Abstract
We examined the relative efficacies of different cardiac screening strategies for infrainguinal arterial bypass. The outcomes of 205 elective leg bypass procedures over a 10-year period, including myocardial infarction (MI), total cardiac complications, and mortality were tallied. Clinical risk factors popularized by Goldman and Eagle, and the results of dipyridamole thallium myocardial imaging (DThal) were recorded. The overall mortality rate was 3.4%, with a 3.4% incidence of Ml and a 5.4% total cardiac complication rate. Both abnormal DThal (p = 0.011) and Goldman class II-IV (p = 0.030) were significant predictors of Ml and cardiac death, but both suffered from poor specificity and positive predictive value. Because logistic regression analysis identified a correlation between angina, CHF, and an abnormal DThal, a customized screening strategy was developed to include the presence of angina, CHF and an abnormal DThal. Eighty-eight percent of patients suffering Ml or death met these criteria, while only 11% of the complication-free group did. This screening strategy provided a superior sensitivity of 88%, specificity of 89%, positive predictive value of 25%, and 99% negative predictive value. A customized screening strategy (angina, CHF, abnormal DThal), developed from a 10-year experience with a single patient group, provided better predictive accuracy than any generalized screening formula. (Ann Vasc Surg 1997; 11:620-625.)
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Hertzer NR. Fatal myocardial infarction following lower extremity revascularization: Two hundred seventy three patients followed six to eleven years. Ann Surg 1981;193:492–498.
Hertzer NR, Beven EG, Young JR, et al. Coronary artery disease in peripheral vascular patients: A classification of 1000 coronary angiograms and results of surgical management. Ann Surg 1984;199:223–233.
Hertzer NR, Avellone JC, Farrell CJ, et al. The risk of vascular surgery in a metropolitan community: With observations on surgeon experience and hospital size. J Vasc Surg 1984;1:13–21.
Krupski WC, Layug EL, Reilly LM, Rapp JH, Mangano DT,and the Study of Perioperative Ischemia (SPI) Research Group. Comparison of cardiac morbidity between aortic and infrainguinal operations. J Vasc Surg 1992; 15:354–365.
Stremple JF, Brass DS, Davis CL, McDonald GO. Comparison of postoperative mortality and morbidity in VA and nonfederal hospitals. J Surg Res 1994;56:405–416.
McGuire HH, Horsley JS, Salter DR, Sobel M. Measuring and managing quality of surgery: Statistical vs. incidental approaches. Arch Surg 1992; 127:733–738.
Hertzer NR. Fatal Myocardial infarction following peripheral vascular operations: A study of 951 patients followed 6 to 11 years postoperatively. Cleve Clin Quaterly 1982;49:1–11.
Taylor LM, Yeager RA, Moneta GL, McConnell DB, Porter JM. The incidence of perioperative myocardial infarction in general vascular surgery. J Vasc Surg 1991;15:52–61.
Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 1977;297:845–850.
Eagle KA, Coley CM, Newell JB, et al. Combining clinical and thallium data optimizes preoperative assessment of cardiac risk before major vascular surgery. Ann Intern Med 1989;110:859–866.
Detsky AS, Abrams HB, McLaughlin JR, et al. Predicting cardiac complications in patients undergoing non-cardiac surgery. J Gen Intern Med 1986,1:211–219.
Brown KA. Prognostic value of thallium-201 myocardial perfusion imaging: A diagnostic tool comes of age. Circulation 1991;83:363–381.
Eagle KA, Singer DE, Brewster DC, Darling RC, Mulley AG, Boucher CA. Dipyridamole-thallium scanning in patients undergoing vascular surgery: Optimizing preoperative evaluation of cardiac risk. JAMA 1987;257:2185–2189.
Boucher CA, Brewster DC, Darling RC, Okada RD, Strauss HW, Pohost GM. Determination of cardiac risk by dipyridamole-thallium imaging before peripheral vascular surgery. N Engl J Med 1985;312:389–394.
Lepo J, Plaja J, Gioonet M, Tumolo J, Paraskos JA, Cutler BS. Noninvasive evaluation of cardiac risk before elective vascular surgery. JACC 1987;9:269–276.
Lette J, Waters D, Bernier H, et al. Preoperative and long-term cardiac risk assessment: Predictive value of 23 clinical descriptors, 7 multivariate scoring systems, and quantitative dipyridamole imaging in 360 patients. Ann Surg 1992;216:192–204.
Reifsnyder T, Bandyk DF, Lanza D, Seabrook GR, Towne JB. Use of stress thallium imaging to stratify cardiac risk in patients undergoing vascular surgery. J Surg Res 1992;52:147–151.
Younis LT, Aguirre F, Byer S, et al. Perioperative and long-term prognostic value of intravenous dipyridamole thallium scintigraphy in patients with peripheral vascular disease. Am Heart J 1990;119:1287–1292.
Levinson JR, Boucher CA, Coley CM, Guiney TE, Strauss HW, Eagle KA. Usefulness of semiquantitative analysis of dipyridamole-thallium 201 redistribution for improving risk stratification before vascular surgery. Am J Cardiol 1990;66:406–410.
Pasternack PF, Imparato AM, Riles TS, et al. The value of the radionuclide angiogram in the prediction of perioperative myocardial infarction in patients undergoing lower extremity revascularization procedures. Circulation 1985;72 (suppl II):II 13–17.
Bry JD, Belkin M, O’Donnell TF, et al. An assessment of the positive predictive value and cost-effectiveness of dipyridamole myocardial scintigraphy in patients undergoing vascular surgery. J Vasc Surg 1994;19:112–124.
Gillespie DL, LaMorte WW, Josephs LG, Schneider T, Flock NR, Menzoian JO. Characteristics of patients at risk for peri-operative myocardial infarction after infrainguinal bypass surgery: An exploratory study. Ann Vasc Surg 1995;9:155–162.
Cutler BS, Hendel RC, Leppo JA. Dipyridamole-thallium scintigraphy predicts perioperative and long-term survival after major vascular surgery. J Vasc Surg 1992;15:972–981.
Mangano DT, London MJ, Tubau JF, et al. Dipyridamole thallium-201 scintigraphy as a preoperative screening test: A reexamination of its predictive potential. Circulation 1991; 84:493–502.
McEnroe CS, O’Donnel TF, Yeager A, Konstam M, Mackey WC. Comparison of ejection fraction and Goldman risk factor analysis to dipyridamole-thallium 201 studies in the evaluation of cardiac morbidity after aortic aneurysm surgery. J Vasc Surg 1990;1:497–504.
L’Italien GJ, Cambria RP, Cutler BS, et al. Comparative early and late cardiac morbidity among patients requiring different vascular surgery procedures. J Vasc Surg 1995;21:935–944.
de Virgilio C, Pak S, Arnell T, et al. Cardiac assessment prior to vascular surgery: Is dipyridamole-sestamibi necessary? Ann Vasc Surg 1996;10:325–329.
Hood DB, Weaver FA, Papanicolaou G., et al. Cardiac evaluation of the diabetic patient prior to peripheral vascular surgery. Ann Vasc Surg 1996;10:330–335.
Author information
Authors and Affiliations
Additional information
We wish to thank Luke Wolfe, M.S., Department of Surgery, Medical College of Virginia Hospitals, for his assistance in the statistical analysis of the data presented.
About this article
Cite this article
Matsuura, J.H., Sobel, M., Wong, J. et al. The limits of generalized cardiac screening tests for predicting cardiac complications after infrainguinal arterial reconstruction. Annals of Vascular Surgery 11, 620–625 (1997). https://doi.org/10.1007/s100169900100
Issue Date:
DOI: https://doi.org/10.1007/s100169900100