Abstract
Purpose
Recently, the American College of Cardiology— American Heart Association (ACC-AHA) published guidelines and an associated algorithm for preoperative cardiovascular evaluation of patients undergoing non-cardiac surgery. Our purpose was to (i) test guideline’s ability to predict adverse cardiac events within seven days after surgery, (ii) determine whether medical clinical predictors or surgical risks was a better predictor of cardiac events.
Methods
Retrospective review of 119 cardiology and anesthesia consultations over 15 mo, ending March 31, 1998. Patients were classified into their respective medical clinical predictor and surgical risk groups, as outlined in ACC-AHA guidelines. Associations between the medical predictor and surgical risk scores and adverse cardiac outcomes were quantified via multiple logistic regression analysis. Two outcomes were employed. Outcome 1, included: myocardial infarction/ischemia; angina; congestive heart failure, arrhythmia or death. Outcome 2 expanded the definition to include “cancellation of surgery due to cardiac risk” as a negative cardiac outcome.
Results
Diabetes, Canadian Cardiovascular Class (CCS) 111 or IV angina, and M1 within six months before surgery were strongly associated with the two cardiac outcomes. For outcome 1 and 2, medical predictors and surgical risks, considered simultaneously, performed with a sensitivity of 93% and specificity of 46–51%. When considered separately, major clinical medical predictors had a sensitivity of 87–89%, while surgical risks showed a specificity of 89% in predicting the two outcomes.
Conclusion
Medical predictors in ACC-AHA classification scheme were highly sensitive whereas surgical risks were more specific in predicting adverse post-operative cardiac events. Prospective study is needed to confirm these observations.
Résumé
Objectif
Récemment, I American College of Cardiology—American Heart Association (ACC-AHA) a publié des recommandations, et un algorithme qui leur est associé, pour l’évaluation cardiovasculaire préopératoire des patients qui doivent subir une intervention chirurgicale non cardiaque. Notre objectif était de (i) tester la capacité des recommandations à prédire les complications cardiaques qui pourraient se produire dans les sept jours suivant l’opération, (ii) déterminer si ce sont les facteurs prédictifs médicaux cliniques ou les risques chirurgicaux qui peuvent le mieux prédire les complications cardiaques.
Méthode
On a procédé à une revue rétrospective de 119 consultations en cardiologie et en anesthésie des 15 mois précédant le 31 mars 1998. Les patients ont été répartis en divers groupes selon leur facteur prédictif médical clinique respectif et les risques chirurgicaux liés à leur condition, comme l’indiquent les recommandation ACC-AHA. Les associations entre les facteurs prédictifs médicaux et les scores de risques chirurgicaux et les complications cardiaques ont été quantifiées au moyen d’une analyse de régression logistique multifactorielle. Deux complications ont servi à l’analyse. La complication I comprenait l’infarctus du myocarde (IM)/I’ischémie, l’angine, l’insuffisance cardiaque congestive, l’arythmie ou la mort. La complication 2 étendait la définition pour inclure, dans les complications cardiaques, «l’annulation de l’opération à cause des risques cardiaques».
Resultats
Le diabète, l’angine des classes III et IV de la Société Cardiovasculaire Canadienne (SCC) et l’IM se produisant pendant les six mois qui précèdent l’opération ont été étroitement associés aux deux complications cardiaques. Dans le cas des complications 1 et 2, les facteurs prédictifs médicaux et les risques chirurgicaux, considérés simultanément, ont montré une sensibilité de 93 % et une spécificité de 46–51 %. Considérés séparément, les facteurs prédictifs médicaux cliniques les plus importants ont présenté une sensibilité de 87–89 % tandis que les risques chirurgicaux ont montré une spécificité de 89 % en prédisant les deux complications.
Conclusion
Les facteurs prédictifs médicaux de la classification ACC-AHA ont été très sensibles alors que les risques chirurgicaux ont été plus spécifiques en prédisant des complications cardiaques postopératoires. Une étude prospective demeure nécessaire pour confirmer ces observations.
Article PDF
Similar content being viewed by others
References
National Center for Health Statistics. Health, United States, 1988.In: Advance data from vital and health statistics. Washington, D.C.: Government Printing Office, 1989: 10–17, 66, 67, 100, 101. (DHHS Publication no. (PHS) 89-1232).
Harrison DC. Cost containment in medicine: why cardiology? Am J Cardiol 1985; 56: 10C-5.
Mangano DT. Perioperative cardiac morbidity. Anesthesiology 1990; 72: 153–84.
McPhail N, Calvin JE, Shariatmadar A, Barber GG, Scobie TK. The use of preoperative exercise testing to predict cardiac complications after arterial reconstruction. J Vasc Surg 1988; 7: 60–8.
Lubitz J, Deacon R. The rise in incidence of hospitalizations for the aged, 1967 to 1979. Health Care Financing Review 1982; 3: 21–40.
ACC/AHA Task Force Report. Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology /American Heart Association Task Force on Practice Guidelines. JACC 1996; 27: 910–48.
Detsky AS, Abrams HB, McLaughlin JR, et al. Predicting cardiac complications in patients undergoing non-cardiac surgery. J Gen Intern Med 1986; 1: 211–9.
Steen PA, Tinker JH, Tarhan S. Myocardial reinfarction after anesthesia and surgery. JAMA 1978; 239: 2566–70.
Eagle KA, Coley CM, Newell JB, et al. Combining clinical and thallium data optimizes preoperative assessment of cardiac risk before major vascular surgery. Ann Intern Med 1989; 110: 859–66.
Vanzetto G, Machecourt J, Blendea D, et al. Additive value of thallium single-photon emission computed tomography myocardial imaging for prediction of perioperative events in clinically selected high cardiac risk patients having abdominal aortic surgery. Am J Cardiol 1996; 77: 143–8.
Hlatky MA, Boineau RE, Higginbotham MB, et al. A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J Cardiol 1989; 64: 651–4.
Nelson CL, Herndon JE, Mark DB, Pryor DB, Califf RM, Hlatky MA. Relation of clinical and angiographic factors to functional capacity as measured by Duke Activity Status Index. Am J Cardiol 1991; 68: 973–5.
Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 1977; 297: 845–50.
Lundqvist BW, Bergström R, Enghoff E, Eriksson I, Modig J, Ström G. Cardiac risk in abdominal aortic surgery. Acta Chir Scand 1989; 155: 321–8.
Steyerberg EW, Kievit J, de Mol Van Otterloo JCA, van Bockel JH, Eijkemans MJC, Habbema JDF. Perioperative mortality of elective abdominal aortic aneurysm surgery. A clinical prediction rule based on literature and individual patient data. Arch Intern Med 1995; 155: 1998–2004.
Michel LA, Jamart J, Bradpiece HA, Malt RA. Prediction of risk in noncardiac operations after cardiac operations. J Thorac Cardiovasc Surg 1990; 100: 595–605.
Miller K, Atzenhofer K, Gerber G, Reichel M. Risk prediction in operatively treated fractures of the hip. Clin Orthop 1993; 293: 148–52.
Poldermans D, Arnese M, Fioretti PM, et al. Improved cardiac risk stratification in major vascular surgery with dobutamine-atropine stress echocardiography. J Am Coll Cardiol 1995; 26: 648–53.
Mangano DT, Layug EL, Wallace A, Tateo L. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. N Engl J Med 1996; 335: 1713–20.
Wallace A, Layug B, Tateo L, et al. Prophylactic atenolol reduces postoperative myocardial ischemia. Anesthesiology 1998; 88: 7–17.
Fleisher LA. Preoperative assessment of patient with cardiovascular disease. ASA Refresher Course Lectures 1997; 144: 1–7.
Jeffrey CC, Kunsman J, Cullen DJ, Brewster DC. A prospective evaluation of cardiac risk index. Anesthesiology 1983; 58: 462–4.
Fleisher LA, Eagle KA. Screening for cardiac disease in patients having noncardiac surgery. Ann Intern Med 1996; 124: 767–72.
Zeldin RA. Assessing cardiac risk in patient who undergo noncardiac surgical procedures. Can J Surg 1984; 27: 402–4.
Larson SF, Olesen ICH, Jacobsen E, et al. Prediction of cardiac risk in non-cardiac surgery. Eur Heart J 1987; 8: 179–85.
Mangano DT, Goldman L. Preoperative assessment of patients with known or suspected coronary disease. N Engl J Med 1995; 333: 1750–6.
Mason JJ Owens DK, Harris RA, Cooke JP, Hlatky MA. The role of coronary angiography and coronary revascularization before noncardiac vascular surgery. JAMA 1995; 273: 1919–25.
Foster ED, Davis KB, Carpenter JA, Abele S, Fray D. Risk of noncardiac operation in patients with defined coronary disease: the Coronary Artery Surgery Study (CASS) registry experience. Ann Thorac Surg 1986; 41:42–50.
Freed LA, Levy D, Levine RA, et al. Prevalence and clinical outcome of mitral-valve prolapse. N Engl J Med 1999; 341: 1–7.
Naruke T, Goya T, Tsuchiya R, Suemasu K Prognosis and survival in resected lung carcinoma based on the new international staging system. J Thorac Cardiovasc Surg 1988; 96: 440–7.
Brewster DC, Geller SC, Kaufman JA, et al. Initial experience with endovascular aneurysm repair: comparison of early results with outcome of conventional open repair. J Vasc Surg 1998; 27: 992–1005.
Khuri SF, Daley J, Henderson W, et al. The National Veterans Administration Surgical Risk Study: risk adjustment for the comparative assessment of the quality of surgical care. J Am Coll Surg 1995; 180: 519–31.
Des Prez RD, Friesinger GC, Reed GW, et al. A simple accurate model of predicting myocardial infarction after general surgery (Abstract). Circulation 1995; 92: 1–744.
Palda VA, Detsky AS. Perioperative assessment and management of risk from coronary artery disease. Ann Intern Med 1997; 127: 313–28.
Christopherson R, Beattie C, Frank SM, et al. Perioperative morbidity in patients randomized to epidural or general anesthesia for lower extremity vascular surgery. Perioperative Ischemia Randomized Anesthesia Trial Study Group. Anesthesiology 1993; 79: 422–34.
Baron J-F, Bertrand M, Barré E, et al. Combined epidural and general anesthesiaversus general anesthesia for abdominal aortic surgery. Anesthesiology 1991; 75: 611–8.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Ali, M.J., Davison, P., Pickett, W. et al. ACC/AHA guidelines as predictors of postoperative cardiac outcomes. Can J Anesth 47, 10–19 (2000). https://doi.org/10.1007/BF03020725
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/BF03020725