Cardiac screening tests prior to lower extremity revascularization: routine versus selective application.

Coronary artery disease (CAD) is the most important comorbidity associated with peripheral vascular disease. Consensus on the optimal approach to the cardiac evaluation of patients presenting for peripheral vascular operations has not been achieved. We developed a large experience with routine cardiac screening using dipyridamole thallium scintigraphy (DTS) and radionuclide ventriculography. The incidence of reversible ischemia on DTS and the subsequent documentation of severe CAD on coronary angiography was similar in vascular patients with a history of CAD (angina or myocardial infarction) and those with a negative CAD history. However, the analysis of overall risks and benefits does not support a recommendation for routine screening. We suggest that selection of patients for screening should be based on the estimated benefit of coronary revascularization for the individual patient considering both perioperative and long-term survival. In addition, screening is also considered if identification of unsuspected CAD will alter the decision to perform the proposed peripheral vascular operation. Thus, the older patient who requires an infrainguinal bypass for limb-threatening ischemia is unlikely to benefit from cardiac screening. Documentation of the extent of CAD with screening studies may be beneficial in younger patients or in patients with claudication.