Frequency and prognostic significance of silent coronary artery disease in patients with cerebral ischemia undergoing carotid endarterectomy.

To evaluate the prevalence and prognostic role of silent coronary artery disease (CAD) in patients with symptomatic high-grade carotid stenosis (70 to 99%) undergoing carotid endarterectomy, and with neither history nor symptoms of CAD, 106 patients (76 men, 30 women, mean age 58.7 years [range 42 to 71]) with recent cerebral ischemia were prospectively studied. Patients were stratified as to the presence (n = 27, 25%) or absence (n = 79, 75%) of silent CAD defined by concordant abnormal exercise electrocardiographic testing and thallium-201 myocardial scintigraphy. The male sex, the severity of the symptomatic carotid lesion (greater than 90%), and the coexistence of contralateral carotid disease identified patients with higher probability of coexisting CAD. The 106 patients underwent 121 operations (bilateral in 15). In the perioperative period, no deaths or cardiac events occurred, 1 patient suffered a recurrent stroke and 3 had a transient ischemic attack. During a mean follow-up period of 5.4 years, 9 patients died (1.7%/year): fatal myocardial infarction occurred in 5 (all in the silent CAD group), cancer in 3 and vertebrobasilar stroke in 1. Nonfatal events occurred in 9 patients: myocardial infarction in 1 (without silent CAD), unstable angina in 3 (with silent CAD), and cerebral ischemic attacks in 5. After 7 years, the Kaplan-Meier estimated survival free from coronary events was 51% in patients with silent CAD, and 98% in patients without CAD (p less than 0.01). In conclusion, among patients with symptomatic high-grade carotid stenosis undergoing carotid endarterectomy, even in absence of history or symptoms of CAD, a silent CAD is detectable in one fourth of the patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Type and extent of myocardial injury related to brain damage and its significance in heart transplantation: a morphometric study.

BACKGROUND: Focal myocardial necrosis reported in patients who died of brain lesions and in donor hearts soon after insertion has been attributed to catecholamine-related injury induced before operation, or in the perioperative period. Interpretation of the morphofunctional type of myocardial injury observed and its quantification may help understand both its pathophysiology and clinical relevance. METHODS: In 27 patients without heart disease who died of intracranial brain hemorrhage after berry aneurysm rupture, terminal clinical signs were correlated with the presence of absence of myocardial injury. All hearts were systematically examined, and the total histologic area was measured in square millimeters, with both the number of foci and myocardial cells showing necrosis, normalized to 100 mm2. Forty-five cases of fatal head trauma (26 "instantaneous" and 19 "rapid" deaths) in normal subjects and 38 cases of acquired immunodeficiency syndrome with (14 cases) or without (24 cases) severe brain damage were used as control subjects. RESULTS: Contraction band necrosis was the only form of myocardial necrosis found in 89% of patients with acute brain hemorrhage. Its extent was 26 +/- 34 foci and 67 +/- 104 necrotic myocardial cells x 100 mm2. In patients with acquired immunodeficiency syndrome, its frequency was 58% in those without and 78.5% with severe brain lesions, with foci and myocardial cell values of 1 +/- 1.5 and 10 +/- 22 and 7 +/- 16 and 17 +/- 32, respectively. In head trauma cases with instantaneous death, the frequency was 4% (one case only with foci 0.5 and myocardial cells 35), whereas with a rapid death it was 40% (foci 12 +/- 18 and myocardial cells 21 +/- 33). CONCLUSIONS: The observed myocardial injury was present in all groups examined, being maximal in patients with intracranial brain hemorrhage with longer survival and minimal in patients with head trauma who died instantaneously. In this setting, this lesion is typical of catecholamine myotoxicity and may express a sympathetic overstimulation either in the agonal period and independent of therapy or be caused by brain injury, especially intracranial brain hemorrhage. However, the extent of myocardial injury observed was minimal and should not jeopardize cardiac function if hearts from such subjects are transplanted.

Tricuspid valve repair with the Cosgrove-Edwards annuloplasty system: early clinical and echocardiographic results.

BACKGROUND: The use of flexible rings for tricuspid valve repair is becoming popular. The purpose of this study was to evaluate the Cosgrove-Edwards annuloplasty system for tricuspid regurgitation. METHODS: From June 1998 to December 2000, 22 patients with significant secondary tricuspid regurgitation underwent tricuspid valve repair with the Cosgrove-Edwards annuloplasty system. All patients had disease of left-sided heart valves in addition to tricuspid disease; 34 concomitant procedures were performed. Twenty-one patients (95.5%) were in preoperative New York Heart Association functional class 3 or 4. The mean follow-up was 19.9 +/- 9.7 months. RESULTS: There were two in-hospital nonvalve-related cardiac deaths (9.1%) and one noncardiac death after discharge (4.5%). All survivors were in New York Heart Association functional class 1 or 2; their tricuspid regurgitation was well controlled within grade 1+ and there was a significant reduction of systolic pulmonary artery pressure. Five (83.3%) of the 6 survivors with preoperative pulmonary hypertension had no or trivial residual tricuspid regurgitation. CONCLUSIONS: The Cosgrove-Edwards annuloplasty system is very effective in the treatment of secondary tricuspid regurgitation, also in the presence of pulmonary hypertension.

Heart-brain interactions in cerebral ischaemia: a non-invasive cardiologic study protocol.

The cardiologic evaluation of patients with cerebral ischaemia should be aimed at: (1) identifying potential cardiac sources for cerebral emboli, (2) detecting a coexisting ischaemic heart disease, even asymptomatic. The present data concerns a ten-year experience of a systematic cardiologic evaluation of patients admitted to the 1st Division of Neurosurgery, Bellaria Hospital, Bologna, Italy, for cerebral ischaemia. A two-dimensional echocardiography was carried out in 344 consecutive patients (mean age 53 years), cardiac abnormalities were observed in 92 (28%) out of the 328 cases with technically adequate examination, embologenic lesions in 57 (17%). In 18 cases the cardiac lesion was unknown before the cerebral event. An exercise ECG testing was carried out in 322 patients (mean age 56 years), resulting in abnormal in 69 out of the 258 with adequate examination (17%). A subsequent exercise 201Tl myocardial scintigraphy confirmed the presence of ischaemic heart disease in 58 cases. Among patients unable to perform an adequate exercise, a dipyridamole 201Tl myocardial scintigraphy was performed in 38 cases showing perfusional defects in 23 (60%), while a dipyridamole echocardiography was performed in 25 cases showing wall motion abnormalities in 9 (36%). A 24-h Holter monitoring was performed in 65 cases: arrhythmias were detected in 27 patients (41%), but a correlation with the cerebral event was suggested only in 3 cases with atrial fibrillation. According to our experience patients with recent ischaemia should be submitted to the following non-invasive cardiologic screening: (1) exercise ECG testing followed, if abnormal or indeterminant, by 201Tl myocardial scintigraphy in all patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative efficacy of nicardipine, a new calcium antagonist, versus nifedipine in stable effort angina.

The relative efficacy of nicardipine and nifedipine was examined in a double-blind placebo-controlled randomized crossover trial. We studied 12 patients with chronic effort angina involving reproducible angina and greater than or equal to 1.5 mm of ST-segment depression on exercise treadmill test performed before and after a 1-week control period of single-blind placebo administration. Subsequently, indistinguishably prepared nicardipine 20 mg, nifedipine 10 mg, or placebo, four times a day, was administered in a randomized double-blind crossover fashion for 3 weeks (total study period 9 weeks). Exercise treadmill test was performed at the end of each 3-week period. Both nicardipine and nifedipine significantly reduced the frequency of anginal attacks and nitroglycerin consumption. Compared with placebo both drugs caused a comparable increase of the duration of exercise, of the time to angina and to the appearance of 1.5 mm ST-segment depression (P less than 0.05 placebo versus nicardipine; P less than 0.01 placebo versus nifedipine respectively). No significant side effects were observed with either drug. We conclude that nicardipine and nifedipine produce similar hemodynamic and clinical effects in patients with stable effort angina.

Cardiologic complications of subarachnoid hemorrhage.

Cardiac complications are frequent in patients with subarachnoid hemorrhage (SAH). They include ECG abnormalities, cardiac arrhythmias, myocardial damage, and neurogenic pulmonary edema. The pathophysiology of these abnormalities is related to an imbalance of the autonomic cardiovascular control and to increased circulating and local myocardial tissue catecholamines. Cardiac involvement is more common in patients with severe neurological deficits and it may increase the morbidity associated with SAH because of the occurrence of life-threatening arrhythmias or pulmonary edema. Monitoring of cardiac events in patients with SAH might result in a better understanding of their clinical outcome, as well as providing a basis for specific treatment capable of preventing myocardial necrosis and cardiac arrhythmias.

[Reconstructive surgery of the mitral and tricuspid valves with a Cosgrove-Edwards flexible ring]. / Chirurgia ricostruttiva delle valvole mitrale e tricuspide con anello flessibile di Cosgrove-Edwards.

BACKGROUND: Mitral and tricuspid valve asymmetric annular dilation represents the most important mechanism which produces insufficiency. Recent computerized in vitro and in vivo three-dimensional models have been developed in order to better understand the competing factors (annular dilation, displacement of papillary muscles, left and right ventricular geometry). The leading cause of mitral and tricuspid competence is a sphincteric action of both annuli, during systole and diastole, the loss of which produces asymmetric dilation and therefore the absence of cusp coaptation. The Cosgrove-Edwards dynamic ring corrects, alone or in combination with other procedures on the valves, this patho-anatomic feature in a physiological way by restoring the normal annular dimensions and the sphincteric movements during the cardiac cycle. METHODS: Between June 1998 and May 1999, 30 adult patients underwent mitral (n = 20, Group I) or tricuspid valve repair (n = 10, Group II). Regurgitation was due to a degenerative disease in 13 Group I patients and to ischemic (n = 3), congenital (n = 2) or dilated cardiomyopathy (n = 2) in the others. In Group II the leading cause of insufficiency was functional regurgitation in 7 patients and organic in 3. Associated procedures were carried out in 4 Group I patients and in all Group II patients. Regurgitation was evaluated by transesophageal echocardiography before, during and 3 months after operation. The maximal regurgitant area (MRA) and the grade of insufficiency were evaluated using the equation: MRA < 2 cm2 = grade 0, MRA > 2 < 4 cm2 = 1+, MRA > 4 < 7 cm2 = grade 2+, MRA > 7 < 10 cm2 = 3+, MRA > 10 cm2 = 4+. RESULTS: The operative mortality was 0%. One Group I patient died 3 months after operation due to bronchopneumonia. No patient was reoperated on for plasty failure in both groups during the follow-up. Mitral insufficiency was absent (grade 0) in 17 Group I patients and mild (grade 1+) in 3 at the end of operation. At 3-month postoperative transesophageal echocardiographic control mitral insufficiency was absent in 14 patients, mild (1+) in 4 and moderate (2+) in 2. MRA was 3 cm2 in the 2 patients operated on for dilated cardiomyopathy and < 3 cm2 in the others. Preoperative tricuspid insufficiency of grade 4+ in all Group II patients became absent in 9 of them either at the end of operation or at 3-month postoperative control. CONCLUSIONS: The Cosgrove-Edwards dynamic ring as isolated device or in combination with other plasty mitral or tricuspid procedures is a safe, simple, and reproducible method to restore the distorted motion of valvular annuli. It preserves the sphincteric mechanism of the valve and allows for the coaptation of cusps. Although in a small number of patients and for a short period of follow-up our experience corroborates what other more consistent series of patients operated on have shown.

[Evaluation of the effects of a new calcium antagonist, diltiazem, in patients with stable effort angina and a therapeutic comparison with nifedipine]. / Valutazione dell'efficacia di un nuovo calcioantagonista, diltiazem, in pazienti con angina stabile da sforzo e comparazione terapeutica con la nifedipina.

The comparative efficacy of diltiazem, a new calcium-antagonist drug, and nifedipine were evaluated with computerized treadmill exercise test in 12 patients with stable effort angina. The drugs were administered in a random single-blind fashion in divided doses (diltiazem 60 mg three times daily and nifedipine 10 mg four times daily) over 3 weeks. Maximal exercise tests were performed before and at the end of each 3-week treatment period. Both diltiazem and nifedipine increased the total duration of exercise (p less than 0.001) and the time to appearance of 1.5 mm of ST depression (p less than 0.001). Both drugs reduced resting systolic and diastolic blood pressure; however the effect was greater with nifedipine. Nifedipine, but not diltiazem, caused a significant increase of resting heart rate (p less than 0.05). Both drugs blunted the blood pressure and heart rate response to exercise: nifedipine had a greater effect on the former (p less than 0.001), diltiazem on the latter (p less than 0.05). The rate-pressure product was significantly reduced at rest (p less than 0.01) and submaximal (p less than 0.001), but not maximal exercise with both drugs. The reduction of rate-pressure product is possible as the mechanism by which calcium-antagonist drugs enhance the duration of exercise in the coronary patients. Our results documented a comparable therapeutic efficacy of the two drugs, but side effects were more common with nifedipine.

Effects of tienilic acid used alone and in association with triamterene or amiloride on urinary excretion of electrolytes.

The K-sparing effects of amiloride (A) and triamterene (T) associated with tienilic acid (C) are studied, along with their effects on diuresis and on the urinary excretion of uric acid, Mg, Na, Cl, P, and Ca. Eighteen hospitalized patients, divided into two groups of nine, received the following dosages of the drugs. The first group took 250 mg of C (equivalent to 50 mg hydrochlorothiazide), 5 mg of A and 100 mg of T; the second received double doses of both A and T but the same dose of C. Each treatment was administered on 2 not necessarily consecutive days, so as to have a total of 6 days of treatment per patient according to a balanced randomized design identical for the two groups. The data were obtained from urine collected during the first 8 h after the drug was administered, and during the following 16 h. A and T showed a significant K-sparing effect (p less than 0.01) only for the second group, and only at the higher dosages were minor effects on the urinary excretion of uric acid, Mg, and Cl noted (p less than 0.05). The association of A or T with C was well tolerated, and no important side effects were observed.

Comparative efficacy of nicardipine, a new calcium antagonist, versus nifedipine in effort stable angina.

The relative efficacy of nicardipine and nifedipine was examined in a double-blind randomized trial. We studied 12 patients with chronic effort angina who had reproducible chest pain and greater than or equal to 1.5 mm of ST-segment depression on treadmill exercise testing performed before and after 1-week control period of single-blind placebo administration. Subsequently over a 9-week period, nicardipine 20 mg or nifedipine 10 mg or an identical placebo four times a day, was administered in a randomized double-blind crossover fashion. Treadmill exercise testing was performed at the end of each 3-week period. Both nicardipine and nifedipine reduced the frequency of anginal attacks and trinitrate consumption. Compared with placebo both drugs caused a comparable increase of the total duration of exercise (p less than 0.05 placebo versus nicardipine; p less than 0.01 placebo versus nifedipine) and of the time to the onset of angina (p less than 0.05 placebo versus nicardipine; p less than 0.01 placebo versus nifedipine) and to the appearance of 1.5 mm ST depression (p less than 0.05 placebo versus nicardipine; p less than 0.01 placebo versus nifedipine). Moreover 4 patients no longer had angina with either drug and only 1 patient with placebo. Both drugs increased resting heart rate and reduced systolic blood pressure at resting (p less than 0.01) and submaximal exercise (p less than 0.01). Peak heart rate, systolic blood pressure and rate-pressure product were similar with placebo, nicardipine and nifedipine. No important side effects were observed with either drug. We conclude that nicardipine and nifedipine produce similar haemodynamic and clinical effects in patients with stable angina.

[Cardiac arrhythmias associated with subarachnoid hemorrhage. Prospective study with dynamic electrocardiography]. / Aritmie cardiache associate ad emorragia subaracnoidea. Studio prospettico con elettrocardiografia dinamica.

Electrocardiographic abnormalities associated with intracranial diseases, especially subarachnoid hemorrhage, are well known, while there is hardly mention of cardiac arrhythmias in the neurological and cardiological literature. In order to assess the incidence of arrhythmias 52 consecutive patients with subarachnoid hemorrhage secondary to ruptured aneurysm were investigated with 24-hour Holter recordings. Bradyarrhythmias and tachyarrhythmias were found in 46 patients (88%); premature ventricular beats in 25 pts (12 of these in 3rd-5th Lown classes), ventricular tachycardia in 2, premature supraventricular beats in 14, paroxysmal atrial fibrillation in 1, sinoatrial blocks and arrests in 18, atrioventricular dissociation in 2 and idioventricular rythm in 2. Moreover in 5 pts ST segment changes were found, suggestive of transitory acute myocardial ischemia. The presence and severity of arrhythmias were correlated with the time elapsed from the episode of bleeding, with the QT interval, and with the hemorrhage extent. Our results indicate an high incidence of arrhythmias in subarachnoid hemorrhage, sometimes serious mainly in early stage. Continuous electrocardiographic monitoring is therefore extremely useful and provides data for therapeutic consideration.

Preoperative noninvasive coronary risk stratification in candidates for carotid endarterectomy.

BACKGROUND AND PURPOSE: Patients with symptomatic carotid stenosis who are candidates for carotid endarterectomy are at high short- and long-term risk of coronary events. To stratify patients at different risk of coronary events we investigated the usefulness of a noninvasive preoperative cardiological workup. METHODS: We studied 172 consecutive patients admitted to the Neurosurgical Department for symptomatic high-grade (70% to 99%) carotid stenosis (age, 42 to 74 years; mean, 57.8 years). Patients without history of coronary artery disease (CAD) and able to exercise were submitted to exercise electrocardiographic testing (EET) and, if abnormal, to exercise thallium myocardial imaging (TMI). Patients were classified into four groups: group 1, patients without CAD: no history of CAD, normal EET, or normal TMI in the presence of indeterminant EET (n = 93, 54%); group 2, patients with silent CAD: no history of CAD and concordant abnormal EET and TMI (n = 28, 16%); group 3, patients unable to exercise: no history of CAD and inability to perform adequate EET because of previous stroke or claudication (n = 29, 17%); and group 4, patients with known CAD: history of angina or myocardial infarction (MI) (n = 22; 13%). RESULTS: The four groups were comparable in regard to age, sex, and computed tomographic scan of the brain. The prevalence of stroke was higher in patients unable to exercise; hypercholesterolemia was more frequent in patients with known CAD. During the perioperative period (< or = 30 days after carotid endarterectomy), coronary events occurred in 3 patients (2%): fatal MI in 2 patients in group 4 and 1 patient in group 3. One hundred percent of patients were followed up for 6.2 years. Coronary events occurred in 23 of the 168 patients discharged from the hospital (13.7%); these were fatal in 11 (6.5%): 3 patients of group 1 (3%; sudden death in 2, fatal MI in 1), 8 patients of group 2 (29%; fatal MI in 5, unstable angina in 3), 8 patients of group 3 (28%; fatal MI in 4, nonfatal MI in 4), and 4 patients of group 4 (18%; fatal MI in 2, sudden death in 1, unstable angina in 1). Kaplan-Meier estimated curves of survival free from fatal and nonfatal coronary events were 97%, 51%, 49%, and 59%, respectively (P < .001, group 1 versus groups 2 and 3; P < .01, group 1 versus group 4). CONCLUSIONS: Among patients undergoing carotid endarterectomy, coronary events occurred twice as often as cerebral recurrences. A preoperative noninvasive cardiac investigation, including EET, can adequately identify groups of patients with diverse short- and long-term prognoses. In addition to patients with known CAD, those with silent CAD or who are unable to exercise represent, without the need of further investigation, groups at high risk of coronary events in long-term follow-up.

The value of dipyridamole echocardiography in risk stratification before vascular surgery. A multicenter study. The EPIC (Echo Persantine International Study) Group--Subproject: Risk Stratification Before Major Vascular Surgery.

PURPOSE: Patients undergoing major vascular surgery are at relatively high risk of cardiac events, and pharmacological stress echocardiography is increasingly used for peri-operative risk stratification. PATIENTS AND METHODS: One hundred and twenty-one patients undergoing vascular surgery (age 65 +/- 7 years) were studied by dipyridamole echocardiography testing in six different centres. Of the total 136 patients, 15 were subsequently excluded because surgery was either cancelled (n = 8) or postponed pending cardiac revascularization (n = 7) because of the presence of a 'high-risk' stress echo response (identified 'a priori' as a positive dipyridamole echocardiography testing with a dipyridamole-time < 5 min and/or a peak wall motion score index > 2, upon scoring each segment from 1 = normal to 4 = dyskinetic in an 11-segment model). RESULTS: No major complications occurred during dipyridamole echocardiography testing. Technically adequate images were obtained in all patients; however, in one patient only the low dipyridamole dose (56 mg.kg-1 over 4 min) was given to limit side effects. Of the 121 patients undergoing surgery 28 (23%) had a positive test. Peri-operative events occurred in nine patients (8%): two deaths, two myocardial infarctions, five cases of unstable angina. Sensitivity and specificity of dipyridamole echocardiography testing for predicting cardiac events were 78% and 81%, respectively, with a positive predictive value of 25% and a negative predictive value of 98%. Dipyridamole echocardiography testing effectively singled out patients with, from those without, events, but neither clinical parameters, such as Detsky score, nor baseline echo parameters, such as resting wall motion score index or ejection fraction were able to distinguish between such patients. CONCLUSION: In conclusion, dipyridamole echocardiography testing is safe and well tolerated in patients undergoing major vascular surgery, and provides an effective pre-operative screening test for risk stratification of these patients mainly due to the extremely high negative predictive value. Stress echocardiography is a better discriminator than clinical and rest echocardiographic variables.

[Cardiopathy and acute cerebrovascular insufficiency. Prospective study with two-dimensional echocardiography]. / Cardiopatie ed insufficienza cerebrovascolare acuta. Studio prospettico con ecocardiografia bidimensionale.

Many cardiac disorders can cause acute cerebrovascular insufficiency. The spectrum of potentially embolic cardiac conditions is wide; early recognition may determine a definite change in the management and prognosis of patients. In recent years the relevance of echocardiography in the screening of patients with cerebral ischemia has been emphasized. In order to identify potentially embolic cardiac conditions, 180 consecutive non selected patients with cerebrovascular insufficiency, underwent a clinical cardiological evaluation and an echocardiogram. The study population included 132 men and 48 women; the mean age was 51.7 years (range 19 to 72 years). A technically adequate echocardiogram was obtained in 153 patients. In 131 patients echocardiography was negative; cardiac lesions were detected in 22 patients (14.4%): mitral stenosis in 2, calcified aortic stenosis in 1, valvular endocarditis vegetations in 3, dilatative cardiomyopathy in 2, hypertrophic cardiomyopathy in 4, mitral valve prolapse in 4, regional left ventricular diskynesia in 5, mitral anulus calcification in 1. Patients were divided into 3 groups according to the results of cerebral angiography: 68 patients with normal angiography (Group I), 54 patients with atheromasic lesions on cerebral angiography (Group II), 31 patients in whom cerebral angiography was not performed (Group III). A higher incidence of cardiac diseases was found in the patients of Group I. The lack of lesions on cerebral angiography and the presence of embolic high-risk cardiac conditions strengthened a causal relationship of the cardiac disorder with cerebrovascular insufficiency in 10 of the 23 patients. In the mean follow-up period of 18 months of these 10 patients who underwent cardiac surgery or anticoagulation, no further attacks of cerebrovascular insufficiency were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Perioperative prognostic value of dipyridamole echocardiography in vascular surgery: A large-scale multicenter study in 509 patients. EPIC (Echo Persantine International Cooperative) Study Group.

BACKGROUND: Patients undergoing major vascular surgery are at a relatively high risk of cardiac events, and pharmacological stress echocardiography is increasingly used for perioperative risk stratification. The aim of the current study was to evaluate the value of dipyridamole echocardiography test (up to 0.84 mg/kg over 10 minutes) in predicting cardiac events in a large-scale, multicenter, prospective, observational study design. METHODS AND RESULTS: Five hundred nine patients (mean age 66+/-10 years) were studied before vascular surgery by dipyridamole stress echocardiography in 11 different centers. All patients underwent preoperative clinical risk assessment according to the American Heart Association guidelines. No major complications occurred during dipyridamole stress echocardiography. Technically adequate images were obtained in all patients; however, in 4 patients only the low dipyridamole dose (0.56 mg/kg over 4 minutes) was given for limiting side effects. Eighty-eight (17.3%) had a positive test. Perioperative events occurred in 31 (6.1%) patients: 6 deaths, 11 myocardial infarctions, and 14 episodes of unstable angina. Sensitivity and specificity of dipyridamole stress echocardiography for predicting spontaneous cardiac events were 81% and 87%, respectively, with a positive predictive value of 28% and negative predictive value of 99%. By multivariate analysis, the difference between wall motion score index at rest and peak stress (Deltawall motion score index), test positivity, and ST-segment depression during dipyridamole infusion were independent predictors of any perioperative cardiac event. CONCLUSIONS: Dipyridamole stress echocardiography is safe and well tolerated in patients undergoing major vascular surgery and provides an effective preoperative screening test for the risk stratification of these patients, mainly because of the extremely high negative predictive value, which is a potent predictor of complication-free procedure.