Noninvasive cardiac risk evaluation before elective abdominal aortic aneurysm surgery--clinical value of the Goldman index and echocardiography

Cardiac complications comprise as much as 50% of perioperative vascular surgical morbidity and mortality. Using the Goldman multifactorial index for evaluating cardiac risk pre-operatively, 53 consecutive patients who underwent abdominal aortic aneurysm surgery were prospectively studied. Forty patients (75.5%) were also evaluated with echocardiography for assessment of left ventricular function. There were 14 (23.7%) peri-operative events, of which nine (17.0%) were acute myocardial infarctions--two of whom died (3.8%). The minor complications included three with hypovolaemic renal failure, and one each with acute respiratory failure and cerebrovascular accident. Patients with Goldman cardiac risk index (CRI) classes III and IV were associated with significantly higher risks of peri-operative complications (p less than 0.001), i.e. 77.8% and 66.7% respectively, compared with class II (22.7%) and class I (nil). Echocardiographic left ventricular shortening fraction (LVFS) of less than 28% helped identify high risk groups in all classes, although its positive predictive value was low (42.3%). Combining LVFS less than 28% with Goldman CRI categories II to IV improved the sensitivity to 91.7% and the positive predictive value to 61.1%. Careful pre-operative assessment using the simple Goldman index and echocardiography is helpful in identifying higher risk patients who would benefit from pre-operative stabilisation and more rigorous perioperative hemodynamic monitoring preferably including intensive care (ICU) management, so as to reduce cardiac complications.