Period-dependent Associations between Hypotension during and for Four Days after Noncardiac Surgery and a Composite of Myocardial Infarction and Death

Abstract

Background The relative contributions of intraoperative and postoperative hypotension to perioperative morbidity remain unclear. We determined the association between hypotension and a composite of 30-day myocardial infarction and death over three periods: (1) intraoperative, (2) remaining day of surgery, and (3) during the initial four postoperative days. Methods This was a substudy of POISE-2, a 10,010-patient factorial-randomized trial of aspirin and clonidine for prevention of myocardial infarction. Clinically important hypotension was defined as systolic blood pressure less than 90 mmHg requiring treatment. Minutes of hypotension was the exposure variable intraoperatively and for the remaining day of surgery, whereas hypotension status was treated as binary variable for postoperative days 1 to 4. We estimated the average relative effect of hypotension across components of the composite using a distinct effect generalized estimating model, adjusting for hypotension during earlier periods. Results Among 9,765 patients, 42% experienced hypotension, 590 (6.0%) had an infarction, and 116 (1.2%) died within 30 days of surgery. Intraoperatively, the estimated average relative effect across myocardial infarction and mortality was 1.08 (98.3% CI, 1.03, 1.12; P < 0.001) per 10-min increase in hypotension duration. For the remaining day of surgery, the odds ratio was 1.03 (98.3% CI, 1.01, 1.05; P < 0.001) per 10-min increase in hypotension duration. The average relative effect odds ratio was 2.83 (98.3% CI, 1.26, 6.35; P = 0.002) in patients with hypotension during the subsequent four days of hospitalization. Conclusions Clinically important hypotension—a potentially modifiable exposure—was significantly associated with a composite of myocardial infarction and death during each of three perioperative periods, even after adjustment for previous hypotension.

Effects of Bisoprolol Transdermal Patches for Prevention of Perioperative Myocardial Injury in High-Risk Patients Undergoing Non-Cardiac Surgery ― Multicenter Randomized Controlled Study ―

“…Nonischemic causes, such as hypotension, sepsis, and AF, have also been shown to be more common than ischemic causes. 11,13 We previously reported that left ventricular diastolic dysfunction and intraoperative tachycardia are predictors of PMI, and that AF is a common complication after surgery. 21 Therefore, the use of prophylactic β-blockers before surgery was expected to prevent PMI and associated adverse events.…”

“…10 Indeed, it was recently reported that non-ischemic factors, such as sepsis, tachyarrhythmia, and hypotension, play a greater role than does ischemia. [11][12][13] Beta-blocker treatment has been expected to reduce cardiovascular events after surgery, but a meta-analysis of randomized controlled trials (RCT) suggested that β-blockers reduce non-fatal myocardial infarction but increase stroke and hypotension. 14 The efficacy of perioperative β-blockers, even in high-risk patients, is therefore controversial and current guidelines do not recommend routine use of perioperative β-blockers.…”

A rapid response system reduces the incidence of in-hospital postoperative cardiopulmonary arrest: a retrospective study

“…15,16 It is assumed that postoperative CPA may be prevented (or delayed) by providing early interventions in response to pre-arrest alarms alerting to potential postoperative cardiovascular or respiratory compromise. 17,18 Early warning scores calculated from vital signs have been used to activate emergency response teams in hospitals in the United Kingdom, Australia, and the United States. 19 In our hospital, the automatic electronic dashboard system (BESTboardÒ) tracks vital signs, in addition to blood chemistry tests including pH, PaCO 2 , PaO 2 , lactic acid, and total CO 2 .…”

Effect of intraoperative goal-directed balanced crystalloid versus colloid administration on postoperative maximum NT-proBNP concentration in patients undergoing noncardiac surgery

“…Recent data indicates that intraoperative mean arterial blood pressure greater than 65 mmHg reduces the incidence of MINS. (29,30) However, despite good intraoperative blood pressure control, we observed a fairly high rate of MINS in our relatively healthy study population. This emphasizes that even patients with a low estimated cardiac risk having moderate-to high-risk surgery are at risk of myocardial ischemia.…”