Limited Value of Resting Echocardiography to Predict Cardiac Risk in Patients Undergoing Noncardiac Surgery

• The author has no financial conflicts of interest. cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licens-es/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Although echocardiography is the most popular noninva-sive test to assess cardiac risk before noncardiac surgery (NCS), the guideline 1) recommends that resting echocardiography is useful in selected cases such as patients with dyspnea of unknown origin or those with congestive heart failure. In fact, there are distinct gaps in echocardiography use between real practice and the current guideline. A study by Park et al. 2) tested whether resting echocardiography is useful to predict cardiac complications in patients undergoing NCS. They evaluated resting transthoracic echocardiography together with clinical risk factors and N-terminal pro-brain type natriuretic peptide (NT-proBNP) levels in 1,923 patients. Three echo-cardiographic parameters {left ventricular ejection fraction (LVEF), regional wall motion score index, and E/E'} were inferior to NT-proBNP level and not better than clinical risk factors. 3) Thus, the authors suggested that routine echocar-diography is not helpful to predict major cardiac events. Perioperative cardiac risk can be assessed by clinical risk indices , noninvasive cardiac tests, and invasive cardiac tests. Echocardiography provides information on LVEF, diastolic function, and regional wall motion abnormalities. However, the study by Halm et al. 4) demonstrated that LVEF has low sensitivity (29%) to predict cardiac outcomes and could not predict congestive heart failure before NCS. Thus, resting LV-EF has been ascribed limited prognostic value. The current guideline 1) does not recommend a routine evaluation of resting LV function. Echocardiographic studies related to NCS mainly include stress echocardiography. Stress echocardiog-raphy can detect ischemia, which is an important factor for postoperative cardiac events. Furthermore, stress echocardio-graphy is superior to thallium imaging to predict postopera-tive cardiac events. 5) Comparing resting echocardiography with NT-proBNP level to predict postoperative cardiac events in patients undergoing NCS is somewhat unfair, because elevated NT-proBNP level is related not only to ischemic burden but also to impaired cardiac function. As expected, NT-proBNP level is superior to LVEF or E/E' for predicting cardiac events. It has been known that LVEF is a weak indicator for congestive heart failure (CHF), because it does not represent diastolic heart failure, and reduced LVEF does not always provoke CHF. In contrast, E/E' is an accurate echocardio-graphic index for detecting CHF regardless of …