Abstract
OBJECTIVE: To establish rates of and risk factors for cardiac complications after noncardiac surgery in veterans.
DESIGN: Prospective cohort study.
SETTING: A large urban veterans affairs hospital.
PARTICIPANTS: One thousand patients with known or suspected cardiac problems undergoing 1,121 noncardiac procedures.
MEASUREMENTS: Patients were assessed preoperatively for important clinical variables. Postoperative evaluation was done by an assessor blinded to preoperative status with a daily physical examination, electrocardiogram, and creatine kinase with MB fraction until postoperative day 6, day of discharge, death, or reoperation (whichever occurred earliest). Serial electrocardiograms, enzymes, and chest radiographs were obtained as indicated. Severe cardiac complications included cardiac death, cardiac arrest, myocardial infarction, ventricular tachycardia, and fibrillation and pulmonary edema. Serious cardiac complications included the above, heart failure, and unstable angina.
MAIN RESULTS: Severe and serious complications were seen in 24% and 32% of aortic, 8.3% and 10% of carotid, 11.8% and 14.7% of peripheral vascular, 9.0% and 13.1% of intraabdominal/intrathoracic, 2.9% and 3.3% of intermediate-risk (head and neck and major orthopedic procedures), and 0.27% and 1.1% of low-risk procedures respectively. The five associated patient-specific risk factors identified by logistic regression are: myocardial infarction <6 months (odds ratio [OR], 4.5; 95% confidence interval [CI], 1.9 to 12.9), emergency surgery (OR, 2.6; 95% CI, 1.2 to 5.6), myocardial infarction >6 months (OR, 2.2; 95% CI, 1.4 to 3.5), heart failure ever (OR, 1.9; 95% CI, 1.2 to 3.0), and rhythm other than sinus (OR, 1.7; 95% CI, 0.9 to 3.2). Inclusion of the planned operative procedure significantly improves the predictive ability of our risk model.
CONCLUSIONS: Five patient-specific risk factors are associated with high risk for cardiac complications in the perioperative period of noncardiac surgery in veterans. Inclusion of the operative procedure significantly improves the predictive ability of the risk model. Overall cardiac complication rates (pretest probabilities) are established for these patients. A simple nomogram is presented for calculation of post-test probabilities by incorporating the operative procedure.
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References
Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977;297:845–50.
Jeffrey CC, Kunsman J, Cullen DJ, Brewster DC. A prospective evaluation of cardiac risk index. Anesthesiology. 1983;58:462–4.
Detsky AS, Abrams HB, McLaughlin JR, et al. Predicting cardiac complication in patients undergoing non-cardiac surgery. J Gen Intern Med. 1986;1:211–9.
Mangano DT, Browner WS, Hollenberg M, London MJ, Tubau JF, Tateo MS. Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. N Engl J Med. 1990;323:1781–8.
Ashton CM, Peterson NJ, Wray NP, et al. The incidence of perioperative myocardial infarction in men undergoing noncardiac surgery. Ann Intern Med. 1993;118:504–10.
Skinner JF, Pearce ML. Surgical risk in the cardiac patient. J Chronic Dis. 1964;17:57–72.
Cooperman M, Pflug B, Martin EW Jr, Evans WE. Cardiovascular risk factors in patients with peripheral vascular disease. Surgery. 1978;84:505–9.
Steen PA, Tinker JH, Tarhan S. Myocardial reinfarction after anesthesia and surgery. JAMA. 1978;239:2566–70.
Larsen SF, Olesen KH, Jacobsen E, et al. Prediction of cardiac risk in non-cardiac surgery. Eur Heart J. 1987;8:179–85.
Foster ED, Davis KB, Carpenter JA, Abele S, Fray D. Risk of noncardiac operation in patients with defined coronary disease: the Coronary Artery Surgery Study (CASS) registry experience. Ann Thorac Surg. 1986;4:42–50.
Eagle KA, Coley CM, Newell JB, et al. Combining clinical and thallium data optimizes preoperative assessment of cardiac risk before major vascular surgery. Ann Intern Med. 1989;110:859–66.
Shah KB, Kleinman BS, Rao TLK, Jacobs HK, Mestan K, Schaafsma M. Angina and other risk factors in patients with cardiac diseases undergoing noncardiac operations. Anesth Analg. 1990;70:240–7.
Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100:1043–9.
Hosmer D, Lemeshow S. Applied Logistic Regression. New York, NY: John Wiley and Sons; 1989.
Steyerberg EW, Eijkemans MJ, Harrell FE, Habbema JD. Prognostic modelling with logistic regression analysis: a comparison of selection and estimation methods in small data sets. Stat Med. 2000;19:1059–79.
Sauerbrei W, Schumacher M. A bootstrap resampling procedure for model building: application to the cox regression model. Stat Med. 1992;11:2093–109.
Gong G. Cross-validation, the jackknife and the bootstrap: excess error estimation in forward logistic regression. J Am Stat Assoc. 1986;81:108–13.
Efron B, Tibshirani R. Bootstrap methods for standard errors, confidence intervals, and other measures of statistical accuracy. Stat Sci. 1986;1:54–77.
Hanley JA, McNeil BJ. A method of comparing the areas under receiver operating characteristic curves derived from the same cases. Radiology. 1983;148:839–43.
No authors listed. Interpretation of diagnostic data: 5. How to do it with simple maths. Can Med Assoc J. 1983;129: 947–54.
Mantel N, Haenszel W. Statistical aspects of the analysis of data from retrospective studies of disease. J Natl Cancer Inst. 1959;22:719–48.
Kramer CY. Extension of multiple range tests to group means with unequal numbers of replications. Biometrics. 1956;12:307–10.
Tarhan S, Moffit EA, Taylor WF, Giuliani ER. Myocardial infarction after general anesthesia. JAMA. 1972;220:1451–4.
Backer CL, Tinker JH, Robertson DM, Vlietstra RE. Myocardial reinfarction following local anesthesia for ophthalmic surgery. Anesth Analg. 1980;59:257–62.
Warner MA, Shields SE, Chute CG. Major morbidity and mortality within 1 month of ambulatory surgery and anesthesia. JAMA. 1993;270:1437–41.
Fleisher LA, Eagle KA, Shaffer T, Anderson GF. Perioperative and long term mortality rates after major vascular surgery: the relationship to preoperative testing in Medicare population. Anesth Analg. 1999;89:849–55.
Hertzer NR. Fatal myocardial infarction following abdominal aortic aneurysm resection: three hundred and forty-three patients followed 6–11 years postoperatively. Ann Surg. 1980;192:667–73.
Eagle KA, Brundage BH, Chaitman BR, et al. Guidelines for perioperative evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol. 1996;27:910–48.
Mair J, Morandell D, Genser N, Lechleitner P, Dienstl F, Puschendorf B. Equivalent early sensitivities of myoglobin, creatine kinase MB mass, creatine kinase isoform ratios, and cardiac troponins I and T for acute myocardial infarction. Clin Chem. 1995;41:1266–72.
Adams JE, Sicard GA, Allen BT, et al. Diagnosis of perioperative myocardial infarction with measurement of cardiac troponin I. N Engl J Med. 1994;330:670–4.
Lachenbruch P. Some misuses of discriminant analysis. Methods Inf Med. 1977;16:255–8.
Harrel F, Lee K, Mark D. Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Stat Med. 1996;15:361–87.
Poldermans D, Boersma E, Bax JJ, et al. The effect of Bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. N Engl J Med. 1999;341:1789–94.
Gilbert K, Larocque BJ, Patrick LT. Prospective evaluation of cardiac risk indices for patients undergoing noncardiac surgery. Ann Intern Med. 2000;133:356–9.
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Investigator Initiated Merit Review Proposal #91-017 was funded by Health Services Research and Development Service, Department of Veterans Affairs.
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Kumar, R., McKinney, W.P., Raj, G. et al. Adverse cardiac events after surgery. J GEN INTERN MED 16, 507–518 (2001). https://doi.org/10.1046/j.1525-1497.2001.016008507.x
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DOI: https://doi.org/10.1046/j.1525-1497.2001.016008507.x