Search

Objectives: This study evaluated the prognostic value of asymptomatic low anklebrachial index (ABI) to predict perioperative myocardial damage, incremental to conventional cardiac risk factors imbedded in cardiac risk indices (Revised Cardiac index and Adapted Lee index). Materials and methods: Preoperative ABI measurements were performed in 627 consecutive vascular surgery patients (carotid artery or abdominal aortic aneurysm repair). An ABI < 0.90 was considered abnormal. Patients with ABI > 1.40 or (a history of) intermittent claudication were excluded. Serial troponin-T measurements were performed routinely before and after surgery. The main study endpoint was perioperative myocardial damage, the composite of myocardial ischaemia and infarction. Multivariate regression analyses, adjusted for conventional risk factors, evaluated the relation between asymptomatic low ABI and perioperative myocardial damage. Results: In total, 148 (23%) patients had asymptomatic tow ABI (mean 0.73, standard deviation +/- 0.13). Perioperative myocardial damage was recorded in 107 (18%) patients. Multivariate regression analyses demonstrated that asymptomatic tow ABI was associated with an increased risk of perioperative myocardial damage (odds ratio (CR): 2.4, 95% CI: 1.4-4.2) Conclusions: This study demonstrated that asymptomatic tow ABI has a prognostic value to predict perioperative myocardial damage in vascular surgery patients, incremental to risk factors imbedded in conventional cardiac risk indices. (C) 2009 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Diabetes mellitus (DM) and left ventricular dysfunction (LVD) are often coexistent and invariably associated with increased mortality. Data on long-term prognosis of "isolated" diastolic LVD in diabetics are lacking; therefore, we evaluated these prognostic implications in patients with peripheral arterial disease (PAD) and DM. Using echocardiography, 1321 patients were screened for diastolic, systolic (ejection fraction 6.1 mmol/L were diagnosed with DM. The primary end point was occurrence of cardiovascular death during a mean follow-up of 2.5 +/- 1.9 years. In the total population, DM was diagnosed In 518 patients (39%), and diastolic, systolic, or combined LVD was present in 356 patients (27%); 102 patients (8%), or 156 patients (12%), respectively. In diabetic patients, diastolic and systolic LVDs were associated with increased cardiovascular mortality (hazard ratio 1.8, 95% confidence interval 1.03 to 3.03; hazard ratio 3.1,95% confidence interval 1.46 to 6.38). In nondiabetic patients, the same association between diastolic or systolic LVD and outcome was observed (hazard ratio 2.2, 95% confidence interval 1.30 to 3.74; hazard ratio 3.9, 95% confidence interval 2.00 to 7.52). Combined systolic and diastolic LVD had the worst prognosis. In conclusion, diabetic patients with PAD have an increased prevalence of isolated systolic and combined LVD. In patients with PAD the presence of isolated diastolic, systolic, or combined LVD was independently and equally associated with increased cardiovascular mortality, irrespective of the concomitant presence of DM. (C) 2010 Elsevier Inc. All rights reserved. (Am J Cardiol 2010;106:860-864)

ObjectiveTo objectively assess the presence of polyvascular disease in patients with peripheral arterial disease and its relation to inflammation and clinical risk factors.MethodsA total of 431 vascular surgery patients (mean age 68 years, men 77%) with atherosclerotic disease were enrolled. The presence of atherosclerosis was assessed using ultrasonography. Affected territories were defined as: (1) carotid, stenosis of common or internal carotid artery of ≥50%, (2) cardiac, left ventricular wall motion abnormalities, (3) abdominal aorta, diameter ≥30mm and (4) lower limb, ankle–brachial pressure index

Background Cardiovascular (CV) complications are the leading cause of morbidity and mortality in vascular surgery patients. The Revised Cardiac Risk (RCR) index, identifying. cardiac risk factors, is commonly used for preoperative risk stratification. However, a more direct marker of the underlying atherosclerotic disease, such as the common carotid artery intimamedia thickness (CCA-IMT) may be of predictive value as well. The current study evaluated the prognostic value of the CCA-IMT for postoperative CV outcome. Methods In 508 vascular surgery patients, the CCA-IMT was measured using high-resolution B-mode ultrasonography. We recorded the RCR factors: ischemic heart disease, heart failure, cerebrovascular disease, diabetes mellitus, and renal dysfunction. Repeated Troponin T measurements and electrocardiograms were performed postoperatively. The study end point was the composite of 30-day CV events and long-term CV mortality. Multivariable regression analyses were used to assess the additional value of CCA-IMT for the prediction of cardiac events. Results In total, 30-day events and long-term cardiovascular mortality were noted in 122 (24%) and 81 (16%) patients, respectively. The optimal predictive value of CCA-IMT, using receiver-operating characteristic curve analysis, for the prediction of CV events was calculated to be 1.25 mm (sensitivity 70%, specificity 80%). An increased CCA-IMT was independently associated with 30-day CV events (OR 2.20, 95% CI 1.38-3.52) and long-term CV mortality (HR 6.88, 95% CI 4.11-11.50), respectively. Conclusions This study shows that an increased CCA-IMT has prognostic value in vascular surgery patients to predict 30-day CV events and long-term CV mortality, incremental to the RCR index. (Am Heart J 2009;158:202-8.)

Aims Abdominal aortic aneurysms ( AAA) are often diagnosed at time of (impending) rupture leading to a dramatic increase of morbidity and mortality. A simple screening device might be the key solution for widespread AAA screening. This study evaluated the diagnostic accuracy of a new portable ultrasound scanner (Aortascan BVI 9600) developed for automatic AAA detection. Methods and results A total of 150 patients with presumed aneurysmatic peripheral atherosclerotic disease were included in the study. Patients were first scanned with conventional ultrasound (US), serving as reference technique. An infra-renal abdominal aorta diameter of >= 30 mm was defined as an AAA. Hereafter, the aorta was scanned using the Aortascan BVI 9600. Statistical analyses were performed using SPSS version 15.0 statistical software. Abdominal aortic aneurysms were detected with conventional US in 78 (52%) patients, compared with 74 (49%) AAA's detected with Aortascan BVI 9600. The Aortascan BVI 9600 demonstrated a sensitivity, specificity, positive and negative predictive value of 90, 94, 95, and 89%, respectively, in the detection of AAA's. Conclusion The Aortascan BVI 9600 automatically detects the aortic diameter with a 90% sensitivity without the need for a trained operator. Because of these unique capabilities, it can be used for AAA screening outside the hospital.

Screening for abdominal aortic aneurysms (AAAs) in patients at risk will become more cost effective if a simple, inexpensive, and reliable ultrasound device is available. The aim of this study was to compare a 2-dimensional, handheld ultrasound device and a newly developed ultrasound volume scanner (based on bladder scan technology) with computed tomography (CT) for diagnosing AAA. A total of 146 patients (mean age 69 +/- 10 years; 127 men) were screened for the presence of AAAs (diameter3 cm) using CT. All patients were examined with the handheld ultrasound device and the volume scanner. Maximal diameters and volumes were used for the analyses. AAAs were diagnosed by CT in 116 patients (80%). The absolute difference of aortic diameter between ultrasound and CT was5 mm in 88% of patients. Limits of agreement between ultrasound and CT (-6.6 to 9.4 mm) exceeded the limits of clinical acceptability (+/-5 mm). An excellent correlation between ultrasound and CT was observed (r = 0.98). The correlation coefficient between the volume scanner and CT was 0.86, with agreement of 90% and kappa value of 0.73. Using an optimal cut-off value of56 ml, defined by receiver-operating characteristic curve analysis, sensitivity, specificity, and the positive and negative predictive values of the volume scanner for detecting AAA were 90%, 90%, 97%, and 71%, respectively. In conclusion, this study shows that a 2-dimensional, handheld ultrasound device and a newly developed ultrasound volume scanner can effectively identify patients with AAAs confirmed by CT.

textabstractBackground: Both preoperative left ventricular dysfunction (LVD) and acute kidney injury (AKI) in the postoperative period are independently associated with mortality. We evaluated the prevalence and prognostic implications of AKI in a cohort of vascular surgery patients. Methods: Before vascular surgery, 1,158 patients were screened for LVD. Development of AKI, defined by RIFLE classification, was detected by serial serum creatinine measurements at days 1 to 3 after surgery. Primary end point was cardiovascular mortality during a median follow-up of 2.2 years (interquartile range [IQR] 1.0-4.0). Results: LVD was present in 558 patients (48%), and 120 patients (10%) developed postoperative AKI. Subjects with LVD developed postoperative AKI more often than patients without LVD (8% vs. 13%, p=0.01). Patients were categorized as (i) no LVD, without AKI (n=551, 48%), (ii) LVD without AKI (n=487, 42%), (iii) no LVD, with AKI (n=49, 4%) and (iv) LVD with AKI (n=71/6%). Patients with LVD prior to surgery who developed postoperative AKI had the highest cardiovascular mortality risk (hazard ratio = 4.9; 95% confidence interval, 2.9-8.2). Conclusion: Patients with preoperatively LVD have an increased risk of developing AKI after vascular surgery. The occurrence of AKI in patients with LVD has an incremental predictive value toward cardiovascular mortality risk during long-term follow-up.

Aims This study evaluated the prevalence of left-ventricular (LV) dysfunction in vascular surgery patients and pharmacological treatment, according ESC guidelines. Methods and results Echocardiography was performed pre-operatively in 1005 consecutive patients. Left ventricular ejection fraction (LVEF) ≤50% defined systolic LV dysfunction. Diastolic LV dysfunction was diagnosed based on E/A-ratio, pulmonary vein flow, and deceleration time. Optimal pharmacological treatment to improve LV function was considered as: (i) angiotensin-blocking agent (ACE-I/ARB) in patients with LVEF ≤40%; (ii) ACE-I/ARB and β-blocker in patients with LVEF ≤40% + heart failure symptoms or previous myocardial infarction; and (iii) a diuretic in patients with symptomatic heart failure, regardless of LVEF. Left-ventricular dysfunction was present in 506 patients (50%), of whom 209 (41%) had asymptomatic diastolic LV dysfunction, 194 (39%) had asymptomatic systolic LV dysfunction, and 103 (20%) had symptomatic heart failure. Treatment with ACE-I/ARB and/or β-blocker could be initiated/improved in 67 (34%) of the 199 patients with (a)symptomatic LVEF ≤40%. A diuretic could be initiated in 32 patients (31%) with symptomatic heart failure (regardless of LVEF). Conclusions This study demonstrates a high prevalence of LV dysfunction in vascular surgery patients and under-utilization of ESC recommended pharmacological treatment. Standard pre-operative evaluation of LV function could be argued based on our results to reduce this observed care gap.

Background The prognostic value of heart failure symptoms on postoperative outcome is well acknowledged in perioperative guidelines. The prognostic value of asymptomatic left ventricular (LV) dysfunction remains unknown. This study evaluated the prognostic implications of asymptomatic LV dysfunction in vascular surgery patients assessed with routine echocardiography. Methods Echocardiography was performed preoperatively in 1,005 consecutive vascular surgery patients. Systolic LV dysfunction was defined as LV ejection fraction less than 50%. Ratio of mitral-peak velocity during early and late filling, pulmonary vein flow, and deceleration time was used to diagnose diastolic LV dysfunction. Troponin-T measurements and electrocardiograms were performed routinely perioperatively. Multivariate regression analyses evaluated the relation between LV function and the study endpoints, 30-day cardiovascular events, and long-term cardiovascular mortality. Results Left ventricular dysfunction was diagnosed in 506 (50%) patients of which 80% were asymptomatic. In open vascular surgery (n = 649), both asymptomatic systolic and isolated diastolic LV dysfunctions were associated with 30-day cardiovascular events (odds ratios 2.3, 95% confidence interval [CI] 1.4-3.6 and 1.8, 95% CI 1.1-2.9, respectively) and long-term cardiovascular mortality (hazard ratios 4.6, 95% CI 2.4-8.5 and 3.0, 95% CI 1.5-6.0, respectively). In endovascular surgery (n = 356), only symptomatic heart failure was associated with 30-day cardiovascular events (odds ratio 1.8, 95% CI 1.1-2.9) and long-term cardiovascular mortality (hazard ratio 10.3, 95% CI 5.4-19.3). Conclusions This study demonstrated that asymptomatic LV dysfunction is predictive for 30-day and long-term cardiovascular outcome in open vascular surgery patients. These data suggest that preoperative risk stratification should include not only solely heart failure symptoms but also routine preoperative echocardiography to risk stratify open vascular surgery patients.