complementary pre-operative risk assessment using coronary computed tomography angiography and nuclear myocardial perfusion imaging in non-cardiac surgery: a vision-cta sub-study

The incremental value and optimal utilization of non-invasive testing for prediction of peri-operative cardiac events during non-cardiac surgery are not clear. a sub-study of vision-cta was performed using patients who underwent both coronary computed tomography angiography (ccta) and nuclear myocardial perfusion imaging (mpi) as part of their pre-operative assessment. ccta images were compared with mpi to determine the correlation between ischemia and obstructive coronary artery disease (cad). patients were followed post-operatively for 30 days and primary outcomes were all-cause death and non-fatal myocardial infarction. the predictive capacity of ccta and nuclear mpi in predicting peri-operative major adverse cardiac event (mace) was analyzed. a total of 55 patients (mean age 68.5 ± 8.4 years, 80.0% male) were analyzed. there was a strong correlation between the degree of obstructive cad and the severity of perfusion abnormalities. patients with severe cad (≥ 70% stenosis) had a higher summed stress score than those without severe cad [4.88 ± 1.22 and 1.30 ± 0.62, respectively (p < .05)]. similarly summed difference score was significantly higher in patients with severe cad [1.33 ± 0.46 and 0.17 ± 0.17 (p < .05)]. at 30 days there was a total of 8 (14.5%) mace. the rate of mace was higher in patients with severe cad than those without (20.7% and 7.7%, respectively). myocardial ischemia appeared to be predictive of mace with an unadjusted odds ratio of 14.63 (p = .003). the predictive capacity of mpi further improved when only those patients with severe cad were included (33.00) with a sensitivity, specificity, positive predictive value, and negative predictive value of 100% (79.4-100.0), 72.7% (49.8-89.3), 50.0% (21.1-78.9), and 100% (79.4-100.0), respectively. although patients with significant obstructive disease are at risk of peri-operative mace, the absolute event rate is low. our data, albeit hypothesis generating, suggest that the peri-operative risk be refined further by employing nuclear mpi in those with obstructive disease on ccta.