title: Preoperative cardiac evaluation does not improve or predict perioperative or late survival in asymptomatic diabetic patients undergoing elective infrainguinal arterial reconstruction.
abstract: OBJECTIVE
  Patients undergoing infrainguinal arterial reconstruction frequently have increased cardiac risk factors. Diabetic patients are often asymptomatic despite advanced cardiac disease. This study investigates whether preoperative cardiac testing improves the outcome in diabetic patients at risk for cardiac disease.
  
  
  METHODS
  We retrospectively reviewed all patients undergoing lower-extremity arterial reconstructions in a 32-month period from July 1999 to February 2002. Of the 433 patients identified undergoing 539 procedures, 295 had diabetes mellitus and considered in this study. The patients were stratified into two groups according to the present American College of Cardiology, American Heart Association (ACC/AHA) algorithm. We identified 140 patients with two or more of ACC (Eagle) criteria who met the inclusion criteria for a preoperative cardiac evaluation. These patients were separated into two groups: those undergoing a cardiac work-up (WU) according to the ACC/AHA algorithm and those not undergoing the recommended work-up (NWU). Outcomes included perioperative mortality, postoperative myocardial infarction, congestive heart failure, arrhythmia, and length of hospitalization. Significance of association was assessed by the Fisher exact test. Length of hospitalization was compared using the Kruskal-Wallis rank sum test. Survival data was analyzed with the Kaplan-Meier method.
  
  
  RESULTS
  One hundred forty patients met the criteria for moderate risk. There were 61 patients in the NWU group and 79 in the WU group. Ten patients in the WU group underwent preoperative coronary revascularization (6 had percutaneous transluminal coronary angioplasty, 4 underwent coronary artery bypass grafting). There was no difference between perioperative mortality (WU, 1%; NWU, 2%; P = 1.00) or in postoperative cardiac morbidity, including myocardial infarction, congestive heart failure, and arrhythmia requiring treatment (WU, 5%; NWU, 6%; P = .71). There were no perioperative deaths and one episode of congestive heart failure in the group that had preoperative coronary revascularization. Median length of hospitalization was 10 days in the WU group and 8 days in the NWU group ( P = .11). Patient survival at 12 months for the NWU, WU, and revascularized groups was 85.3%, 78.5%, and 80.0%, respectively; 36-month survival was 73.6%, 62.9%, and 80.0%, respectively. The three survival curves did not differ significantly ( P = .209).
  
  
  CONCLUSIONS
  Preoperative cardiac evaluation, as defined by the ACC/AHA algorithm, does not predict or improve postoperative morbidity, mortality, or 36-month survival in asymptomatic, diabetic patients undergoing elective lower-extremity arterial reconstruction. These data do not support the current ACC/AHA recommendations as a standard of care for diabetic patients with an intermediate clinical predictor who undergo peripheral arterial reconstruction, a high-risk surgical procedure.
authors.affiliation: Department of Surgery, Division of Vascular Surgery, Beth Israel Deaconess Medical Center, 110 Francis Street, Boston, MA 02115, USA.
authors.forename: Thomas S
authors.initials: TS
authors.lastname: Monahan
authors.forename: Gautam V
authors.initials: GV
authors.lastname: Shrikhande
authors.forename: Frank B
authors.initials: FB
authors.lastname: Pomposelli
authors.forename: John J
authors.initials: JJ
authors.lastname: Skillman
authors.forename: David R
authors.initials: DR
authors.lastname: Campbell
authors.forename: Sherry D
authors.initials: SD
authors.lastname: Scovell
authors.forename: Frank W
authors.initials: FW
authors.lastname: Logerfo
authors.forename: Allen D
authors.initials: AD
authors.lastname: Hamdan
mesh_terms: D000465:Algorithms; D001145:Arrhythmias, Cardiac / Q000209:etiology; D048909:Diabetes Complications; D003925:Diabetic Angiopathies / Q000601:surgery*; D017558:Elective Surgical Procedures / Q000401:mortality; D005260:Female; D006333:Heart Failure / Q000209:etiology; D006334:Heart Function Tests; D006801:Humans; D007264:Inguinal Canal; D007902:Length of Stay; D008297:Male; D009203:Myocardial Infarction / Q000209:etiology; D009204:Myocardial Revascularization; D016491:Peripheral Vascular Diseases / Q000601:surgery*; D011183:Postoperative Complications; D011300:Preoperative Care; D019651:Plastic Surgery Procedures / Q000401:mortality; D012189:Retrospective Studies