July 8, 1992, Vol 268, No. 2 >

< Previous Article Next Article >

ARTICLE | July 8, 1992

Ventricular Arrhythmias in Patients Undergoing Noncardiac Surgery FREE

Brian O'Kelly, MB, MRCPI, FRCPC; Warren S. Browner, MD, MPH; Barry Massie, MD; Julio Tubau, MD; Long Ngo, MS; Dennis T. Mangano, PhD, MD; Dennis T. Mangano, PhD, MD; Martin J. London, MD; Warren S. Browner, MD, MPH; Milton Hollenberg, 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; Juliet Li, MD; Maria E. Franks, RN; Yuriko C. Wellington, MS; Mara Balasubramanian, MD; Evelyn Cembrano, MD; Wilfredo Velasco, MD; Nonato Pineda, MD; Safiullah N. Katiby, MD; Diane Beatty; Winifred von Ehrenburg; Brian F. O'Kelly, MB, MRCPI, FRCPC; 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; Ida M. Tateo, MS; Jeffrey Tice; Cary Fox, MA; Angela Heithaus; Jonathan Showstack, MPH; Diana C. Nicoll, MD, PhD; Paul Heinekin, MD; Barry Massie, D; Kanu Chatterjee, MB, FRCP; H. Barrie Fairley, MD; Lawrence W. Way, MD; Warren Winkelstein, MD, MPH

[+] Author Affiliations

A complete list of the participants in the research study group appears at the end of this article.

Reprint requests to Department of Anesthesia, Veterans Affairs Medical Center, 4150 Clement St (129), San Francisco, CA 94121 (Dr Mangano).

JAMA. 1992;268(2):217-221. doi:10.1001/jama.1992.03490020065032

Text Size: A A A

Published online

Article

References

ABSTRACT

ABSTRACT | REFERENCES

Objective. —To determine the incidence, clinical predictors and prognostic importance of perioperative ventricular arrhythmias.

Design. —Prospective cohort study (Study of Perioperative Ischemia).

Setting. —University-affiliated Department of Veterans Affairs Medical Center, San Francisco, Calif.

Subjects. —A consecutive sample of 230 male patients, with known coronary artery disease (46%) or at high risk of coronary artery disease (54%), undergoing major noncardiac surgical procedures.

Measurements. —We recorded cardiac rhythm throughout the preoperative (mean=21 hours), intraoperative (mean=6 hours), and postoperative (mean=38 hours) periods using continuous ambulatory electrocardiographic monitoring. Adverse cardiac outcomes were noted by physicians blinded to information about arrhythmias.

Main Results. —Frequent or major ventricular arrhythmias (>30 ventricular ectopic beats per hour, ventricular tachycardia) occurred in 44% of our patients: 21% preoperatively, 16% intraoperatively, and 36% postoperatively. Compared with the preoperative baseline, the severity of arrhythmia increased in only 2% of patients intraoperatively but in 10% postoperatively. Preoperative ventricular arrhythmias were more common in smokers (odds ratio [OR], 4.1; 95% confidence interval [Cl], 1.2 to 15.0), those with a history of congestive heart failure (OR, 4.1; 95% Cl, 1.9 to 9.0), and those with electrocardiographic evidence of myocardial ischemia (OR, 2.2; 95% Cl, 1.1 to 4.7). Preoperative arrhythmias were associated with the occurrence of intraoperative and postoperative arrhythmias (OR, 7.3; 95% CI, 3.3 to 16.0, and OR, 6.4; 95% Cl, 2.7 to 15.0, respectively). Nonfatal myocardial infarction or cardiac death occurred in nine men; these outcomes were not significantly more frequent in those with prior perioperative arrhythmias, albeit with wide Cls (OR, 1.6; 95% CI, 0.4 to 6.2).

Conclusion. —Almost half of all high-risk patients undergoing noncardiac surgery have frequent ventricular ectopic beats or nonsustained ventricular tachycardia. Our results suggest that these arrhythmias, when they occur without other signs or symptoms of myocardial infarction, may not require aggressive monitoring or treatment during the perioperative period.(JAMA. 1992;268:217-221)

REFERENCES

ABSTRACT | REFERENCES

Dodd R, Sims W, Bone D. Cardiac arrhythmias observed during anesthesia and surgery. Surgery . 1962;;51:440-447.

Kuner J, Enescu V, Utsu F, Boszormenyi E, Bernstein H, Corday E. Cardiac arrhythmias during anesthesia. Dis Chest . 1967;;52:580-588

Vanik P, Davis H. Cardiac arrhythmias during halothane anesthesia. Anesth Analg . 1968;;47:299-307.

Kimbrough H, Crampton R, Gillenwater J. Cardiac rhythm in men during cystoscopy. J Urol . 1975;;113: 846-849.

Bertrand CA, Steiner NV, Jameson AG, Lopez M. Disturbances of cardiac rhythm during anesthesia and surgery. JAMA . 1971;;216:1615-1617.

Goldman L, Caldera D, Nussbaum S, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med . 1977;;297:845-850.

Jeffrey C, Kunsman J, Cullen D, Brewster D. A prospective evaluation of cardiac risk index. Anesthesiology . 1983;;58:462-464.

Detsky A, Abrams H, McLaughlin J, et al. Predicting cardiac complications in patients undergoing noncardiac surgery. J Gen Intern Med . 1986;;1:211-219.

Larsen S, Olesen K, Jacobsen E, et al. Prediction of cardiac risk in noncardiac surgery. Eur Heart J . 1987;;8:179-185.

Mangano D. Perioperative cardiac morbidity. Anesthesiology . 1990;;72:153-184.

Mangano D, Browner W, Hollenberg M, London M, Tubau J, Tateo I. Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. N Engl J Med . 1990;;323:1781-1788.

Coronary Artery Surgery Study (CASS) Coordinating Center, University of Washington, Seattle. Manual of Operations II: Data Collection and Storage: Collaborative Studies in Coronary Artery Surgery . Washington, DC: National Heart, Lung, and Blood Institute; 1978;.

Blackburn H, Keys A, Simonson E, Rautaharju P, Punsar S. The electrocardiogram in population studies: a classification system. Circulation . 1960;;21: 1160-1175.

Braunwald E. The history. In: Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine . 2nd ed. Philadelphia, Pa: WB Saunders Co; 1984;:1-13.

Campeau L. Grading angina pectoris. Circulation . 1976;;54:522-523.

Mangano DT, Hollenberg M, Fegert G, et al. Perioperative myocardial ischemia in patients undergoing noncardiac surgery, I: incidence and severity during the four-day perioperative period. J Am Coll Cardiol . 1991;;17:843-850.

Pratt C, Delclos G, Wierman A, et al. The changing base line of complex ventricular arrhythmias: a new consideration in assessing long-term antiarrhythmic drug therapy. N Engl J Med . 1985;;313:1444-1449.

Podrid P. Aggravation of arrhythmia: a complication of antiarrhythmic drug therapy. Eur Heart J . 1989;;10( (suppl) ):66-72.

Morganroth J. Risk factors for the development of proarrhythmic events. Am J Cardiol . 1987;;59 ( (suppl) ):32E-37E.

Massie BM, Podrid PJ, Hendrix GH, et al. Does asymptomatic worsening of arrhythmia predict sudden death in heart failure? evidence for clinically significant proarrhythmia during milrinone therapy. J Am Coll Cardiol . 1992;;19:78A.

Knoebel S, Crawford M, Dunn M, et al. Guidelines for ambulatory electrocardiography: a report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on Ambulatory Electrocardiography). Circulation . 1989;;79:206-215.

Nademanee K. A tale of the spontaneous variability of premature ventricular contractions. Circulation . 1990;;82:1054-1056.

Hinkle L, Carver S, Stevens M. The frequency of asymptomatic disturbances of cardiac rhythm and conductions in middle-aged men. Am J Cardiol . 1969;; 24:629-650.

Mangano D, Wong M, London M, et al. Perioperative myocardial ischemia in patients undergoing noncardiac surgery, II: incidence and severity during the first week following surgery. J Am Coll Cardiol . 1991;;17:851-857.

Halter J, Pflug A, Porte D. Mechanism of plasma catecholamine response increase during surgical stress in man. J Clin Endocrinol Metab . 1977;;45: 936-944.

Udelsman R, Norton JA, Jelenich SE, et al. Responses of the hypothalamic-pituitary-adrenal and renin-angiotensin axes and the sympathetic system during controlled surgical and anesthetic stress. J Clin Endocrinol Metab . 1987;;64:986-994.

Kjekshus J. Arrhythmias and mortality in congestive heart failure. Am J Cardiol . 1990;;65:421-481.

Hollifield J. Thiazide treatment of systemic hypertension: effects on serum magnesium and ventricular ectopic activity. Am J Cardiol . 1989;;63 ( (suppl) ):22G-25G.

Davis M, Hockings B, El Dessouky M, Hajar H, Taylor R. Cigarette smoking and ventricular arrhythmia in coronary heart disease. Am J Cardiol . 1984;;54:282-285.

Myers M, Benowitz N, Dubbin J, Haynes R, Sole M. Cardiovascular effects of smoking in patients with ischemic heart disease. Chest . 1988;;93:14-19.

Hennekens C, Lown B, Rosner B, Grufferman S, Dalen J. Ventricular premature beats and coronary risk factors. Am J Epidemiol . 1980;;112:93-99.

Hallstron A, Cobb L, Ray R. Smoking as a risk factor for recurrence of sudden cardiac arrest. N Engl J Med . 1986;;314:271-275.

Benowitz N. Pharmacologic aspects of cigarette smoking and nicotine addiction. N Engl J Med . 1988;; 319:1318-1330.

Goldman L. Multifactorial index of cardiac risk in noncardiac surgery: ten-year status report. J Cardiothorac Anesth . 1987;;1:237-244.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal