Risk Of Postoperative Cardiac Complications Research Articles

Prognostic value of left ventricular systolic function before vascular surgery: a systematic review.

Vascular surgery carries a high risk of post-operative cardiac complications. Recent studies have shown an association between asymptomatic left ventricular systolic dysfunction and increased risk of major adverse cardiovascular events (MACE). This systematic review aims to evaluate the prognostic value of left ventricular function as determined by left ventricular ejection fraction (LVEF) measured by resting echocardiography before vascular surgery. This review conformed to PRISMA and MOOSE guidelines. PubMed, OVID Medline and Cochrane databases were searched from inception to 27 October 2022. Eligible studies assessed vascular surgery patients, with multivariable-adjusted or propensity-matched observational studies measuring LVEF via resting echocardiography and providing risk estimates for outcomes. The primary outcomes measures were all-cause mortality and congestive heart failure at 30 days. Secondary outcome included the composite outcome MACE. Ten observational studies were included (4872 vascular surgery patients). Studies varied widely in degree of left ventricular systolic dysfunction, symptom status, and outcome reporting, precluding reliable meta-analysis. Available data demonstrated a trend towards increased incidence of all-cause mortality, congestive heart failure and MACE in patients with pre-operative LVEF <50%. Methodological quality of the included studies was found to be of moderate quality according to the Newcastle Ottawa Checklist. The evidence surrounding the prognostic value of LVEF measurement before vascular surgery is currently weak and inconclusive. Larger scale, prospective studies are required to further refine cardiac risk prediction before vascular surgery.

Management of Patients with Ischemic Heart Disease in Spine Surgery.

In ischemic heart disease (IHD), the myocardium does not receive enough blood and oxygen. Although the IHD-related mortality rate is decreasing, the risk remains and is a major predictor of cardiac complications following noncardiac surgery. Given the increase in the older population, the number of patients with spinal diseases requiring surgery is increasing. Among these patients, those with underlying IHD or a high risk of cardiac complications before and after surgery are also increasing. Given that cardiac complications following spinal surgery are associated with delayed patient recovery and even death, spinal surgeons should be knowledgeable about overall patient management, including medication therapy in those at high risk of developing perioperative cardiac complications for successful patient care. Before surgery, the underlying medical conditions of patients should be evaluated. Patients with a history of myocardial infarction should be checked for a history of surgical treatments, and the anticoagulant dose should be controlled depending on the surgery type. In addition, the functional status of patients must be examined before surgery. Functional status can be assessed according to the metabolic equivalent of task (MET). More preoperative cardiac examinations are needed for patients who are unable to perform four METs in daily because of the high risk of postoperative cardiac complications. Patients with a history of IHD require appropriate preoperative management and further postoperative evaluation. When considering surgery, spinal surgeons should be knowledgeable about patient care before and after surgery.

Utility of an Artificial Intelligence Enabled Electrocardiogram for Risk Assessment in Liver Transplant Candidates.

Post-operative cardiac complications occur infrequently but contribute to mortality after liver transplantation (LT). Artificial intelligence-based algorithms based on electrocardiogram (AI-ECG) are attractive for use during pre-operative evaluation to screen for risk of post-operative cardiac complications, but their use for this purpose is unknown. The aim of this study was to evaluate the performance of an AI-ECG algorithm in predicting cardiac factors such as asymptomatic left ventricular systolic dysfunction or potential for developing post-operative atrial fibrillation (AF) in cohorts of patients with end-stage liver disease either undergoing evaluation for transplant or receiving a liver transplant. A retrospective study was performed in two consecutive adult cohorts of patients who were either evaluated for LT or underwent LT at a single center between 2017 and 2019. ECG were analyzed using an AI-ECG trained to recognize patterns from a standard 12-lead ECG which could identify the presence of left ventricular systolic dysfunction (LVEF < 50%) or subsequent atrial fibrillation. The performance of AI-ECG in patients undergoing LT evaluation is similar to that in a general population but was lower in the presence of prolonged QTc. AI-ECG analysis on ECG in sinus rhythm had an AUROC of 0.69 for prediction of de novo post-transplant AF. Although post-transplant cardiac dysfunction occurred in only 2.3% of patients in the study cohorts, AI-ECG had an AUROC of 0.69 for prediction of subsequent low left ventricular ejection fraction. A positive screen for low EF or AF on AI-ECG can alert to risk of post-operative cardiac dysfunction or predict new onset atrial fibrillation after LT. The use of an AI-ECG can be a useful adjunct in persons undergoing transplant evaluation that can be readily implemented in clinical practice.

Analysis of prognosis factors of postoperative cardiac complications in colorectal cancer patients with comorbid coronary artery disease

Objective: To examine the prognosis factors of postoperative cardiac complications in colorectal cancer patients co-morbidated with coronary artery disease. Methods: Clinical data of 449 patients colorectal cancer patients co-morbidated with coronary artery disease accepted redical surgery from April 2013 to April 2020 at Department of General Surgery, Peking Union Medical College Hospital were analyzed retrospectively. There were 306 males and 143 females, aging (68.7±8.9) years (range: 44 to 89 years). Postoperative acute coronary syndrome, new-onset arrhythmia and heart failure that causes clinical symptoms were recorded as cardiac complications. t test, χ2 test and Fisher exact test were used for univariate analysis of prognosis factors of postoperative cardiac events. The variables with P<0.05 were included in the multivariate Logistic regression was used to determine the independent prognosis factors. Results: After surgery, 44 patients (9.8%) suffered from at least one cardiac event, including 30 patients with acute coronary syndrome, 19 patients with new-onset arrhythmia and 9 patients with heart failure. There were 3 deaths in the cohort within 30 days after surgery. Two patients died from cardiac-related complications, and one from septic shock due to postoperative anastomotic leaks. On Univariate analysis showed that cardiac complications were associated with age ≥80 years, co-morbidated diabetes, emergency surgery, re-operation, anastomotic leakage, intestinal flora disorder and elevation of preoperative neutrophil-lymphocyte ratio (χ2: 4.308 to 12.219, all P<0.05). Multivariate Logistic regression analysis identified age ≥80 years(OR=3.195, 95%CI: 1.379 to 7.407, P=0.007), co-morbidated diabetes (OR=2.551, 95%CI: 1.294 to 5.025, P=0.007), emergency surgery (OR=4.717, 95%CI: 1.052 to 20.833, P=0.043), and elevated preoperative neutrophil-lymphocyte ratio (OR=1.114, 95%CI: 1.018 to 1.218, P=0.018) as independent prognosis factors for cardiac complications. Conclusions: Emergency surgery, advanced age, co-morbidated type 2 diabetes and elevated preoperative neutrophil-lymphocyte ratio may increase the risk of postoperative cardiac complications in colorectal cancer patients with coronary artery disease. Surgeons should strictly master surgical indications, pay attention to preoperative assessment, perioperative monitoring, and diagnosis and treatment of postoperative complications in order to reduce the risk of complications.

Preoperative Heart Failure Treatment Prevents Postoperative Cardiac Complications in Patients With Lower Risk: A Retrospective Cohort Study.

The objective of this study was to identify undertreated subgroups of patients with heart failure who would benefit from better perioperative optimization. Patients with heart failure have increased risks of postoperative cardiac complications after noncardiac surgery. In this analysis of hospital registry data of 130,677 patients undergoing noncardiac surgery, the exposure was preoperative history of heart failure. The outcome, cardiac complications, was defined as a composite of myocardial infarction, cardiac arrest, acute heart failure, and mortality within 30 postoperative days. History of heart failure (n = 10,256; 7.9%) was associated with increased risk of cardiac complications [8.1% vs 1.1%; adjusted odds ratio, 2.28 (95% CI, 2.02-2.56); P < 0.001). Patients with heart failure and who carried a lower risk profile had increased risks of postoperative cardiac complications secondary to heart failure [adjusted absolute risk difference, 1.7% (95% CI, 1.4%-2.0%, lower risk); P < 0.001 vs 0.5% (95% CI, -0.6% to 1.6%, higher risk); P = 0.38]. Patients with heart failure and lower risk received a lower level of health care utilization preoperatively, and less frequently received anti-heart failure medications (59% vs 72% and 61% vs 82%; both P < 0.001). These preventive therapies significantly decreased the risk of cardiac complications in patients with heart failure. In patients with heart failure who have a lower preoperative risk profile, clinicians often make insufficient attempts to optimize their clinical condition preoperatively. Preoperative preventive treatment reduces the risk of postoperative cardiac complications in these lower-risk patients with heart failure.

Preoperative Cardiac Stress Testing in Patients Undergoing Vascular Surgery: Preliminary Results of a Systematic Review

Introduction: Coronary artery disease (CAD) is a major cause of perioperative morbidity and mortality in patients undergoing vascular surgery. Several tests have been used to assess risk of postoperative cardiac complications. In this systematic review we compared the prognostic accuracy of preoperative cardiac stress tests in predicting postoperative cardiac events in patients undergoing vascular surgery. Methods: A study protocol was designed in accordance with PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) and registered with the International Prospective Register of Systematic Reviews (CRD42019117846). A search of Medline, Embase, Scopus, CINAHL and the Cochrane library databases was conducted to identify studies correlating postoperative cardiac events of patients undergoing vascular surgery to preoperative cardiac stress tests between 1998 and 2018. For the purpose of this review, only pharmacological stressing agents were included. Quality was assessed using the Newcastle-Ottawa scores (NOS). Sensitivity and specificity of each test was calculated from published results. Summary receiver operator characteristic (SROC) curve and forest plots were used to compare different tests. Results: A total of 17 studies (3182 patients) were included. The mean age was 67±3 years and 82% were male. Twelve studies (71%) were prospective and 13 (76%) had a Newcastle-Ottawa scale score ³7. Seven studies used stress echocardiography (SE), 8 myocardial perfusion imaging (MPI) and 2 studies compared SE and MPI. With regards to predicting postoperative cardiac events, MPI and SE had a sensitivity of 70% (95% confidence interval [CI] 44% to 83%) and 49% (95% CI 32% to 70%) respectively whilst specificity was 60% (95% CI 45% to 79%) and 85% (95% CI 74% to 87%) respectively. Conclusion: Overall prognostic accuracy of cardiac stress tests for postoperative cardiac events after vascular surgery remains modest. Further research is required in vascular surgery patients using newer techniques and modalities that have been shown to have higher diagnostic accuracy of predicting CAD. Disclosure: Nothing to disclose

External validation of the Revised Cardiac Risk Index and update of its renal variable to predict 30-day risk of major cardiac complications after non-cardiac surgery: rationale and plan for analyses of the VISION study

IntroductionThe Revised Cardiac Risk Index (RCRI) is a popular classification system to estimate patients' risk of postoperative cardiac complications based on preoperative risk factors. Renal impairment, defined as serum creatinine...

Contemporary open repair of ruptured abdominal aortic aneurysms

ObjectiveAlthough endovascular repair of ruptured abdominal aortic aneurysms (rAAAs) is increasingly more prevalent and may yield better results, open repair of rAAAs is still commonly performed. Our goal was to assess the contemporary practice patterns and outcomes of open repair of rAAA. MethodsThe 2011-2014 American College of Surgeons National Surgical Quality Improvement Program targeted open AAA database was queried for all rAAAs. Patient characteristics, presentation, aneurysm details, and operative details were analyzed to identify factors that may affect outcome in this population of patients. ResultsWe identified 404 patients who underwent open repair of rAAA. The average age was 72 ± 9.4 years, and 76.2% were male. There were 230 (56.9%) patients who presented with hypotension. The operative approach was retroperitoneal in 16.3% of cases. The proximal extents of the aneurysms were infrarenal (52.5%), juxtarenal (24.3%), pararenal (4.2%), and suprarenal (8.2%). The distal extents were aortic (38.6%), common iliac artery (34.2%), and external or internal iliac artery (8.9%). Renal, visceral, and lower extremity revascularization was performed in 6.4%, 2.2%, and 7.9% of patients, respectively. Thirty-day mortality was 35.6%, and postoperative complications included cardiac (18.3%), pulmonary (42.3%), wound complications (6.7%), acute renal failure (17.3%), and ischemic colitis (9.4%). Postoperative length of stay was 13.1 ± 12.7 days, and 30-day readmission was 4.5%. Predictors of 30-day mortality were transperitoneal approach (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.38-7.89; P < .001), hypotension at presentation (OR, 2.03; 95% CI, 1.2-3.56; P = .007), and age (OR, 1.05; 95% CI, 1.02-1.09; P = .001). Transperitoneal approach also increased the risk of postoperative cardiac complications (OR, 3.25; 95% CI, 1.01-10.4; P = .047). Postoperative pulmonary complications were predicted by chronic obstructive pulmonary disease (OR, 2.06; 95% CI, 1.07-3.94; P = .03) and hypotension at presentation (OR, 1.77; 95% CI, 1.06-2.96; P = .03). ConclusionsThe majority of contemporary open rAAA repairs were performed for infrarenal aneurysms. Transperitoneal approach, hypotension, and chronic obstructive pulmonary disease were associated with higher mortality and postoperative complications. Thirty-day mortality after rAAA was lower compared with historical data.

Do orthopaedic trauma patients develop higher rates of cardiac complications? An analysis of 56,000 patients.

Less than 5% of orthopaedic patients develop postoperative cardiac complications; however, there are little data suggesting which orthopaedic patients are at greatest risk. In an era where emerging reimbursement models place an emphasis on quality, reducing complications through perioperative planning will be of paramount importance for orthopaedic surgeons. The purpose of this study was to determine whether orthopaedic trauma patients are at greater risk for postoperative cardiac complications and to reveal which factors are most predictive of these complications. All orthopaedic patients were identified in the 2006-2013 ACS-NSQIP database. Cardiac complications were defined as cardiac arrests or myocardial infarctions within 30days following surgery. Chi squared analysis determined differences in cardiac complication rates between trauma and non-trauma patients. Bivariate analysis incorporating over 40 patient/surgical characteristics determined significant associations between patient characteristics and cardiac complications. These factors were incorporated into a multivariate regression model to identify predictive risk factors for cardiac complications. The presence of a traumatic injury resulted in greater odds of developing cardiac complications (OR: 1.645, p<0.001). The cardiac complication rate in the trauma group was 1.3% compared to 0.3% in the non-trauma group (p<0.001). For trauma patients, ventilator use (OR: 27.354, p=0.004), recent transfusion (OR: 19.780, p=0.001), and history of coma (OR: 17.922, p=0.020) were most predictive of cardiac complications. Orthopaedic trauma patients are more likely to develop cardiac complications than non-trauma patients. To reduce cardiac complications, orthopaedic traumatologists should be aware of patient risk factors including ventilator use, blood transfusion, and history of coma.

Beta-adrenergic blockers for perioperative cardiac risk reduction in people undergoing vascular surgery.

People undergoing major vascular surgery have an increased risk of postoperative cardiac complications. Beta-adrenergic blockers represent an important and established pharmacological intervention in the prevention of cardiac complications in people with coronary artery disease. It has been proposed that this class of drugs may reduce the risk of perioperative cardiac complications in people undergoing major non-cardiac vascular surgery. To review the efficacy and safety of perioperative beta-adrenergic blockade in reducing cardiac or all-cause mortality, myocardial infarction, and other cardiovascular safety outcomes in people undergoing major non-cardiac vascular surgery. The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (January 2014) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2013, Issue 12). We searched trials databases and checked reference lists of relevant articles. We included prospective, randomised controlled trials of perioperative beta-adrenergic blockade of people over 18 years of age undergoing non-cardiac vascular surgery. Two review authors independently performed study selection and data extraction. We resolved disagreements through discussion. We performed meta-analysis using a fixed-effect model with odds ratios (ORs) and 95% confidence intervals (CIs). We included two studies in this review, both of which were double-blind, randomised controlled trials comparing perioperative beta-adrenergic blockade (metoprolol) with placebo, on cardiovascular outcomes in people undergoing major non-cardiac vascular surgery. We included 599 participants receiving beta-adrenergic blockers (301 participants) or placebo (298 participants). The overall quality of studies was good. However, one study did not report random sequence generation or allocation concealment techniques, indicating possible selection bias, and the other study did not report outcome assessor blinding and was possibly underpowered. It should be noted that several of the outcomes were only reported in a single study and neither of the studies reported on vascular patency/graft occlusion, which reduces the quality of evidence to moderate. There was no evidence that perioperative beta-adrenergic blockade reduced all-cause mortality (OR 0.62, 95% CI 0.03 to 15.02), cardiovascular mortality (OR 0.34, 95% CI 0.01 to 8.32), non-fatal myocardial infarction (OR 0.83, 95% CI 0.46 to 1.49; P value = 0.53), arrhythmia (OR 0.70, 95% CI 0.26 to 1.88), heart failure (OR 1.71, 95% CI 0.40 to 7.23), stroke (OR 2.67, 95% CI 0.11 to 67.08), composite cardiovascular events (OR 0.87, 95% CI 0.55 to 1.39; P value = 0.57) or re-hospitalisation at 30 days (OR 0.86, 95% CI 0.48 to 1.52). However, there was strong evidence that beta-adrenergic blockers increased the odds of intra-operative bradycardia (OR 4.97, 95% CI 3.22 to 7.65; P value < 0.00001) and intra-operative hypotension (OR 1.84, 95% CI 1.31 to 2.59; P value = 0.0005). This meta-analysis currently offers no clear evidence that perioperative beta-adrenergic blockade reduces postoperative cardiac morbidity and mortality in people undergoing major non-cardiac vascular surgery. There is evidence that intra-operative bradycardia and hypotension are more likely in people taking perioperative beta-adrenergic blockers, which should be weighed with any benefit.

What evidence is there for intraoperative predictors of perioperative cardiac outcomes? A systematic review

BackgroundPatients undergo cardiac preoperative evaluation to identify those at risk of adverse perioperative cardiac events. The Revised Cardiac Risk index is commonly used for this task, although it is unable to accurately risk stratify in all patients. This may be partly a result of intraoperative events which significantly modify preoperative risk.MethodsWe conducted a systematic review to identify independent intraoperative predictors of adverse cardiac events in patients undergoing non-cardiac surgery. Four databases (Ovid Healthstar 1966 to Jan 2012, Ovid Medline 1946 to 6 March 2012, EMBASE 1974 to March 05 2012 and The Cochrane Library to March 06 2012) were searched.ResultsFourteen eligible studies were identified. The need for intraoperative blood transfusion (odds ratio (OR), 2.3; 95% confidence interval (CI), 1.4-3.3), vascular surgery (OR, 2.3; 95% CI, 1.2-3.4) and emergent/urgent surgery (OR, 2.3; 95% CI, 1.1-3.5) were the only independent intraoperative risk predictors identified in more than study. Other independent intraoperative factors identified included a >20 mmHg fall in mean arterial blood pressure for > 60 min (OR, 3.0; 95% CI, 1.8-4.9), >30% increase in baseline systolic pressure (OR, 8.0; 95% CI, 1.3-50), tachycardia in the recovery room (>30 beats per min (bpm) from baseline for >5 min) (OR, 7; 95% CI, 1.9-26), new onset atrial fibrillation (OR, 6.6; 95% CI, 2.5-20), hypothermia (OR, 2.2; 95% CI, 1.1-5) and remote ischemic preconditioning (OR, 0.22; 95% CI, 0.07-0.67). Other markers of surgical complexity were not independently associated with postoperative adverse cardiac outcomes. None of these studies controlled for blood transfusion.ConclusionsIntraoperative events significantly increase the risk for postoperative cardiac complications, although only intraoperative blood transfusion has strong evidence supporting this finding. It is possible that modification of these intraoperative risk factors by anesthetists and surgeons may reduce postoperative cardiac events and improve outcome. The Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) Study will add important information to understanding intraoperative risk factors for adverse cardiac events.

ROLE OF ALDOSTERONE IN MYOCARDIAL INJURY DURING HEPATIC ISCHAEMIA/REPERFUSION

ObjectivesHepatic ischaemia reperfusion (HIR) injury is common in major liver surgery including liver transplantation and hepatectomy. Furthermore, hepatic ischaemia reperfusion is associated with excess aldosterone production and greatly increases risk...

A meta-analysis of intraoperative factors associated with postoperative cardiac complications

Background: Preoperative cardiac risk is commonly determined with the help of risk scores and risk stratification tools. This predetermined cardiac risk may be profoundly changed by intraoperative surgical events. This meta-analysis aimed to identify intraoperative factors that independently predict postoperative cardiac complications in the presence of preoperative cardiac risk factors. Method: A PubMed Central search was conducted from January 1966 to June 2010, to identify independent intraoperative predictors of postoperative cardiac complications in observational perioperative studies and randomised controlled trials which controlled for preoperative cardiac risk factors. Results: Eleven studies were identified for inclusion in this meta-analysis. Intraoperative blood transfusion [odds ratio (OR) 2.6, 95% confidence interval (CI) 1.8-3.4] was the only independent intraoperative risk predictor identified in more than one study. Other identified independent intraoperative factors included a > 20 mmHg fall in mean arterial blood pressure for > 60 minutes (OR 3.0, 95% CI 1.8-4.9), > 30% increase in baseline systolic pressure (OR 8.0, 95% CI 1.3-50), tachycardia in the recovery room (> 30 beats per minute from baseline for > 5 minutes) (OR 7, 95% 1.9-26), new onset atrial fibrillation (OR 6.6, 95% CI 2.5-20), hypothermia (OR 2.2, 95% CI 1.1-5) and remote ischaemic preconditioning (OR 0.22, 95% CI 0.070.67). None of these studies controlled for blood transfusion. Conclusion: Both surgical and haemodynamic intraoperative events significantly increased the risk of postoperative cardiac complications. Intraoperative blood transfusion has the strongest evidence that supports this finding. It is possible that modification of these intraoperative risk factors by anaesthetists and surgeons might reduce postoperative cardiac events.

Cardiac History and Risk of Post-cystectomy Cardiac Complications

To evaluate risk factors for postoperative cardiac complications (POCC). Patients undergoing cystectomy often have significant baseline cardiac disease. Despite preoperative medical optimization, postoperative cardiac complications remain a significant source of morbidity. A retrospective review of all radical cystectomies for bladder cancer between January 2004 and September 2006 was performed. Twelve preoperative risk factors were evaluated, including age, Charlson Comorbidity Index, type of urinary diversion, and previous cardiac history. All complications, including myocardial infarction (MI) and new onset arrhythmia, were recorded for 90 days postoperatively. Univariate and multivariate analysis were performed. A total of 283 patients underwent cystectomy for bladder cancer between January/2004 and September 2006. The median age of the cohort was 70 (35-90) years. Of 283 patients, 64 (23%) had a significant preoperative cardiac history, including 18 (6%) with prior coronary artery bypass and 30 (11%) with a history of MIs. Thirty-one (11%) patients had either new onset arrhythmia (22, 8%) or MI (10, 4%) and 1 had both. On univariate analysis, cardiac history, age, type of urinary diversion, and the Charlson Comorbidity Index demonstrated significance. The risk of POCC was associated with ileal conduit urinary diversion (P = .026, OR 5.58 [1.23-25.36]) and the Charlson Index score (P = .030, OR 1.28 [1.024-1.60]) on multivariate analysis. Multiple, inter-related factors may predict cardiac complications in the early postoperative period. Despite perioperative optimization, patients with a prior cardiac history should be counseled, regarding the increased risk of postoperative cardiac complications. The association between cardiac complications and ileal conduit diversion highlights the selection bias toward patients with preexisting comorbid disease.

Drug-eluting stent thrombosis in patients undergoing non-cardiac surgery: is it always a problem?

BackgroundRecent publications have reported high incidence of perioperative complications in patients with drug-eluting stent (DES). The recommendations for bare-metal stents (BMS) are not applicable to DES. In fact, large evidence-based studies are lacking on which to base a consensus for the perioperative management of patients with DES. The aim of the present study is to evaluate the postoperative cardiac risk associated with DES. MethodsProspectively collected data were examined for the rate of postoperative cardiac complications in 96 consecutive patients with DES who underwent digestive, urologic, orthopaedic, or vascular surgery. The average delay between revascularization and non-cardiac surgery was 14 (11) months (extremes 1 week and 36 months). The occurrence of postoperative troponin release (troponin I ≥0.15 ng ml−1) and the rate of in-stent thrombosis were analysed. ResultsTwelve patients (12%) presented a postoperative troponin release, without EKG abnormalities in 10 cases (83%). Two patients (2%) developed an in-stent thrombosis. None of the patients had excessive postoperative blood loss. ConclusionsPatients with DES are at higher risk of postoperative cardiac complications. Nevertheless, the specific thrombotic complications of the DES were uncommon in this series and this is in contrast to previous alarming reports. A balanced perioperative management of anti-platelet agents, considering both risk for bleeding and risk of thrombotic complications, in patients with DES, is associated with a low risk of thrombosis in the postoperative period. The rate of cardiac complications remains high in these patients due to co-morbidities.

Preoperative evaluation and treatment of stable cad in patients scheduled for major elective vascular surgery

One of the most controversial topics in clinical cardiology is the extent of preoperative studies that is required among patients scheduled for major elective noncardiac operations. Patients in need of an elective operation for either an expanding aortic aneurysm or lower limb ischemia have the highest risk of postoperative cardiac complications because of the high prevalence of coronary artery disease and the hemodynamic stresses associated with the vascular procedures. The decision to perform preoperative coronary angiography should be reserved for only those patients who are deemed clinically unstable or are functionally limited by cardiac symptoms. Among patients with minimal symptoms, preoperative coronary artery revascularization with either coronary artery bypass graft surgery or percutaneous coronary interventions delays the needed operation and does not improve short-term outcomes or long-term survival.

The potential preventability of postoperative myocardial infarction: underuse of perioperative beta-adrenergic blockade.

Among selected patients undergoing major noncardiac surgery, beta-adrenergic blockade has been shown to reduce the risk for postoperative cardiac complications and mortality. We sought to determine how often postoperative MI might be considered preventable through appropriate use of these medications. We reviewed the medical records of patients who developed a postoperative MI between January 1, 1998, and October 31, 2001, at Baystate Medical Center, a 570-bed community-based teaching hospital in Springfield, Mass. We calculated a Revised Cardiac Risk Index score and used criteria from previous randomized trials to determine whether patients would have been candidates for perioperative beta-adrenergic blockade. Postoperative MI was considered potentially preventable if the patient appeared to have been an ideal candidate for beta-blocker therapy but did not receive it before the infarction. We compared the mortality of ideal candidates who did and did not receive beta-blockers before their infarction using multivariable logistic regression. Seventy (97%) of the 72 patients who developed postoperative MI could have been identified as being at increased risk for cardiac complications, and 58 (81%) appeared to be ideal perioperative beta-blocker candidates. Thirty ideal candidates (52%) were treated with beta-blockers before the development of the infarction. Among ideal candidates, treatment with a beta-blocker before infarction was associated with an odds ratio of in-hospital mortality of 0.19 (95% confidence interval, 0.04-0.87). A large percentage of the postoperative MIs at our institution might have been prevented if a beta-blocker had been administered to all ideal candidates around the time of surgery. Use of beta-blockers before infarction may reduces overall mortality, even among patients who go on to develop this complication.

Preoperative electrocardiogram abnormalities do not predict postoperative cardiac complications in geriatric surgical patients.

Preoperative electrocardiograms (ECGs) are routinely performed on older patients before surgery. Whether patients with abnormalities on preoperative ECGs have an increased likelihood of developing postoperative cardiac complications is unknown. This study was designed to determine whether abnormalities on preoperative ECGs were predictive of postoperative cardiac complications. Prospective observational study. One of the teaching hospitals of the University of California, San Francisco, Medical Center. Five hundred thirteen patients aged 70 and older undergoing noncardiac surgery. Preoperative ECGs were analyzed using the Minnesota Codes. Predefined preoperative risk factors and in-hospital postoperative cardiac complications were measured. The association between ECG abnormalities and postoperative cardiac complications was determined by multivariate logistic regression after controlling for clinical covariates. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported. Three hundred eighty-six of 513 patients (75.2%) had at least one abnormality on their preoperative ECGs. On multivariate analysis, the predictors of postoperative cardiac complications included American Society of Anesthesiologists physical status classification of 3 or greater (OR = 2.5, 95%CI = 1.28-4.89, P = .007) and a history of congestive heart failure (OR = 2.1, 95% CI = 1.1-5.1, P = .034). The presence of abnormalities on preoperative ECGs was not associated with an increased risk of postoperative cardiac complications (OR = 0.63, 95% CI = 0.28-1.40, P = .26). Abnormalities on preoperative ECGs are common but are of limited value in predicting postoperative cardiac complications in older patients undergoing noncardiac surgery. These results suggest that obtaining preoperative ECGs based on an age cutoff alone may not be indicated, because ECG abnormalities in older people are prevalent but nonspecific and less useful than the presence and severity of comorbidities in predicting postoperative cardiac complications.

Usefulness of transthoracic echocardiography as a tool for risk stratification of patients undergoing major noncardiac surgery

Transthoracic echocardiography (TTE) is frequently ordered before noncardiac surgery, although its ability to predict perioperative cardiac complications is uncertain. To evaluate the incremental information provided by TTE after consideration of clinical data for prediction of cardiac complications after noncardiac surgery, 570 patients who underwent TTE before major noncardiac surgery at a university hospital were studied. Preoperative clinical data and clinical outcomes were collected prospectively according to a structured protocol. TTE data included left ventricular (LV) function, hypertrophy indexes, and Doppler-derived measurements. In univariate analyses, preoperative systolic dysfunction was associated with postoperative myocardial infarction (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.1 to 7.0), cardiogenic pulmonary edema (OR 3.2, 95% CI 1.4 to 7.0), and major cardiac complications (OR 2.4, 95% CI 1.3 to 4.5). Moderate to severe LV hypertrophy, moderate to severe mitral regurgitation, and increased aortic valve gradient were also associated with major cardiac events (OR 2.3, 95% CI 1.2 to 4.6; OR 2.2, 95% CI 1.1 to 4.3; OR 2.1, 95% CI 1.0 to 4.5, respectively). In logistic regression analysis, models with echocardiographic variables predicted major cardiac complications significantly better than those that included only clinical variables (c statistic 0.73 vs 0.68; p <0.05). Echocardiographic data added significant information for patients at increased risk for cardiac complications by clinical criteria, but not in otherwise low-risk patients. In conclusion, preoperative TTE before noncardiac surgery can provide independent information about the risk of postoperative cardiac complications in selected patients.

Angioplasty and noncardiac surgery: risks of myocardial infarction

Prophylactic percutaneous transluminal coronary angioplasty is one revascularization strategy employed to reduce risks of cardiac complications after noncardiac surgery in certain patients. Reduced adverse cardiac event rates are at least partially offset by costs and complications of angioplasty. Patients who undergo noncardiac surgery within 90 days of coronary angioplasty may be at increased risk for postoperative cardiac complications.