SELECTION OF PATIENTS FOR CARDIAC EVALUATION BEFORE PERIPHERAL VASCULAR OPERATIONS

Purpose:This study evaluated the value of preoperative cardiac screeni ng with dipyridamole thallium scintigraphy and radionuclide ventriculo graphy in vascular surgery patients. Methods: From July 1, 1989, to De c. 31, 1991, we routinely (irrespective of the patient's cardiac histo ry or symptomatology) performed dipyridamole thallium scintigraphy (DT S) and radionuclide ventriculography (RVG) in 394 patients being consi dered for an elective vascular operation. Patients with reversible def ects on DTS underwent coronary arteriography Results: DTS results were normal in 146 patients (37%), showed a fixed defect in 75 (19%), and showed a reversible defect in 173 (44%). Patients with and without a h istory of angina or myocardial infarction had identical rates of rever sible defects. Normal left ventricular function (>50%) was noted in 76 % of the patients; 17% had moderate dysfunction (35% to 50%) and 7% ha d a low ejection fraction (<35%), The finding of-severe coronary arter y disease led to cardiac revascularization in 17 patients who had no p rior history of cardiac disease and in 13 patients with a history of a ngina or myocardial infarction, Tao deaths and nine major complication s were associated with coronary arteriography and cardiac revasculariz ation. Vascular procedures (144 aortic, 53 carotid, 146 infrainguinal) were ultimately performed in 343 patients, with a mortality rate of 1 .7% (3.5% aortic, OZ carotid, and 0.7% infrainguinal bypass). The nonf atal perioperative myocardial infarction rate was 2.0%. We monitored a ll 394 patients for cardiovascular events, with a mean follow-up of 40 months. Patients who underwent cardiac revascularization had a 4-year survival rate of 75%, which was similar to those with a normal DTS. L ate cardiac events were significantly more frequent in patients who ha d either a reversible DTS or RVG <35%. Conclusions: Routine cardiac sc reening of vascular surgery patients had similar impact on patients ir respective of their prior history or current-symptoms suggesting coron ary artery disease. Routine screening did not result in substantial be nefit; Screening studies such as DTS or RVG may be most useful as part of an overall risk versus benefit assessment in patients without acti ve symptoms of coronary artery disease who have less compelling indica tions for vascular intervention (claudication, moderate-sized aortic a neurysms, or asymptomatic carotid disease).