Testing Cardiac Reserve: Then & Now

Department of Anesthesiology, Emory University Hospital, 1364 Clifton Rd NE, Atlanta, GA 30322. .
Anesthesia and analgesia (Impact Factor: 3.47). 11/2012; 115(5):991-2. DOI: 10.1213/ANE.0b013e31825d2c09
Source: PubMed
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    ABSTRACT: In this meta-analysis we compared thallium imaging (TI) and stress echocardiography (SE) in patients at risk for myocardial infarction (MI) scheduled for elective noncardiac surgery. Two searches of published articles were used to identify relevant articles. We included all studies that stated the criteria for a positive test and detailed the frequency of postoperative MI and in-hospital death. Data were abstracted by two authors and captured preoperative patient characteristics, study design, blinding, and outcome adjudication. We defined a positive test as a test with a reversible defect and, where possible, quantified the size of the defects in each study. MI and/or death were the only postoperative outcomes of interest. We calculated the sensitivity, specificity, and likelihood ratio (LR) and, where possible, the Receiver Operating Characteristic (ROC) curve of a cardiac event in each study. The LR and ROC were combined by meta-analyses using the random effects model. Heterogeneity was assessed using the I2 test. The search revealed 68 studies of 10,049 patients. There were 25 SE studies and 50 TI studies. There were 7 studies with a direct comparison of the two methodologies. The quality of studies differed; routine screening for MI was used more frequently in SE studies (47.8% versus 21.2%; P = 0.008) and screening dictated treatment more often after TI (72.1%) than after SE (46.3%) (P = 0.027). The LR for SE was more indicative of a postoperative cardiac event than TI (LR, 4.09; 95% CI, 3.21-6.56 versus 1.83; 1.59-2.10; P = 0.001). This difference was attributable to fewer false-negative SEs. There was no difference in the cumulative ROC curves from qualitative studies (SE, 0.80; 95% CI, 0.76-.84 versus TI, 0.75; 95% CI, 0.70-081). Again, the LR for a negative SE was less (0.23; 95% CI, 0.17-0.32 versus 0.44; 95% CI, 0.36-0.54). A moderate-to-large defect, seen in 14% of patients, by either method predicts a postoperative cardiac event (LR, 8.35; 95% CI, 5.6-12.45). This meta-analysis possesses the statistical power to demonstrate that SE has better negative predicative characteristics than TI. A moderate-to-large perfusion defect by either SE or TI predicts postoperative MI and death. We conclude the SE is superior to TI in predicting postoperative cardiac events.
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    ABSTRACT: Endocardial motion and surface/volume changes during the cardiac cycle are echocardiographic methods for regional (analysis of wall motion) and global (fractional area change, stroke volume, and ejection fraction) evaluation of cardiac function. These conventional methods can be subjective, and/or time consuming and, depending upon circumstances, may divert the anesthesiologist's attention from intraoperative activities. Doppler tissue imaging (DTI) is a novel echocardiographic technique, which displays and measures systolic and diastolic velocity from a myocardial region. DTI is simple to perform and independent of adequate endocardial imaging. The numeric information (velocity or time intervals) is easily obtained and measured. Assessment of systolic and diastolic function on regional (detection of ischemia) as well as global level (ejection fraction, grading of diastolic dysfunction) and evaluation of filling pressure can be derived from DTI signals and used by any practicing cardiac anesthesiologist. This review describes the principles, imaging modalities, and clinical applications of DTI.
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