SUSTAINED PROGNOSTIC VALUE OF DOBUTAMINE STRESS ECHOCARDIOGRAPHY FOR LATE CARDIAC EVENTS AFTER MAJOR NONCARDIAC VASCULAR-SURGERY

Background Late cardiac events after major noncardiac vascular surgery are an important cause of morbidity and mortality. We studied the pro gnostic value of preoperative dobutamine stress echocardiography, rela tive to clinical risk assessment, in predicting late cardiac events. M ethods and Results Three hundred sixteen patients undergoing major vas cular surgery were studied. All patients underwent clinical evaluation for the presence of cardiac risk factors (smoking, hypertension, angi na, diabetes, history of heart failure, previous infarction, and age > 70 years) and dobutamine stress echocardiography. Left ventricular wal l motion was evaluated at rest, and the extent and severity of stress- induced new wall motion abnormalities were quantified. The heart rate threshold at which new wall motion abnormalities occurred was noted. P atients were followed perioperatively and for 19+/-11 months post-oper atively, and the occurrence of cardiac events was noted. Univariate an d multivariate Cox proportional hazards regression models were used to identify predictors of late cardiac events. Thirty-two cardiac events occurred (11 cardiac deaths, 11 non-fatal myocardial infarctions, and 10 incidents of unstable angina). By multivariate regression analysis , the occurrence of extensive (three or more segments) or limited (one or two segments) stress-induced new wall motion abnormalities and pre vious infarction independently predicted late cardiac events, elevatin g the risk by 6.5-, 2.9-, and 3.8-fold, respectively. The severity of ischemia during stress and the heart rate threshold for ischemia were not independently predictive. Conclusions Patients with a history of m yocardial infarction or stress-induced ischemia have a high risk of fa tal and nonfatal cardiac events after vascular surgery. Patients with both a history of infarction and extensive stress-induced ischemia are at especially high risk and deserve intensive management.