Patients undergoing major vascular surgery have an increased risk of perioperative major adverse cardiovascular events (MACE). Accordingly, in this population, it is of particular importance to appropriately risk stratify patients’ risk for these complications and optimize risk factors prior to surgical intervention. Comorbidities that portend a higher risk of perioperative MACE include coronary artery disease, heart failure, left-sided valvular heart disease, and significant arrhythmic burden. In this review, we provide a current approach to risk stratification prior to major vascular surgery and describe the strengths and weaknesses of different cardiac risk indices; discuss the role of noninvasive and invasive cardiac testing; and review perioperative pharmacotherapies.

Stress echocardiography is a diagnostic cardiovascular exam that is commonly utilized for multiple indications, including but not limited to the assessment of obstructive coronary artery disease, valvular disease, obstructive hypertrophic cardiomyopathy, and diastolic function. Stress echocardiography can be performed via both exercise and pharmacologic modalities. Exercise stress is performed with either treadmill or bicycle-based exercise. Pharmacologic stress is performed via either dobutamine or vasodilator-mediated (i.e., dipyridamole, adenosine) stress testing. Each of these modalities is associated with a low overall prevalence of major, life-threatening adverse outcomes, though adverse events are most common with dobutamine stress echocardiography. In light of the recent COVID-19 pandemic, the risk of infectious complications to both the patient and stress personnel cannot be negated; however, when certain precautions are taken, the risk of infectious complications appears minimal. In this article, we review each of the stress echocardiographic modalities, examine major potential adverse outcomes and contraindications, assess the risks of stress testing in the setting of a global pandemic, and examine the utilization and safety of stress testing in special patient populations (i.e., language barriers, pediatric patients, pregnancy).

Case: A 50-year-old woman with a prior right carotid aneurysm repair presented for chest pain. An evaluation 13 years ago showed a normal echo and cardiac catheterization. Four years prior, an echo showed an enlarged left ventricle with ejection fraction 57% and mid-anterolateral and inferolateral wall hypokinesis. Coronary angiography showed diffuse aneurysms of all coronary arteries with a proximal stenosis of the LAD, followed by a giant coronary aneurysm (Figure 1). CT angiography revealed bilateral intercostal artery aneurysms and a mildly ectatic aorta. She underwent bypass of the LAD with the LIMA. Aortic biopsy revealed no aortitis and prior carotid aneurysm pathology showed plasmalymphocytic inflammation; labs showed hypereosinophilia and elevated inflammatory markers with other negative immunologic work-up. She was diagnosed with hypereosinophilic vasculitis without evidence of granulomatosis and started on immunosuppressants.Due to symptoms, she underwent coronary angiography. Her LAD was occluded ostially with distal flow via a patent LIMA (Figure 2). There was progression of her aneurysmal disease at her proximal right coronary artery. No intervention was recommended. Instead, to improve control of her vasculitis, a Janus kinase inhibitor will be started. Discussion: Hypereosinophilic vasculitis, a variant of eosinophilic granulomatosis with polyangiitis, affects small- and medium-sized arteries and is challenging to diagnose. This case highlights a rare cardiac complication that can occur with this condition. Cardiac involvement often manifests as heart failure, pericarditis, valvular insufficiency, or rarely, coronary aneurysms.

Epinephrine is a commonly used medication for emergent conditions, such as anaphylaxis, respiratory distress, and shock. However, its versatility can also lead to iatrogenic errors in dosages, concentrations, and routes of administration. In this case, a 47-year-old female experiencing anaphylaxis received an intravenous dose of 0.3 mg (1:1000) epinephrine formulated for intramuscular injection, resulting in cardiac arrest and acute heart failure due to myocardial stunning, as diagnosed by echocardiography. Management included invasive ventilation and hemodynamic support until cardiac function recovered. This case highlights the potential dangers of epinephrine overdose, and to our knowledge, is the first reported case of iatrogenic epinephrine-induced Takotsubo cardiomyopathy in a rural area. In addition, we review the literature on iatrogenic epinephrine toxicity-associated cardiomyopathy and the epidemiology of epinephrine errors. Safety measures must be considered for improving communication in emergencies, increasing awareness via training, and changing epinephrine’s antiquated packaging design.