The use of preoperative exercise testing to predict cardiac complications after arterial reconstruction

Abstract

To assess the value of exercise testing in the prediction of cardiac risk, 100 patients requiring arterial reconstructive surgery had either treadmill testing or arm ergometry before operation. Thirty-four patients then had abdominal aortic aneurysm repair, 48 had reconstructions for aortoiliac occlusive disease, and 18 had infrainguinal revascularization procedures. Cardiac complications included myocardial infarction in 10%, acute congestive failure in 5%, malignant ventricular arrhythmias in 7%, and cardiac death in 7%. Contingency table analysis showed that patients who achieved less than 85% of their predicted maximum heart rate (PMHR) during exercise testing had a complication rate of 24%, whereas patients who achieved more than 85% of PMHR had a 6% complication rate (p = 0.0396). The degree of ST segment depression during exercise testing was not a significant predictor of cardiac complications. However, patients who had a positive stress test (ST depression more than 1 mm) and achieved less than 85% of their PMHR had a complication rate of 33%, whereas patients with a positive stress test who achieved more than 85% of their PMHR had no complications (p = 0.048). Statistical analysis with a logistic regression model showed two factors to be significant. Patients who achieved a high maximum heart rate during exercise testing had a low probability of developing postoperative cardiac complications (p = 0.04), as did patients who achieved high cardiac work load maximal oxygen uptake (p = 0.03). We conclude that preoperative exercise testing is useful to predict cardiac complications after arterial reconstruction. Patients who are able to achieve more than 85% of their PMHR and a high maximal oxygen uptake represent a low-risk group.

2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery

“…The risk of perioperative cardiac events and long-term risk are increased significantly in patients with an abnormal exercise ECG at low workloads. 176,178,179 In contrast to the above-mentioned studies of patients with vascular disease, in a general population of patients in which only 20% to 35% had peripheral vascular disease and who were undergoing noncardiac surgery, Carliner et al 185 reported exercise-induced ST-segment depression greater than or equal to 1 mm in 16% of 200 patients older than 40 years (mean age 59 years) being considered for elective surgery. Only 2 patients (1%) had a markedly abnormal (ST-segment depression of 2 mm or more) exercise test.…”

“…In most series, very-highrisk patients (recent MI, unstable angina, HF, and serious ventricular arrhythmias) were excluded. McPhail et al 176 reported on preoperative exercise treadmill testing and supplemental arm ergometry in 100 patients undergoing surgery for peripheral vascular disease or abdominal aortic aneurysm. Of the 100 patients, 30 were able to reach 85% of agepredicted heart rate maximum, and only 2 had cardiac complications (6%).…”

Anaesthesia for abdominal aortic surgery — a review (Part I)

“…66-67 Patients able to achieve greater than 85 per cent of their predicted maximum heart rate at high maximal oxygen uptake may represent a low risk group for major vascular surgery. 68 The ability of vascular surgery patients to participate in exercise studies may be hampered by claudication, arthritis and amputation while digitalis, diuretic and beta-blocking agent administration may cause difficulties of interpretation. 69 In addition, limited sensitivity and low specificity have been reported for exercise testing.…”

II Diretriz de Avaliação Perioperatória da Sociedade Brasileira de Cardiologia

“…An important limitation of this test in perioperative evaluation for noncardiac surgeries is the fact that 30% to 50% of the patients referred to the cardiologist for preoperative evaluation for major or vascular surgeries cannot achieve sufficient load during exercise to assess cardiac reserve [37][38][39] .…”