DOES THE CLINICAL-EVALUATION OF THE CARDIAC STATUS PREDICT OUTCOME IN PATIENTS WITH ABDOMINAL AORTIC-ANEURYSMS

A cost-effective method to reduce mortality rates after abdominal aortic aneurysm repair centers on selecting and investigating only those patients at risk for cardiac-related death. All 146 patients undergoing asymptomatic abdominal aortic aneurysm repair over a 5-year period (1986 to 1990) were retrospectively placed into one of the three following groups on the basis of a clinical evaluation. Group I: no history of myocardial infarction or angina, no congestive heart failure, and no ischemic changes on electrocardiogram (ECG). Group II: history of myocardial infarction or class I-II angina or ischemic changes on ECG. Group III: presence of congestive heart failure or class III-IV angina. Patients in group I had no further cardiac work-up; patients in group II with angina had left ventricular ejection fraction assessment by multiple gated acquisition (all > 37%) and were cleared for operation by a cardiologist; patients in group II without angina had no further cardiac work-up; patients in group III had coronary angiography and then coronary revascularization. The overall mortality rate was 4.8%, with a cardiac mortality rate of 3.4%. The mortality rate in group I (n = 64) was 1.8%, with no cardiac-related deaths; the mortality rate in group II (n = 63) was 9.5% (8% cardiac-related deaths). No deaths occurred in group III (n = 19). The difference between the cardiac mortality rates in groups I and II was significant (p = 0.02) as was the postoperative cardiac morbidity: total myocardial infarctions (p < 0.001); congestive heart failure (p = 0.02); tachyarrythmias (p = 0.05). Significantly fewer postoperative myocardial infarctions occurred in group III compared with group II (p = 0.05). Within group II, neither the left ventricular ejection fraction nor the presence of angina or ST-T segment changes were predictors of increased cardiac-related deaths. This study demonstrates that even mild-to-moderate cardiac symptoms as in group II deserve a more aggressive cardiac evaluation that would include dipyridamole-thallium scans and/or coronary angiography. Patients who have clinically severe coronary artery discase appear to benefit from previous coronary bypass and should be assessed before abdominal aortic aneurysm repair with coronary angiography.