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Role of Clinical Characteristics, Dobutamine Echocardiography, and -Blocker Therapy

Eric Boersma, PhD; Don Poldermans, MD,PhD; Jeroen J. Bax, MD,PhD; Ewout W. Steyerberg, MD,PhD; Ian R. Thomson, MD; Jan D. Banga, MD,PhD; Louis L. M. van de Ven, MD,PhD; Hero van Urk, MD,PhD; Jos R. T. C. Roelandt, MD,PhD; for the DECREASE Study Group

JAMA. 2001;285:1865-1873.

Context  Patients who undergo major vascular surgery are at increased risk of perioperative cardiac complications. High-risk patients can be identified by clinical factors and noninvasive cardiac testing, such as dobutamine stress echocardiography (DSE); however, such noninvasive imaging techniques carry significant disadvantages. A recent study found that perioperative -blocker therapy reduces complication rates in high-risk individuals.

Objective  To examine the relationship of clinical characteristics, DSE results, -blocker therapy, and cardiac events in patients undergoing major vascular surgery.

Design and Setting  Cohort study conducted in 1996-1999 in the following 8 centers: Erasmus Medical Centre and Sint Clara Ziekenhuis, Rotterdam, Twee Steden Ziekenhuis, Tilburg, Academisch Ziekenhuis Utrecht, Utrecht, and Medisch Centrum Alkmaar, Alkmaar, the Netherlands; Ziekenhuis Middelheim, Antwerp, Belgium; and San Gerardo Hospital, Monza, Istituto di Ricovero e Cura a Carattere Scientifico, San Giovanni Rotondo, Italy.

Patients  A total of 1351 consecutive patients scheduled for major vascular surgery; DSE was performed in 1097 patients (81%), and 360 (27%) received -blocker therapy.

Main Outcome Measure  Cardiac death or nonfatal myocardial infarction within 30 days after surgery, compared by clinical characteristics, DSE results, and -blocker use.

Results  Forty-five patients (3.3%) had perioperative cardiac death or nonfatal myocardial infarction. In multivariable analysis, important clinical determinants of adverse outcome were age 70 years or older; current or prior angina pectoris; and prior myocardial infarction, heart failure, or cerebrovascular accident. Eighty-three percent of patients had less than 3 clinical risk factors. Among this subgroup, patients receiving -blockers had a lower risk of cardiac complications (0.8% [2/263]) than those not receiving -blockers (2.3% [20/855]), and DSE had minimal additional prognostic value. In patients with 3 or more risk factors (17%), DSE provided additional prognostic information, for patients without stress-induced ischemia had much lower risk of events than those with stress-induced ischemia (among those receiving -blockers, 2.0% [1/50] vs 10.6% [5/47]). Moreover, patients with limited stress-induced ischemia (1-4 segments) experienced fewer cardiac events (2.8% [1/36]) than those with more extensive ischemia (5 segments, 36% [4/11]).

Conclusion  The additional predictive value of DSE is limited in clinically low-risk patients receiving -blockers. In clinical practice, DSE may be avoided in a large number of patients who can proceed safely for surgery without delay. In clinically intermediate- and high-risk patients receiving -blockers, DSE may help identify those in whom surgery can still be performed and those in whom cardiac revascularization should be considered.

Author Affiliations: University Hospital Rotterdam, Rotterdam (Drs Boersma, Poldermans, Steyerberg, van de Ven, van Urk, and Roelandt), the University Hospital Leiden, Leiden (Dr Bax), and University Hospital Utrecht, Utrecht (Dr Banga), the Netherlands; and University of Manitoba, Winnipeg (Dr Thomson).

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