Cutler B S
Surg Clin North Am. 1986 Apr;66(2):281-92. doi: 10.1016/s0039-6109(16)43881-8.
The prevalence of severe coronary artery disease in peripheral vascular patients exceeds 50 per cent. It is therefore not surprising that complications of coronary artery disease are the most common causes of mortality following peripheral vascular operations. If the incidence of cardiac complications is to be reduced, it is first necessary to identify patients at risk through screening tests that will reliably detect hemodynamically important coronary occlusive disease. The operative risk can then be reduced by modifying the magnitude of the procedure, taking measures that can enhance the tolerance for a specific operation, or employing a combination of both. Screening methods in current use include risk factor analysis, exercise testing, routine coronary angiography, and dipyridamole thallium-201 scintigraphy. The risk factor approach has the advantage of being widely applicable since it makes use of historical, physical, and electrocardiographic findings that are already familiar to surgeons and anesthesiologists. It is also inexpensive. However, it may overlook the patient who has no symptoms of coronary artery disease, possibly as a result of the sedentary lifestyle imposed by complications of peripheral vascular disease. The electrocardiographically monitored stress test will identify the asymptomatic patient with occult coronary disease and is helpful in predicting operative risk. However, a meaningful test is dependent on the patient's ability to exercise--an activity that is frequently limited by claudication, amputation, or arthritis. Exercise testing also suffers from a lack of sensitivity and specificity when compared with coronary arteriography. Routine preoperative coronary angiography overcomes the exercise limitation of treadmill testing but is not widely applicable as a screening test for reasons of cost and inherent risk. Dipyridamole thallium-201 scanning, on the other hand, is safe and of relatively low cost and does not require exercise. Further, it has a high degree of sensitivity and specificity when compared with coronary arteriography. It appears to be an accurate predictor of postoperative cardiac complications.
外周血管疾病患者中严重冠状动脉疾病的患病率超过50%。因此，冠状动脉疾病并发症是外周血管手术后最常见的死亡原因也就不足为奇了。如果要降低心脏并发症的发生率，首先必须通过筛查试验识别出有风险的患者，这些试验要能可靠地检测出对血流动力学有重要影响的冠状动脉闭塞性疾病。然后可以通过调整手术规模、采取能提高对特定手术耐受性的措施或两者结合来降低手术风险。目前使用的筛查方法包括危险因素分析、运动试验、常规冠状动脉造影和双嘧达莫铊-201心肌显像。危险因素评估方法具有广泛适用性的优点，因为它利用了外科医生和麻醉医生已经熟悉的病史、体格检查和心电图检查结果。而且成本也较低。然而，它可能会忽略没有冠状动脉疾病症状的患者，这可能是由于外周血管疾病并发症导致的久坐不动的生活方式所致。心电图监测的应激试验可以识别出隐匿性冠心病的无症状患者，并有助于预测手术风险。然而，一项有意义的试验取决于患者的运动能力——而这种活动常常受到跛行、截肢或关节炎的限制。与冠状动脉造影相比，运动试验的敏感性和特异性也较差。常规术前冠状动脉造影克服了跑步机试验的运动限制，但由于成本和固有风险的原因，作为一种筛查试验并未广泛应用。另一方面，双嘧达莫铊-201扫描安全且成本相对较低，不需要运动。此外，与冠状动脉造影相比，它具有高度的敏感性和特异性。它似乎是术后心脏并发症的准确预测指标。
