiologists and the Society for Vascular Surgery. An updated version of the guidelines was published in 2002. The guidelines were based on the then-available literature as well as expert opinions from the disciplines of anesthesiology, cardiology, electrophysiology, vascular medicine, vascular surgery, and noninvasive cardiac testing. The guidelines provided an 8-step algorithm for stratifying the patient’s risks and triaging to either surgery or cardiac evaluation. The first three steps of the guidelines consider the urgency of the operation and the recency of cardiac evaluation and intervention. If the operation is not emergent and if there has not been recent cardiac evaluation and/or intervention with no significant interim changes, then the remainder of the guidelines are applied. Steps 4 through 7 deal with an assessment of the patient’s clinical predictors of cardiac risk, functional status, and the risk of the surgery proposed. Step 8, or noninvasive cardiac testing to further define the patient’s risk, is indicated (1) if the patient has a major clinical predictor, (2) if the patient has an intermediate clinical predictor and either has poor functional status or is undergoing a high-risk surgery, or (3) if the patient has poor functional status and is undergoing a high-risk surgery. As defined by the ACC–AHA, major clinical predictors are unstable coronary syndrome, decompensated congestive heart failure (CHF), significant arrhythmias, and severe valvular disease. Intermediate clinical predictors are mild angina pectoris, history of myocardial infarction (MI) or CHF, diabetes mellitus, and chronic renal failure with serum creatinine greater than 2 mg/dl. A high-risk surgery carries a greater than 5% perioperative risk of cardiac events such as MI, CHF, or death and is exemplified by emergent major operations, especially in the elderly, aortic, and other major vascular procedures, peripheral vascular bypass procedures, and anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss. An intermediate-risk surgery carries 1–5% perioperative risk of cardiac events and is exemplified by carotid endarterectomy, intraperitoneal and Director of Vascular Anesthesia, Department of Anesthesia & Critical Care, Beth Israel Deaconess Medical Center, and Associate Professor of Anaesthesia, Harvard Medical School.

Correlation of location of acute myocardial infarct after noncardiac vascular surgery with preoperative dobutamine echocardiographic findings

T aim of this study was to assess the usefulness of preoperative dobutamine stress echocardiography (DSE) for the identification of culprit coronary lesions in patients who died within 30 days of major vascular surgery and underwent autopsy. • • • The records of all 1,065 patients who underwent elective major vascular surgery (abdominal aortic aneurysm resection, aortofemoral bypass, and infrainguinal arterial reconstruction) between 1989 and 2000 at the Eramus Medical Centre, Rotterdam, The Netherlands, were screened. Patients were included in the study if they had undergone preoperative DSE, died within 30 days of elective major vascular surgery, and had available autopsy results. We excluded any patients who underwent myocardial revascularization subsequent to DSE but before vascular surgery. A presumptive diagnosis of perioperative acute myocardial infarction (AMI) was made in patients with a serum creatine kinase-MB fraction of 10%, and new electrocardiographic Q waves lasting 0.03 second. DSE was performed as previously described. The left ventricle was divided into 16 segments, and wall motion was scored on a 5-point scale (1 normal, 2 mild hypokinesia, 3 severe hypokinesia, 4 akinesia, and 5 dyskinesia). The result was considered positive if wall motion in any segment deteriorated by 1 grade during testing new wall motion abnormalities (NWMA). Ischemic segments were grouped into 3 coronary territories: left anterior descending, left circumflex, and right coronary arteries. A cardiac pathologist (MK), unaware of the DSE results, reviewed all postmortem reports and the heart specimen sections and determined the presence and location of recent AMI. Coronary arteries were cut at 5-mm intervals. AMIs were subsequently grouped into the appropriate coronary territories, whether a coronary thrombus was present or not. Established myocardial scars were not included, but recent ischemia adjacent to a scar was. Continuous data are presented as mean value (range); dichotomous data are presented as percentages. Sensitivity and specificity figures, global and region specific, are determined for DSE-induced ischemia to predict AMI as assessed by autopsy. No inferential statistics were obtained. Thirty-two patients met our inclusion criteria of preoperative DSE, elective major vascular surgery, perioperative death, and available autopsy results. The clinical characteristics, DSE results, and autopsy findings of these patients are listed in Table 1. Most patients were elderly, and the clinically suspected cause of death was cardiac in 53%. DSE was positive (i.e., stress-induced NWMA) in 16 patients (50%). In 7 of these patients, ischemia was induced in 1 coronary territory. Stress-induced NWMA was apparent in the left anterior descending (n 11 [69%]), left circumflex (n 9 [56%]), and right coronary artery (6 [38%]) territories. Twenty-one patients (66%) showed evidence of myocardial infarction at autopsy. In 9 of these patients (43%), infarction involved 1 coronary territory. Infarction was localized to the left anterior descending (n 14 [66%]), left circumflex (n 12 [57%]), and right coronary artery (n 7 [33%]) territories. Surgery was performed 41 days (range 5 to 81) after DSE. Autopsy was performed within 2 days after patients’ death. In all of the 16 patients with inducible ischemia during DSE, the clinically suspected cause of death was cardiac and all showed AMI at autopsy. However, 5 patients without preoperative stress-induced ischemia also exhibited evidence of recent myocardial ischemia at autopsy. Of these 5 patients, the suspected cause of death was stroke in 2, sepsis in 1, massive bleeding in 1, and cardiac in 1. The sensitivity and specificity DSE for prediction of a perioperative AMI in this subset of patients were 76% (16 of 21 patients) and 100% (11 of 11 patients), respectively. In 81% of these patients (13 of 16), AMI was located in a coronary artery territory that also exhibited stress-induced ischemia on DSE. However, in 9 of 16 patients (56%), pathologic evidence of infarction was apparent in a coronary artery territory that did not exhibit NWMA during DSE. The sensitivity and specificity of DSE for prediction of infarction in a specific territory were 44% (7 of 16 patients) and 69% (11 of 16 patients), respectively. • • • This study showed that patients who died after major noncardiac vascular surgery frequently had significant coronary pathology. Preoperative DSE is useful in identifying these patients. Inducible ischemia on DSE was noted in 16 of 32 patients and all 16 of these patients had perioperative AMI. Only 5 patients with From the Thoraxcentre and Department of Pathology, Erasmus Medical Centre, Rotterdam, The Netherlands; and The University of Manitoba, Winnipeg, Manitoba, Canada. Dr. Poldermans’ address is: Thoraxcentre, Room H921, Erasmus University, Rotterdam, The Netherlands. E-mail: poldermans@hlkd.azr.nl. Manuscript received May 29, 2001; revised manuscript received and accepted August 24, 2001.