A meta-analysis comparing the prognostic accuracy of six diagnostic tests for predicting perioperative cardiac risk in patients undergoing major vascular surgery

Abstract

Objective: To evaluate the discriminatory value and compare the predictive performance of six noninvasive tests used for perioperative cardiac risk stratification in patients undergoing major vascular surgery. Design: Meta-analysis of published reports. Methods: Eight studies on ambulatory electrocardiography, seven on exercise electrocardiography, eight on radionuclide ventriculography, 23 on myocardial perfusion scintigraphy, eight on dobutamine stress echocardiography, and four on dipyridamole stress echocardiography were selected, using a systematic review of published reports on preoperative non-invasive tests from the Medline database (January 1975 and April 2001). Random effects models were used to calculate weighted sensitivity and specificity from the published results. Summary receiver operating characteristic (SROC) curve analysis was used to evaluate and compare the prognostic accuracy of each test. The relative diagnostic odds ratio was used to study the differences in diagnostic performance of the tests. Results: In all, 8119 patients participated in the studies selected. Dobutamine stress echocardiography had the highest weighted sensitivity of 85% (95% confidence interval (CI) 74% to 97%) and a reasonable specificity of 70% (95% CI 62% to 79%) for predicting perioperative cardiac death and non-fatal myocardial infarction. On SROC analysis, there was a trend for dobutamine stress echocardiography to perform better than the other tests, but this only reached significance against myocardial perfusion scintigraphy (relative diagnostic odds ratio 5.5, 95% CI 2.0 to 14.9). Conclusions: On meta-analysis of six non-invasive tests, dobutamine stress echocardiography showed a positive trend towards better diagnostic performance than the other tests, but this was only significant in the comparison with myocardial perfusion scintigraphy. However, dobutamine stress echocardiography may be the favoured test in situations where there is valvar or left ventricular dysfunction. P atients undergoing major vascular surgery are at increased risk for cardiovascular complications such as cardiac death and non-fatal myocardial infarction because of underlying coronary artery disease.

A meta‐analysis of the utility of pre‐operative brain natriuretic peptide in predicting early and intermediate‐term mortality and major adverse cardiac events in vascular surgical patients

“…Dobutamine stress echocardiography was reported to have a sensitivity and specificity of 85% (95% CI 74-97%) and 70% (95% CI 62-79%) respectively for the prediction of 30-day MACE in vascular surgical patients [2]. The sensitivity and specificity for BNP or NT-pro-BNP for the same outcome in vascular surgical patients presented in this paper is 83% (95% CI 69-91%) and 73% (95% CI 68-77%).…”

“…The predictive value of BNP ⁄ NT-pro-BNP for MACE following vascular surgery The results presented in this meta-analysis allow the reader to compare the performance of pre-operative BNP or NT-pro-BNP with meta-analytical data presented for Short-term studies Yeh [12] Short term (to discharge < 30 days) NT-pro-BNP 450 **** * *** Berry [13] Short term (48 h) BNP 100 **** * *** Cuthbertson [14] Short term (30 days) BNP 40 **** * *** Feringa [6] Short term (30 days) NT-pro-BNP 533 **** * *** Mahla [15] Short term (30 days) NT-pro-BNP 280 **** * *** Intermediate-term studies Cuthbertson [11] Intermediate term (180 days) BNP 35 **** * *** Feringa [7] Intermediate term (180 days) NT-pro-BNP 319 **** * *** Mahla [15] Intermediate term (180 days) NT-pro-BNP 280 **** * *** ambulatory ECG, exercise ECG, radionuclide ventriculography, myocardial perfusion scintigraphy, dypridamole stress echocardiography and dobutamine stress echocardiography in vascular surgical patients [2]. Dobutamine stress echocardiography was reported to have a sensitivity and specificity of 85% (95% CI 74-97%) and 70% (95% CI 62-79%) respectively for the prediction of 30-day MACE in vascular surgical patients [2].…”

“…This was recently confirmed in a meta-analysis of six pre-operative tests for vascular surgical patients, which included: ambulatory ECG, exercise ECG, radionuclide ventriculography, myocardial perfusion scintigraphy, dipyridamole stress echocardiography and dobutamine stress echocardiography [2]. Dobutamine stress echocardiography had a trend to the best performance of the six tests for the prediction of major adverse cardiac events (defined as peri-operative cardiac death and nonfatal myocardial infarction (MI)) within 30 days of surgery [2], with a positive likelihood ratio (LR) and negative LR of 2.8 and 0.21 respectively. As statistically good discrimination requires a LR of < 0.2 and > 10, there are clearly clinical limitations to the utility of these pre-operative tests for vascular surgical patients [1].…”

“…In addition, it was a prerequisite that this metaanalysis included a 30-day major adverse cardiac events (MACE), defined as a composite of cardiac death and nonfatal myocardial infarction (MI). The reason being that Kertai et al [2] used this outcome in their metaanalysis of pre-operative diagnostic tests in vascular surgical patients. Thus, presenting the same outcome in this meta-analysis would allow for the comparison of the performance of pre-operative BNP or NT-pro-BNP, with the performance of the diagnostic tests presented by Kertai et al [2].…”

Revisão sistemática e meta-análise de estudos de diagnóstico e prognóstico: um tutorial

“…However, most of the times, it is unfeasible or unethical to perform all tests or invasive tests in all patients, and this issue is controversial 28 . In the comparison of tests, there are techniques for the construction of sROC curves of the tests alone or in combination, evaluating whether the combination of tests increases the diagnostic or prognostic accuracy 13,29 .…”