Nuclear Cardiology: Practical Applications, Third Edition by Gary V. Heller & Robert C. Hendel

Author:Gary V. Heller & Robert C. Hendel [Gary V. Heller & Robert C. Hendel]
Language: eng
Format: epub
Publisher: McGraw-Hill Education
Published: 2017-08-07T00:00:00+00:00

Table 16-3

Preoperative Multimodality Imaging for Noncardiac Surgery Appropriate Use Criteria

Appropriate use key: A, appropriate; M, may be appropriate; R, rarely appropriate.

General Key: CAD, coronary artery disease; CCTA, coronary computed tomography angiography; CMR, cardiac magnetic resonance; ECG, electrocardiogram; Echo, echocardiography; METs, metabolic equivalents; MPI, myocardial perfusion imaging.

Adapted with permission from Wolk MJ, Bailey SR, Doherty JU, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2014;63(4):380–406.

The ACCF and the American Heart Association Guidelines provide a Class IIB recommendation (level of evidence C) for noninvasive testing in end-stage renal disease (ESRD) and end-stage liver disease (ESLD) patients without active cardiac issues if there are cardiovascular risk factors.26 There is, however, no validated number of clinical risk factors needed to elicit such testing in ESRD or ESLD patients. Presently, the AUC consider radionuclide imaging appropriate in the setting of ESRD and ESLD prior to transplantation. Wide variability in sensitivity (0.29–0.92) and specificity (0.67–0.89) regarding the detection of significant coronary artery disease for MPI is present in ESRD patients. Similar variability is notable for dobutamine stress echocardiography. Nonetheless, a meta-analysis assessing the use of MPI or dobutamine stress echocardiography in ESRD patients were notable for almost six times the risk of myocardial ischemia and four times the risk of cardiac death among those with inducible ischemia. Fixed defects were associated with five times the risk for cardiac death.27 In comparing the modalities, there is recent evidence that MPI may have higher diagnostic accuracy versus dobutamine echocardiography and also lead to a cost savings as well; however the data is limited to a single center.28 In ESLD patient, MPI has limited correlation with findings on cardiac catheterization and cardiac events after liver transplantation due to poor specificity. The presence of baseline coronary vasodilation in this population may also be a factor with regard to diagnostic sensitivity.26,29,30

Preoperative cardiac evaluation in patients undergoing bariatric surgery provides certain challenges as these patients can be difficult to evaluate noninvasively due to their body habitus. Although perioperative mortality and cardiac event rates with these procedures are low,31 there are times when preoperative cardiac evaluation is indicated. The data on such evaluations are sparse. Gemignani et al. examined 383 stress MPI studies performed on patients who planned to undergo bariatric surgery at their institution.32 MPI failed to predict 1-year survival, and postoperative cardiac event rates were low.

Cardiac PET stress testing is an option for these patients given its greater accuracy in obese patients,33 but there are no systematic studies published in the area of evaluation prior to bariatric surgery. Issues with PET imaging in this setting include some patients exceeding the weight limit of the scanner and some being unable to physically fit in the scanner.

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