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Original Investigation
Pacific Coast Surgical Association
November 15, 2017

Incidence of Myocardial Infarction After High-Risk Vascular Operations in Adults

Author Affiliations
  • 1Center for Advanced Surgical and Interventional Technology, UCLA (University of California, Los Angeles)
  • 2Department of Surgery, George Washington University, Washington, DC
  • 3School of Medicine, University of California, Irvine
  • 4Department of Cardiology, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
  • 5Department of Cardiology, UCLA
  • 6Department of Surgery, UCLA
JAMA Surg. 2017;152(11):e173360. doi:10.1001/jamasurg.2017.3360
Key Points

Question  What are the temporal trends of postoperative myocardial infarction incidence following high-risk vascular procedures in the past decade?

Findings  In this cohort study of 90 303 adults who underwent either open aortic surgery or infrainguinal bypass, the incidence of postoperative myocardial infarction remained stable following the procedure. However, increasing rates of cardiac arrest and mortality were observed for those who had undergone an open aortic procedure and mortality improved for those who had undergone an infrainguinal bypass.

Meaning  Despite major advances in perioperative cardiac care in the past decade and the availability of an endovascular surgical approach, high-risk vascular procedures were not associated with lower rates of postoperative myocardial infarction.

Abstract

Importance  Advances in perioperative cardiac management and an increase in the number of endovascular procedures have made significant contributions to patients and postoperative myocardial infarction (POMI) risk following high-risk vascular procedures. Whether these changes have translated into real-world improvements in POMI incidence remain unknown.

Objective  To examine the temporal trends of myocardial infarction (MI) following high-risk vascular procedures.

Design, Setting, and Participants  A retrospective cohort study was performed using data collected from January 1, 2005, to December 31, 2013, in the American College of Surgeons National Surgery Quality Improvement Program database, to which participating hospitals across the United States report their preoperative, operative, and 30-day outcome data. A total of 90 303 adults who underwent a high-risk vascular procedure—open aortic surgery or infrainguinal bypass—during the study period were identified. Patients were divided into cohorts based on their year of operation, and their baseline cardiac risk factors and incidence of POMI were compared. Cases from 2005 to 2014 in the database were eligible for inclusion if one of their Current Procedural Terminology codes matched any of the operations identified as a high-risk vascular procedure. Data analysis took place from August 1, 2016, to November 15, 2016.

Exposures  The main exposure was the year of the operation. Other variables of interest included demographics, comorbidities, and other risk factors for MI.

Main Outcomes and Measures  Primary outcome of interest was the incidence of POMI.

Results  Of the 90 303 patients included in the study, 22 836 (25.3%) had undergone open aortic surgery and 67 467 (74.7%) had had infrainguinal bypass. The open aortic cohort comprised 16 391 men (71.9%), had a mean (SD) age of 69.1 (11.5) years, and was predominantly white (18 440 patients [80.8%] self-identified as white race/ethnicity). The infrainguinal bypass cohort included 41 845 men (62.1%), had a mean (SD) age of 66.7 (11.7) years, and had 51 043 patients (75.7%) who self-identified as white race/ethnicity. During the study period, patients who underwent open aortic procedures were more likely to be classified as American Society of Anesthesiologists class IV (7426 patients [32.6%] vs 15 683 [23.3%] for the infrainguinal bypass cohort) or class V (1131 [5.0%] vs 206 [0.3%]; P < .001) and to undergo emergency procedures (4852 [21.3%] vs 4954 [7.3%]; P < .001). The open aortic procedure cohort also experienced significantly higher actual incidence of POMI (464 [3.0%] vs 1270 [1.9%]; P < .001). From 2009 to 2014, the incidence of POMI demonstrated no substantial temporal change (2.7% in 2009 to 3.1% in 2014; P = .64 for trend). Postoperative MI was consistently associated with poor prognosis, with a 3.62-fold (95% CI, 2.25-5.82) to 11.77-fold (95% CI, 6.10-22.72) increased odds of cardiac arrest and a 3.01-fold (95% CI, 2.08-4.36) to 6.66-fold (95% CI, 4.66-9.52) increased odds of mortality.

Conclusions and Relevance  The incidence of MI did not significantly decrease in the past decade and has been consistently associated with worse clinical outcomes. Further inquiry into why advanced perioperative care did not reduce cardiac complications is important to quality improvement efforts.

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