Perioperative and long-term prognostic value of dipyridamole Tc-99m sestamibi myocardial tomography in patients evaluated for elective vascular surgery

✍ Scribed by Mylan C. Cohen; Andrea E. Siewers; John D. Dickens Jr; Thomas Hill; James E. Muller

• Publisher: Springer
• Year: 2003
• Tongue: English
• Weight: 128 KB
• Volume: 10
• Category: Article
• ISSN: 1071-3581
• DOI: 10.1016/s1071-3581(03)00550-6

✦ Synopsis

Background. Patients with peripheral vascular disease are at increased risk for perioperative and long-term cardiac morbidity and mortality. Substantial data exist supporting the use of preoperative clinical risk stratification and planar thallium myocardial scintigraphy. Only limited data are available assessing the role of technetium-99m (Tc-99m) single photon emission computed tomography (SPECT) for preoperative evaluation in this population.

Methods and Results. In our study 153 patients who underwent peripheral vascular surgery were followed up for up to 4 years after preoperative dipyridamole Tc-99m sestamibi SPECT to determine clinical and SPECT predictors of perioperative and long-term adverse cardiac events by multivariate analysis. There were no statistically significant clinical or SPECT predictors of perioperative risk, although no perioperative events occurred in patients with normal scans. Abnormality in the left anterior descending (LAD) territory (risk ratio ‫؍‬ 3.1; 95% confidence interval, 1.4-7.1) was the only statistically significant univariate predictor of long-term death or myocardial infarction. Only abnormality in the LAD territory appeared to improve model fit beyond clinical risk (risk ratio ‫؍‬ 2.9; 95% confidence interval, 1.2-7.3; P ‫؍‬ .02).

Conclusions

. Patients with normal preoperative scans have a low risk of perioperative cardiac events and may safely undergo peripheral vascular surgery without further coronary intervention. However, scan abnormality in the LAD distribution confers poor long-term prognosis, suggesting that patients with this finding before peripheral vascular surgery should receive aggressive medical therapy and possibly invasive intervention to improve long-term survival. (J Nucl Cardiol 2003;10:464-72.) Key Words: Peripheral vascular disease • single photon emission computed tomography • technetium 99m sestamibi • left anterior descending territory

Perioperative cardiac morbidity and mortality remain important concerns for consultants and surgeons and account for an estimated $20 billion of health care expenditure in the United States each year. 1 Risk may be reduced with alterations in medical therapy 2,3 and coronary intervention. 4,5 Thus risk stratification has been attempted in order to identify those individuals who might benefit from the addition of a ␤-blocker or the performance of coronary angiography among other pos-sible interventions. Conversely, it is desirable to avoid costly, invasive cardiac procedures for patients who may have coronary disease yet are at a low risk for perioperative and long-term cardiac complications.

Patients with peripheral vascular disease have reduced survival compared with the normal population. 6 There is substantial evidence that combined clinical assessment with planar thallium myocardial scintigraphy offers prognostic utility perioperatively [7][8][9][10][11] and in the