Patients With Positive Preoperative Stress Tests Undergoing Vascular Surgery Kyung W. Tim Park, MD, Kathirvel Subramaniam, MD, Feroze Mahmood, MD, Fred Shapiro, MD, Selina Long, MD, and David Napoli, MD Objective: To examine the perioperative cardiac morbidity Cardiology and 7 had a left ventricular ejection fraction and mortality in patients undergoing major vascular surgery <40%. Twenty-three patients had been on a ␤-blocker and with ␤-blockade after a positive stress test or cardiac cath- continued on it, while the remainder started on it de novo eterization. perioperatively. None of the patients suffered from myocar- Design: Retrospective review of a quality assurance data- dial infarction, congestive heart failure, or cardiac death base. perioperatively. Setting: A university teaching hospital. Conclusions: This case series reports on the authors’ ex- Participants: A consecutive series of 31 patients undergo- perience with patients undergoing high-risk vascular sur- ing peripheral vascular or aortic surgery after a positive gery after a positive stress test or catheterization, but with- stress test or catheterization between November 2001 and out an intervening coronary intervention. All patients received perioperative ␤-blockade and had a very low ad- September 2003. verse cardiac event rate. With reduction of adverse events Intervention: None. by ␤-blockade, the likelihood of a positive event may be Measurements and Main Results: All 31 patients had a reduced and the utility of the test in risk stratification may preoperative positive stress test and/or cardiac catheteriza- be questioned. tion, with 12 having multiple areas at risk for myocardial © 2005 Elsevier Inc. All rights reserved. ischemia. None had an intervening coronary revasculariza- tion. Twenty-seven had at least one of the intermediate KEY WORDS: vascular surgery, stress test, risk stratification, clinical predictors as defined by the American College of ␤-blockade HE AMERICAN COLLEGE of Cardiology (ACC)/Amer- operative ␤-blockade with bisoprolol or placebo and showed Tican Heart Association (AHA) guidelines on preoperative that even in such high-risk patients perioperative ␤-blockade cardiac evaluation recommend that for patients undergoing reduced 30-day mortality from 17% to 3.4% and nonfatal MI high-risk surgery such as aortic or peripheral vascular bypass from 17% to 0%. Such a study, especially if reproduced, may surgeries, a noninvasive cardiac test be performed, if the patient provide justification for proceeding with high-risk noncardiac has a major clinical predictor such as unstable angina or evolv- surgery despite the known presence of coronary artery disease ing myocardial infarction (MI) or if the patient has either an (CAD), without surgical or percutaneous coronary revascular- 3 intermediate clinical predictor (eg, history of MI or congestive ization. In this report, the authors’ experience with vascular heart failure [CHF]) or poor functional status.1 If the result of surgical patients who were known to have CAD either by a such noninvasive cardiac testing is positive, it is implied that preoperative stress test or cardiac catheterization and then un- further cardiac workup and/or treatment may then be indicated derwent vascular surgery without an intervening surgical or percutaneous coronary intervention is presented. The data pre- before the proposed noncardiac surgery. However, at present, sented are based on screening of the authors’ quality assurance there are no clear data from randomized trials whether such database for identification of such patients (all of whom were patients should be triaged to myocardial revascularization be- anesthetized by the authors), review of the anesthetic records, fore the noncardiac surgery or an aggressive perioperative nursing records in the recovery room and on the ward, and regimen of ␤-adrenergic blockade during noncardiac surgery medical records. This experience mirrors the study result of without prior revascularization. Poldermans et al2 and may further bolster triage of such pa- 2 Poldermans et al studied vascular surgical patients with new tients to surgery without coronary intervention. reversible wall motion abnormalities on preoperative dobut- amine stress echocardiography (DSE) but with normal left CASE SERIES ventricular function. The authors excluded patients with exten- sive wall motion abnormalities, asthma, or stress testing sug- Between November 2001 and September 2003, the authors have provided anesthetic care for 31 vascular surgical patients, having either gestive of left main or 3-vessel coronary artery disease. With- aortic or peripheral vascular bypass surgery, who preoperatively had out triaging the patients to further diagnostic workup or positive noninvasive or invasive cardiac testing and did not have an treatment, the authors randomized the patients to either peri- intervening surgical or percutaneous coronary revascularization. This number represents all such patients in the quality assurance database, which captures all patients undergoing vascular surgery at the authors’ From the Beth Israel Deaconess Medical Center, Harvard Medical institution. The decision on whether to do a stress test and whether to School, Boston, MA. treat the patient medically rather than interventionally after a positive Presented in part at the 2003 annual meeting of the International stress test was up to each patient’s cardiologist. The stress test took Anesthesia Research Society, New Orleans, LA, March 21-25, 2003. place 68 Ϯ 117 (median 13) days before the surgery. Demographic and Address reprint requests to Kyung W. Tim Park, MD, Department of comorbidity profile of the patients is shown in Table 1. The types of Anesthesiology, Santa Clara Valley Medical Center, 751 S Bascom surgeries undertaken are shown in Table 2. Avenue, San Jose, CA 95128. E-mail: [email protected]. Twenty-seven of the 31 patients had at least one of the intermediate ca.us clinical predictors, as defined by the ACC/AHA1 (Table 1). Fifteen of © 2005 Elsevier Inc. All rights reserved. the patients had multiple intermediate clinical predictors. History of 1053-0770/05/1904-0014$30.00/0 angina, documented in only 4 of 31 patients, might have been under- doi:10.1053/j.jvca.2005.05.008 documented because most of the patients had diabetes and had limited 494 Journal of Cardiothoracic and Vascular Anesthesia, Vol 19, No 4 (August), 2005: pp 494-498 PREOPERATIVE STRESS TESTS 495 Table 1. Demographic and Comorbidity Profile of the Patients Comorbidity or Demographic Variable N Sex (male:female) 20:11 Age (mean Ϯ SD) 72 Ϯ 12 Ն65 24/31 Ն75 13/31 Intermediate clinical predictors Diabetes mellitus 17/31 History of myocardial infarction 15/31 History of angina 4/31 History of congestive heart failure 6/31 Serum creatinine Ն2 mg/dL 5/31 At least 1 of the intermediate clinical predictors 27/31 Two of the intermediate clinical predictors 10/31 Three or more of the intermediate clinical predictors 5/31 Preoperative medications ␤-adrenergic blocker 23/31 Statin 23/31 Angiotensin-converting enzyme inhibitor 20/31 Fig 1. Flow diagram depicting the preoperative workup of the patients. Calcium channel blocker 8/31 Oral nitrate 7/31 Aspirin 13/31 Other comorbidities test with thallium nuclear imaging to detect perfusion defects. In 3 Hypertension 25/31 patients, a positive stress test was followed by a cardiac catheterization, Hypercholesterolemia 22/31 which revealed diffuse 3-vessel coronary artery disease in 1 patient, History of smoking 18/31 occlusion of a previously grafted artery in the second patient, and a Cerebrovascular accident or transient ischemic 10/31 minimal 1-vessel disease (40% obstruction of the left circumflex artery) attacks in the third. The patient with the 3-vessel disease was the only one Asthma or chronic obstructive pulmonary disease 5/31 referred to cardiac surgery but was turned down for coronary artery surgery because of poor risk profile and yet presented for vascular surgery. All patients were thus managed medically preoperatively, without any surgical or percutaneous coronary intervention. A sche- activity from peripheral vascular disease. Functional status could not be matic of the preoperative workup is shown in Figure 1. Results of the easily assessed in most patients because of the limited activity level stress tests are summarized in Table 3. Twelve of the 31 patients had from peripheral vascular insufficiency. In the 13 patients whose func- multiple areas at risk for myocardial ischemia. The inferior (16/31) and tional status could be determined, the New York Heart Association anterior walls (14/31) were the most commonly affected. Seven of 31 status averaged 2.4, with a median of 2. In the 4 patients without any patients had a left ventricular ejection fraction Ͻ40%. of the intermediate clinical predictors, activity level was severely Twenty-three of the 31 patients had been on a ␤-adrenergic blocking limited by peripheral vascular disease or severe degenerative arthritis. agent and continued on the medication. The remainder were started on The incidence of other commonly examined comorbidities is listed in a ␤-adrenergic blocking agent de novo in the perioperative period. For Table 1. In 3 patients, cardiac catheterization was performed without a pre- ceding stress test and showed 3-vessel disease in 1 patient and occlu- Table 3. Results of Preoperative Cardiac Workup sion of a previously revascularized coronary artery in the other 2 patients; in all 3, no surgical or percutaneous coronary