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Predictors of Cardiac Events After Major Vascular Surgery Role of Clinical Characteristics, Dobutamine Echocardiography, and ␤-Blocker Therapy

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Predictors of Cardiac Events After Major Vascular Surgery Role of Clinical Characteristics, Dobutamine Echocardiography, and ␤-Blocker Therapy ORIGINAL CONTRIBUTION Predictors of Cardiac Events After Major Vascular Surgery Role of Clinical Characteristics, Dobutamine Echocardiography, and b-Blocker Therapy Eric Boersma, PhD Context Patients who undergo major vascular surgery are at increased risk of peri- Don Poldermans, MD, PhD operative cardiac complications. High-risk patients can be identified by clinical factors and noninvasive cardiac testing, such as dobutamine stress echocardiography (DSE); Jeroen J. Bax, MD, PhD however, such noninvasive imaging techniques carry significant disadvantages. A re- Ewout W. Steyerberg, MD, PhD cent study found that perioperative b-blocker therapy reduces complication rates in Ian R. Thomson, MD high-risk individuals. Objective To examine the relationship of clinical characteristics, DSE results, b-blocker Jan D. Banga, MD, PhD therapy, and cardiac events in patients undergoing major vascular surgery. Louis L. M. van de Ven, MD, PhD Design and Setting Cohort study conducted in 1996-1999 in the following 8 cen- Hero van Urk, MD, PhD ters: Erasmus Medical Centre and Sint Clara Ziekenhuis, Rotterdam, Twee Steden Ziek- enhuis, Tilburg, Academisch Ziekenhuis Utrecht, Utrecht, and Medisch Centrum Alkmaar, Jos R. T. C. Roelandt, MD, PhD Alkmaar, the Netherlands; Ziekenhuis Middelheim, Antwerp, Belgium; and San Gerardo for the DECREASE Study Group Hospital, Monza, Istituto di Ricovero e Cura a Carattere Scientifico, San Giovanni Rotondo, Italy. ATIENTS WITH SEVERE PERIPH- Patients A total of 1351 consecutive patients scheduled for major vascular surgery; eral vascular disease frequently b have underlying coronary artery DSE was performed in 1097 patients (81%), and 360 (27%) received -blocker therapy. disease. Hence, patients under- Main Outcome Measure Cardiac death or nonfatal myocardial infarction within 30 b Pgoing major vascular surgery are at days after surgery, compared by clinical characteristics, DSE results, and -blocker use. increased risk for cardiac complications Results Forty-five patients (3.3%) had perioperative cardiac death or nonfatal myo- during or shortly after surgery. Appro- cardial infarction. In multivariable analysis, important clinical determinants of adverse out- priate patient management then includes come were age 70 years or older; current or prior angina pectoris; and prior myocardial assessment of the perioperative cardiac infarction, heart failure, or cerebrovascular accident. Eighty-three percent of patients had less than 3 clinical risk factors. Among this subgroup, patients receiving b-blockers had a risk, as well as strategies to reduce this lower risk of cardiac complications (0.8% [2/263]) than those not receiving b-blockers risk. Several investigations demon- (2.3% [20/855]), and DSE had minimal additional prognostic value. In patients with 3 or strated the utility of dobutamine stress more risk factors (17%), DSE provided additional prognostic information, for patients with- echocardiography (DSE) for preopera- out stress-induced ischemia had much lower risk of events than those with stress- tive cardiac risk assessment.1-5 Patients induced ischemia (among those receiving b-blockers, 2.0% [1/50] vs 10.6% [5/47]). More- with stress-induced new wall-motion over, patients with limited stress-induced ischemia (1-4 segments) experienced fewer cardiac abnormalities (NWMAs), a hallmark of events (2.8% [1/36]) than those with more extensive ischemia ($5 segments, 36% [4/11]). myocardial ischemia, are at an 8% to 38% Conclusion The additional predictive value of DSE is limited in clinically low-risk pa- risk of cardiac death or myocardial infarc- tients receiving b-blockers. In clinical practice, DSE may be avoided in a large number of tion (MI) within 30 days after sur- patients who can proceed safely for surgery without delay. In clinically intermediate- and b gery.2,4,6,7 In contrast, patients without high-risk patients receiving -blockers, DSE may help identify those in whom surgery can NWMAs have much lower complica- still be performed and those in whom cardiac revascularization should be considered. tion rates: in the range of 0% to 5%. There JAMA. 2001;285:1865-1873 www.jama.com are, however, significant disadvantages Author Affiliations are listed at the end of this article. Group. The effect of bisoprolol on perioperative mor- associated with the routine use of DSE Members of the Dutch Echocardiographic Cardiac Risk tality and myocardial infarction in high-risk patients (or other noninvasive imaging tech- Evaluation Applying Stress Echocardiography group undergoing vascular surgery. N Engl J Med. 1999; are listed in Poldermans D, Boersma E, Bax JJ, et al, 341:1789-1794. niques) in all vascular surgery candi- for the Dutch Echocardiographic Cardiac Risk Evalu- Corresponding Author information is at the end of the dates. These include the substantial costs ation Applying Stress Echocardiography Study article. ©2001 American Medical Association. All rights reserved. (Reprinted) JAMA, April 11, 2001—Vol 285, No. 14 1865 Downloaded from www.jama.com at Johns Hopkins University, on October 28, 2005 b-BLOCKER THERAPY INFLUENCE of the test, and, more importantly, the forty-five additional patients under- verse events committee adjudicated all risk of delaying surgery in patients with went DSE at the discretion of the treat- end points. Deaths were considered to large aortic aneurysms or critical limb ing physician, based on other risk fac- be cardiac related unless there was ex- ischemia. The recent Dutch Echo- tors (eg, hyperlipidemia and smoking). plicit evidence for a noncardiac cause. cardiographic Cardiac Risk Evaluation Thus, in total 1091 patients (81%) un- Myocardial infarction was defined by Applying Stress Echocardiography derwent DSE. Perioperative b-blockers either a serum creatine kinase level of (DECREASE) study demonstrated that were administered to 360 patients more than 110 U/L with a myoglobin perioperative b-adrenergic blockade with (27%): 301 (22%) of the 1351 patients isoenzyme fraction of more than 10%, bisoprolol reduces the risk of 30-day were treated long-term with b-block- or by new Q waves faster than 30 mil- complications in patients with NWMAs ers, and 59 (5%) were randomized to re- liseconds in duration on the 12-lead to a risk level as observed in patients with- ceive b-blockers within the framework electrocardiogram. out NWMAs.8,9 This finding raises the of the DECREASE study. Eight pa- question of whether DSE is indicated in tients who had extensive resting and/or Data Analysis all patients scheduled for vascular stress-induced ischemia were ex- Univariable and multivariable logistic surgery. Does simple perioperative cluded from the DECREASE study. Four regression analyses were applied to administration of b-blockers reduce or of these underwent coronary artery by- evaluate the relations between a lim- eliminate the need for noninvasive pre- pass graft surgery, and 2 of them died ited number of baseline clinical char- operative cardiac testing?10 On the other during this operation. The 2 surviving acteristics, DSE results, b-blocker hand, in some patients the cardiopro- patients subsequently underwent un- therapy, and the composite end points tective effect of b-blockers may be insuf- eventful vascular surgery with periop- as outlined above. All variables that ficient to effectively reduce periopera- erative b-blocker administration for car- reached a P value ,.50 in univariable tive cardiac events. These patients may diac protection. The other 4 patients analysis entered the multivariable stage. benefit from additional coronary revas- underwent vascular surgery without Multivariable models were con- cularization. To address these issues prior myocardial revascularization structed by backward deletion of the we studied the relationship between clini- and received b-blockers for cardiac least significant characteristics, apply- cal characteristics, DSE results, b-block- protection. None of the other non- ing the Akaike optimal information cri- ers, and adverse cardiac outcome in DECREASE patients received b-block- terion.12,13 Special attention was paid to a large series of consecutive patients ers for cardiac protection. the extent to which DSE results and scheduled to undergo major vascular b-blocker therapy contributed to the surgery. Dobutamine Stress prognostic information obtained from Echocardiography clinical characteristics alone. Odds ra- METHODS Dobutamine stress echocardiography tios (ORs) and corresponding 95% con- Patients was performed according to a stan- fidence intervals (CIs) are reported. The study population consisted of 1351 dard protocol.11 The left ventricle was Despite the fact that the population consecutive patients scheduled for divided into 16 segments and wall mo- consisted of patients undergoing high- elective major vascular surgery who tion was scored on a 5-point ordinal risk surgery, the number of outcome were screened for eligibility for the scale (1, normal wall motion; 2, mild events appeared to be limited. There- DECREASE study at 8 of the following hypokinesis; 3, severe hypokinesis; 4, fore, there was a serious concern that participating centers: Erasmus Medical akinesis; and 5, dyskinesis). The re- model overfitting would occur. To over- Centre and Sint Clara Ziekenhuis, Rot- sults of DSE were considered positive come this, we limited the number of terdam, Twee Steden Ziekenhuis, Til- if new wall-motion abnormalities candidate clinical variables to be in- burg, Academisch Ziekenhuis Utrecht, (NWMAs) occurred (ie, if wall
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