Improved cardiac risk stratification in major vascular surgery with dobutamine-atropine stress echocardiography
D Poldermans,
M Arnese,
PM Fioretti,
A Salustri,
E Boersma,
IR Thomson,
Roelandt JR,
and
H van Urk
Thoraxcentre, Erasmus University, Rotterdam, The Netherlands.
OBJECTIVES. This study sought to optimize preoperative cardiac risk stratification in a large group of consecutive candidates for vascular surgery by combining clinical risk assessment and semiquantitative dobutamine-atropine stress echocardiography. BACKGROUND. Dobutamine-atropine stress echocardiography has been used for the prediction of perioperative cardiac risk in a small group of patients scheduled for elective major vascular surgery on the basis of the presence or absence of stress-induced regional left ventricular wall motion abnormalities. METHODS. Clinical risk assessment and dobutamine-atropine stress echocardiography were performed in 302 consecutive patients presenting for major vascular surgery. The extent and severity of stress wall motion abnormalities and the heart rate at which they occurred, in addition to the presence of wall motion abnormalities at rest, were assessed. RESULTS. The absence of clinical risk factors (angina, diabetes, Q waves on the electrocardiogram, symptomatic ventricular tachyarrhythmias, age > 70 years) identified a low risk group of 100 patients with a 1% cardiac event rate (unstable angina). Dobutamine-atropine stress echocardiographic findings were positive in 72 patients. Twenty-seven patients had a perioperative cardiac event (cardiac death in 5, nonfatal infarction in 12, unstable angina pectoris in 10); all 27 patients had positive stress test results (positive predictive value 38%, negative predictive value 100%). The semiquantitative assessment of the extent and severity of ischemia did not provide additional prognostic information in patients with positive test results. In contrast, the heart rate at which ischemia occurred defined a high risk group with a low ischemic threshold (38 patients with 20 events [53%]) and an intermediate risk group with a high ischemic threshold (34 patients with 7 events [21%]). All 5 patients with a fatal outcome and 8 of 12 with a nonfatal myocardial infarction were in the high risk group with a low ischemic threshold. CONCLUSIONS. Clinical variables identify 33% of patients at very low risk for perioperative complications of vascular surgery in whom further testing is redundant. In all other candidates, dobutamine-atropine stress echocardiography is a powerful tool that identifies those patients at intermediate risk and a small group at very high risk. Risk stratification with a combination of clinical assessment and pharmacologic stress echocardiography has the potential to facilitate clinical decision making and conserve resources.
This article has been cited by other articles:
|
|
|
|
 
American College of Cardiology Foundation, American Heart Association Task Force on Practice, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interve, Society for Vascular Medicine, Society for Vascular Surgery, L. A. Fleisher, et al.
2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery
J. Am. Coll. Cardiol.,
November 24, 2009;
54(22):
e13 - e118.
[Full Text]
[PDF]
|
|
|
|
|
|
|
2007 WRITING COMMITTEE MEMBERS, L. A. Fleisher, J. A. Beckman, K. A. Brown, H. Calkins, E. L. Chaikof, K. E. Fleischmann, W. K. Freeman, J. B. Froehlich, E. K. Kasper, et al.
2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
Circulation,
November 24, 2009;
120(21):
e169 - e276.
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Hoeks and D. Poldermans
CHAPTER 34 Non-cardiac Surgery in Cardiac Patients
ESC Textbook of Cardiovascular Medicine,
January 1, 2009;
2(1):
med-9780199566990-chapter - med-9780199566990-chapter.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Poldermans, S. E. Hoeks, and H. H. Feringa
Pre-Operative Risk Assessment and Risk Reduction Before Surgery
J. Am. Coll. Cardiol.,
May 20, 2008;
51(20):
1913 - 1924.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. M. Tsutsui, F. Xie, D. Cloutier, S. Kalvaitis, A. Elhendy, and T. R. Porter
Real-time dobutamine stress myocardial perfusion echocardiography predicts outcome in the elderly
Eur. Heart J.,
February 1, 2008;
29(3):
377 - 385.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
N. Sutaria and J. Mayet
Preoperative screening for coronary disease: who needs it and how do you do it?
Heart,
December 1, 2007;
93(12):
1497 - 1499.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. A. Fleisher, J. A. Beckman, K. A. Brown, H. Calkins, E. L. Chaikof, K. E. Fleischmann, W. K. Freeman, J. B. Froehlich, E. K. Kasper, J. R. Kersten, et al.
ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery
J. Am. Coll. Cardiol.,
October 23, 2007;
50(17):
e159 - e242.
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. A. Fleisher, J. A. Beckman, K. A. Brown, H. Calkins, E. L. Chaikof, K. E. Fleischmann, W. K. Freeman, J. B. Froehlich, E. K. Kasper, J. R. Kersten, et al.
ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)
Circulation,
October 23, 2007;
116(17):
e418 - e500.
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Poldermans, O. Schouten, R. Vidakovic, J. J. Bax, I. R. Thomson, S. E. Hoeks, H. H.H. Feringa, M. Dunkelgrun, P. de Jaegere, A. Maat, et al.
A Clinical Randomized Trial to Evaluate the Safety of a Noninvasive Approach in High-Risk Patients Undergoing Major Vascular Surgery: The DECREASE-V Pilot Study
J. Am. Coll. Cardiol.,
May 1, 2007;
49(17):
1763 - 1769.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Raux, G. Godet, R. Isnard, P. Mergoni, J.-P. Goarin, M. Bertrand, M. Fleron, P. Coriat, and B. Riou
Low negative predictive value of dobutamine stress echocardiography before abdominal aortic surgery
Br. J. Anaesth.,
December 1, 2006;
97(6):
770 - 776.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. H. Marwick
Ischaemia and outcome with normal coronary arteries
Eur. Heart J.,
October 2, 2005;
26(20):
2077 - 2078.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. M. Tsutsui, A. Elhendy, J. R. Anderson, F. Xie, A. C. McGrain, and T. R. Porter
Prognostic Value of Dobutamine Stress Myocardial Contrast Perfusion Echocardiography
Circulation,
September 6, 2005;
112(10):
1444 - 1450.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. D'Andrea, S. Severino, P. Caso, B. Liccardo, A. Forni, A. Fusco, R. Lo Piccolo, M. Scherillo, N. Mininni, and R. Calabro
Prognostic value of supine bicycle exercise stress echocardiography in patients with known or suspected coronary artery disease
Eur J Echocardiogr,
August 1, 2005;
6(4):
271 - 279.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. F. Armstrong and W. A. Zoghbi
Stress Echocardiography: Current Methodology and Clinical Applications
J. Am. Coll. Cardiol.,
June 7, 2005;
45(11):
1739 - 1747.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Sharma and S. J Brecker
Dobutamine stress echocardiography in diabetes
The British Journal of Diabetes & Vascular Disease,
January 1, 2005;
5(1):
42 - 46.
[Abstract]
[PDF]
|
|
|
|
|
|
|
J. N. Ghansah and J. T. Murphy
Complications of Major Aortic and Lower Extremity Vascular Surgery
Seminars in Cardiothoracic and Vascular Anesthesia,
December 1, 2004;
8(4):
335 - 361.
[Abstract]
[PDF]
|
|
|
|
|
|
|
M Bountioukos, A Elhendy, R T van Domburg, A F L Schinkel, J J Bax, B J Krenning, E Biagini, V Rizzello, M L Simoons, and D Poldermans
Prognostic value of dobutamine stress echocardiography in patients with previous coronary revascularisation
Heart,
September 1, 2004;
90(9):
1031 - 1035.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. B. Labib, M. Goldstein, P. M. Kinnunen, and E. C. Schick
Cardiac events in patients with negative maximal versus negative submaximal dobutamine echocardiograms undergoing noncardiac surgery: Importance of resting wall motion abnormalities
J. Am. Coll. Cardiol.,
July 7, 2004;
44(1):
82 - 87.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M D Kertai, E Boersma, J J Bax, M H Heijenbrok-Kal, M G M Hunink, G J L'talien, J R T C Roelandt, H van Urk, and D Poldermans
A meta-analysis comparing the prognostic accuracy of six diagnostic tests for predicting perioperative cardiac risk in patients undergoing major vascular surgery
Heart,
November 1, 2003;
89(11):
1327 - 1334.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. D. Kertai, E. Boersma, J. J. Bax, I. R. Thomson, M. J. Cramer, L. L. M. van de Ven, M. G. Scheffer, G. Trocino, C. Vigna, H. F. Baars, et al.
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
Arch Intern Med,
October 13, 2003;
163(18):
2230 - 2235.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A D'Andrea, S Severino, P Caso, L De Simone, B Liccardo, A Forni, M Pascotto, G Di Salvo, M Scherillo, N Mininni, et al.
Prognostic value of pharmacological stress echocardiography in diabetic patients
Eur J Echocardiogr,
September 1, 2003;
4(3):
202 - 208.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. A. Grayburn and L D. Hillis
Cardiac Events in Patients Undergoing Noncardiac Surgery: Shifting the Paradigm from Noninvasive Risk Stratification to Therapy
Ann Intern Med,
March 18, 2003;
138(6):
506 - 511.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. D. Kertai, E. W. Steyerberg, E. Boersma, J. J. Bax, Y. Vergouwe, H. van Urk, J. D. F. Habbema, J. R. T. C. Roelandt, and D. Poldermans
Validation of Two Risk Models for Perioperative Mortality in Patients Undergoing Elective Abdominal Aortic Aneurysm Surgery
Vascular and Endovascular Surgery,
January 1, 2003;
37(1):
13 - 21.
[Abstract]
[PDF]
|
|
|
|
|
|
|
T. H Marwick
Stress echocardiography
Heart,
January 1, 2003;
89(1):
113 - 118.
[Full Text]
[PDF]
|
|
|
|
|
|
|
P.-G. Chassot, A. Delabays, and D. R. Spahn
Preoperative evaluation of patients with, or at risk of, coronary artery disease undergoing non-cardiac surgery
Br. J. Anaesth.,
November 1, 2002;
89(5):
747 - 759.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
F. Jin and F. Chung
Minimizing perioperative adverse events in the elderly{dagger}
Br. J. Anaesth.,
October 1, 2001;
87(4):
608 - 624.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D Poldermans, E Boersma, J.J Bax, I.R Thomson, B Paelinck, L.L.M van de Ven, M.G Scheffer, G Trocino, C Vigna, H.F Baars, et al.
Bisoprolol reduces cardiac death and myocardial infarction in high-risk patients as long as 2 years after successful major vascular surgery
Eur. Heart J.,
August 1, 2001;
22(15):
1353 - 1358.
[Abstract]
[PDF]
|
|
|
|
|
|
|
E. Boersma, D. Poldermans, J. J. Bax, E. W. Steyerberg, I. R. Thomson, J. D. Banga, L. L. M. van de Ven, H. van Urk, J. R. T. C. Roelandt, and for the DECREASE Study Group
Predictors of Cardiac Events After Major Vascular Surgery: Role of Clinical Characteristics, Dobutamine Echocardiography, and {beta}-Blocker Therapy
JAMA,
April 11, 2001;
285(14):
1865 - 1873.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. H. Marwick, C. Case, S. Sawada, C. Rimmerman, P. Brenneman, R. Kovacs, L. Short, and M. Lauer
Prediction of mortality using dobutamine echocardiography
J. Am. Coll. Cardiol.,
March 1, 2001;
37(3):
754 - 760.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Poldermans, J. J. Bax, A. Elhendy, F. Sozzi, E. Boersma, I. R. Thomson, and L. J. Jordaens
Long-term Prognostic Value of Dobutamine Stress Echocardiography in Patients With Atrial Fibrillation
Chest,
January 1, 2001;
119(1):
144 - 149.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Mantha
Rational Cardiac Risk Stratification Before Peripheral Vascular Surgery: Application of Evidence-Based Medicine and Bayesian Analysis
Seminars in Cardiothoracic and Vascular Anesthesia,
November 1, 2000;
4(4):
198 - 212.
[PDF]
|
|
|
|
|
|
|
M. K. Das, P. A. Pellikka, D. W. Mahoney, V. L. Roger, J. K. Oh, R. B. McCully, and J. B. Seward
Assessment of cardiac risk before nonvascular surgery: Dobutamine stress echocardiography in 530 patients
J. Am. Coll. Cardiol.,
May 1, 2000;
35(6):
1647 - 1653.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Doshi and B. N. Singh
Reducing Perioperative Cardiac Risk in Noncardiac Surgery: A Time to Delineate Simpler Strategies?
Journal of Cardiovascular Pharmacology and Therapeutics,
January 1, 2000;
5(2):
69 - 75.
[PDF]
|
|
|
|
|
|
|
W. K. Freeman
Expert Commentary
Perspectives in Vascular Surgery and Endovascular Therapy,
January 1, 2000;
12(2):
49 - 51.
[PDF]
|
|
|
|
|
|
|
D. Poldermans, E. Boersma, J. J. Bax, I. R. Thomson, L. L.M. van de Ven, J. D. Blankensteijn, H. F. Baars, T.-I. Yo, G. Trocino, C. Vigna, et al.
The Effect of Bisoprolol on Perioperative Mortality and Myocardial Infarction in High-Risk Patients Undergoing Vascular Surgery
N. Engl. J. Med.,
December 9, 1999;
341(24):
1789 - 1794.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. H. Lee
Reducing Cardiac Risk in Noncardiac Surgery
N. Engl. J. Med.,
December 9, 1999;
341(24):
1838 - 1840.
[Full Text]
|
|
|
|
|
|
|
R. Sicari, A. Ripoli, E. Picano, A. Djordjevic-Dikic, R. Di Giovanbattista, G. Minardi, S. Matskeplishvili, S. Ambatiello, G. Pulignano, M. Accarino, et al.
Perioperative Prognostic Value of Dipyridamole Echocardiography in Vascular Surgery : A Large-Scale Multicenter Study in 509 Patients
Circulation,
November 9, 1999;
100
(2009):
II-269 - II-274.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. Bossone, F. J. Martinez, R. I. Whyte, M. D. Iannettoni, W. F. Armstrong, and D. S. Bach
DOBUTAMINE STRESS ECHOCARDIOGRAPHY FOR THE PREOPERATIVE EVALUATION OF PATIENTS UNDERGOING LUNG VOLUME REDUCTION SURGERY
J. Thorac. Cardiovasc. Surg.,
September 1, 1999;
118(3):
542 - 546.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Schroeder
The Preoperative Period Summary
Chest,
May 1, 1999;
115
(2009):
44S - 46S.
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. Belzberg and A. I. Rivkind
Preoperative Cardiac Preparation
Chest,
May 1, 1999;
115
(2009):
82S - 95S.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Krivokapich, J. S. Child, D. O. Walter, and A. Garfinkel
Prognostic value of dobutamine stress echocardiography in predicting cardiac events in patients with known or suspected coronary artery disease
J. Am. Coll. Cardiol.,
March 1, 1999;
33(3):
708 - 716.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Poldermans, P. M. Fioretti, E. Boersma, J. J. Bax, I. R. Thomson, J. R. T. C. Roelandt, and M. L. Simoons
Long-Term Prognostic Value of Dobutamine-Atropine Stress Echocardiography in 1737 Patients With Known or Suspected Coronary Artery Disease : A Single-Center Experience
Circulation,
February 16, 1999;
99(6):
757 - 762.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Poldermans, F. J. ten Cate, A. Elhendy, G. Rocchi, J. J. Bax, W. Vletter, and J. R. T. C. Roelandt
Ventricular Tachycardia During Dobutamine Stress Myocardial Contrast Imaging
Chest,
January 1, 1999;
115(1):
307 - 308.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Sonksen, R. Gray, and P. H. Hickman
Safer non-cardiac surgery for patients with coronary artery disease
BMJ,
November 21, 1998;
317(7170):
1400 - 1401.
[Full Text]
|
|
|
|
|
|
|
L. Goldman
A 75-Year-Old Woman With an Abdominal Aortic Aneurysm and Emphysema
JAMA,
July 22, 1998;
280(4):
366 - 372.
[Full Text]
[PDF]
|
|
|
|
|
|
|
S.-C. Chuah, P. A. Pellikka, V. L. Roger, R. B. McCully, and J. B. Seward
Role of Dobutamine Stress Echocardiography in Predicting Outcome in 860 Patients With Known or Suspected Coronary Artery Disease
Circulation,
April 21, 1998;
97(15):
1474 - 1480.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. T. Mangano and L. Goldman
Preoperative Assessment of Patients with Known or Suspected Coronary Disease
N. Engl. J. Med.,
December 28, 1995;
333(26):
1750 - 1756.
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. Rossi, L. M. Biasucci, F. Citterio, S. Pelliccioni, C. Monaco, F. Ginnetti, D. J. Angiolillo, G. Grieco, G. Liuzzo, and A. Maseri
Risk of Myocardial Infarction and Angina in Patients With Severe Peripheral Vascular Disease: Predictive Role of C-Reactive Protein
Circulation,
February 19, 2002;
105(7):
800 - 803.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
