Columbo Jesse A, Barnes J Aaron, Jones Douglas W, Suckow Bjoern D, Walsh Daniel B, Powell Richard J, Goodney Philip P, Stone David H
Section of Vascular Surgery, Geisel School of Medicine at Dartmouth, Hanover, NH.
Section of Vascular Surgery, Geisel School of Medicine at Dartmouth, Hanover, NH.
J Vasc Surg. 2020 Nov;72(5):1584-1592. doi: 10.1016/j.jvs.2020.01.061. Epub 2020 Apr 1.
Cardiac risk assessment is a critical component of vascular disease management before surgical intervention. The predictive risk reduction of a negative cardiac stress test result remains poorly defined. The objective of this study was to compare the incidence of postoperative cardiac events among patients with negative stress test results vs those who did not undergo testing.
We reviewed all patients who underwent elective open abdominal aortic aneurysm repair, suprainguinal bypass, endovascular aneurysm repair (EVAR), carotid endarterectomy (CEA), and infrainguinal bypass within the Vascular Study Group of New England from 2003 to 2017. We excluded patients with positive stress test results (n = 3312) and studied two mutually exclusive groups: elective surgery patients with a negative stress test result and elective surgery patients with no stress test (total n = 26,910). The primary outcome was a composite of in-hospital postoperative cardiac events (dysrhythmia, heart attack, heart failure) or death.
A preoperative stress test was obtained in 66.3% of open repairs, 42.8% of suprainguinal bypasses, 37.1% of EVARs, 36.0% of CEAs, and 31.2% of infrainguinal bypasses. The proportion of patients receiving a preoperative stress test varied widely across centers, from 37.1% to 80.0%. The crude odds ratio of in-hospital postoperative cardiac event or death was 1.37 (95% confidence interval [CI], 1.07-1.76) for open repair and 1.52 (CI, 1.13-2.03) for suprainguinal bypass, indicating that patients with negative stress test results before these procedures were 37% and 52% more likely to suffer a postoperative event or die compared with patients selected to proceed directly to surgery without testing. Conversely, the crude odds ratio was 0.92 (CI, 0.66-1.29) for EVAR, 0.92 (CI, 0.70-1.21) for CEA, and 1.13 (CI, 0.90-1.40) for infrainguinal bypass, indicating that patients undergoing these procedures had a similar likelihood of sustaining an event whether they had a negative stress test result or proceeded directly to surgery without a stress test.
The use of cardiac stress testing before vascular surgery varies widely throughout New England. Whereas patients are often appropriately selected to proceed directly to surgery, a negative preoperative stress test result should not assuage the concern for an adverse outcome as these patients retain a substantial likelihood of cardiac events, especially after large-magnitude procedures.
心脏风险评估是手术干预前血管疾病管理的关键组成部分。心脏负荷试验结果为阴性时预测性风险降低的情况仍未明确界定。本研究的目的是比较心脏负荷试验结果为阴性的患者与未进行该项检查的患者术后心脏事件的发生率。
我们回顾了2003年至2017年在新英格兰血管研究组接受择期开放性腹主动脉瘤修复术、腹股沟上旁路移植术、血管腔内动脉瘤修复术（EVAR）、颈动脉内膜切除术（CEA）和腹股沟下旁路移植术的所有患者。我们排除了心脏负荷试验结果为阳性的患者（n = 3312），并研究了两个相互排斥的组：心脏负荷试验结果为阴性的择期手术患者和未进行心脏负荷试验的择期手术患者（总数n = 26,910）。主要结局是术后住院期间心脏事件（心律失常、心脏病发作、心力衰竭）或死亡的综合情况。
66.3%的开放性修复术、42.8%的腹股沟上旁路移植术、37.1%的EVAR、36.0%的CEA和31.2%的腹股沟下旁路移植术患者进行了术前心脏负荷试验。接受术前心脏负荷试验的患者比例在各中心差异很大，从37.1%到80.0%不等。开放性修复术患者术后住院期间心脏事件或死亡的粗比值比为1.37（95%置信区间[CI]，1.07 - 1.76），腹股沟上旁路移植术患者为1.52（CI，1.13 - 2.03），这表明在这些手术前心脏负荷试验结果为阴性的患者与直接选择手术而未进行检查的患者相比，术后发生事件或死亡的可能性分别高37%和52%。相反，EVAR患者的粗比值比为0.92（CI，0.66 - 1.29），CEA患者为（CI，0.70 - 1.21），腹股沟下旁路移植术患者为1.13（CI，0.90 - 1.40），这表明接受这些手术的患者无论心脏负荷试验结果是否为阴性，发生事件的可能性相似。
在新英格兰地区，血管手术前心脏负荷试验的使用差异很大。虽然患者通常被适当地选择直接进行手术，但术前心脏负荷试验结果为阴性不应消除对不良结局的担忧，因为这些患者仍有相当大的心脏事件发生可能性，尤其是在大型手术之后。
