COMPARATIVE PROGNOSTIC VALUE OF CLINICAL RISK INDEXES, RESTING 2-DIMENSIONAL ECHOCARDIOGRAPHY, AND DIPYRIDAMOLE STRESS TL-201 MYOCARDIAL IMAGING FOR PERIOPERATIVE CARDIAC EVENTS IN MAJOR NONVASCULAR SURGERY PATIENTS

The relative prognostic value of widely accessible resting two-dimensi onal echocardiographic ventricular function data has not been compared with recognized clinical and scintigraphic risk markers in patients w ho are unable to exercise before major nonvascular surgery. To this en d, 53 consecutive patients aged 67 +/- 13 years undergoing preoperativ e evaluation (intraabdominal, 23%; orthopedic, 30%; thoracic, 9%; othe r, 38%) for known or suspected coronary artery disease were followed u p to evaluate the prognostic value of these studies for the perioperat ive cardiac events (cardiac death [n = 4), myocardial infarction [n = 2], unstable angina [n = 3], and pulmonary edema [n = 8]) that occurre d in 13 of the 53 patients (25%). Dipyridamole thallium-201 myocardial redistribution defects occurred in 15 (28%) patients. Resting echocar diographic left ventricular dysfunction was present in 21 (40%) patien ts. Multivariate analysis of clinical, echocardiographic, and scintigr aphic risk predictors revealed that cardiac events were not predicted by clinical variables, including Goldman class or score. Cardiac event s were independently predicted only by the presence of significant lef t ventricular dysfunction on resting two-dimensional echocardiography (p < 0.042) and dipyridamole thallium-201 defect redistribution (p < 0 .026). A dipyridamole-induced reversible thallium-201 perfusion defect was predictive of subsequent cardiac death or myocardial infarction ( p < 0.02), whereas left ventricular dysfunction on resting echocardiog raphy was predictive of perioperative pulmonary edema (p < 0.023). We conclude that stress thallium-201 perfusion imaging and resting two-di mensional echocardiography provide independent prognostic information in patients undergoing major nonvascular surgery who are at significan t risk for ischemic cardiac events and who are unable to perform stand ard exercise stress tests. Clinical risk indexes were not predictive o f cardiac events in these patients when analyzed in combination with n oninvasive risk assessment.