Perioperative Major Adverse Cardiovascular and Cerebrovascular Events Associated With Noncardiac Surgery

Abstract

Importance Major adverse cardiovascular and cerebrovascular events (MACCE) are a significant source of perioperative morbidity and mortality following non-cardiac surgery. Objective To evaluate national trends in perioperative cardiovascular outcomes and mortality after major non-cardiac surgery and identify surgical subtypes associated with cardiovascular events using a large administrative database of United States hospital admissions. Design, Setting, Participants Patients who underwent major non-cardiac surgery from 2004 to 2013 were identified using the National Inpatient Sample. Main Outcomes Perioperative MACCE (primary outcome), defined as in-hospital, all-cause death, acute myocardial infarction (AMI), or acute ischemic stroke, were evaluated over time. Results Among 10,581,621 hospitalizations for major non-cardiac surgery, perioperative MACCE occurred in 317,479 (3.0%), corresponding to an annual incidence of ≈150,000 after applying sample weights. Major adverse cardiovascular and cerebrovascular events occurred most frequently in patients undergoing vascular (7.7%), thoracic (6.5%), and transplant surgery (6.3%). Between 2004 and 2013, the frequency of MACCE declined from 3.1% to 2.6% (p for trend <0.0001; adjusted OR 0.95, 95% CI 0.94–0.97) driven by a decline in frequency of perioperative death (adjusted OR 0.79, 95% CI 0.77–0.81) and AMI (adjusted OR 0.87, 95% CI 0.84–0.89) but with an increase in perioperative ischemic stroke from 0.52% in 2004 to 0.77% in 2013 (p for trend <0.0001; adjusted OR 1.79; CI 1.73–1.86). Conclusions & Relevance Perioperative MACCE occurs in 1 of every 33 hospitalizations for non-cardiac surgery. Despite reductions in the rate of death and AMI among patients undergoing major non-cardiac surgery in the United States, perioperative ischemic stroke increased over time. Additional efforts are necessary to improve cardiovascular care in the perioperative period of patients undergoing non-cardiac surgery.

Perioperative bleeding and thrombotic risks in patients with Von Willebrand disease

“…[6] Patients were included if they had a principal International Classification of Diseases, Ninth Revision (ICD-9) procedure code for a major therapeutic operating room procedure (HCUP Procedure Class 4). Principal CCS procedure codes, which represent an aggregate of relevant primary ICD-9 procedure codes by surgical subtype, were used to exclude patients who underwent cardiac procedures (n=1,655,567), cardiac surgery and cardiac transplantation (n=582,726), bone marrow transplantation (n=18,151), ophthalmologic surgery (n=13,342), radiation therapy (n=9,817), dental surgery (n=1,779), and non-operating room procedures (n=386) as a principal in-hospital procedure.…”

Sequential Surgical Procedures in Vascular Surgery Patients Are Associated With Perioperative Adverse Cardiac Events

“…Patients at elevated risk for cardiovascular complications are prone to perioperative adverse cardiac events, such as myocardial injury after non-cardiac surgery (MINS) (1) and face higher perioperative mortality (1)(2)(3)(4). Atherosclerosis and its complications are driven by systemic inflammation (5), however the mechanisms underlying perioperative cardiovascular complications are not fully understood (6,7).…”

The use of echocardiography as a routine perioperative monitoring standard: The perspective of a cardiothoracic anesthesiologist

“…Throughout the world, there are more than 300 million major surgery each year, and major cardiovascular adverse events are a significant cause of perioperative morbidity and mortality. 1 This certainly relates to the nature of anesthetic agents that are mostly cardiovascular-depressant. Anesthetic agents such as propofol, ketamine, opioids, inhalation anesthetic agents, and many others, can directly affect the cardiovascular system.…”

“…This frequently reduces the alertness of an anesthesiologist, especially when performing perioperative monitoring. A study from Smilowitz et al, 1 showed that out of 10,581,621 patients admitted to hospital for major non-cardiac surgery plans, 317,479 (3%) patients had experienced major cardiac events. Which can be illustrated that major cardiac events occur in 1 in 33 patients treated for major non-cardiac surgery.…”