Cardiac vagal dysfunction and myocardial injury after non-cardiac surgery: a planned secondary analysis of the measurement of Exercise Tolerance before surgery study

Abstract

BackgroundThe aetiology of perioperative myocardial injury is poorly understood and not clearly linked to pre-existing cardiovascular disease. We hypothesised that loss of cardioprotective vagal tone [defined by impaired heart rate recovery ≤12 beats min−1 (HRR ≤12) 1 min after cessation of preoperative cardiopulmonary exercise testing] was associated with perioperative myocardial injury.MethodsWe conducted a pre-defined, secondary analysis of a multi-centre prospective cohort study of preoperative cardiopulmonary exercise testing. Participants were aged ≥40 yr undergoing non-cardiac surgery. The exposure was impaired HRR (HRR≤12). The primary outcome was postoperative myocardial injury, defined by serum troponin concentration within 72 h after surgery. The analysis accounted for established markers of cardiac risk [Revised Cardiac Risk Index (RCRI), N-terminal pro-brain natriuretic peptide (NT pro-BNP)].ResultsA total of 1326 participants were included [mean age (standard deviation), 64 (10) yr], of whom 816 (61.5%) were male. HRR≤12 occurred in 548 patients (41.3%). Myocardial injury was more frequent amongst patients with HRR≤12 [85/548 (15.5%) vs HRR>12: 83/778 (10.7%); odds ratio (OR), 1.50 (1.08–2.08); P=0.016, adjusted for RCRI). HRR declined progressively in patients with increasing numbers of RCRI factors. Patients with ≥3 RCRI factors were more likely to have HRR≤12 [26/36 (72.2%) vs 0 factors: 167/419 (39.9%); OR, 3.92 (1.84–8.34); P<0.001]. NT pro-BNP greater than a standard prognostic threshold (>300 pg ml−1) was more frequent in patients with HRR≤12 [96/529 (18.1%) vs HRR>12 59/745 (7.9%); OR, 2.58 (1.82–3.64); P<0.001].ConclusionsImpaired HRR is associated with an increased risk of perioperative cardiac injury. These data suggest a mechanistic role for cardiac vagal dysfunction in promoting perioperative myocardial injury.

Acquired loss of cardiac vagal activity is associated with myocardial injury in patients undergoing non-cardiac surgery: prospective observational mechanistic cohort study

“…The principle finding of our study is that patients undergoing non-cardiac surgery who developed PMI had a decrease in cardiac parasympathetic activity within 24h of surgery. The association of delayed HRR before surgery and PMI after the standardised orthostatic challenge is consistent with a large multicentre cohort study that demonstrated the same association with delayed heart rate recovery, quantified using CPET before noncardiac surgery (4) . Using a standardised orthostatic challenge, we were able demonstrate that delayed HRR and its association with PMI persist 24h after surgery.…”

Chronotropic incompetence and myocardial injury after noncardiac surgery: planned secondary analysis of a prospective observational international cohort study

“…Myocardial injury is more likely to occur in patients with preoperative cardiac vagal (parasympathetic) dysfunction, identified by impaired HR recovery (i.e. decrease) after exercise 4 . Cardiac vagal autonomic impairment is a common feature in deconditioned surgical patients,5, 6, 7 in whom preoperative cardiopulmonary exercise testing (CPET) also reveals physiological features of cardiac failure, including lower peak oxygen consumption and higher resting HR 8 …”

Can routine perioperative haemodynamic parameters predict postoperative morbidity after major surgery?

“…In addition, dysfunction of the sympathetic nervous system at baseline before surgery has also been associated both with increased postoperative morbidity (Abbott et al 2019a). This is distinct from parasympathetic vagal dysfunction-a secondary analysis of the VISION database has suggested a link between loss of vagal tone preoperatively and MINS (Abbott et al 2019b;May et al 2019). Impairment of heart rate recovery (HRR), which should be > 12 beats per minute from maximum heart rate achieved at maximal oxygen consumption during cardiopulmonary exercise testing, is associated with adverse postoperative outcome (Ackland et al 2019).…”

“…Impairment of heart rate recovery (HRR), which should be > 12 beats per minute from maximum heart rate achieved at maximal oxygen consumption during cardiopulmonary exercise testing, is associated with adverse postoperative outcome (Ackland et al 2019). Further, some signals of intraoperative tachycardia or bradycardia have also been linked to increased risk of adverse events (Abbott et al 2019b;Ackland et al 2019;May et al 2019;Wijeysundera et al 2018). The value of intraoperative haemodynamic parameters (during anaesthesia) in influencing postoperative outcomes became apparent when a prospective, randomised clinical trial of increased risk patients showed that (Futier et al 2017).…”