Ouriel K, Green R M, DeWeese J A, Varon M E
Department of Surgery, University of Rochester, New York 14642, USA.
J Vasc Surg. 1995 Dec;22(6):671-7; discussion 678-9. doi: 10.1016/s0741-5214(95)70057-9.
A variety of preoperative provocative tests have been used to define the risk of cardiac morbidity and mortality after peripheral vascular procedures, including dipyridamole myocardial scintigraphy and dobutamine stress echocardiography. Although highly sensitive, these tests are time-consuming and associated with significant expense. We investigated outpatient echocardiography as a less resource-intensive means of assessing cardiac risk with operation.
Over a 2-year period 250 consecutive patients underwent outpatient transthoracic echocardiography before elective peripheral vascular operation was performed. The accuracy of the Goldman, Detsky, and the American Society of Anesthesiologists' Physical Status Classification clinical indexes of cardiac risk were assessed with regard to the development of cardiac complications such as unstable angina, myocardial infarction, life-threatening ventricular arrhythmias, severe congestive heart failure, and cardiogenic shock. The accuracy of echocardiographically determined left ventricular ejection fraction was determined at threshold values between 20% and 60%.
Perioperative cardiac events developed in 23 (9.2%) of the patients, and nine (3.6%) of the patients died as a result of these complications. Clinical indexes lacked sensitivity in the preoperative prediction of cardiac complications. Receiver operating curve analysis defined a left ventricular ejection fraction of less than 50% as an appropriate threshold for defining patients at high risk, with a sensitivity of 78% and a specificity of 81% in the identification of patients who had cardiac morbidity. The positive predictive value was 27%, and the negative predictive value was 97%. The economic impact of outpatient echocardiography was well below that of dipyridamole myocardial scintigraphy or dobutamine stress echocardiography.
Outpatient echocardiography appears to offer a cost-efficient compromise between clinical criteria alone and provocative cardiac testing such as dipyridamole myocardial scintigraphy and dobutamine stress echocardiography in the preoperative screening of patients undergoing peripheral vascular surgical procedures.
多种术前激发试验已被用于确定外周血管手术后心脏发病和死亡的风险，包括双嘧达莫心肌闪烁显像和多巴酚丁胺负荷超声心动图检查。尽管这些检查高度敏感，但它们耗时且费用高昂。我们研究了门诊超声心动图检查作为一种资源消耗较少的评估手术心脏风险的方法。
在2年期间，250例连续患者在择期外周血管手术前接受了门诊经胸超声心动图检查。评估了戈德曼、德茨基以及美国麻醉医师协会身体状况分类的心脏风险临床指标对于心脏并发症（如不稳定型心绞痛、心肌梗死、危及生命的室性心律失常、严重充血性心力衰竭和心源性休克）发生情况的准确性。在20%至60%的阈值范围内确定了超声心动图测定的左心室射血分数的准确性。
23例（9.2%）患者发生围手术期心脏事件，其中9例（3.6%）患者因这些并发症死亡。临床指标在术前预测心脏并发症方面缺乏敏感性。受试者操作曲线分析确定左心室射血分数低于50%为定义高危患者的合适阈值，在识别有心脏发病的患者时，敏感性为78%，特异性为81%。阳性预测值为27%，阴性预测值为97%。门诊超声心动图检查的经济影响远低于双嘧达莫心肌闪烁显像或多巴酚丁胺负荷超声心动图检查。
在对外周血管手术患者进行术前筛查时，门诊超声心动图检查似乎在仅依靠临床标准与双嘧达莫心肌闪烁显像和多巴酚丁胺负荷超声心动图检查等激发性心脏检查之间提供了一种经济高效的折衷方案。
