Implications of Pre-operative Ischemia Evaluation in Patients Undergoing Non-cardiac Vascular Surgery

Introduction: A significant proportion of peri-procedural morbidity and mortality in non-cardiac vascular procedures are due to cardiovascular reasons. The purpose of this study was to evaluate the effect of peri-operative ischemia testing on management and outcomes of patients undergoing high-risk vascular surgery in a real-world setting.

Methods: Of 1866 patients who underwent vascular surgery during the years 2012-2016 we included 151 patients who underwent high-risk vascular surgery. Adherence to guidelines was assessed as well as the proportion of cases in which the testing led to a change in pre-operative management. The primary outcome measure was a composite of peri-operative myocardial infarction (MI) and death.

Results: Peri-operative mortality or MI occurred in a total of 12 patients (8%). Pre-procedural ischemia testing was performed in 31-65% of patients without guideline mandated indication, whereas 24-41% of patients with a guideline mandated indication did not undergo pre-procedural ischemia testing. Patients with a guideline mandated indication for ischemia testing had significantly higher incidence of peri-procedural MI. Non-invasive ischemia testing, which was performed in 96 patients, led to coronary angiography in only 6 patients and to a revascularization procedure in only 1.

Conclusions: Adherence to guidelines in our study was partial. The yield of guideline-mandated non-invasive ischemia testing in our study was minimal. Non-guideline mandated non-invasive ischemia testing proved completely futile, supporting the policy advocated by current guidelines which avoids further testing in these patients.