Basic Data Related to Cardiac Testing and Cardiac Risk Associated with Vascular Surgery

Basic Data for Decision-Making in Clinical Vascular Surgery Section Editor - John M. Porter, M D (Portland, Oregon)

Basic Data Related to Cardiac Testing and Cardiac Risk Associated with Vascular Surgery

Richard A. Yeager, MD, Portland, Oregon

Exercise electrocardiography as well as various radionuclide cardiac tests provide information that is predictive for the arteriographic presence of coronary artery disease, adverse cardiac events, and patient survival. A condensed interpretation of these data is difficult due to variability with study methodologies and patient populations. Nevertheless, some practical information can be derived from available data which may prove useful to the vascular surgeon who frequently faces a difficult surgical decision in patients with associated coronary artery disease. The various tests should be viewed as complementary rather than competitive, since they frequently reflect different parameters of myocardial function. Exercise of dipyridamole thallium-201 scanning assesses for segmental myocardial hypopFrom the Division of Vascular Surgery, Department of Surgery, Oregon Health Sciences University, and Portland Veterans Administration Medical Center, Portland, Oregon. Reprint requests: Richard A. Yeager, MD, Surgical Service lI2P, Portland Veterans Administration Medical Center, P.O. Box 1034, Portland, Oregon 97207. 193

effusion, while electrocardiographic abnormalities associated with exercise may be related to metabolic changes caused by regional myocardial hypoxia and ion flux [1]. Radionuclide arteriography can provide important prognostic information by measuring ventricular function at rest and with exercise. The vascular surgeon is keenly interested in the ability of these tests to predict perioperative cardiac complications including myocardial infarction and cardiac death. Variability with study end-points and end-point definitions is a confounding factor adversely affecting meaningful interpretation of these data. The incidence of perioperative myocardial infarction in these studies is highly dependent on the authors' method of identification and criteria for defining myocardial infarction. Although no perfect test exists for the prediction of perioperative cardiac complications following vascular surgery, the three tests analyzed (exercise ECG, thallium-201 scans, and radionuclide arteriography) have proved useful for preoperatively assessing cardiac risk.

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BASIC DATA FOR D E C I S I O N - M A K I N G I N CLINICAL V A S C U L A R S URGER Y

TABLE I,--Incidence of perioperative myocardial infarction with vascular surgery

Procedure Carotid endarterectomy Abdominal aortic aneurysm repair lschemic lower extremity revascularization Mixture of general vascular surgery

Overall MI* Fatal MI incidence incidence Ref(%) (%) erences 2.0 0.8 2-9 6.4 2.2 10-17 6.0

2.3

18-22

5.5

2.9

23-30

*MI = myocardial infarction

ANNALS OF VASCULAR SURGERY

TABLE II.--incidence of perioperative myocardial infarction following vascular surgery according to method of study and criteria for myocardial infarction MI incidence (%) 3.0

Method and MI* criteria Retrospective Prospective using ECG changes and cardiac enzyme elevation Prospective using MB isoenzyme elevation as only criterion

9.7

References 2--4,6,7,9,14, 15,19,2226 8,16,17,2729

14.7

13,20

*MI = myocardial infarction

TABLE III.--Ability of test to predict presence of arteriographically significant coronary artery disease Test (criterion for positive test) Exercise electrocardiography (ST depression) Stress-thallium scan (exercise defect) Intravenous dipyridamole thallium scan (Transient or persistent defect) Radionuclide arteriography (resting ejection fraction <50% or wall motion abnormality) Radionuclide arteriography (resting or exercise abnormality) Radionuclide arteriography (new exercise induced wall motion abnormality)

Sensitivity (%) 60-75

Specificity (%) 75-85

References 1,31-33

80-90

80-90

1,34,35

93

80

36

48

88

37

85

59

38

76

95

39, 40

Positive Senpresi- Speci- dictive tivity ficity value Ref(%) (%) (%) erences 89 69 38 27t,29, 30, 41- 43 t 49 78 39 21,27 t, 28,29, 45 41

Positive Test with Sensi- Speci- predictive criterion for tivity ficity value Refpositivity (%) (%) (%) erences Dipyridamole-thallium 92 66 22 27,30, scanning 41(redistribution) 43 Exercise 50 79 21 21,27, electrocardiography 44 (Ischemic ST-T segment depression) Radionuclide 44 94 52 13,17, arteriography 20 (ejection fraction -< 35%) *Cardiac complications other than myocardial infarction or cardiac death are excluded

TABLE V.--Prediction of perioperative cardiac complications* associated with vascular surgery

Test with criterion for positivity Dipyridamole-thallium scanning (redistribution) Exercise electrocardiography (ischemic ST-T segment depression) Radionuclide arteriography (ejection fraction -< 35%)

TABLE IV,--Prediction of perioperative myocardial infarction or cardiac death associated with vascular surgery*

94

50

8,13t,17 t, 2O*

*Cardiac death, myocardial infarction, pulmonary edema, ventricular arrhythmia, cardiac ischemia tlncluded only myocardial infarction or cardiac death

TABLE VI.--Prediction of perioperative myocardial infarction or cardiac death associated with elective aortic surgery

Method of risk assessment with criterion for positivity Goldman classification (class 2 & 3) Dipyridamolethallium scanning (two or more areas of redistribution) Radionuclide arteriography (ejection fraction -< 35%)

Positive predictive value Ref(%) erences 16 12"

Sensitivity (%) 64

Specificity (%) 59

100

72

26

46

46

91

40

13, 17

*Included cardiac death, myocardial infarction, pulmonary edema and ventricular tachycardia as endpoints

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TABLE Vll.--Survivat data based on resting radionuclide arteriography ejection fraction Survival (%) Patient population

Results EF* < 30%

Patients with known or suspected coronary artery disease Patients after myocardial infarction (MI) with preadmission New York Heart Association Functional Classes If-IV

1 year

2 years

References

7.5-80

55-65

47

40

48

97

48

95 88 79 93 81 74

49

EF < 40%, ventricular ectopy -> 10 depolarizations per hour, pulmonary raies upper lung fields EF ->40%, ventricular ectopy < 10 depolarizations per hour, no pulmonary rales in upper tung fields EF >- 51% .41 -< EF < ,51 EF -< .40 EF -> 51% ,41 -< EF < .51 EF -< ,40

Patients after MI with preadmission New York Heart Association Functional Class I Patients after MI Patients after MI with clinical ventricular failure

49

*EF = ejection fraction

TABLE VIII.--Prediction of future cardiac events

Patient population Patients post-MI Patients post-MI Patients post-MI

Patients with known or suspected coronary artery disease

Test Resting radionuclide arteriography Intravenous dipyridamotethallium scan Exercise thallium scan

Exercise thallium scan

Results Ejection fraction <35% Redistribution defects Multiple defects with exercise, redistribution, increased thallium tung activity Normal scan

Abnormal myocardial thallium scan but normal thallium activity in the lungs Increased thallium uptake by the lungs

Positive predictive value Death, Death, MI, or or new myocardial onset Cardiac infarction severe death, MI, (MI) by angina by or coronary 19 36 bypass by months months 60 months

References

36%

50

33%

50 51

86%

5%

52

25%

52

67%

52

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ANNALS OF

VASCULAR SURGERY

TABLE IX.--Survival data based on various types of stress testing

Patient population Chest pain patients

Patients with arteriographically significant coronary artery disease Patients with arteriographically significant coronary artery disease and resting radionuclide ejection fraction > 20% and < 55% Patients with arteriographically significant three vessel coronary disease

Test Exercise-thallium scan Exercise electrocardiography

Results

Negative Positive

Exercise radionuclide arteriography

Normal response Abnormal response

Exercise radionuclide arteriography and electrocardiography

ST segment depression -> lmm and decrease radionuclide ejection fraction with exercise

Normal

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