Circulation, Vol 84, 493-502, Copyright © 1991 by American Heart Association
DT Mangano, MJ London, JF Tubau, WS Browner, M Hollenberg, W Krupski, EL Layug and B Massie
BACKGROUND. We examined the value of dipyridamole thallium-201 (201Tl)
scintigraphy as a preoperative screening test for perioperative myocardial
ischemia and infarction. METHODS AND RESULTS. We prospectively studied 60
patients undergoing elective vascular surgery. We performed 201Tl
scintigraphy preoperatively and blinded all treating physicians to the
results. Historical, clinical, laboratory, and physiological data were
gathered throughout hospitalization. Myocardial ischemia was assessed
during the intraoperative period using continuous 12-lead
electrocardiography (ECG) and transesophageal echocardiography (TEE) and
during the postoperative period using continuous two-lead ambulatory ECG.
Adverse cardiac outcomes (cardiac death, myocardial infarction, unstable
angina, severe ischemia, or congestive heart failure) were assessed daily
throughout hospitalization. Twenty-two patients (37%) had defects that
improved or reversed on delayed scintigrams (redistribution defects), 18
(30%) had persistent defects, and 20 (33%) had no defects on 201Tl
scintigraphy. There was no association between redistribution defects and
adverse cardiac outcomes: 54% (seven of 13) of adverse outcomes occurred in
patients without redistribution defects, and the risk of an adverse outcome
was not significantly increased in patients with redistribution defects
(relative risk 1.5, 95% confidence interval 0.6-3.9, p = 0.43). Consistent
with these findings, there was also no association between redistribution
defects and perioperative ischemia: 54% (19 of all 35) of perioperative ECG
and TEE ischemic episodes and 58% (14 of 24) of severe ischemic episodes
occurred in patients without redistribution defects. The sensitivity of
201Tl scintigraphy for perioperative ischemia and adverse outcomes ranged
from 40% to 54%, specificity from 65% to 71%, positive predictive value
from 27% to 47% and negative predictive value from 61% to 82%. CONCLUSIONS.
These results differ from those of previous studies and suggest that the
routine use of 201Tl scintigraphy for preoperative screening of patients
undergoing vascular surgery may not be warranted.
ARTICLES
Dipyridamole thallium-201 scintigraphy as a preoperative screening test. A reexamination of its predictive potential. Study of Perioperative Ischemia Research Group
Department of Anesthesia, University of California, San Francisco.
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