Perioperative Cardiac Morbidity Research Articles

High-Sensitivity Cardiac Troponin T and Frailty Predict Short-Term Mortality in Patients ≥75 Years Undergoing Emergency Abdominal Surgery: A Prospective Observational Study.

An elevated cardiac troponin concentration is a prognostic factor for perioperative cardiac morbidity and mortality. In elderly patients undergoing emergency abdominal surgery, frailty is a recognized risk factor, but little is known about the prognostic value of cardiac troponin in these vulnerable patients. Therefore, we investigated the prognostic significance of elevated high-sensitivity cardiac troponin T (hs-cTnT) concentration and frailty in a cohort of elderly patients undergoing emergency abdominal surgery. We included consecutive patients ≥75 years of age who presented for emergency abdominal surgery, defined as abdominal pathology requiring surgery within 72 hours, in a university hospital in Norway. Patients who underwent vascular procedures or palliative surgery for inoperable malignancies were excluded. Preoperatively, frailty was assessed using the Clinical Frailty Scale (CFS), and blood samples were measured for hs-cTnT. We evaluated the predictive power of CFS and hs-cTnT concentrations using receiver operating characteristic (ROC) curves and Cox proportional hazard regression with 30-day mortality as the primary outcome. Secondary outcomes included (1) a composite of 30-day all-cause mortality and major adverse cardiac event (MACE), defined as myocardial infarction, nonfatal cardiac arrest, or coronary revascularization; and (2) 90-day mortality. Of the 210 screened and 156 eligible patients, blood samples were available in 146, who were included. Troponin concentration exceeded the 99th percentile upper reference limit (URL) in 83% and 89% of the patients pre- and postoperatively. Of the participants, 53% were classified as vulnerable or frail (CFS ≥4). The 30-day mortality rate was 12% (18 of 146). Preoperatively, a threshold of hs-cTnT ≥34 ng/L independently predicted 30-day mortality (hazard ratio [HR] 3.14, 95% confidence interval [CI], 1.13-9.45), and the composite outcome of 30-day mortality and MACE (HR 2.58, 95% CI, 1.07-6.49). In this model, frailty (continuous CFS score) also independently predicted 30-day mortality (HR 1.42, 95% CI, 1.01-2.00) and 30-day mortality or MACE (HR 1.37, 95% CI, 1.02-1.84). The combination of troponin and frailty, 0.14 × hs-cTnT +4.0 × CFS, yielded apparent superior predictive power (area under the receiver operating characteristics curve [AUC] 0.79, 95% CI, 0.68-0.88), compared to troponin concentration (AUC 0.69, 95% CI, 0.55-0.83) or frailty (AUC 0.69, 95% CI, 0.57-0.82) alone. After emergency abdominal surgery in elderly patients, increased preoperative troponin concentration and frailty were independent predictors of 30-day mortality. The combination of increased troponin concentration and frailty seemed to provide better prognostic information than troponin or frailty alone. These results must be validated in an independent sample.

Classic Timothy Syndrome Associated With Bilateral Border Digit Syndactyly: A Case Series

Timothy syndrome (TS) is characterized by congenital long-QT arrhythmia and limb syndactyly. Patients who undergo syndactyly repair with undiagnosed TS may have their abnormal cardiac electrical activity unmasked during surgery. The purpose of this study was to detail the extremity phenotype seen in patients with TS, which may help hand surgeons in their preoperative assessment. This was a retrospective review of all patients with TS seen at our institution from 1998 to 2022. Descriptive statistics regarding their demographics, medical and surgical histories, and syndactyly phenotypes were obtained. Seven patients (5 males and 2 females) with TS were seen at our institution for multidisciplinary evaluation (median age at presentation was 23 months). Six patients had finger syndactyly and 5 had toe syndactyly. One patient did not have any extremity syndactyly and was noted to have a specific TS mutation known to lack musculoskeletal abnormalities. All patients with finger syndactyly had border digit involvement, with 5 out of 6 patients displaying syndactyly of the middle-ring and ring-little finger web spaces. Toe syndactyly was more heterogeneous, with 1 patient lacking any lower extremity syndactyly and others having variable involvement of the second-third, third-fourth, and fourth-little toe web spaces. Complexity ranged from simple to complete. Four patients had intraoperative cardiac events leading to TS diagnoses after surgery. Bilateral border digit hand syndactyly, with or without bilateral toe syndactyly, should raise concerns for TS and prompt further investigation into potential cardiac disease to avoid perioperative cardiac morbidity and mortality. Therapeutic V.

Prevalence and risk factors for cardiac arrest and myocardial infarction after pelvic reconstructive surgery: a national, multi-institutional, surgical database study

There is limited data available regarding the risk for perioperative cardiac morbidity following pelvic reconstructive surgery (PRS). We sought to determine the incidence of cardiac arrest and myocardial infarction within 30days of pelvic organ prolapse (POP) surgery and determine which factors may contribute to an increased risk of these complications. Using the American College of Surgeons National Quality Improvement Program (NSQIP) database, we identified patients who underwent PRS procedures between 2010 to 2015 using Current Procedural Terminology (CPT) codes. Patient demographics and clinical and surgical factors were obtained. Patients who experienced myocardial infarction or cardiac arrest (MICA) were compared with patients without these complications. Differences between groups were calculated using the chi-square and Student's t test. Stepwise backward multivariate logistic regression was used to identify factors associated with acute cardiac morbidity. A total of 46, 367 women were identified. The incidence of MICA was 0.11% and of death was 0.01% for the entire cohorot. Age >70years [adjusted odds ratio (aOR)=2.99, 95% confidence interval (CI) 1.56-5.73], length of stay >1 day (aOR=3.34, 95% CI 1.70-6.40), dependent functional status (aOR=5.99 95% CI 1.95-16.32), hypertension (aOR=2.86, 95% CI 1.36-6.04), American Society of Anesthesiologists (ASA) class 3 (aOR=2.01, 95% CI 1.10-3.64), and inpatient status (aOR=4.35, 95% CI 1.78-10.49). The rate of MICA is low following PRS. Additional studies are necessary to determine whether more extensive preoperative cardiac evaluation is warranted in this patient population.

Anaesthetic Management of Ischemic Heart Disease Patients in Noncardiac Surgery

Perioperative myocardial infarction is one of the most important predictors of short and long term morbidity and mortality associated with noncardiac surgery. Myocardial infraction occurs whenever myocardial oxygen supply does not match myocardial oxygen demand. Intraoperative ischemia can be precipitated by increase in myocardial oxygen demand caused by tachycardia, hypertension, anaemia, stress, sympathomimatic drugs or discontinuation of beta blocker. Clinical predictors of perioperative cardiac morbidity are acute myocardial infraction or recent myocardial infraction, unstable or severe angina, decompensated heart failure, severe valvular disease, mild angina pectoris, previous myocardial infraction, diabetic mellitus etc. The preoperative history is meant to elicit the severity, progression and functional limitations imposed by ischemic heart disease. Limited exercise tolerance in the absence of significant lung disease is very good evidence of decreased cardiac reserve. The basic challenges during induction and maintenance of anaesthesia in patients with ischemic heart disease are prevent myocardial infraction by increasing myocardial O2 supply and reducing myocardial O2 demand and monitor for ischemia and to treat ischemia if it develops. There are no one best myocardial protective agents or technique. Maintenance of balance between myocardial oxygen supply and demand is more important than the specific technique or drugs selected to produce anaesthesia and muscle relaxation. Potential benefits of a regional anaesthetic include excellent pain control, a decreased incidence of deep vein thrombosis (DVT) in some patients and the opportunity to continue the block into the postoperative period. The postoperative period appears to present the highest risk for cardiac morbidity. It is during this period where 67% of the ischemic events occur. Effective pain management is essential to prevent these adverse outcomes. Successful perioperative evaluation and treatment of cardiac patients undergoing noncardiac surgery requires careful teamwork and communication between patient, anaesthesiologist and surgeon.
 Ibrahim Cardiac Med J 2014; 4(2): 56-60

The impact of acute preoperative beta- blockade on perioperative cardiac morbidity and all-cause mortality in hypertensive South African vascular surgery patients.

Acute β-blockade has been associated with poor perioperative outcomes in non-cardiac surgery patients, probably as a result of P-blocker-induced haemodynamic instability during the perioperative period, which has been shown to be more severe in hypertensive patients. To determine the impact of acute preoperative β-blockade on the incidence of perioperative cardiovascular morbidity and all-cause mortality in hypertensive South African (SA) patients who underwent vascular surgery at a tertiary hospital. We conducted two separate case-control analyses to determine the impact of acute preoperative β-blockade on the incidence of major adverse cardiovascular events (MACEs, a composite outcome of a perioperative troponin-I leak or all-cause mortality) and perioperative troponin-I leak alone. Case and control groups were compared using χ2, Fisher's exact, McNemar's or Student's t-tests, where applicable. Binary logistic regression was used to determine whether acute preoperative -blocker use was an independent predictor of perioperative MACEs/troponin-I leak in hypertensive SA vascular surgery patients. We found acute preoperative β-blockade to be an independent predictor of perioperative MACEs (odds ratio (OR) 3.496; 95% confidence interval (CI) 1.948 - 6.273; p<0.001) and troponin-I leak (OR 5.962; 95% CI 3.085 - 11.52; p<0.001) in hypertensive SA vascular surgery patients. Our findings suggest that acute preoperative β-blockade is associated with an increased risk of perioperative cardiac morbidity and all-cause mortality in hypertensive SA vascular surgery patients.

Left upper lobectomy after coronary artery bypass grafting

ObjectiveLeft upper pulmonary lobectomy or segmentectomy after coronary artery bypass grafting (CABG) risks injury to the grafts. We reviewed our experience. MethodsThis is a retrospective review of a prospective database from 1 surgeon, of patients who underwent left upper lobectomy after having previous CABG. ResultsBetween June 1998 and June 2014, a total of 2207 patients underwent lobectomy by 1 surgeon; 458 (21%) had a left upper lobectomy, and 28 (6.1%) had had a previous CABG. Twenty-seven patients (96.4%) had a left internal mammary artery (LIMA) used for the bypass. Twenty-six patients (96.2%) had significant adhesions between their lung and the bypass grafts. Of patients who had a LIMA graft, 25 (92.6%) had the left upper lobe completely dissected free from their grafts, whereas 2 patients (7.1%) had a sliver of their lung left on the grafts. No patient had a postoperative myocardial infarction, and 30-day and 90-day survival rates were both 100%. All patients had a curative resection, and all had complete thoracic lymphadenectomy. ConclusionsLeft upper lobectomy after CABG, in patients with previous CABG and LIMA grafting, is safe. Usually the entire lung can be safely mobilized off the bypass grafts; if needed, a small sliver of lung can be left on the grafts. A curative resection is possible with minimal perioperative cardiac morbidity, and excellent 30- and 90-day mortality.

Perioperative Cardiac Morbidity in Elderly Patients with Epidural versus Systemic Analgesia for Hip Fracture Surgery

Abstract Introduction. Patients with hip fracture are usually older patients. Uncontrolled acute pain and surgical stress in elderly patients may cause increased cardiac morbidity and mortality. Epidural analgesia blocks sympathetic nervous system and reduces the incidence of myocardial ischemia and dysrhythmias as well as the response to stress. Methods. Sixty patients with hip fracture older than 65 years with previously defined high peroperative cardiac risk according to ACC/AHA guidelines were included and were randomly assigned to two groups of 30 patients: SA group-patients with systemic analgesia. niflam 2 × 100 mg/iv and tramadol 1 mg/kg/iv every 8 hours; and EDC group-patients with a continuous epidural analgesia with bupivacaine 0.125%-5 ml/h and fentanyl 3 µg/ml. As end points of the study the incidence of cardiac events in both groups were registered: cardiac death, myocardial infarction, congestive heart failure, unstable angina and new-onset atrial fibrillation. Laboratory parameters and pain intensity were determined in all patients by using Verbal Descriptive Scale. Side effects were also monitored. Results. The epidural analgesia decreased the incidence of peroperative cardiac events in patients with high per-operative cardiac risk for hip fracture surgery (46.6% in SA group vs. 15% in EDC group) and at the same time decreased cardiac mortality (10% in SA group vs. 0% in EDC group). The values of VDS were significantly lower in patients with EDC block versus patients with systemic analgesia in all experimental times and there was a smaller number of side effects. Conclusion. Early administration of continuous epidural analgesia in patients with high peroperative risk with hip fracture decreases the incidence of cardiac morbidity and mortality and provides superior pre- and post-operative analgesia compared to systemic analgesia with minimal side effects.

HIV, vascular surgery and cardiovascular outcomes: a South African cohort study

Risk factors for peri-operative cardiac morbidity are poorly described in HIV-positive patients. This prospective observational study describes cardiovascular risk factors in a cohort of vascular surgical patients of known HIV status. We recruited 225 patients with 73 (32%) being HIV-positive. When compared with HIV-negative patients, the HIV-positive patients were younger (mean (SD) 56.4 (13.3) vs 40.5 (10.4)years, respectively, p<0.01). They had fewer Revised Cardiac Risk Index cardiovascular risk factors (median (range [IQR]) 1 (0-5 [0-2]) vs 0 (0-2 [0-0]), respectively, p<0.001), with the exception of congestive cardiac failure (p=0.23) and renal dysfunction (p=0.32), and so were of a significantly lower Revised Cardiac Risk Index risk category (p<0.01). HIV-positive and -negative patients had similar outcomes in: 30-day mortality (p=0.78); three-day postoperative troponin leak (p=0.66); and a composite outcome of mortality and troponin release (p=0.69). We conclude that although HIV-positive patients have fewer cardiovascular risk factors, they have similar peri-operative major adverse cardiac events to HIV-negative patients. Research should focus on why this is the case, and if alternative clinical risk predictors can be developed for HIV patients.

Carotid Endarterectomy National Trends Over A Decade: Does Sex Matter?

The objective was to evaluate the difference in timing (if any) of in-hospital carotid endarterectomy (CEA) or outcomes of CEA based on sex among men and women hospitalized for carotid artery disease. This was a retrospective cross-sectional study using the Nationwide Inpatient Sample Database. All patients from 2000-2009 who underwent CEA during their hospitalization were examined. International Classification of Diseases, 9th revision codes were used to identify patients who underwent CEA during hospitalization, stratify asymptomatic and symptomatic patients, determine time in days from admission to CEA, and examine in-hospital complications, including perioperative stroke, cardiac events, and death. Statistical analysis was performed with chi-squared and t-tests. Linear and logistic regression models were used to evaluate relationships between sex and outcomes. The main outcome measures were time from admission to surgery, in-hospital mortality, complications, mean duration of stay, and discharge disposition. Two hundred twenty-one thousand two hundred fifty three patients underwent CEA during hospitalization. More than 9% (9.2%) had symptomatic carotid artery disease. Among symptomatic patients, bivariate analysis found that women had a longer mean time from admission to surgery (2.8 vs. 2.6 days; P < 0.001) and a longer duration of hospital stay (6.4 vs. 5.9 days; P < 0.001) than their male counterparts. However, there was no difference between men and women with regard to rates of perioperative stroke, cardiac complications, myocardial infarction, or death. Among asymptomatic patients, women had a longer mean time from admission to surgery (0.53 vs. 0.48 days; P < 0.001) and a trend toward increased perioperative stroke (0.6% vs. 0.5%; P = 0.06), but a lower rate of cardiac complications (1.5% vs. 1.7%; P = 0.01) and in-hospital mortality (0.26% vs. 0.31%; P = 0.05). However, on multivariable analysis adjusting for differences in age, elective status, insurance, race, hospital location, hospital region, and hospital teaching status, there was no sex disparity in time from admission to surgery, regardless of symptomatic status. In addition, asymptomatic women were less likely than men to have a cardiac complication (odds ratio [OR]: 0.90; 95% confidence interval [CI]: 0.83-0.97) or in-hospital mortality (OR: 0.83; 95% CI: 0.70-0.98). Symptomatic women were also less likely than men to have a cardiac complication (OR: 0.78; 95% CI: 0.63-0.97). In this decade-long national population-based study of hospitalized patients undergoing CEA, women had lower perioperative cardiac morbidity and mortality rates than men. After adjusting for patient, clinical, and hospital factors, there is no discernible difference in timing of CEA based on sex.

Revised Cardiac Risk Index (RCRI) Is a Useful Tool for Evaluation of Perioperative Cardiac Morbidity in Kidney Transplant Recipients

We evaluated a published Revised Cardiac Risk Index (RCRI) to determine if this preoperative cardiovascular risk stratification tool would be useful in the kidney transplant recipient population. We identified all kidney transplants from 2005 to 2009 (n=1652) at our institution. We performed a detailed retrospective chart review of (a) all recipients who underwent preoperative coronary angiography (n=169) and (b) an age-matched and transplantation year-matched group who did not undergo coronary angiography (n=156). Charts were reviewed for the presence of specific preoperative cardiovascular risk factors and perioperative cardiovascular complications (as defined by RCRI plus elevation of troponin) from time of surgery to hospital discharge. The total number of risk factors for each patient was compared with the occurrence of postoperative cardiac complications to identify a possible association. The number of risk factors was highly predictive of cardiovascular complications (receiver operating characteristic area, 0.77; P<0.0001). History of coronary artery disease was most strongly associated (odds ratio, 20.59; confidence interval, 4.73-89.53; P=0.0001) and history of congestive heart failure was also significantly associated with cardiac complications (odds ratio, 2.95; confidence interval, 1.01-8.59; P=0.0475). The RCRI is a useful tool for cardiac risk stratification in kidney transplantation and could be used to develop protocols for intraoperative and postoperative care to minimize complications.

Invited commentary

In this retrospective study, Samson and colleagues present excellent results (2% neurologic event rate, 0.7% mortality, and no clinically apparent myocardial infarctions) in 147 consecutive contralateral carotid occlusion patients, who underwent carotid endarterectomy (CEA) without shunting. They attribute their success to the use of general anesthesia with careful maintenance of systolic blood pressure above 130 mm Hg. Their results add fuel to the controversies over neurologic risk in contralateral occlusion patients and over the role of shunting. While provocative, the study is not definitive. It suffers from the weaknesses inherent in retrospective analyses. The credibility of the outcome data suffers from the absence of independent routine pre- and post-CEA neurologic assessment and of a set protocol for post-CEA brain imaging. It is almost certain that there were more perioperative strokes than they report, though these events were clinically silent or subtle. Furthermore, given the authors' use of phenylephrine-induced hypertension as a means of cerebral protection, their failure to routinely monitor postoperative cardiac enzymes represents a missed opportunity to confirm the safety of their protocol. Theoretically, at least, the routine use of vasopressors will add to the hemodynamic stress of the surgery, thereby raising the risk of perioperative cardiac morbidity. Despite these shortcomings, this report confirms four facts: (1) Well-trained surgeons, working with detail-oriented anesthesiologists and adhering to well-defined management protocols, can achieve excellent results with CEA even in putatively high-risk patients. (2) CEA patients with contralateral occlusion are not necessarily at high neurologic risk. (3) The argument that contralateral occlusion represents an indication for carotid stenting is specious. (4) Contralateral occlusion is not an absolute indication for shunt placement during CEA. The report does not establish the superiority of the authors' practices, but it does establish their management protocol as one acceptable approach to the management of CEA patients with contralateral occlusion. Those who achieve excellent results in this patient population with carotid stenting or with CEA with shunting are not likely to be converted by these data, but now have another standard against which to measure their outcomes. Controversy over the risk associated with contralateral occlusion and the role of shunting will continue. In the face of ongoing controversy, surgeons will continue to adopt and report those practices that provide optimal results for their patients. Contralateral carotid artery occlusion is not a contraindication to carotid endarterectomy even if shunts are not routinely usedJournal of Vascular SurgeryVol. 58Issue 4PreviewAlthough controversial, carotid artery stenting (CAS) has been proposed as being safer than carotid endarterectomy (CEA) for patients with a contralateral internal carotid occlusion (CCO). Arguably, with a CCO, CAS should be even safer than CEA if a shunt is not used. Accordingly, we reviewed our experience with 2183 CEAs performed routinely without a shunt to evaluate the risk of CEA performed in a subset of 147 patients with a CCO. Full-Text PDF Open Archive

Reducing perioperative cardiac morbidity and mortality

One million people die annually following noncardiac surgery and 4% of patients suffer an adverse cardiac event after surgery. As the number of people having surgery grows, our ability to risk stratify patients becomes more important, particularly in the setting of perioperative myocardial ischemia/necrosis. In recent publications, an increased troponin following noncardiac surgery has been associated with a higher morbidity/mortality in the perioperative setting. The level of troponin elevation associated with increased morbidity/mortality is now believed to be far lower than was previously considered to be pathologic. The presence of troponin elevations following noncardiac surgery, particularly in at-risk patients, may enable practitioners to better identify high-risk patients in the postoperative setting. After recognizing those patients at increased risk for poor outcomes, practitioners can then make interventions, which may decrease the patients' in-hospital, 30-day and potentially long-term mortality.

Perioperative statin therapy: understanding the evidence in a Bayesian context

Over the past decade, there has been a marked increase in the level of interest in studying different pharmacologic approaches to reduce the perioperative cardiovascular risk for noncardiac surgery. The focus of much of the work has been on two specific classes of drugs: beta-blockers and statins. There is widespread consensus that these drugs should be continued perioperatively in those patients already taking them, but there is a great deal of controversy regarding initiation of these agents immediately prior to surgery. This controversy has been further heightened by conflicting study results and recent questions regarding the quality of some of the related randomized-controlled trials. In attempting to determine the optimal strategy, it is important to understand both the protocols utilized in the studies and the underlying pharmacologic basis for therapy. In this context, the study by Neilipovitz et al. in this issue of the Journal examines the short-term effects of an atorvastatin regimen for vascular-prone subjects and contributes significantly to the literature. Perioperative cardiac morbidity is clearly multifactorial, involving supply/demand imbalances as well as inflammatory changes and thrombosis. The multifactorial etiology has led investigators to approach treatment in a multimodal manner. Beta-blockers have been advocated primarily for their hemodynamic effects. There has been a great deal of interest in statin therapy since these drugs have both anti-inflammatory and plaque-stabilizing effects, properties that Neilipovitz et al. discuss in their article. However, most package inserts for this class of agents recommend drug discontinuation in the perioperative period because of the risk of rhabdomyolysis. This recommendation is not based on clinical trials of risk versus benefit, but rather on data extrapolated from individual cases, which has led investigators to hypothesize that statins may have beneficial effects worth studying in a clinical trial setting. In that case, how do we respond to new information? To answer this question, it is important to understand the influence of prior beliefs on the acceptance of new evidence. Bayes’ theorem postulates that the existing view (the prior probability) of the evidence and/or pathophysiologic basis for treatment influences the way we perceive the importance of new information. If our prior belief is strongly positive, then new evidence will be embraced strongly even if the quality of the new evidence is weaker. In considering the role of statins in perioperative cardioprotection, as physicians, we are predisposed to believe that statins may be beneficial on the basis of outcome studies in nonsurgical patients. These beliefs are further strengthened to the perioperative period by Lindenauer et al. Thus, clearly a case was to be made for the use of statins on the basis of studies in which statins were initiated prior to surgery. In 2004, Durazzo et al. performed a small randomized trial comparing preoperative atorvastatin with placebo in vascular surgery patients, and they found a significant reduction in cardiac events at six months. The study had a very large treatment effect (three times larger than those seen in the cardiology literature) despite the small sample size, which led many investigators and guidelines committees to embrace the results. In light of new evidence, it is important when interpreting the study to L. A. Fleisher, MD (&) Department of Anesthesiology and Critical Care and Medicine, Perelman School of Medicine of the University of Pennsylvania, 3400 Spruce Street, Dulles 680, Philadelphia, PA 19104, USA e-mail: lee.fleisher@uphs.upenn.edu

Preoperative Cardiac Evaluation and Perioperative Cardiac Therapy in Patients Undergoing Open Surgery for Abdominal Aortic Aneurysms: Effects on Cardiovascular Outcome

Cardiovascular complications, such as death, myocardial infarction, or heart failure, are the leading causes of morbidity and mortality in adult patients undergoing major noncardiac surgery. To evaluate the effects of an accurate preoperative cardiac evaluation, together with optimized perioperative drug therapy, in reducing cardiovascular events in patients undergoing open aortic surgery for abdominal aneurysm. Between January 2000 and December 2008, we considered all consecutive patients undergoing elective abdominal aortic open surgery at the Vascular Surgery Unit of the University of Study-Spedali Civili (Italy). Since January 2003, we have used an intensive cardiac preoperative evaluation: patients with at least one cardiac risk factor received a preoperative cardiac evaluation; all non-invasive and invasive tests were performed preoperatively when indicated by the consultant cardiologist, that also optimized the pharmacological perioperative therapy. The outcome of the 418 patients undergoing surgery between 2003 and 2008 was compared with those of the 204 patients in the previous triennium 2000 to 2002, when only patients with positive history for cardiac disease received a standard preoperative cardiological clinical or instrumental evaluation. Patients enrolled in the 2003 to 2008 interval were slightly older and with a higher prevalence of comorbidities compared with those observed in the previous triennium; furthermore, the number of noninvasive tests performed before surgery increased significantly. Nevertheless, the number of major cardiac perioperative complications decreased over time: particularly, in-hospital mortality rate was 0.9% in the latter period, compared with 3.4% in the years 2000 to 2002. Also, the long-term mortality was significantly reduced in patients operated on between 2003 and 2008 compared with those operated on in the previous triennium. These data suggest a significant benefit of an intensive cardiac preoperative evaluation in reducing the incidence of perioperative and postoperative cardiac morbidity and mortality.

The influence of surgery on the onset of symptomatic coronary artery disease

We speculated that asymptomatic patients undergoing routine surgery might be at higher risk of subsequent cardiac events. We studied 183,534 patients with no prior admission for heart disease, aged 50-75 years, admitted electively for one of five operations considered medium to low risk of peri-operative cardiac morbidity, between January 1997 and December 2005. Controls were generated from linked records. Within 3 years 3444 (1.9%) patients undergoing operations had subsequent myocardial infarction/acute coronary syndrome (MI/ACS) compared with 3708 (2.0%) controls (p < 0.001). Overall 8406 (4.6%) patients undergoing surgery had MI/ACS compared with 9306 (5.1%) controls (p < 0.001). Of patients undergoing surgery, 20.2% died compared with 25.7% of controls (p < 0.001). Patients undergoing certain surgical procedures did not have a higher incidence of readmission for cardiac events, but had a general survival benefit compared with other elective hospital admissions. Assessment for surgery may represent a health benefit beyond the original surgery.

Vascular Surgery Patients Prescribed Preoperative β-Blockers Experienced a Decrease in the Maximal Heart Rate Observed During Induction of General Anesthesia

To investigate the association of preoperative β-blocker usage and maximal heart rates observed during the induction of general anesthesia. Retrospective descriptive, univariate, and multivariate analyses of electronic hospital and anesthesia medical records. A tertiary-care medical center within the Veterans Health Administration. Consecutive adult elective and emergent patients presenting for vascular surgery during calendar years 2005 to 2011. None. Of the 430 eligible cases, 218 were prescribed β-blockers, and 212 were not taking β-blockers. The two groups were comparable across baseline patient factors (ie, demographic, morphometric, surgical duration, and surgical procedures) and induction medication doses. The β-blocker group experienced a lower maximal heart rate during the induction of general anesthesia compared with the non-β-blocker group (105 ± 41 beats/min v 115 ± 45 beats/min, respectively; p < 0.01). Adjusted linear regression found a statistically significant association between lower maximal heart rate and the use of β-blockers (β = -11.1 beats/min, p < 0.01). There was no difference between groups in total intraoperative β-blocker administration. Preoperative β-blockade of vascular surgery patients undergoing general anesthesia is associated with a lower maximal heart rate during anesthetic induction. There may be potential benefits in administering β-blockers to reduce physiologic stress in this surgical population at risk for perioperative cardiac morbidity. Future research should further explore intraoperative hemodynamic effects in light of existing practice guidelines for optimal medication selection, dosage, and heart rate control.

Thoracic Epidural Analgesia and Acute Pain Management

AIN continues to be a significant problem for many patients after major surgery. In addition to improving patient satisfaction and decreasing pain scores, enhanced perioperative pain control can improve clinical outcomes. Thoracic epidural analgesia (TEA) remains a critical tool for anesthesiologists to use in acute pain management. TEA is particularly effective for reducing pain after thoracic and upper abdominal surgery and likely permits major surgical procedures to be performed on patients with moderate to severe comorbid diseases, who several years ago may have been determined to be too great a risk for surgery. In the past 10 yr, peripheral nerve blockade has improved perioperative analgesia for patients undergoing extremity surgery. Although nerve blocks have reduced the use of continuous lumbar epidural analgesia, anesthesiologists must understand the indications, placement techniques, solutions administered, potential complications, and evidence-based outcomes for TEA in acute pain management. Indications

O-08 Pre-admission insulin therapy is an indicator of worse long-term outcome in diabetic patients undergoing major non-cardiac surgery

Insulin-treated diabetes mellitus is regarded as a predictor of increased perioperative cardiac morbidity and mortality, but preoperative glucose control with oral hypoglycaemics (OH) has also been associated with increased postoperative mortality [1,2]. We hypothesized that preadmission antidiabetic therapy does not influence long-term outcome in diabetic patients undergoing major non-cardiac surgery.

Revised Cardiac Risk Index (Lee) and Perioperative Cardiac Events as Predictors of Long-Term Mortality in Patients Undergoing Endovascular Abdominal Aortic Aneurysm Repair

Conclusion: Long-term mortality is high after endovascular repair of abdominal aortic aneurysm (AAA). In the setting of endovascular AAA repair, the Lee Index may be useful for stratifying short-term and long-term mortality in high-risk patients. Summary: Perioperative myocardial infarction remains a vexing problem. In very high-risk vascular surgical patients, perioperative myocardial ischemic injury may be as high as 18% to 35% (J Vasc Surg 2006;43:533-538). Although a large majority of patients survive a perioperative myocardial ischemic event, they are at risk of increased late mortality (J Vasc Surg 1994;20:598-604). Because it appears long-term survival is not improved by endovascular aneurysm repair (EVAR) vs conventional open AAA repair, it is reasonable to investigate whether patients undergoing EVAR can be stratified according to the Revised Cardiac Risk Index (Lee). This was a retrospective review from a single academic medical center involving 225 patients with AAA treated with EVAR between 1999 and 2006. The goal was to determine if the Lee Index is useful is stratifying patients by risk of both perioperative cardiac morbidity and long-term all-cause mortality. Data were collected from physician quality assurance databases, office records, and medical records. There were no in-hospital cardiac deaths. The major cardiac adverse event (MACE) rate perioperatively was 6.2%. Long-term all-cause mortality was 23%. By univariate analysis, a history of coronary artery disease (likelihood ratio [LR], 8.7; P = .023), history of congestive heart failure (LR, 4; P = .042), and a Revised Cardiac Risk Index (RCRI) ≥3 (LR, 8.6; P = .004) were all predictors of perioperative MACE. Long-term all-cause mortality was associated with a history of coronary artery disease (LR, 10.7; P = .002), perioperative cardiac events (LR, 15.9; P < .0001), echocardiographic evidence of myocardial infarction (LR, 8.5; P = .006), and exercise tolerance of only on block (LR, 8.4; P = .005). Long-term mortality is increased after perioperative cardiac events within the RCRI ≥3 subgroup (LR, 6.1; P = .019). Comment: It would seem logical that a patient who develops a myocardial ischemic event after EVAR should undergo further evaluation for coronary artery disease. Long-term survival appears significantly impaired after EVAR, and more so after even a minor myocardial infarction following EVAR. Whether the minor perioperative myocardial event is a cause of long-term mortality or merely a marker of long-term increased cardiac risk is a question that deserves further investigation.

Perioperative management of the patient with a coronary stent

In recent years, an increasing number of patients have received coronary stents as a treatment for coronary artery disease. It is expected that more such patients will present to the operating room. The purpose of this review is to highlight the key issues and provide possible management strategies for these patients. Currently published studies suggest that patients with coronary stents, and in particular those with drug-eluting stents, are at an increased risk of perioperative cardiac morbidity and mortality due to stent thrombosis. Total and premature discontinuation of dual antiplatelet therapy (aspirin and clopidogrel) is considered as the main culprit. Caring for patients with coronary stents in the perioperative period requires input from a team consisting of anesthesiologists, surgeons and cardiologists. The management of the dual antiplatelet therapy regimen should be customized to each patient depending on the type and urgency of surgery, type of coronary stent, time since the coronary intervention and complexity of the coronary intervention. For patients identified at high risk for stent thrombosis, surgery should be planned in a hospital with cardiac catheterization facilities. Postoperatively, these patients require a monitored setting and their antiplatelet agents restarted immediately. Signs and symptoms of stent thrombosis should be promptly recognized and aggressively treated with percutaneous coronary intervention.