The American journal of cardiology
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Coronary artery disease (CAD) represents an important risk in patients undergoing elective noncardiac surgical procedures, in whom the stress of surgery and postoperative recovery can represent a significant ischemic burden. Population considerations: Preoperative cardiac assessment should be based on the prevalence of CAD (if known) in the population undergoing the procedure and the institutional event rate for the procedure. Procedures considered high-risk are vascular, intra-abdominal or thoracic, major orthopedic, and any emergency procedures. Individual considerations: ⋯ A history of angina, congestive heart failure, diabetes mellitus, prior myocardial infarction, ventricular ectopy, and/or elderly (age > 70) are clinical parameters of increased risk. Functional capacity: Good functional capacity is the ability of a 50-70-year-old patient to achieve 6-8 METS of activity without significant symptoms of dyspnea on exertion. Further noninvasive testing: Preoperative testing may include routine treadmill exercise testing, ambulatory ECG monitoring, echocardiographic stress testing with dobutamine or exercise, and/or thallium perfusion imaging. Strategy for high risk patients: Assessing the severity of an abnormality (e.g., with thallium) results in a small percentage of positive test results yielding a high positive predictive value for events. Therefore, more aggressive interventions should be reserved for the most abnormal noninvasive test results, and the severity of the risk assessment should impact the timing of any coronary revascularization procedure, not the decision to proceed to more invasive testing and therapies. In summary, it is important to realize that most of the patients being screened, even vascular surgery patients (with high prevalence of CAD and procedural risk), will be found suitable to go to surgery without additional invasive intervention and cardiac revascularization. Thus good functional capacity and absence of cardiac risk factors should direct 30-40% of this population to elective surgery without further evaluation. The finding of high-risk perfusion scan abnormalities appears to be limited to 15-20% of those patients being recommended for further noninvasive testing.
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Comparative Study Clinical Trial Controlled Clinical Trial
Accuracy and usefulness of atrial pacing in conjunction with transesophageal echocardiography in the detection of cardiac ischemia (a comparative study with scintigraphic tomography and coronary arteriography).
A comparative study of transesophageal echocardiography with single-photon emission computed tomography (SPECT) and coronary arteriography was performed in a community outpatient setting to determine accuracy and feasibility of the technique. Forty-one of 55 patients underwent all 3 procedures within a 90-day period. Fourteen patients underwent only SPECT and were compared with transesophageal echocardiography with pacing (TEEP). ⋯ The 1 view that appeared to pick up the highest yield of abnormalities was the transgastric short-axis view. Thus, TEEP is indicated in the detection of chronotropically incompetent patients and those unable to exercise whose transthoracic images are not optimal. It is highly accurate compared with angiography or SPECT.
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To determine the additional diagnostic value of biplane transesophageal echocardiography (TEE) in patients undergoing mitral valve surgery, we studied 48 patients with severe mitral regurgitation. Transesophageal echocardiographic video recordings were reorganized in separate transverse and longitudinal sections to allow independent evaluation. Mechanism of mitral regurgitation and anatomic abnormalities of the mitral valve were assessed by all 3 transesophageal echocardiographic modalities and were related to surgical findings. ⋯ Although the yield of biplane TEE was better than either transverse or longitudinal TEE alone, the differences did not reach statistical significance, because of the size of the patient group. The surgical procedure (either valve repair or replacement) was correctly predicted with transverse TEE in 71%, with longitudinal TEE in 69%, and with biplane TEE in 79% of the patients. All 3 transesophageal echocardiographic modalities are very capable of assessing the anatomic abnormalities and mechanism of mitral regurgitation, as well as predicting the feasibility of valve repair.
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To assess the incidence of a specific etiology and the role of methods for specific etiologic diagnosis in patients with primary acute pericarditis, we studied 100 patients with primary acute pericarditis consecutively admitted to our hospital between 1991 and 1993. A general diagnostic protocol was performed in all patients, whereas only pericardiocentesis was performed in patients with clinical cardiac tamponade or an unfavorable course with anti-inflammatory drugs. Surgical drainage and pericardial biopsy was performed in patients with tamponade relapse. ⋯ Pericardial biopsy results were negative in the 5 patients in whom it was performed. Cardiac tamponade and an unfavorable clinical outcome were significantly (p < 0.001) associated with the finding of a specific etiology; when both features were combined, sensitivity was 86% and specificity 85%, positive predictive value 63% and negative predictive value 96%. We conclude that the specific etiology in patients with primary acute pericarditis is about 20% to 25%, and that about 90% of these specific cases can be discovered by using the described systematic diagnostic protocol only in patients with an unfavorable outcome (cardiac tamponade or poor clinical course).