0
ARTICLE |

Long-term Cardiac Prognosis Following Noncardiac Surgery

Dennis T. Mangano, PhD, MD; Warren S. Browner, MD, MPH; Milton Hollenberg, MD; Juliet Li, MD; Ida M. Tateo, MS; Martin J. London, MD; Julio F. Tubau, MD; Jacqueline M. Leung, MD; William C. Krupski, MD; Joseph A. Rapp, MD; Marcus W. Hedgcock, MD; Edward D. Verrier, MD; Scott Merrick, MD; M. Lou Meyer, MS; Linda Levenson; Martin G. Wong, RDMS; Elizabeth Layug, MD; Maria E. Franks, RN; Yuriko C. Wellington, MS; Mara Balasubramanian, MD; Evelyn Cembrano, MD; Wilfredo Velasco, MD; Safiullah N. Katiby, MD; Thea Miller; Winifred von Ehrenburg; Brian F. O'Kelly, MB, MRCPI, FRCP; Jadwiga Szlachcic, MD; Andrew A. Knight, MD; Virginia Fegert, MD; Paul Goehner, MD; David N. Harris, MD, FFARCS; Deanna Siliciano, MD; Nancy H. Mark, MD; Randy Smith, MD; Jeffrey Tice; Cary Fox, MA; Angela Heithaus; Jonathan Showstack, PhD; Diana C. Nicoll, MD, PhD; Paul Heineken, MD; Barry Massie, MD; Kanu Chatterjee, MB, FRCP; H. Barrie Fairley, MD; Lawrence W. Way, MD; Warren Winkelstein, MD, MPH
JAMA. 1992;268(2):233-239. doi:10.1001/jama.1992.03490020081035.
Text Size: A A A
Published online

Objective.  —To determine the long-term (2-year) cardiac prognosis of high-risk patients undergoing noncardiac surgery and to determine the predictors of long-term adverse cardiac outcome.

Design.  —Prospective cohort study. Historical, clinical, and laboratory data were collected during the in-hospital period, and at 6 months, 1 year, and 2 years following surgery. Data were analyzed using proportional hazards models.

Setting.  —University-affiliated Veterans Affairs medical center.

Population.  —A consecutive sample of 444 patients with or at high risk for coronary artery disease who had undergone elective noncardiac surgery and were discharged from the hospital in stable condition.

Main Outcome Measures.  —Cardiac death, myocardial infarction, unstable angina, progressive angina requiring coronary artery bypass graft surgery or coronary angioplasty, and new unstable angina requiring hospitalization.

Results.  —Forty-seven patients (11%) had major cardiovascular complications during a 728-day (median) follow-up period: 24 had cardiac death; 11, nonfatal myocardial infarction; six, progressive angina requiring coronary artery bypass graft surgery or coronary angioplasty; and six, new unstable angina requiring hospitalization. Thirty percent of outcomes occurred within 6 months of surgery and 64% within 1 year. Five independent predictors of long-term outcome were identified. Three predictors reflected the preexisting chronic disease state: (1) the presence of known vascular disease (hazard ratio, 6.1; 95% confidence interval [Cl], 2.5 to 15.0; P<.0001); (2) a history of congestive heart failure (hazard ratio, 5.0; 95% Cl, 2.0 to 12.0; P<.0005); and (3) known coronary artery disease (hazard ratio, 3.7; 95% Cl, 1.7 to 8.0; P<.0007). Two predictors reflected acute postoperative ischemic events: (1) myocardial infarction/unstable angina (hazard ratio, 20; 95% Cl, 7.5 to 53.0; P<.0001) and (2) myocardial ischemia (hazard ratio, 2.2; 95% Cl, 1.1 to 4.3; P<.03). Patients surviving a postoperative in-hospital myocardial infarction had a 28-fold increase in the rate of subsequent cardiac complications within 6 months following surgery, a 15-fold increase within 1 year, and a 14-fold increase within 2 years (95% Cl, 5.8 to 32; P<.00001). Seventy percent of all long-term adverse outcomes were preceded by in-hospital postoperative ischemia that occurred at least 30 days (median, 282 days) before the long-term event. The development of congestive heart failure or ventricular tachycardia (without ischemia) during hospitalization was not associated with adverse long-term outcome.

Conclusions.  —The incidence of long-term adverse cardiac outcomes following noncardiac surgery is substantial. At increased risk are patients with chronic cardiovascular disease; at highest risk are patients with acute perioperative ischemic events. We conclude that survivors of in-hospital perioperative ischemic events, specifically myocardial infarction, unstable angina, and postoperative ischemia, warrant more aggressive long-term follow-up and treatment than is currently practiced.(JAMA. 1992;268:233-239)

Topics

Sign In to Access Full Content

Don't have Access?

Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more

Subscribe for full-text access to content from 1998 forward and a host of useful features

Activate your current subscription (AMA members and current subscribers)

Purchase Online Access to this article for 24 hours

Figures

Tables

References

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Sign In to Access Full Content

Related Content

Customize your page view by dragging & repositioning the boxes below.

Jobs
brightcove.createExperiences();