Association of High Mortality With Postoperative Myocardial Infarction After Major Vascular Surgery Despite Use of Evidence-Based Therapies

Abstract

IMPORTANCE Patients undergoing vascular surgery are at high risk of postoperative myocardial infarction (POMI). Postoperative myocardial infarction is independently associated with significant risk of in-hospital mortality.OBJECTIVE To examine the association of patient and procedural characteristics with the risk of POMI after vascular surgery and determine the association of evidence-based therapies with longer-term outcomes. DESIGN, SETTING, AND PARTICIPANTSA retrospective cohort study of prospectively collected data within a statewide quality improvement collaborative database between January 2012 and December 2017. Patient demographics, comorbid conditions, and perioperative medications were captured. Patients were grouped according to occurrence of POMI. Univariate analysis and logistic regression were used to identify factors associated with POMI. The collaborative collects data from private and academic hospitals in Michigan. Patients undergoing major vascular surgery, defined as endovascular aortic aneurysm repair, open abdominal aortic aneurysm, peripheral bypass, carotid endarterectomy, or carotid artery stenting were included. Analysis began December 2018. MAIN OUTCOMES AND MEASURESThe presence of a POMI and 1-year mortality. RESULTSOf 26 231 patients identified, 16 989 (65.8%) were men and the overall mean (SD) age was 69.35 (9.89) years. A total of 410 individuals (1.6%) experienced a POMI. Factors associated with higher rates of POMI were age (odds ratio [OR], 1.032 [95% CI,

Perioperative cardiovascular outcome in patients with coronary artery disease undergoing major vascular surgery: A retrospective cohort study

“…[ 15 ] Recent evidence, however, stated a 37.4% incidence of 1-year mortality in patients who had PMI after undergoing high-risk vascular surgery. [ 30 ] Although excluding thoracoabdominal surgery from analysis, they had included carotid artery procedures, peripheral artery surgeries, and endovascular aortic aneurysm repair procedures, which are specifically known for their low risk of PMI. The elevated risk in our cohort can thus be associated with the focussed analysis of patients with CAD and the inclusion of more morbid surgeries involving the thoracic aorta.…”

Diabetes mellitus was not associated with lower amputation-free survival after open revascularization for chronic limb-threatening ischemia – A nationwide propensity score adjusted analysis

“…32 Beaulieu et al studied the risk of postoperative myocardial infarction after major vascular surgery and found a high risk of AMI following peripheral bypass surgery, with approximately 49% having DM among those suffering from AMI postoperatively. 7 Two randomized controlled trials 33,34 have shown that low-dose rivaroxaban taken twice a day plus aspirin once a day reduced major adverse cardiovascular and limb events when compared with ASA alone; therefore, it is of great importance to consider that patients are treated with the best medical therapy not only after the procedure but perhaps at an earlier stage.…”

“…5 Individuals with both DM and PAD have a more distal distribution of the arterial disease, and tend to have more significant comorbidities. 6 In view of these factors, minimal invasive endovascular therapy for CLTI among patients with DM might induce less myocardial stress 7 compared to open surgery, and therefore be more beneficial to achieve higher amputation-free survival. Indeed, endovascular therapy was associated with a lower risk of mortality in patients with type 2 diabetes compared to those without DM among patients with infrainguinal CLTI.…”

Preoperative evaluation and perioperative management of patients undergoing major vascular surgery

“…7,8 Open aortic procedures are especially associated with a higher risk of postoperative myocardial infarction, which is in turn associated with up to 650% increased risk of 1-year mortality. 9,10 Although postoperative stroke in noncarotid vascular surgery is rare (< 1%), it is associated with a significantly increased risk of 30-day perioperative mortality (approximately three to sixfold increase). 11,12 Postoperative arrhythmias affect a large percentage of patients undergoing noncardiac surgery, with the incidence of 7-8% -most frequently atrial fibrillation (~4.4%).…”