Risk Of Perioperative Myocardial Infarction Research Articles

Women have increased risk of perioperative myocardial infarction and higher long-term mortality rates after lower extremity arterial bypass grafting

Purpose: The purpose of this study was to determine the effect of gender on the immediate and long-term postoperative morbidity, mortality, and patency rates for infrainguinal autogenous vein bypass grafts. Methods: Data were abstracted for consecutive patients who were followed in a prospective surveillance protocol after undergoing infrainguinal autogenous vein bypass grafting during the years 1988 to 1994. There were 165 grafts constructed in 148 patients (101 in 87 men, and 64 in 61 women). Gender differences were analyzed with Student t test or χ 2 test for risk factors, indications for reconstruction, and complications. The patency rates and the long-term survival rates were compared by means of life-table analysis. Eagle criteria and long-term survival rates were compared with multivariate analysis. Results: The mean follow-up period was 36 months (39 months for men, and 32 months for women), with a range of 6 to 123 months for the total follow-up period. The two groups did not differ in age at the time of operation (66.6 ± 1.2 years for men, and 66.7 ± 1.5 years for women) or in history of diabetes (48% for men, and 56% for women). The risks were similar for hypertension (48% for men vs 45% women), preoperative myocardial infarction (23% for men vs 26% for women), and previous coronary artery bypass grafting (9% for men vs 8% for women). The thallium stress scintigraphy results showed a diagnosis of proportionately more preoperative defects in men (reversible, 34% vs 18%, P < .05; overall, 75% vs 43%, P < .05). The 30-day limb loss rates (0.9% for men, and 0% for women) and mortality rates (2.2% for men, and 5% for women) were similar. Women had statistically more perioperative myocardial infarctions than did men (6 of 61, 9.8% vs 2 of 101, 2%; P < .05), as was documented with electrocardiography and cardiac isoenzymes. Two of these women died within a 30-day postoperative period. The 3-year primary patency rate was 85% for the men and 88% for the women, and the primary assisted patency rate was 97% for the men and 97% for the women. The secondary patency rate was 98% for the men and 97% for the women. The limb salvage rate was slightly higher for the men than for the women (93% vs 87%), although this was not statistically significant. The 5-year survival rate for women was statistically less than for men, with life-table analysis (58% for men vs 42% for women; P < .05). Conclusion:After distal bypass grafting, men and women have similar rates of patency and limb salvage, but women have a higher incidence rate of perioperative myocardial infarction and a decreased 5-year survival rate. These data suggest that women have unrecognized cardiac disease that affects them adversely in the perioperative period and the long term when compared with men who undergo the same operation. (J Vasc Surg 1999;29:807-13.)

Perioperative cardiovascular morbidity in patients with coronary artery disease undergoing vascular surgery after percutaneous transluminal coronary angioplasty

Objective: Patients with coronary artery disease (CAD) who undergo noncardiac surgery are at increased risk for perioperative myocardial infarction (PMI). Undergoing successful coronary artery bypass grafting (CABG) before such surgery has been shown to decrease perioperative cardiac morbidity and mortality. Percutaneous transluminal coronary angioplasty (PTCA) is an alternative treatment for these patients. Perioperative cardiac morbidity in patients with CAD who underwent PTCA before their vascular surgery was reviewed. Setting: A tertiary care referral center for patients with cardiovascular heart disease. Participants: Review of vascular surgery database for patients who underwent vascular surgery preceded by PTCA between 1984 and 1995. Patients were excluded if they had a history of CABG within 2 years of surgery, had PTCA more than 18 months before surgery, or had incomplete data. Measurements: Data were collected concerning cardiac history, left ventricular (LV) function, perioperative cardiac morbidity (angina, MI, congestive heart failure [CHF], and arrhythmias). Main Results: Of 194 patients who underwent aortic abdominal surgery, carotid endarterectomy (CEA), or peripheral vascular surgery preceded by PTCA, 104 (54%) had a previous MI. Twenty-six patients (13.4%) had perioperative cardiac morbidity. Only one patient had an MI (0.5%; 95% confidence interval [CI], 0.0 to 2.8), whereas one patient died of CHF followed by multisystem organ failure (0.5%). The median interval between PTCA and surgery was 11 days (interquartile range, [IQR] 3 to 49 days). Patients who developed perioperative cardiac morbidity were older than those who did not ( p = 0.02). Patients who had a history of CABG (before PTCA) had a higher incidence of postoperative angina ( p = 0.04). The degree of preoperative LV dysfunction was linearly related to the incidence of new postoperative CHF ( p = 0.01). Arrhythmias were more common in patients undergoing abdominal vascular surgery (17.9%) than in those undergoing CEA (2.5%; p = 0.03) or peripheral vascular surgery (5.2%; p = 0.02). Conclusion: High-risk cardiac patients undergoing vascular surgery who have had PTCA performed up to 18 months preoperatively have a low incidence of perioperative cardiac morbidity. Prophylactic PTCA may be beneficial in patients with CAD who are at high risk for perioperative cardiac complications.

Serial Prognostic Capabilities of Electrocardiographic Indices of Infarcted and Hibernating Myocardium in Predicting Short- and Long-Term-Outcome following Coronary Artery Bypass Surgery

The present study was performed to test the hypothesis that patients with a large amount of ischemic (hibernating) myocardium are most likely to develop a perioperative myocardial infarction undergoing coronary artery bypass grafting (CABG). Furthermore, we evaluated the Selvester QRS scoring system as a postoperative prognostic tool. A relationship between a high amount of hibernating myocardium determined by ventriculographic and electrocardiographic investigations and an increased risk of perioperative myocardial infarction was found. The Selvester QRS scoring system used in diagnosing and prognosing after acute myocardial infarction was proven valid in predicting prognosis after CABG as well.

PREOPERATIVE ASSESSMENT OF COMMON DISEASES IN THE OUTPATIENT SETTING

Perioperative myocardial infarction (MI) is a major source of morbidity and mortality in surgical patients. Each year an estimated 50,000 patients in the United States experience perioperative and mortality exceeds 20,000 annually.44 The average cost to hospitals is estimated in one source to be $12,000 per ~atient.4~ The risk of perioperative MI is greatly increased in patients with previous infarction within 6 months of 69 and elective outpatient surgery should be postponed in such patients. In patients with previous MI for whom surgery cannot be postponed an appropriate number of weeks, or in patients without prior MI who have coronary artery disease (CAD) or stable angina, the use of preoperative testing can identify which patients are at increased risk of perioperative cardiac ischemia. For patients with recent MI in whom surgery is not completely elective but not truly emergent (e.g., a patient with a resectable malignancy) evaluation of left ventricular function and exercise tolerance may identify patients with relatively small risks. The nature of the surgery to be undertaken has considerable influence over the risks of surgery in patients with CAD. Backer et a1 found that ophthalmologic surgery under local anesthesia was safe, even in patients with recent ML4 The number of patients in the study who underwent ophthalmologic surgery under general anesthesia was small, but they also did well. Transurethral resection of the prostate appears to carry low risk, even in patients with serious heart disease,-*' and many authors suggest that the risks of peripheral extremity procedures is also l0w.7~ Vascular surgery is associated with increased risk.60 The identification of patients with preoperative myocardial ischemia is an important step in identifying patients at increased anesthetic and surgical risk. Slogoff and Keatsm demonstrated that perioperative myocardial ischemia is associated with perioperative MI. Preoperative testing that defines patients at

Current incidence and determinants of perioperative myocardial infarction in coronary artery surgery

Increasingly, patients undergoing coronary artery bypass grafting (CABG) are elders, have had previous CABG, and have poor left ventricular function. To evaluate determinants of perioperative myocardial infarction (PMI) after isolated CABG, 499 consecutive patients were reviewed. Definite PMI (total peak creatine kinase [CK] >700 U/L, creatine kinase MB [CK-MB] >30 ng/ml, and new pathologic electrocardiographic Q waves) occurred in 25 patients (5.0%) and probable PMI (total peak CK >700 U/L, CK-MB >30 ng/ml, and a new wall-motion abnormality) occurred in 10 (2.0%) patients. According to multivariate logistic regression analysis, independent risk factors for definite or probable PMI (odds ratios; 95% confidence intervals) were emergency surgery (3.1; 1.1 to 8.4; p = 0.003), aortic cross-clamp time >100 minutes (4.2; 1.6 to 11.2; p = 0.004), myocardial infarction in the preceding week (2.6; 1.0 to 6.4; p = 0.04), and previous revascularization (2.4; 1.1 to 5.2; p = 0.02). In conclusion, both preoperative and intraoperative factors influence the risk of PMI after CABG. Despite changes in the profile of patients undergoing CABG, the incidence of PMI in this tertiary center is comparable with that found in earlier series, probably because of improvements in surgical techniques and postoperative care.

454 Haemostatic markers, hypercoaguability and the risk of perioperative myocardial infarction after peripheral vascular surgery

454 Haemostatic markers, hypercoaguability and the risk of perioperative myocardial infarction after peripheral vascular surgery

Perioperative myocardial infarction in peripheral vascular surgery

The commonest major complication in patients undergoing peripheral vascular surgery is perioperative myocardial infarction.1 No study in Britain has prospectively assessed this risk, but a recent retrospective study found an incidence of 6.3% in patients undergoing aortic surgery.2 We report the incidence of perioperative myocardial infarction in our unit, which is a regional centre for peripheral vascular surgery. We studied consecutive patients undergoing peripheral vascular surgery after excluding those who were undergoing surgery for trauma, venous surgery, and minor procedures. Patients thought to be at high risk of perioperative myocardial infarction were referred to a cardiologist for further preoperative assessment. Concentrations of creatinine kinase MB isoenzymes were measured (by Imx STAT) for the first three days after surgery, and electrocardiograms were recorded on admission, …

107. Haemostatic factors and the risk of perioperative myocardial infarction in peripheral vascular surgery

107. Haemostatic factors and the risk of perioperative myocardial infarction in peripheral vascular surgery

Diabetes Mellitus and Morbidity and Mortality Risks after Coronary Artery Bypass Surgery

Of 1025 patients (912 men, 113 women) who underwent coronary artery bypass grafting and were followed up for a mean of 7.4 years, 45 (4.4%) had diabetes mellitus. Norwegian population is 1.8-2%). Early mortality was not significantly greater among diabetics than in non-diabetics (2.2 vs. 3.1%, odds ratio--OR-0.44, confidence interval--CI- 0.05-3.56). Diabetic patients had no increased risk of perioperative myocardial infarction (OR = 0.87, CI 0.36-2.10) or of low-output syndrome necessitating intraortic balloon pumping (OR = 0.42, CI 0.55-3.05), and no excess incidence of late non-fatal myocardial infarction (relative risk = 0.69, CI 0.10-1.28) or late chronic heart failure (OR = 2.50, CI 0.5-11.0). Long-term mortality was increased in the diabetic patients (relative risk 1.87, CI 1.60-2.14). Thus diabetes did not entail heightened risk of early mortality, perioperative myocardial infarction or low-output syndrome. Nor was there excess risk of recurrent angina pectoris, late non-fatal myocardial infarction or chronic heart failure among the diabetic patients, but the late mortality risk was increased.

A Difficult Case: Perform carotid endarterectomy and coronary artery bypass surgery as a single procedure

This patient has appreciable carotid and coronary artery disease. Surgical correction of one disorder in the presence of the other carries an associated risk of morbidity and death. As regards the carotid stenosis and the patient's neurological state, advocating surgery as opposed to a conservative policy has been verified by several prospective randomised trials.1 2 The risk of myocardial infarction in patients having carotid endarterectomy is estimated as 18% in patients with stable angina.3 This patient has unstable angina and therefore we presume that the risk of perioperative myocardial infarction is greater. The risk of stroke in patients having coronary artery …

Coronary reoperation: Results of adding an internal mammary artery graft to a stenotic vein graft

Although it is desirable at coronary reoperation to replace a stenotic vein graft to the left anterior descending coronary artery (LAD) with an internal mammary artery (IMA) graft, previous reports have shown that if the stenotic vein graft is removed, that strategy can be complicated by severe hemodynamic deterioration and increased perioperative mortality. We report the results for 90 patients in whom an IMA was used to graft a completely obstructed LAD with the stenotic vein graft left intact. For 10 patients, reoperation involved only an IMA-LAD graft, and in 80 patients, a second IMA, veins, or both were used to graft other vessels. There were no hospital deaths. One patient had a perioperative myocardial infarction. Follow-up at a mean postoperative interval of 58 months documented 11 late deaths (eight cardiac related) and actuarial 5-year survival of 88%. Twenty-two patients underwent coronary angiography at a mean postoperative interval of 48 months. The IMA-LAD graft was found to be perfectly patent in 20 and obstructed in 2. The strategy of adding an IMA graft to the LAD and leaving a stenotic vein graft intact has been associated with a low risk of perioperative myocardial infarction, the late clinical results are favorable, and repeat angiography indicates that serious competitive flow from the stenotic vein graft is uncommon.

Death and adverse cardiac events after carotid endarterectomy

This study evaluated operative mortality rate and adverse cardiac events after carotid endarterectomy. Efficacy of preoperative cardiac evaluation was studied and stroke mortality rate was determined. This was a retrospective review of 562 patients undergoing carotid endarterectomy at a 740-bed community hospital. Data were analyzed with chi 2 analysis, logistic regression analysis, and Goldman criteria for cardiac risk. The mortality rate was 1.6% (nine patients). There were 10 myocardial infarctions (1.8%). Six of these (1.1%) were fatal. The Goldman Index allowed us to classify 530 patients in a low-risk group (Goldman classes I and II, operative mortality rate = 1.1%) and 32 patients in a high-risk group (Goldman classes III and IV, mortality rate = 9.4%). Independent risk variables were identified for myocardial infarction and overall operative death. These variables were then used to develop a probability model for prediction of operative death and adverse cardiac events. The stroke rate in the 562 patients was 0.7% (four patients). For the 345 patients with symptoms, the stroke rate was 0.6% (two patients); for the 217 symptom-free patients, it was 0.9% (two patients). The combined stroke mortality rate was 2.3%. For patients with symptoms, it was 2.9%; for symptom-free patients, it was 1.4%. Independent clinical variables can help determine patients at increased risk for perioperative myocardial infarction or operative death. Patients in Goldman classes III and IV are at increased risk for adverse events. Carotid surgery can be performed safely in our medical community.

Sleep Apnea and the Risk for Perioperative Myocardial Infarction

Letters1 November 1993Sleep Apnea and the Risk for Perioperative Myocardial InfarctionCarol M. Ashton, MD and Louis Wu, MDCarol M. Ashton, MDSearch for more papers by this author and Louis Wu, MDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-119-9-199311010-00023 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail IN RESPONSE:The prevalence of obstructive sleep apnea appears to be greater among men with a history of ischemic heart disease [1]. The existence of a causal link between obstructive sleep apnea and myocardial ischemia (in men with preexisting coronary artery disease) or between obstructive sleep apnea and the development of coronary atherosclerosis has not been established; the alternative is that obstructive sleep apnea is a proxy for an as-yet-unknown causal factor. Nevertheless, as Dr. Ortega and colleagues point out, it is reasonable to assume that a man with coexisting sleep apnea syndrome and coronary artery disease might be at ...

Sleep Apnea and the Risk for Perioperative Myocardial Infarction

Sleep Apnea and the Risk for Perioperative Myocardial Infarction

The Role of a Defined Protocol for Cardiac Risk Assessment in Decreasing Perioperative Myocardial Infarction in Vascular Surgery

Abstract Major elective peripheral vascular surgery has historically carried a significant risk of perioperative myocardial infarction; this risk has been quantified further by its association with proved reduction in cardiac reserve/presence of coronary artery disease by stress testing or invasive monitoring. Recognition of this risk logically should lead to protocols that delineate coronary artery disease/cardiac reserve before surgery and correct for observed abnormalities during surgery. This study sought to show that a coherent algorithm of preoperative cardiac assessment combined with aggressive perioperative management could indeed reduce perioperative myocardial infarction rates. Six hundred thirty consecutive elective vascular operations were performed by the author during 6 years. All patients were entered into a prospective protocol for preoperative cardiac risk assessment, which then determined the choice of operation, type of anesthesia, and level of hemodynamic monitoring. Sixty-eight percent of the patients demonstrated clinical coronary artery disease, 15% had previously undergone coronary catheterization or surgery, and 9% had ejection fractions 75 years of age or with ejection fraction

Postoperative changes in coagulant and anticoagulant factors following abdominal aortic surgery

The extent and time course of changes in selected procoagulant and anticoagulant factors were investigated in 19 patients undergoing elective abdominal aortic surgery. The coagulation factors were measured preoperatively, and on days two, four, and six postoperatively. It was found that there were no significant changes outside the normal range in prothrombin time, partial thromboplastin time, or thrombin clotting time. However, there were large increases in the procoagulants, fibrinogen, factor VIII coagulant, factor VIIIRag/von Willebrand factor, and in α 1-antitrypsin. Over the same time there were marked decreases in the naturally occurring anticoagulants, protein C and antithrombin III, and in α 2-macroglobulin. These changes implied that the patients were “hypercoagulable” in the postoperative period. The maximum changes in the procoagulants occurred on either postoperative day two or day four. The maximum changes in the natural anticoagulants occurred on postoperative day two. There were no significant changes in factor V, factor X, α 2-antiplasmin, or platelet aggregability. The timing of the changes coincided with a period of high risk of perioperative myocardial infarction in this group of patients. Thus, it is possible that postoperative hypercoagulability contributes to the development of coronary artery thrombosis and myocardial infarction following abdominal aortic surgery.

Silent myocardial ischemia monitoring predicts late as well as perioperative cardiac events in patients undergoing vascular surgery.

In a previous study we have shown that perioperative monitoring for silent myocardial ischemia can noninvasively identify those patients undergoing peripheral vascular surgery who are at significantly increased risk for perioperative myocardial infarction. In the present study a group of 385 patients undergoing peripheral vascular surgery was studied long-term as well as short-term to determine whether perioperative monitoring for silent ischemia can identify those patients who are at significantly increased risk of late cardiac death or late cardiac complications as well as those patients at increased risk of perioperative myocardial infarction. All patients were monitored before, during, and after operation and were divided into two groups on the basis of results of monitoring: patients whose total duration of silent ischemia as a percentage of the total duration of perioperative monitoring was 1% or greater (group I, n = 120) and those for whom this value was less than 1% (group II, n = 265). Among patients in group I 13.3% (16 of 120) suffered a perioperative myocardial infarction in contrast to only 1.1% (3 of 265) patients in group II (p less than 0.001). Multivariate logistic regression analysis of preoperative and perioperative characteristics showed that the presence of a total perioperative percent time ischemic 1% or greater and age were the only significant predictors of perioperative myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)

Silent myocardial ischemia monitoring predicts late as well as perioperative cardiac events in patients undergoing vascular surgery

In a previous study we have shown that perioperative monitoring for silent myocardial ischemia can noninvasively identify those patients undergoing peripheral vascular surgery who are at significantly increased risk for perioperative myocardial infarction. In the present study a group of 385 patients undergoing peripheral vascular surgery was studied long-term as well as short-term to determine whether perioperative monitoring for silent ischemia can identify those patients who are at significantly increased risk of late cardiac death or late cardiac complications as well as those patients at increased risk of perioperative myocardial infarction. All patients were monitored before, during, and after operation and were divided into two groups on the basis of results of monitoring: patients whose total duration of silent ischemia as a percentage of the total duration of perioperative monitoring was 1% or greater (group I, n = 120) and those for whom this value was less than 1% (group II, n = 265). Among patients in group I 13.3% (16 of 120) suffered a perioperative myocardial infarction in contrast to only 1.1% (3 of 265) patients in group II (p < 0.001). Multivariate logistic regression analysis of preoperative and perioperative characteristics showed that the presence of a total perioperative percent time ischemic 1% or greater and age were the only significant predictors of perioperative myocardial infarction. Actuarial freedom at 24 months after operation for group I compared with group II was, respectively, 89.1% versus 98.4% for late myocardial infarction (p < 0.001), 89.5% versus 99.2% for late cardiac death (p < 0.001), and 58.7% versus 69.4% for late cardiac death or late cardiac complication (angina, myocardial infarction, cardiac evaluation, or cardiac revascularization) (p < 0.02). Cox proportional hazards analysis showed that only the occurrence of a total perioperative percent time ischemic 1% or greater and age were significant independent predictors of early or late myocardial infarction and early or late cardiac death as combined end points. These results show that perioperative monitoring for silent myocardial ischemia can noninvasively identify those patients undergoing peripheral vascular surgery who are at increased risk for late cardiac death or complication as well as perioperative myocardial infarction.

Outcome of Noncardiac Operations in Patients with Severe Coronary Artery Disease Successfully Treated Preoperatively with Coronary Angioplasty

HUBER, K. C.; EVANS, M. A.; BRESNAHAN, J. F.; GIBBONS, R. J.; HOLMES, D. R. JR. Author Information

The role of a defined protocol for cardiac risk assessment in decreasing perioperative myocardial infarction in vascular surgery

Major elective peripheral vascular surgery has historically carried a significant risk of perioperative myocardial infarction; this risk has been quantified further by its association with proved reduction in cardiac reserve/presence of coronary artery disease by stress testing or invasive monitoring. Recognition of this risk logically should lead to protocols that delineate coronary artery disease/cardiac reserve before surgery and correct for observed abnormalities during surgery. This study sought to show that a coherent algorithm of preoperative cardiac assessment combined with aggressive perioperative management could indeed reduce perioperative myocardial infarction rates. Six hundred thirty consecutive elective vascular operations were performed by the author during 6 years. All patients were entered into a prospective protocol for preoperative cardiac risk assessment, which then determined the choice of operation, type of anesthesia, and level of hemodynamic monitoring. Sixty-eight percent of the patients demonstrated clinical coronary artery disease, 15% had previously undergone coronary catheterization or surgery, and 9% had ejection fractions < 35%. All patients underwent baseline detailed cardiac histories, radionuclide cardioangiography, and electrocardiograms. Patients with significant historic coronary artery disease or ejection fraction <50% underwent stress thallium testing; patients with positive fixed or redistribution defects then underwent catheterization, constituting 7% of the series. Risk stratification by age and cardiac assessment then dictated the perioperative care. The overall perioperative myocardial infarction rate was 0.7% (5628), ranging from 0% for 156 aortic operations and 114 carotid endarterectomies to 0.6% for 159 femoropopliteal and 3.3% for 90 femorotibial revascularizations. All perioperative myocardial infarctions occurred with limb salvage infrapopliteal reconstruction in patients > 75 years of age or with ejection fraction <35%. Comparison with perioperative myocardial infarction rates from the recent literature suggests that our protocol is highly useful in reducing perioperative myocardial infarction rates for aortic and other inflow operations, of only moderate utility for screening outflow operations, and of little use for carotid endarterectomy.