Correlation between preoperative ischemia and major cardiac events after peripheral vascular surgery

Volume 321:1296-1300		November 9, 1989		Number 19

Correlation between preoperative ischemia and major cardiac events after peripheral vascular surgery

KE Raby, L Goldman, MA Creager, EF Cook, MC Weisberg, AD Whittemore, and AP Selwyn

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Abstract

Patients who undergo peripheral vascular surgery are at increased risk for postoperative cardiac events and are difficult to assess preoperatively because of limitations on their activity. We prospectively studied 176 consecutive eligible patients undergoing elective vascular surgery to determine the value in predicting a postoperative cardiac event of preoperative electrocardiographic monitoring to detect myocardial ischemia. Of the 176 patients, 32 (18 percent) had 75 episodes of monitored ischemic ST-segment depression preoperatively (of which 73 were asymptomatic), and 13 (7 percent) met strict criteria for major postoperative cardiac events, including 1 with a fatal myocardial infarction, 3 with nonfatal infarctions, 4 with unstable angina, and 5 with ischemic pulmonary edema. Of the 32 patients with ischemia before their operations, 12 had postoperative events (univariate relative risk, 54; 95 percent confidence interval, 7.2 to 400). Only 1 postoperative event occurred among 144 patients who did not have preoperative ischemia. The sensitivity of preoperative ischemia was 92 percent, the specificity 88 percent, the predictive value of a positive result 38 percent, and the predictive value of a negative result 99 percent. In multivariate analyses, preoperative ischemia was the most significant correlate of postoperative cardiac events and remained a statistically significant independent correlate even after we had controlled for all other preoperative factors (multivariate relative risk, 24.4; 95 percent confidence interval, 6.8 to 88). These preliminary data suggest that preoperative electrocardiographic monitoring to detect episodes of myocardial ischemia is a useful method for assessing cardiac risk in patients who undergo elective vascular surgery. In particular, the absence of ischemia during monitoring indicates a very low risk.

Source Information

Cardiovascular Division, Brigham and Women's Hospital, Boston, MA 02115.

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Priebe, H.-J. (2004). Triggers of perioperative myocardial ischaemia and infarction. Br J Anaesth 93: 9-20 [Abstract] [Full Text]
Kertai, M D, Boersma, E, Bax, J J, Heijenbrok-Kal, M H, Hunink, M G M, L'talien, G J, Roelandt, J R T C, van Urk, H, Poldermans, D (2003). A meta-analysis comparing the prognostic accuracy of six diagnostic tests for predicting perioperative cardiac risk in patients undergoing major vascular surgery. Heart 89: 1327-1334 [Abstract] [Full Text]
Gokce, N., Keaney, J. F. Jr, Hunter, L. M., Watkins, M. T., Nedeljkovic, Z. S., Menzoian, J. O., Vita, J. A. (2003). Predictive value of noninvasivelydetermined endothelial dysfunction for long-term cardiovascular events inpatients with peripheral vascular disease. J Am Coll Cardiol 41: 1769-1775 [Abstract] [Full Text]
Grayburn, P. A., Hillis, L D. (2003). Cardiac Events in Patients Undergoing Noncardiac Surgery: Shifting the Paradigm from Noninvasive Risk Stratification to Therapy. ANN INTERN MED 138: 506-511 [Abstract] [Full Text]
Chassot, P.-G., Delabays, A., Spahn, D. R. (2002). Preoperative evaluation of patients with, or at risk of, coronary artery disease undergoing non-cardiac surgery. Br J Anaesth 89: 747-759 [Abstract] [Full Text]
Torella, F., Ashleigh, R. J, Bolia, A., Nasim, A. (2002). Review: The management of tibial artery disease in diabetes. British Journal of Diabetes & Vascular Disease 2: 162-166 [Abstract]
Badner, N. H., Freeman, D., Spence, J. D. (2001). Preoperative Oral B Vitamins Prevent Nitrous Oxide-Induced Postoperative Plasma Homocysteine Increases. Anesth. Analg. 93: 1507-1510 [Abstract] [Full Text]
Beattie, W. S., Badner, N. H., Choi, P. (2001). Epidural Analgesia Reduces Postoperative Myocardial Infarction: A Meta-Analysis. Anesth. Analg. 93: 853-858 [Abstract] [Full Text]
Poldermans, D, Boersma, E, Bax, J.J, Thomson, I.R, Paelinck, B, van de Ven, L.L.M, Scheffer, M.G, Trocino, G, Vigna, C, Baars, H.F, van Urk, H, Roelandt, J.R.T.C (2001). Bisoprolol reduces cardiac death and myocardial infarction in high-risk patients as long as 2 years after successful major vascular surgery. Eur Heart J 22: 1353-1358 [Abstract]
Urban, M. K., Markowitz, S. M., Gordon, M. A., Urquhart, B. L., Kligfield, P. (2000). Postoperative Prophylactic Administration of {beta}-Adrenergic Blockers in Patients at Risk for Myocardial Ischemia. Anesth. Analg. 90: 1257-1261 [Abstract] [Full Text]
Sicari, R., Ripoli, A., Picano, E., Djordjevic-Dikic, A., Di Giovanbattista, R., Minardi, G., Matskeplishvili, S., Ambatiello, S., Pulignano, G., Accarino, M., Lusa, A. M., Franco Del Rosso, G., Pedrinelli, R., Buziashvili, Y. (1999). Perioperative Prognostic Value of Dipyridamole Echocardiography in Vascular Surgery : A Large-Scale Multicenter Study in 509 Patients. Circulation 100 : II-269-II-274 [Abstract] [Full Text]
Crawford, M. H., Bernstein, S. J., Deedwania, P. C., DiMarco, J. P., Ferrick, K. J., Garson, A. Jr, Green, L. A., Greene, H. L., Silka, M. J., Stone, P. H., Tracy, C. M., Gibbons, R. J., Alpert, J. S., Eagle, K. A., Gardner, T. J., Garson, A. Jr, Gregoratos, G., Russell, R. O., Ryan, T. J., Smith, S. C. Jr (1999). ACC/AHA guidelines for ambulatory electrocardiography: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the Guidelines for Ambulatory Electrocardiography) developed in collaboration with the North American Society for Pacing and Electrophysiology. J Am Coll Cardiol 34: 912-948 [Full Text]
Raby, K. E., Brull, S. J., Timimi, F., Akhtar, S., Rosenbaum, S., Naimi, C., Whittemore, A. D. (1999). The Effect of Heart Rate Control on Myocardial Ischemia Among High-Risk Patients After Vascular Surgery. Anesth. Analg. 88: 477-477 [Abstract] [Full Text]
Goldman, L. (1998). A 75-Year-Old Woman With an Abdominal Aortic Aneurysm and Emphysema. JAMA 280: 366-372 [Full Text]
Potyk, D., Raudaskoski, P. (1998). Preoperative Cardiac Evaluation for Elective Noncardiac Surgery. Arch Fam Med 7: 164-173 [Abstract] [Full Text]
Andrews, T. C., Raby, K., Barry, J., Naimi, C. L., Allred, E., Ganz, P., Selwyn, A. P. (1997). Effect of Cholesterol Reduction on Myocardial Ischemia in Patients With Coronary Disease. Circulation 95: 324-328 [Abstract] [Full Text]
Mangano, D. T., Layug, E. L., Wallace, A., Tateo, I., The Multicenter Study of Perioperative Ischemia Re, (1996). Effect of Atenolol on Mortality and Cardiovascular Morbidity after Noncardiac Surgery. NEJM 335: 1713-1721 [Abstract] [Full Text]
Bolognesi, R., Tiberti, G., Azzarone, M., Tecchio, T., Pellegrino, F., Manca, C. (1996). Clinical, Electrocardiographic, and Echocardiographic Features in Patients with Asymptomatic Aortic Abdominal Aneurysm. ANGIOLOGY 47: 1139-1144 [Abstract]
Mangano, D. T., Goldman, L. (1995). Preoperative Assessment of Patients with Known or Suspected Coronary Disease. NEJM 333: 1750-1756 [Full Text]
Ramsay, J., Thomas, B. (1995). Preoperative Cardiac Evaluation and Perioperative Monitoring for Noncardiac Vascular Surgery. JAMA 274: 1671-1671 [Abstract]
Haljamae, H., Jivegard, L. E.H. (1995). Cardiac Risk Factors: The Effect of Preoperative Evaluation on Outcome. PERSPECT VASC SURG ENDOVASC THER 8: 86-97
Baron, J.-F., Mundler, O., Bertrand, M., Vicaut, E., Barre, E., Godet, G., Samama, C. M., Coriat, P., Kieffer, E., Viars, P. (1994). Dipyridamole-Thallium Scintigraphy and Gated Radionuclide Angiography to Assess Cardiac Risk before Abdominal Aortic Surgery. NEJM 330: 663-669 [Abstract] [Full Text]
Goldman, L. (1994). Assessment of Perioperative Cardiac Risk. NEJM 330: 707-709 [Full Text]
Wilcox, C. M., Faibicher, M., Wenger, N. K., Shalek, K. A. (1993). Prevalence of Silent Myocardial Ischemia and Arrhythmias in Patients With Coronary Heart Disease Undergoing Gastrointestinal Tract Endoscopic Procedures. Arch Intern Med 153: 2325-2332 [Abstract]
Velanovich, V. (1993). How Much Routine Preoperative Laboratory Testing Is Enough?. American Journal of Medical Quality 8: 145-151 [Abstract]
Eisenberg, M. J., London, M. J., Leung, J. M., Browner, W. S., Hollenberg, M., Tubau, J. F., Tateo, I. M., Schiller, N. B., Mangano, D. T., the Study of Perioperative Ischemia Research Group, , Mangano, D. T., Browner, W. S., Hollenberg, M., Tubau, J. F., Leung, J. M., Krupski, W. C., Rapp, J. A., Hedgcock, M. W., Verrier, E. D., Merrick, S., Meyer, M. L., Levenson, L., Wong, M. G., Layug, E., Li, J., Franks, M. E., Wellington, Y. C., Balasubramanian, M., Cembrano, E., Velasco, W., Pineda, N., Katiby, S. N., Miller, T., von Ehrenburg, W., O'Kelly, B. F., Szlachcic, J., Knight, A. A., Fegert, V., Goehner, P., Harris, D. N., Siliciano, D., Mark, N. H., Smith, R., Helman, J., Tateo, I. M., Tice, J., Fox, C., Heithaus, A., Showstack, J., Nicoll, D. C., Heineken, P., Massie, B., Chatterjee, K., Fairley, H. B., Way, L. W., Winkelstein, W. (1992). Monitoring for Myocardial Ischemia During Noncardiac Surgery: A Technology Assessment of Transesophageal Echocardiography and 12-Lead Electrocardiography. JAMA 268: 210-216 [Abstract]
Raby, K. E., Barry, J., Creager, M. A., Cook, E. F., Weisberg, M. C., Goldman, L. (1992). Detection and Significance of Intraoperative and Postoperative Myocardial Ischemic in Peripheral Vascular Surgery. JAMA 268: 222-227 [Abstract]
Browner, W. S., Li, J., Mangano, D. T., Study of Perioperative Ischemia Research Group, , Mangano, D. T., Browner, W. S., Hollenberg, M., Tubau, J. F., Leung, J. M., Krupski, W. C., Rapp, J. A., Merrick, S., Hedgcock, M. W., Verrier, E., London, M. J., Layug, E., Li, J., Levenson, L., Franks, M., Wong, M. G., Meyer, M. L., Tateo, I. M., Miller, T. (1992). In-Hospital and Long-term Mortality in Male Veterans Following Noncardiac Surgery. JAMA 268: 228-232 [Abstract]
Mangano, D. T., Browner, W. S., Hollenberg, M., Li, J., Tateo, I. M., Study of Perioperative Ischemia Research Group, , Mangano, D. T., London, M. J., Browner, W. S., Hollenberg, M., Tubau, J. F., Leung, J. M., Krupski, W. C., Rapp, J. A., Hedgcock, M. W., Verrier, E. D., Merrick, S., Meyer, M. L., Levenson, L., Wong, M. G., Layug, E., Li, J., Franks, M. E., Wellington, Y. C., Balasubramanian, M., Cembrano, E., Velasco, W., Katiby, S. N., Miller, T., von Ehrenburg, W., O'Kelly, B. F., Szlachcic, J., Knight, A. A., Fegert, V., Goehner, P., Harris, D. N., Siliciano, D., Mark, N. H., Smith, R., Tateo, I. M., Tice, J., Fox, C., Heithaus, A., Showstack, J., Nicoll, D. C., Heineken, P., Massie, B., Chatterjee, K., Fairley, H. B., Way, L. W., Winkelstein, W. (1992). Long-term Cardiac Prognosis Following Noncardiac Surgery. JAMA 268: 233-239 [Abstract]
Wong, T., Detsky, A. S. (1992). Preoperative Cardiac Risk Assessment for Patients Having Peripheral Vascular Surgery. ANN INTERN MED 116: 743-753 [Abstract]
Roizen, M. F. (1990). Anesthesiology. JAMA 263: 2625-2627 [Abstract]
(1989). PREOPERATIVE ECG MONITORING PREDICTS POSTOPERATIVE CARDIAC EVENTS. JWatch General 1989: 4-4 [Full Text]
Goldstone, J. (1989). Editor's Perspective. PERSPECT VASC SURG ENDOVASC THER 2: 37-38
Gokce, N., Keaney, J. F. Jr, Hunter, L. M., Watkins, M. T., Menzoian, J. O., Vita, J. A. (2002). Risk Stratification for Postoperative Cardiovascular Events via Noninvasive Assessment of Endothelial Function: A Prospective Study. Circulation 105: 1567-1572 [Abstract] [Full Text]

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