Impact of left ventricular ejection fraction and preoperative hemoglobin level on perioperative adverse cardiovascular events in noncardiac surgery

Abstract

The prediction of a perioperative adverse cardiovascular event (PACE) is an important clinical issue in the medical management of patients undergoing noncardiac surgery. Although several predictors have been reported, simpler and more practical predictors of PACE have been needed. The aim of this study was to investigate the predictors of PACE in noncardiac surgery. We retrospectively analyzed 723 patients who were scheduled for elective noncardiac surgery and underwent preoperative examinations including 12-lead electrocardiography, transthoracic echocardiography, and blood test. PACE was defined as cardiac death, non-fatal myocardial infarction, unstable angina, congestive heart failure, arrhythmia attack that needs emergency treatment (rapid atrial fibrillation, ventricular tachycardia, and bradycardia), acute pulmonary embolism, asystole, pulseless electrical activity, or stroke during 30 days after surgery. PACE occurred in 54 (7.5%) of 723 patients. High-risk operation (11% vs. 3%, p = 0.003) was more often seen, left ventricular ejection fraction (LVEF) (55 ± 8% vs. 60 ± 7%, p = 0.001) and preoperative hemoglobin level (11.8 ± 2.2 g/dl vs. 12.7 ± 2.0 g/dl, p = 0.001) were lower in patients with PACE compared to those without PACE. By multivariate logistic regression analysis, high-risk operation (odds ratio (OR): 7.05, 95% confidence interval (CI) 2.16-23.00, p = 0.001), LVEF (OR 1.06, every 1% decrement, 95% CI 1.03-1.09, p = 0.001), and preoperative hemoglobin level (OR 1.22, every 1 g/dl decrement, 95% CI 1.07-1.39, p = 0.003) were identified as independent predictors of PACE. Receiver operating characteristic analysis demonstrated that LVEF of 58% (sensitivity = 80%, specificity = 61%, area under the curve (AUC) = 0.723) and preoperative hemoglobin level of 12.2 g/dl (sensitivity = 63%, specificity = 64%, AUC = 0.644) were optimal cutoff values for predicting PACE. High-risk operation, reduced LVEF, and reduced preoperative hemoglobin level were independently associated with PACE in patients undergoing noncardiac surgery.

2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery

“…bTTE is recommended in patients with poor functional capacity c and/or high NT-proBNP/ BNP, d or if murmurs are detected before high-risk NCS, in order to undertake risk-reduction strategies 121,124,127,[141][142][143]. …”

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

“…Comparing our findings with prior research reveals a consistent pattern of association between impaired LV systolic function (as measured by LVEF) and adverse cardiovascular outcomes following vascular surgery. Previous studies have established similar results, demonstrating that reduced LVEF is associated with an increased risk of all‐cause mortality, cardiac death and congestive heart failure following vascular surgery 21,22,27–34 . Postulated mechanisms include a surge in circulating catecholamines and perioperative fluid shifts leading to increased ventricular afterload and alterations in preload 9,10 .…”

“…Of these, 10 observational studies were eligible for inclusion in the analysis. 3,7,[21][22][23][24][25][26][27][28] Detailed rationale for exclusion of full-text studies is provided in the supplementary material (Data S2).…”

“…Previous studies have established similar results, demonstrating that reduced LVEF is associated with an increased risk of all-cause mortality, cardiac death and congestive heart failure following vascular surgery. 21,22,[27][28][29][30][31][32][33][34] Postulated mechanisms include a surge in circulating catecholamines and perioperative fluid shifts leading to increased ventricular afterload and alterations in preload. 9,10 We attempted to stratify outcomes based on degree of LV systolic dysfunction, but were limited by the inconsistent reporting.…”

Anesthetic Management of Patients with Dilated Cardiomyopathy Undergoing Noncardiac Surgery

“…Therefore, a symptom-guided management approach is recommended [ 86 ]. Sougawa H et al suggested that a lower preoperative hemoglobin level (<12.2 g/dL) was independently associated with a perioperative adverse cardiovascular event (PACE) in patients undergoing noncardiac surgery [ 87 ]. Therefore, we should be more aggressive in terms of blood transfusion in DCM patients with low preoperative hemoglobin levels.…”