Perioperative ischemia and cardiac complications in major vascular surgery: Importance of the preoperative twelve-lead electrocardiogram

Abstract

To investigate the associations between specific preoperative 12-lead electrocardiogram (ECG) abnormalities , perioperative ischemia, and postoperative myocardial infarction or cardiac death in major vascular surgery.Methods: Two prospective studies on perioperative myocardial ischemia performed in two tertiary university hospitals were combined to include 405 patients. All preoperative ECGs were analyzed according to the Sokolow-Lyon criteria for left ventricular hypertrophy by investigators who were blinded to the patients' perioperative clinical course. Perioperative myocardial ischemia was detected by continuous ECG recording, and postoperative cardiac complications included myocardial infarction and cardiac death.Results: A total of 19 postoperative cardiac complications occurred (two cardiac deaths and 17 myocardial infarctions). Voltage criteria for left ventricular hypertrophy (78 patients, 19%) and ST segment depression greater than 0.5 mm (98 patients, 24.2%) on preoperative ECGs were both significantly associated with postoperative myocardial infarction or cardiac death (odds ratio, 4.2 and 4.7; p = 0.001 and 0.0005, respectively) and with longer intraoperative and postoperative myocardial ischemia. In each of the two study groups, a preoperative ECG abnormality that involved voltage criteria, ST segment depression, or both (134 patients, 33.1%) was more predictive of postoperative cardiac complications than any other preoperative clinical variable, including a history of myocardial infarction or angina pectoris, diabetes mellitus, pathologic Q-wave by ECG, or preoperative myocardial ischemia. The combined duration of intraoperative and postoperative ischemia and the preoperative ECG with either voltage criteria or ST segment depression were the only independent factors associated with adverse cardiac events by multivariate analysis (p -< 0.0001 and p = 0.02, respectively). Conclusion:Left ventricular hypertrophy and ST segment depression on preoperative 12-lead ECGs are important markers of increased risk for myocardial infarction or cardiac death after major vascular surgery.

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery

“…164 -172 In particular, the presence of LV hypertrophy or ST-segment depression on a preoperative 12-lead ECG predicts adverse perioperative cardiac events. 173 The resting 12-lead ECG has been examined both preoperatively and postoperatively to evaluate its prognostic value. To create an index for risk of cardiovascular complications, Lee and colleagues studied 4135 patients aged 50 years or older undergoing major noncardiac surgery.…”

2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery

“…37,48,49 The prevalence of HF is increasing steadily, 50 likely because of aging of the population and improved survival with newer cardiovascular therapies. Thus, the number of patients with HF requiring preoperative assessment is increasing.…”

Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association

“…Continuous arrhythmia monitoring in patients undergoing major vascular surgery such as invasive aneurysm repair deserves further study to determine benefit/nonbenefit in the postoperative period, given the very high rate of ischemia reported. 321 The risk factors for major vascular problems (eg, smoking, hypertension, hyperlipidemia, diabetes mellitus) are analogous to those of cardiac disease. These patients may have undiagnosed coro nary lesions, which may be identified on postoperative STsegment monitoring, triggering a need for evalua tion and potential intervention.…”