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CLINICAL STUDIES

Assessment of cardiac risk before nonvascular surgery

Dobutamine stress echocardiography in 530 patients

Mini K. Das, MD^*, Patricia A. Pellikka, MD, FACC^*, Douglas W. Mahoney, MS, Veronique L. Roger, MD, FACC^*, Jae K. Oh, MD, FACC^*, Robert B. McCully, MD, FACC^* and James B. Seward, MD, FACC^*

^* Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
Section of Biostatistics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA

Manuscript received July 22, 1999; revised manuscript received November 30, 1999, accepted January 13, 2000.

Reprint requests and correspondence: Dr. Patricia A. Pellikka, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905

OBJECTIVE

This study evaluated the incremental value of dobutamine stress echocardiography (DSE) for assessment of cardiac risk before nonvascular surgery.

BACKGROUND

Limited information exists regarding the preoperative assessment of cardiac risk in patients with known or suspected coronary artery disease who are to undergo nonvascular surgery.

METHODS

All patients (303 men, 227 women) who underwent DSE before nonvascular surgery and did not sustain an intervening event (coronary revascularization or cardiac event) were studied. Clinical, electrocardiographic and rest and stress echocardiographic variables were evaluated to identify predictors of postoperative cardiac events.

RESULTS

Events occurred in 6% of patients: 1 cardiac death and 31 nonfatal myocardial infarctions. All of these patients had inducible ischemia on DSE (sensitivity 100%, specificity 63%). Multivariate predictors of postoperative events in patients with ischemia were history of congestive heart failure (p = 0.006; odds ratio = 4.66; confidence interval 1.55 to 14.02) and ischemic threshold less than 60% of age-predicted maximal heart rate (p = 0.0001; odds ratio 7.002; confidence interval 2.79 to 17.61). Clinical variables of Eagle’s index identified 21% of patients as low, 68% as intermediate and 11% as high risk preoperatively; the postoperative event rates were 3%, 6% and 14%, respectively. Dobutamine stress echocardiography identified 60% of patients as low (no ischemia), 32% as intermediate (ischemic threshold 60% or more) and 8% as high risk (ischemic threshold < 60%); postoperative event rates were 0%, 9% and 43%, respectively.

CONCLUSIONS

In this population of patients with known or suspected coronary artery disease evaluated before nonvascular surgery, DSE had incremental value over clinical, electrocardiographic and rest echocardiographic variables for identifying patients at low, intermediate and high risk for postoperative cardiac events. Ischemia occurring at less than 60% of age-predicted maximal heart rate identified patients at highest risk.

Abbreviations and Acronyms   CI = confidence interval   DSE = dobutamine stress echocardiography   OR = odds ratio

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