The Role of Myocardial Perfusion Scanning, Heart Rate Variability and D-dimers in Predicting the Risk of Perioperative Cardiac Complications after Peripheral Vascular Surgery

• Published in: European journal of vascular and endovascular surgery 2001-12, Vol.22 (6), p.499-508
• Main Authors: Mamode, N., Docherty, G., Lowe, G.D.O., Macfarlane, P.W., Martin, W., Pollock, J.G., Cobbe, S.M.
• Format: Article
• Language: English
• Subjects: Aged; Ambulatory electrocardiography; Coronary Circulation; Dipyridamole; Electrocardiography, Ambulatory; Endpoint Determination; Fibrin fibrinogen degradation products; Heart - diagnostic imaging; Heart Diseases - diagnosis; Heart Diseases - etiology; Heart Diseases - mortality; Heart Rate; Humans; Logistic Models; Models, Statistical; Multivariate Analysis; Myocardial Infarction - diagnosis; Myocardial Infarction - etiology; Odds Ratio; Postoperative Complications; Prognosis; Prospective Studies; Radionuclide Ventriculography; Risk Factors; ROC Curve; Sensitivity and Specificity; Thallium; Thallium radioisotopes; Vascular Surgical Procedures - adverse effects
• ISSN: 1078-5884; 1532-2165
• DOI: 10.1053/ejvs.2001.1529

Objectives: to study the value of a number of proposed prognostic factors in prediction of the risk of perioperative cardiac events after vascular surgery. Design and Methods: two hundred and ninety-seven patients undergoing peripheral vascular surgery were prospectively studied. Patients underwent preoperative 24 h ambulatory electrocardiography, measurement of haemostatic variables, myocardial assessment of perfusion by dipyridamole–thallium scintigraphy and radionuclide ventriculography. The primary endpoint was cardiac death or nonfatal myocardial infarction within 30 days of surgery. A combined endpoint included the primary endpoint plus occurrence of cardiac failure, unstable angina or serious arrhythmias. Results: the primary endpoint occurred in 21 (7%), and the combined endpoint in 41 (14%) of patients. On multivariate analysis, increased age, previous myocardial infarction, aortic surgery, impaired heart rate variability and a positive thallium scan were independent predictors of primary end-points. Preoperative atrial fibrillation and increased fibrin D-dimer were additional predictors of the combined endpoint. Construction of receiver-operator characteristic curves to examine the incremental value of predictive models showed that sensitivity and specificity of clinical data alone for primary endpoints was 71% and 72% respectively, while for the full model (incorporating heart rate variability and thallium data) this rose to 84% and 80% (p=0.0001). Conclusions: preliminary screening using clinical data has limited value in risk assessment prior to vascular surgery but preoperative heart rate variability, D-dimers and thallium scanning provide modest incremental predictive value.