Complementary pre-operative risk assessment using coronary computed tomography angiography and nuclear myocardial perfusion imaging in non-cardiac surgery: A VISION-CTA sub-study

Background The incremental value and optimal utilization of non-invasive testing for prediction of peri-operative cardiac events during non-cardiac surgery are not clear. Methods 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. Results 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. Conclusion 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 may be refined further by employing nuclear MPI in those with obstructive disease on CCTA.