Predictors of Electrocardiographic Change, Cardiac Troponin Elevation, and Survival after Major Vascular Surgery: A Community Hospital Experience

Abstract

Cardiovascular disease is the leading cause of perioperative morbidity and mortality after vascular surgery. The purpose of this study was to identify risk factors for myocardial ischemia after vascular surgery and to investigate a potential association of ischemia with mortality in a community hospital setting. A retrospective review was conducted after 190 major vascular procedures. Electrocardiogram (ECG) results and troponin I levels were obtained serially during the first 24 postoperative hours. Outcomes analyzed were ischemic ECG changes, troponin I level more than 2 ng/mL, 6-month mortality, and overall survival. The authors investigated any association of these outcomes with each other and the type of operation, history of coronary artery disease, diabetes, recent coronary intervention, age older than 70 years, or postoperative symptoms. Twenty-seven (14%) patients experienced ischemic ECG changes. Twenty-one (11%) patients experienced troponin I elevation. Univariate analysis revealed a history of coronary artery disease, diabetes, concerning symptoms, and troponin elevation to be predictive of ECG change ( P < 0.05). ECG change and symptoms were predictive of troponin elevation ( P < 0.01). Cox multivariate analysis revealed only infrainguinal bypass to predict 6-month mortality (odds ratio = 2.92, P = 0.02). Diabetes was the sole predictor of overall mortality (odds ratio = 1.94, P = 0.001). Nonsustained ischemic postoperative ECG changes during the first 24 postoperative hours do not independently influence 6-month or overall mortality after major vascular surgery. Postoperative troponin elevation likely conveys a mortality risk in the subsequent 6 months. In the community hospital setting, midterm survival rates after vascular surgery equivalent to those in higher volume centers can be achieved. Patients undergoing infrainguinal bypass and diabetics continue to be the most moribund vasculopaths.

Prognostic Value of Troponin and Creatine Kinase Muscle and Brain Isoenzyme Measurement after Noncardiac Surgery

“…All studies evaluated the prognostic properties of troponin measurement after surgery (14 evaluated mortality, 6 -16,18,22,23 and five evaluated major cardiovascular events 12,14,16,21,22 ), whereas only four studies evaluated the prognostic properties of CK-MB measurement. 6,10,11,18 Ten studies evaluated troponin I exclusively, 8,9,[12][13][14][15][16]18,22,23 three evaluated troponin T exclusively, 7,11,21 and two studies evaluated troponin I and T. 6,10 There was wide variation across studies in the threshold for an increased troponin and the timing and frequency of troponin measurements. An increased troponin measurement was observed in 8.4 -52.9% of patients across studies, and an increased CK-MB was observed in 7.6 -23.7% of patients across studies.…”

“…Eight of these 10 studies performed time-to-event analyses and reported hazard ratios (HRs) from Cox proportional hazards models. 6,7,[11][12][13][14][15][16] One of these studies also performed a logistic regression analysis, but did not report the numerical results. 16 The authors of this study provided us with the ORs from this analysis.…”

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

“…PMI is recognized as an important surrogate for shortand long-term mortality after non-cardiac surgery. [1][2][3][4][5][6][7][8][9] The main pathology of PMI is myocardial ischemia, possibly caused by pre-existing CAD, plaque rupture, or imbalance between myocardial oxygen supply and demand. Anemia and hemodynamic instability caused by major bleeding during surgery may accelerate myocardial ischemia.…”

“…It occurs in 8-52% of patients who undergo non-cardiac surgery and has received considerable attention since it was reported to be associated with an increased risk of morbidity and mortality. [1][2][3][4][5][6][7][8][9] The main pathology of PMI is thought to be myocardial ischemia, possibly attributable to pre-existing coronary artery disease (CAD), plaque rupture, or imbalance between myocardial oxygen supply and demand. Interestingly, the incidence of coronary artery stenosis is poorly correlated patients undergoing non-cardiac surgery.…”

Percutaneous revascularization of long femoral artery lesions for claudication

“…There are several reasons why percutaneous treatment with out‐patient surveillance is attractive to many patients with lifestyle limiting claudication compared to surgical bypass. These include the less invasive approach and lower cardiovascular risk afforded by percutaneous treatment compared to femoral bypass surgery where rates of perioperative mortality and myocardial infarction are ∼1–3% and 10–15% [6–11]. In contrast, the risks associated with initial and repeat percutaneous treatment are much lower than initial and repeat vascular surgeries.…”