Prognosis of patients with vascular disease after clinical evaluation and dobutamine stress echocardiography.
BACKGROUND
Coronary disease is an important cause of long-term morbidity in patients needing major vascular surgery. We sought to assess the efficacy of preoperative clinical evaluation and the detection of inducible ischemia for prediction of immediate and long-term cardiac outcomes of patients undergoing vascular surgery.


METHODS
In 233 patients undergoing vascular procedures, we assessed risk clinically on the basis of Eagle's criteria. Dobutamine echocardiography was performed with a standard protocol and results were classified as showing ischemia, scar, or a normal response. Patients were observed perioperatively, and late follow-up (28 +/- 13 months) was completed in all surgical survivors. A composite end point of cardiac death, myocardial infarction, and unstable and progressive angina requiring late revascularization was used to judge event-free survival.


RESULTS
Of 233 patients undergoing preoperative dobutamine echocardiography, 39 (17%) had inducible ischemia and 36 (15%) had scar. Perioperative events occurred in 8 patients (3%). None of the patients with ischemia had perioperative events, reflecting the effect of revascularization in 9 patients. Late events occurred in 36 patients; ischemia on preoperative stress testing was a predictor of these events even after adjusting for clinical variables and left ventricular dysfunction (relative risk = 3.3; 95% confidence interval 1.6 to 6.8; P =.001). The association of ischemia with clinical predictors was associated with incrementally worse outcome.


CONCLUSIONS
In addition to perioperative assessment, the combined use of clinical and dobutamine echocardiographic evaluation may stratify the risk of late cardiac events.
Ballal
R S
RS
Cleveland Clinic Foundation, Cleveland, OH, USA.
Kapadia
S
S
Secknus
M A
MA
Rubin
D
D
Arheart
K
K
Marwick
T H
TH
D000318:Adrenergic beta-Agonists; D000368:Aged; D000787:Angina Pectoris / Q000209:etiology / Q000601:surgery; D000789:Angina, Unstable / Q000209:etiology / Q000601:surgery; D002921:Cicatrix / Q000000981:diagnostic imaging; D016001:Confidence Intervals; D003327:Coronary Disease / Q000175:diagnosis* / Q000000981:diagnostic imaging; D016757:Death, Sudden, Cardiac / Q000209:etiology; D004280:Dobutamine; D004452:Echocardiography; D005260:Female; D005500:Follow-Up Studies; D005544:Forecasting; D006321:Heart / Q000187:drug effects; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000000981:diagnostic imaging / Q000209:etiology; D017202:Myocardial Ischemia / Q000175:diagnosis / Q000000981:diagnostic imaging; D009204:Myocardial Revascularization; D011379:Prognosis; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015996:Survival Rate; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects; D018487:Ventricular Dysfunction, Left / Q000175:diagnosis
D000318:Adrenergic beta-Agonists; D004280:Dobutamine