Predictors of cardiac events after major vascular surgery - Role of clinical characteristics, dobutamine echocardiography, and beta-blocker therapy

Context Patients who undergo major vascular surgery are at increased risk o f perioperative cardiac complications. High-risk patients can be identified by clinical factors and noninvasive cardiac testing, such as dobutamine st ress echocardiography (DSE); however, such noninvasive imaging techniques c arry significant disadvantages. A recent study found that perioperative bet a -blocker therapy reduces complication rates in high-risk individuals. Objective To examine the relationship of clinical characteristics, DSE resu lts, beta -blocker therapy, and cardiac events in patients undergoing major vascular surgery. Design and Setting Cohort study conducted in 1996-1999 in the following 8 c enters: Erasmus Medical Centre and Sint Clara Ziekenhuis, Rotterdam, Twee S teden Ziekenhuis, Tilburg, Academisch Ziekenhuis Utrecht, Utrecht, and Medi sch Centrum Alkmaar, Alkmaar, the Netherlands; Ziekenhuis Middelheim, Antwe rp, Belgium; and San Gerardo Hospital, Monza, Istituto di Ricovero e Cura a Carattere Scientifico, San Giovanni Rotondo, Italy. Patients A total of 1351 consecutive patients scheduled for major vascular surgery; DSE was performed in 1097 patients (81%), and 360 (27%) received b eta -blocker therapy. Main Outcome Measure Cardiac death or nonfatal myocardial infarction within 30 days after surgery, compared by clinical characteristics, DSE results, and beta -blocker use. Results Forty-five patients (3.3%) had perioperative cardiac death or nonfa tal myocardial infarction, In multivariable analysis, important clinical de terminants of adverse outcome were age 70 years or older; current or prior angina pectoris; and prior myocardial infarction, heart failure, or cerebro vascular accident. Eighty-three percent of patients had less than 3 clinica l risk factors. Among this subgroup, patients receiving beta -blockers had a lower risk of cardiac complications (0.8% [2/263]) than those not receivi ng beta -blockers (2.3% [20/855]), and DSE had minimal additional prognosti c value. In patients with 3 or more risk factors (17%), DSE provided additi onal prognostic information, for patients without stress-induced ischemia h ad much lower risk of events than those with stress-induced ischemia (among those receiving beta -blockers, 2.0% [1/50] vs 10.6% [5/47]). Moreover, pa tients with limited stress-induced ischemia (1-4 segments) experienced fewe r cardiac events (2.8%[1/36]) than those with more extensive ischemia (grea ter than or equal to5 segments, 36% [4/11]). Conclusion The additional predictive value of DSE is limited in clinically low-risk patients receiving beta -blockers. In clinical practice, DSE may b e avoided in a large number of patients who can proceed safely for surgery without delay. In clinically intermediate- and high-risk patients receiving beta -blockers, DSE may help identify those in whom surgery can still be p erformed and those in whom cardiac revascularization should be considered.