Long-term Cardiac Prognosis Following Noncardiac Surgery

Abstract

<h3>Objective.</h3> —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. <h3>Design.</h3> —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. <h3>Setting.</h3> —University-affiliated Veterans Affairs medical center. <h3>Population.</h3> —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. <h3>Main Outcome Measures.</h3> —Cardiac death, myocardial infarction, unstable angina, progressive angina requiring coronary artery bypass graft surgery or coronary angioplasty, and new unstable angina requiring hospitalization. <h3>Results.</h3> —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;<i>P</i>&lt;.0001); (2) a history of congestive heart failure (hazard ratio, 5.0; 95% Cl, 2.0 to 12.0;<i>P</i>&lt;.0005); and (3) known coronary artery disease (hazard ratio, 3.7; 95% Cl, 1.7 to 8.0;<i>P</i>&lt;.0007). Two predictors reflected acute postoperative ischemic events: (1) myocardial infarction/unstable angina (hazard ratio, 20; 95% Cl, 7.5 to 53.0;<i>P</i>&lt;.0001) and (2) myocardial ischemia (hazard ratio, 2.2; 95% Cl, 1.1 to 4.3;<i>P</i>&lt;.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;<i>P</i>&lt;.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. <h3>Conclusions.</h3> —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. (<i>JAMA</i>. 1992;268:233-239)