Abstract
BACKGROUND:The association between intraoperative cardiovascular changes and perioperative myocardial injury has chiefly focused on hypotension during noncardiac surgery. However, the relative influence of blood pressure and heart rate (HR) remains unclear. We investigated both individual and codependent relationships among intraoperative HR, systolic blood pressure (SBP), and myocardial injury after noncardiac surgery (MINS).METHODS:Secondary analysis of the Vascular Events in Noncardiac Surgery Cohort Evaluation (VISION) study, a prospective international cohort study of noncardiac surgical patients. Multivariable logistic regression analysis tested for associations between intraoperative HR and/or SBP and MINS, defined by an elevated serum troponin T adjudicated as due to an ischemic etiology, within 30 days after surgery. Predefined thresholds for intraoperative HR and SBP were: maximum HR >100 beats or minimum HR <55 beats per minute (bpm); maximum SBP >160 mm Hg or minimum SBP <100 mm Hg. Secondary outcomes were myocardial infarction and mortality within 30 days after surgery.RESULTS:After excluding missing data, 1197 of 15,109 patients (7.9%) sustained MINS, 454 of 16,031 (2.8%) sustained myocardial infarction, and 315 of 16,061 patients (2.0%) died within 30 days after surgery. Maximum intraoperative HR >100 bpm was associated with MINS (odds ratio [OR], 1.27 [1.07–1.50]; P < .01), myocardial infarction (OR, 1.34 [1.05–1.70]; P = .02), and mortality (OR, 2.65 [2.06–3.41]; P < .01). Minimum SBP <100 mm Hg was associated with MINS (OR, 1.21 [1.05–1.39]; P = .01) and mortality (OR, 1.81 [1.39–2.37]; P < .01), but not myocardial infarction (OR, 1.21 [0.98–1.49]; P = .07). Maximum SBP >160 mm Hg was associated with MINS (OR, 1.16 [1.01–1.34]; P = .04) and myocardial infarction (OR, 1.34 [1.09–1.64]; P = .01) but, paradoxically, reduced mortality (OR, 0.76 [0.58–0.99]; P = .04). Minimum HR <55 bpm was associated with reduced MINS (OR, 0.70 [0.59–0.82]; P < .01), myocardial infarction (OR, 0.75 [0.58–0.97]; P = .03), and mortality (OR, 0.58 [0.41–0.81]; P < .01). Minimum SBP <100 mm Hg with maximum HR >100 bpm was more strongly associated with MINS (OR, 1.42 [1.15–1.76]; P < .01) compared with minimum SBP <100 mm Hg alone (OR, 1.20 [1.03–1.40]; P = .02).CONCLUSIONS:Intraoperative tachycardia and hypotension are associated with MINS. Further interventional research targeting HR/blood pressure is needed to define the optimum strategy to reduce MINS.
Highlights
The relative influence of blood pressure and heart rate remains unclear. We investigated both individual and co-dependent relationships between intraoperative heart rate (HR), systolic blood pressure (SBP), and myocardial injury after non-cardiac surgery (MINS)
Maximum intraoperative HR >100 bpm was associated with MINS, myocardial infarction and mortality
Minimum SBP
Summary
One in ten patients sustain myocardial injury after non-cardiac surgery (MINS), characterized by a transient rise in serum troponin levels usually unaccompanied by any clinical or electrocardiographic signs/symptoms. Postoperative troponin elevation is strongly associated with death after surgery, which occurs in up to 1-4% of eight million surgical procedures carried out in the United Kingdom each year. the aetiology of MINS remains unclear, numerous retrospective studies implicate extreme intraoperative changes in blood pressure and/or heart rate. few of these studies have used an objective, subclinical marker of MINS. The aetiology of MINS remains unclear, numerous retrospective studies implicate extreme intraoperative changes in blood pressure and/or heart rate. . The aetiology of MINS remains unclear, numerous retrospective studies implicate extreme intraoperative changes in blood pressure and/or heart rate.7, 8 Few of these studies have used an objective, subclinical marker of MINS. In the largest prospective perioperative cohort of its kind, we tested whether high or low intraoperative heart rate or systolic blood pressure, in isolation or combination, were associated with MINS, myocardial infarction or mortality within 30 days after non-cardiac surgery in the VISION study cohort. We tested whether the duration of high or low heart rate/systolic blood pressure was associated with MINS within 30 days of non-cardiac surgery
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