Skip to main content
PMC home page
Annals of Surgery logoLink to Annals of Surgery
. 1990 Jan;211(1):84–90. doi: 10.1097/00000658-199001000-00015

Postoperative myocardial infarction and cardiac death. Predictive value of dipyridamole-thallium imaging and five clinical scoring systems based on multifactorial analysis.

J Lette 1, D Waters 1, J Lassonde 1, S Dubé 1, F Heyen 1, M Picard 1, M Morin 1
PMCID: PMC1357899  PMID: 2294849

Abstract

Sixty-six patients unable to complete a standard preoperative exercise test because of physical limitations were studied to determine the predictive value of individual clinical parameters, of clinical scoring systems based on multifactorial analysis, and of dipyridamole-thallium imaging before major general and vascular surgery. Study endpoints were limited to postoperative myocardial infarction or cardiac death before hospital discharge. There were nine postoperative cardiac events (seven deaths and two nonfatal infarctions). There was no statistical correlation between cardiac events and preoperative clinical descriptors, including individual clinical parameters, the Dripps-American Surgical Association score, the Goldman Cardiac Risk Index score, the Detsky Modified Cardiac Risk Index score, Eagle's clinical markers of low surgical risk, and the probability of postoperative events as determined by Cooperman's equation. There were no cardiac events in 30 patients with normal dipyridamole-thallium scans or in nine patients with fixed myocardial perfusion defects. Of 21 patients with reversible perfusion defects who underwent surgery, nine had a postoperative cardiac event (sensitivity, 100%; specificity, 43%). In the six other patients with reversible defects, preoperative angiography showed severe coronary disease or cardiomyopathy. Thus in patients unable to complete a standard exercise stress test, postoperative outcome cannot be predicted clinically before major general and vascular surgery, whereas dipyridamole-thallium imaging successfully identified all patients who sustained a postoperative cardiac event.

Full text

PDF
84

Images in this article

85Figs. 1A-C.
on p.85

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Arous E. J., Baum P. L., Cutler B. S. The ischemic exercise test in patients with peripheral vascular disease. Implications for management. Arch Surg. 1984 Jul;119(7):780–783. doi: 10.1001/archsurg.1984.01390190024005. [DOI] [PubMed] [Google Scholar]
  2. BLACKBURN H., KEYS A., SIMONSON E., RAUTAHARJU P., PUNSAR S. The electrocardiogram in population studies. A classification system. Circulation. 1960 Jun;21:1160–1175. doi: 10.1161/01.cir.21.6.1160. [DOI] [PubMed] [Google Scholar]
  3. Berman D. S., Rozanski A., Knoebel S. B. The detection of silent ischemia: cautions and precautions. Circulation. 1987 Jan;75(1):101–105. doi: 10.1161/01.cir.75.1.101. [DOI] [PubMed] [Google Scholar]
  4. Boucher C. A., Brewster D. C., Darling R. C., Okada R. D., Strauss H. W., Pohost G. M. Determination of cardiac risk by dipyridamole-thallium imaging before peripheral vascular surgery. N Engl J Med. 1985 Feb 14;312(7):389–394. doi: 10.1056/NEJM198502143120701. [DOI] [PubMed] [Google Scholar]
  5. Braunwald E., Kloner R. A. The stunned myocardium: prolonged, postischemic ventricular dysfunction. Circulation. 1982 Dec;66(6):1146–1149. doi: 10.1161/01.cir.66.6.1146. [DOI] [PubMed] [Google Scholar]
  6. Brewster D. C., Okada R. D., Strauss H. W., Abbott W. M., Darling R. C., Boucher C. A. Selection of patients for preoperative coronary angiography: use of dipyridamole-stress--thallium myocardial imaging. J Vasc Surg. 1985 May;2(3):504–510. doi: 10.1067/mva.1985.avs0020504. [DOI] [PubMed] [Google Scholar]
  7. Cooperman M., Pflug B., Martin E. W., Jr, Evans W. E. Cardiovascular risk factors in patients with peripheral vascular disease. Surgery. 1978 Oct;84(4):505–509. [PubMed] [Google Scholar]
  8. Cutler B. S., Leppo J. A. Dipyridamole thallium 201 scintigraphy to detect coronary artery disease before abdominal aortic surgery. J Vasc Surg. 1987 Jan;5(1):91–100. doi: 10.1067/mva.1987.avs0050091. [DOI] [PubMed] [Google Scholar]
  9. Cutler B. S. Prevention of cardiac complications in peripheral vascular surgery. Surg Clin North Am. 1986 Apr;66(2):281–292. doi: 10.1016/s0039-6109(16)43881-8. [DOI] [PubMed] [Google Scholar]
  10. Cutler B. S., Wheeler H. B., Paraskos J. A., Cardullo P. A. Applicability and interpretation of electrocardiographic stress testing in patients with peripheral vascular disease. Am J Surg. 1981 Apr;141(4):501–506. doi: 10.1016/0002-9610(81)90148-3. [DOI] [PubMed] [Google Scholar]
  11. DRIPPS R. D., LAMONT A., ECKENHOFF J. E. The role of anesthesia in surgical mortality. JAMA. 1961 Oct 21;178:261–266. doi: 10.1001/jama.1961.03040420001001. [DOI] [PubMed] [Google Scholar]
  12. Deron S. J., Kotler M. N. Noncardiac surgery in the cardiac patient. Am Heart J. 1988 Sep;116(3):831–838. doi: 10.1016/0002-8703(88)90345-6. [DOI] [PubMed] [Google Scholar]
  13. Detsky A. S., Abrams H. B., McLaughlin J. R., Drucker D. J., Sasson Z., Johnston N., Scott J. G., Forbath N., Hilliard J. R. Predicting cardiac complications in patients undergoing non-cardiac surgery. J Gen Intern Med. 1986 Jul-Aug;1(4):211–219. doi: 10.1007/BF02596184. [DOI] [PubMed] [Google Scholar]
  14. Eagle K. A., Singer D. E., Brewster D. C., Darling R. C., Mulley A. G., Boucher C. A. Dipyridamole-thallium scanning in patients undergoing vascular surgery. Optimizing preoperative evaluation of cardiac risk. JAMA. 1987 Apr 24;257(16):2185–2189. [PubMed] [Google Scholar]
  15. Falcone C., de Servi S., Poma E., Campana C., Sciré A., Montemartini C., Specchia G. Clinical significance of exercise-induced silent myocardial ischemia in patients with coronary artery disease. J Am Coll Cardiol. 1987 Feb;9(2):295–299. doi: 10.1016/s0735-1097(87)80378-9. [DOI] [PubMed] [Google Scholar]
  16. Gage A. A., Bhayana J. N., Balu V., Hook N. Assessment of cardiac risk in surgical patients. Arch Surg. 1977 Dec;112(12):1488–1492. doi: 10.1001/archsurg.1977.01370120078009. [DOI] [PubMed] [Google Scholar]
  17. Goldman L., Caldera D. L., Nussbaum S. R., Southwick F. S., Krogstad D., Murray B., Burke D. S., O'Malley T. A., Goroll A. H., Caplan C. H. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977 Oct 20;297(16):845–850. doi: 10.1056/NEJM197710202971601. [DOI] [PubMed] [Google Scholar]
  18. Goldman L., Cook E. F., Mitchell N., Flatley M., Sherman H., Cohn P. F. Pitfalls in the serial assessment of cardiac functional status. How a reduction in "ordinary" activity may reduce the apparent degree of cardiac compromise and give a misleading impression of improvement. J Chronic Dis. 1982;35(10):763–771. doi: 10.1016/0021-9681(82)90087-x. [DOI] [PubMed] [Google Scholar]
  19. Gottlieb S. O., Gottlieb S. H., Achuff S. C., Baumgardner R., Mellits E. D., Weisfeldt M. L., Gerstenblith G. Silent ischemia on Holter monitoring predicts mortality in high-risk postinfarction patients. JAMA. 1988 Feb 19;259(7):1030–1035. [PubMed] [Google Scholar]
  20. Gottlieb S. O., Weisfeldt M. L., Ouyang P., Mellits E. D., Gerstenblith G. Silent ischemia predicts infarction and death during 2 year follow-up of unstable angina. J Am Coll Cardiol. 1987 Oct;10(4):756–760. doi: 10.1016/s0735-1097(87)80267-x. [DOI] [PubMed] [Google Scholar]
  21. Hertzer N. R. Fatal myocardial infarction following peripheral vascular operations. A study of 951 patients followed 6 to 11 years postoperatively. Cleve Clin Q. 1982 Spring;49(1):1–11. doi: 10.3949/ccjm.49.1.1. [DOI] [PubMed] [Google Scholar]
  22. Leppo J., Boucher C. A., Okada R. D., Newell J. B., Strauss H. W., Pohost G. M. Serial thallium-201 myocardial imaging after dipyridamole infusion: diagnostic utility in detecting coronary stenoses and relationship to regional wall motion. Circulation. 1982 Sep;66(3):649–657. doi: 10.1161/01.cir.66.3.649. [DOI] [PubMed] [Google Scholar]
  23. Leppo J., Plaja J., Gionet M., Tumolo J., Paraskos J. A., Cutler B. S. Noninvasive evaluation of cardiac risk before elective vascular surgery. J Am Coll Cardiol. 1987 Feb;9(2):269–276. doi: 10.1016/s0735-1097(87)80374-1. [DOI] [PubMed] [Google Scholar]
  24. McCabe C. J., Reidy N. C., Abbott W. M., Fulchino D. M., Brewster D. C. The value of electrocardiogram monitoring during treadmill testing for peripheral vascular disease. Surgery. 1981 Feb;89(2):183–186. [PubMed] [Google Scholar]
  25. Mohr R., Smolinsky A., Morag B., Bass A., Rubinstein Z. J., Adar R. Cardiac complications in vascular procedures: comparison of percutaneous angioplasty and surgery. Cathet Cardiovasc Diagn. 1983;9(4):339–343. doi: 10.1002/ccd.1810090403. [DOI] [PubMed] [Google Scholar]
  26. Puls A., Thadani U. Rupture of abdominal aortic aneurysm during exercise. Gated blood pool studies. Am J Med. 1986 Nov;81(5):887–889. doi: 10.1016/0002-9343(86)90362-1. [DOI] [PubMed] [Google Scholar]
  27. Rocco M. B., Nabel E. G., Campbell S., Goldman L., Barry J., Mead K., Selwyn A. P. Prognostic importance of myocardial ischemia detected by ambulatory monitoring in patients with stable coronary artery disease. Circulation. 1988 Oct;78(4):877–884. doi: 10.1161/01.cir.78.4.877. [DOI] [PubMed] [Google Scholar]
  28. Sachs R. N., Tellier P., Larmignat P., Azorin J., Fischbein L., Beaudet B., Cadilhac P., Cupa M., De Saint Florent G., Vulpillat M. Assessment by dipyridamole-thallium-201 myocardial scintigraphy of coronary risk before peripheral vascular surgery. Surgery. 1988 May;103(5):584–587. [PubMed] [Google Scholar]
  29. Taillefer R., Lette J., Phaneuf D. C., Léveillé J., Lemire F., Essiambre R. Thallium-201 myocardial imaging during pharmacologic coronary vasodilation: comparison of oral and intravenous administration of dipyridamole. J Am Coll Cardiol. 1986 Jul;8(1):76–83. doi: 10.1016/s0735-1097(86)80094-8. [DOI] [PubMed] [Google Scholar]
  30. Weiner D. A., Ryan T. J., McCabe C. H., Ng G., Chaitman B. R., Sheffield L. T., Tristani F. E., Fisher L. D. Risk of developing an acute myocardial infarction or sudden coronary death in patients with exercise-induced silent myocardial ischemia. A report from the Coronary Artery Surgery Study (CASS) registry. Am J Cardiol. 1988 Dec 1;62(17):1155–1158. doi: 10.1016/0002-9149(88)90251-2. [DOI] [PubMed] [Google Scholar]
  31. von Knorring J. Postoperative myocardial infarction: a prospective study in a risk group of surgical patients. Surgery. 1981 Jul;90(1):55–60. [PubMed] [Google Scholar]

Articles from Annals of Surgery are provided here courtesy of Lippincott, Williams, and Wilkins

RESOURCES