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(Circulation. 1997;95:53-58.)
© 1997 American Heart Association, Inc.

Articles

Sustained Prognostic Value of Dobutamine Stress Echocardiography for Late Cardiac Events After Major Noncardiac Vascular Surgery

Don Poldermans, MD; Mariarosaria Arnese, MD; Paolo M. Fioretti, MD, FESC; Eric Boersma, BSE; Ian R. Thomson, MD; Riccardo Rambaldi, MD; Hero van Urk, MD

the Thoraxcenter (M.A., P.M.F., E.B., R.R.) and the Department of Surgery (D.P., H.vanU.), University Hospital Rotterdam-Dijkzigt and Erasmus University, Rotterdam, The Netherlands; and the Department of Anesthesia (I.R.T.) University of Manitoba, Winnipeg, Manitoba, Canada.

Correspondence to Dr Don Poldermans, University Hospital Rotterdam-Dijkzigt, Dr Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.

Background Late cardiac events after major noncardiac vascular surgery are an important cause of morbidity and mortality. We studied the prognostic value of preoperative dobutamine stress echocardiography, relative to clinical risk assessment, in predicting late cardiac events.

Methods and Results Three hundred sixteen patients undergoing major vascular surgery were studied. All patients underwent clinical evaluation for the presence of cardiac risk factors (smoking, hypertension, angina, diabetes, history of heart failure, previous infarction, and age >70 years) and dobutamine stress echocardiography. Left ventricular wall motion was evaluated at rest, and the extent and severity of stress-induced new wall motion abnormalities were quantified. The heart rate threshold at which new wall motion abnormalities occurred was noted. Patients were followed perioperatively and for 19±11 months postoperatively, and the occurrence of cardiac events was noted. Univariate and multivariate Cox proportional hazards regression models were used to identify predictors of late cardiac events. Thirty-two cardiac events occurred (11 cardiac deaths, 11 nonfatal myocardial infarctions, and 10 incidents of unstable angina). By multivariate regression analysis, the occurrence of extensive (three or more segments) or limited (one or two segments) stress-induced new wall motion abnormalities and previous infarction independently predicted late cardiac events, elevating the risk by 6.5-, 2.9-, and 3.8-fold, respectively. The severity of ischemia during stress and the heart rate threshold for ischemia were not independently predictive.

Conclusions Patients with a history of myocardial infarction or stress-induced ischemia have a high risk of fatal and nonfatal cardiac events after vascular surgery. Patients with both a history of infarction and extensive stress-induced ischemia are at especially high risk and deserve intensive management.

Key Words: echocardiography • stress • prognosis • surgery

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