Download Perioperative Cardiovascular Evaluation: Is There a

CCTA, Furgerson
Perioperative Cardiovascular Evaluation: Is There a Role for Coronary
Computed Tomography Angiography?
James L. Furgerson, M.D.
Cardiology Service, Brooke Army Medical Center, Fort Sam Houston, TX
Introduction
Perioperative cardiovascular complications resulting
from non-cardiac surgery are an important cause of
morbidity and mortality. Using a step-wise approach
and selective cardiac testing, those at highest risk of
cardiovascular complications can be identified and
offered medical therapy and revascularization – when
indicated – in order to reduce the risk of perioperative
myocardial infarction and other cardiovascular
complications and improve their overall prognosis.
Currently used non-invasive techniques have some
limitations, especially in those who cannot exercise
adequately prior to surgery. Coronary computed
tomography angiography (CCTA) is now a wellestablished non-invasive technique which is very
effective at identifying those with advanced
multivessel and left main coronary artery disease and
may have a future role in the cardiac evaluation of
patients prior to non-cardiac surgery. In this review,
current guidelines on perioperative cardiovascular
evaluation are reviewed with a focus on non-invasive
imaging techniques, including CCTA.
Background
Perioperative cardiovascular complications of
moderate to high risk surgery are an important source
of morbidity and mortality. Of the approximately 230
million noncardiac surgeries performed each year
worldwide,
approximately
2,300,000
major
cardiovascular events and 690,000 cardiovascular
deaths result.1 The short term mortality associated
with perioperative MI (PMI) is estimated at 3.5-25%,
and the occurrence of PMI results in substantial
increases in hospital stay and cost.2,3 Identification of
patients who are harboring advanced coronary artery
disease prior to surgery may allow for optimal risk
reduction for cardiovascular events in the
perioperative period using medical therapy and
selective revascularization.
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Noninvasive Preoperative Cardiovascular
Assessment
Current guidelines for preoperative cardiovascular
assessment call for careful clinical assessment to
identify active cardiovascular conditions, such as
unstable angina, decompensated congestive heart
failure, and severe valvular heart disease.4 In patients
without active conditions, the use of additional testing
to further define cardiovascular risk is controversial
and is generally reserved only for cases when the
outcome of such investigation will affect subsequent
management.
Consideration of noninvasive testing for coronary
artery disease is appropriate when the patient will be
undergoing intermediate or high risk surgery, has poor
functional capacity, and carries three or more clinical
risk factors. While exercise testing is preferred,
preoperative patients are frequently not capable of
exercising adequately, and a history of poor functional
capacity exacerbates the problem of effectively
exercising patients as a form of risk stratification prior
to the planned procedure. For those patients who
cannot exercise adequately, the following noninvasive
options are available: vasodilator nuclear perfusion
imaging, dobutamine stress echocardiography,
dobutamine magnetic resonance imaging, vasodilator
magnetic resonance perfusion imaging, and coronary
CT angiography (CCTA). The diagnostic accuracy of
these techniques is given in Table 1.
Vasodilator nuclear perfusion imaging, using
adenosine, dipyridamole, or a newer adenosine
agonist is supported by robust clinical investigation
data showing its value in predicting perioperative
events and outcomes.5,6 However, nuclear perfusion
imaging in general is hampered by the occurrence of
soft tissue attenuation and other imaging artifacts
which can adversely affect the specificity of the test
and its corresponding positive predictive value.
Additionally, in patients with advanced multivessel
disease, the presence of "balanced ischemia" may give
J Am Osteopath Coll Radiol 2013; Vol. 2, Issue 2
CCTA, Furgerson
Table 1.
Accuracy of Noninvasive
Techniques for Detection of Coronary
Artery Disease .
Modality
Sensitivity
Specificity
Exercise ECG (27)
0.68
0.77
Exercise Echo (28)
0.86
0.81
Dobutamine Echo (28)
0.85
0.85
Exercise Nuclear Perfusion (29)
0.87
0.73
Pharmacologic Nuclear (29)
0.86
0.75
Dobutamine MRI (9)
0.86
0.86
MRI Perfusion (8)
0.86
0.76
CT Coronary Angiography (11)
0.95
0.83
a falsely negative test result, particularly when the
added value of exercise ECG testing is not available.7
Dobutamine stress echocardiography also has
extensive prior investigational data associated with its
use in the periprocedural period,4 and is a useful test
in patients who can tolerate dobutamine infusion and
have adequate acoustic windows for detailed
myocardial imaging, which is required for this test.
While the risk of dobutamine infusion is relatively low
and acceptable in most situations, care must be used
to avoid precipitating ischemia and or complex
ventricular arrhythmia with the administration of this
agent. Additionally, considerable expertise is required
on the part of the echocardiographic technician in
obtaining adequate images and similar expertise is
required by the interpreting physician, which may not
be available in many centers.
Magnetic resonance imaging to detect inducible
wall motion abnormalities with the infusion of
dobutamine or by detection of perfusion defects with
first pass imaging to vasodilator is well-developed in a
few centers where operating characteristics are
favorable compared with other noninvasive tests.8,9
However, this is not well proven in the perioperative
setting.
CCTA is known to be a highly sensitive modality for
detecting coronary atherosclerosis and has received
increasing acceptance after multiple clinical trials have
J Am Osteopath Coll Radiol 2013; Vol. 2, Issue 2
shown very good accuracy when compared with
invasive
coronary
angiography.10-12
Radiation
exposure, use of radiocontrast media, and limited
specificity when imaging patients with extensive
coronary calcium, large body habitus, and irregular
rhythm, have traditionally been detractors of this
technology. However, with the latest technology,
radiation exposure has become acceptable in most
clinical scenarios, and arrhythmia and body habitus are
less problematic than in the past.
Invasive Preoperative coronary Angiography
For preoperative patients who have undergone
noninvasive testing, indications for preoperative
invasive coronary angiography are similar to those
identified in the nonoperative setting.13 Specifically, in
the asymptomatic patient, the occurrence of high risk
findings should lead to consideration for referral for
invasive coronary angiography. Such high risk findings
include greater than 10% ischemic myocardium or
transient ischemic dilation by nuclear perfusion
imaging, stress-induced wall motion abnormality in
greater than or equal to two myocardial segments, or
stress induced left ventricular dysfunction by stress
echocardiography. In the patient with symptoms of
ischemic heart disease, abnormal findings on
noninvasive testing, baseline resting left ventricular
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CCTA, Furgerson
dysfunction with a positive viability study, and high
clinical suspicion of disease without further
noninvasive testing would be indications for invasive
coronary angiography. In a patient with established
atherosclerotic heart disease, uncontrolled ischemic
symptoms, which are worsening or limiting on medical
therapy, and high risk findings by noninvasive testing
might prompt referral for invasive coronary
angiography.
Prophylactic revascularization prior to noncardiac
surgery is a highly controversial practice. The rationale
behind such revascularization seems to be that
bypassing or dilating areas of high-grade stenosis
within the coronary tree will prevent the occurrence of
ischemia and ultimately infarction related to periods of
high myocardial oxygen demand in the perioperative
setting. However, this rationale is not well supported,
and greater than half of all PMI is associated with in
situ coronary thrombosis, which frequently occurs in
areas
without
high-grade
fixed
disease
preoperatively.14 Thus, the increase in inflammatory
activity, procoagulant activity, and shear stress within
the coronary tree and the affect of these factors on
nonobstructive atheroma with subsequent plaque
rupture and thrombosis is an important mechanism of
PMI;3 this cannot be predicted by invasive coronary
angiography
or
attenuated
by
coronary
revascularization in many cases. However, some PMI is
likely related to high-grade fixed disease and periods
of supply-demand mismatch.15 Within the last decade,
at least two important randomized clinical trials have
been conducted to examine the role of prophylactic
revascularization prior to high risk surgery. 16,17 Both
studies showed no improvement in short-term or longterm prognosis with successful preoperative coronary
revascularization. Conversely, while also somewhat
controversial, medical therapy using heart rate control
has in general been shown to favorably affect
outcomes in patients with ischemic heart disease
when carefully provided.18-21
Current guidelines for prophylactic revascularization
are based on traditional indications for coronary
bypass surgery in improving survival in patients with
advanced coronary artery disease.22 Such patients
include those with greater than 50% left main stenosis,
greater than 70% stenosis in 3 epicardial vessels,
greater than 70% stenosis in the proximal LAD with
one additional vessel stenosis, those with two-vessel
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disease with extensive ischemia, and those with
proximal LAD or two-vessel disease with left
ventricular dysfunction and demonstrable viability.
These indications for prophylactic revascularization
are largely based on the individual’s coronary anatomy
as determined by invasive coronary angiography.
Additionally, a recent prospective randomized study of
a systematic strategy of prophylactic coronary
angiography versus a "selective strategy" using
coronary angiography on the basis of abnormal
noninvasive testing showed improvement in long-term
outcome in patients who underwent routine invasive
coronary angiography prior to vascular surgery.23
Cardiac CTA
CCTA is a highly sensitive test for coronary
atherosclerosis with excellent sensitivity and
specificity for coronary artery disease when compared
with invasive coronary angiography (Figure 1).10-12 The
negative predictive value for left main and left anterior
descending artery obstruction by coronary CT
angiography is especially high,24 which is of particular
importance when identifying patients thought to
benefit from prophylactic coronary revascularization
prior to non-cardiac surgery. However, there are no
randomized controlled data from clinical trials to
examine outcomes when CCTA is used in the
preoperative setting. It is currently considered an
"uncertain" indication for preoperative assessment in
patients waiting intermediate to high risk surgery with
a low functional capacity and who carry three or more
clinical risk factors.25
An ongoing clinical trial at Brooke Army Medical
Center will examine the role of CCTA versus
vasodilator nuclear perfusion imaging in the
preoperative assessment of patients awaiting
intermediate to high risk surgery with three or more
clinical risk factors who cannot adequately exercise.
Since many of the patients enrolling in the study will
have peripheral vascular disease and by proxy
underlying advanced coronary atherosclerosis, the
presence of coronary calcium may become
problematic in identifying patients with left main and
proximal three-vessel disease by CT angiography.
Conversely, with a relatively high pretest likelihood of
advanced coronary atherosclerosis, the potential for a
false negative vasodilator perfusion scan related to
J Am Osteopath Coll Radiol 2013; Vol. 2, Issue 2
CCTA, Furgerson
Figure 1.
Correlation of CT
Angiography with Invasive Coronary
Angiography. Reformatted cardiac
CTA images (A thru C) demonstrate
obstruction of the mid right coronary
artery. Corresponding image by
invasive coronary angiography (D)
demonstrates
similar/identical
findings.
balanced ischemia will be a potential risk of the
vasodilator perfusion imaging in this setting. If
adequate coronary imaging can reliably be performed
in this group of patients which will likely have rather
advanced atherosclerosis, it is felt that CT coronary
angiography will be an ideal method to identify
patients at risk of ischemic complications in the
perioperative period, as well as identifying patients
who will benefit from prophylactic coronary
revascularization and additional medical therapy.
It is likely that continued advances in CCTA, which
will lessen imaging artifacts associated with coronary
calcium, will lead to additional acceptance of the use
of this modality in preoperative cardiovascular risk
assessment. A similar anatomy-based approach has
been suggested and is being tested in patients with
non-acute symptoms of ischemic heart disease;30 it
has been well established as a safe, effective, and costconscious means of evaluating those with acute
symptoms of possible acute coronary syndrome and
low or intermediate pretest probability of coronary
artery disease.26
J Am Osteopath Coll Radiol 2013; Vol. 2, Issue 2
Summary
Perioperative cardiovascular complications resulting
from non-cardiac surgery are an important cause of
morbidity and mortality. Using a step-wise approach
and selective cardiac testing, those at highest risk of
cardiovascular complications can be identified and
offered medical therapy and revascularization when
indicated in order to reduce the risk of perioperative
myocardial infarction and other cardiovascular
complications and improve their overall prognosis.
Currently used non-invasive techniques have some
limitations, especially in those who cannot exercise
adequately prior to surgery. Coronary computed
tomography angiography (CCTA) is now a wellestablished non-invasive technique which is very
effective at identifying those with advanced multivessel and left main coronary artery disease. Since
much of the data supporting current guidelines on
medical management and coronary revascularization
of those at risk for perioperative adverse
cardiovascular events are based on the presence and
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CCTA, Furgerson
severity of anatomic coronary stenoses, there is a
strong rationale for use of CCTA in the preoperative
assessment of these patients. Additional research data
are needed to establish CCTA as an effective means of
cardiovascular risk assessment prior to intermediate
or high risk surgery. With further improvements in
CCTA imaging technology, which will lessen the impact
of coronary calcium on image quality, and additional
research efforts, it is likely that CCTA will be accepted
as an effective means of preoperative risk assessment.
strategies.
The views expressed in this material are those
of the author, and do not reflect the official
policy or position of the U.S. Government, the
Department of Defense, or the Department of
the Army or Air Force.
8.
9.
10.
11.
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