Changing Risk of Perioperative Myocardial Infarction

Transcription

1 ORIGINAL RESEARCH & CONTRIBUTIONS Chnging Risk of Periopertive Myocrdil Infrction Kenneth D Lrsen, MD, PhD; Iln S Rubinfeld, MD, MBA Perm J 2012 Fll;16(4):4-9 Abstrct Introduction: Yers go, ptients with recent myocrdil infrction (MI) were reported to be t high risk of reinfrction (27%) nd deth fter surgery. Therpy hs chnged in the 3 decdes since those reports, so we reexmined tht risk s well s other crdic comorbidities nd surgicl work vlues in predicting dverse outcome. Methods: We used the Ntionl Surgicl Qulity Improvement Progrm Prticipnt Use Files for 2005 to We included ll ptients of ll included specilties, for outptient nd inptient surgery. Crdic comorbidities included history of congestive hert filure (30 dys) or MI (6 months), percutneous coronry intervention, previous crdic surgery, nd history of ngin (30 dys). Other predictors included frilty index nd Americn Society of Anesthesiologists (ASA) clss. Adverse crdic events included crdic rrest requiring crdiopulmonry resuscittion, MI, nd deth. Cses were strtified ccording to surgicl work units. Univrite χ 2 nlysis nd multivrite logistic regression estblished simple reltionships nd interctions, with p < 0.05 significnt. Results: Of ptients who hd recent MI, 2.1% hd reinfrction periopertively nd 26% of those died. The odds rtio for infrction with vs without recent MI in inptients ge 40 yers of ge nd older ws 4.6. Frilty nd ASA clss were stronger predictors of periopertive MI nd crdic rrest thn ws history of MI, nd risk incresed s surgicl work incresed. Discussion: The risk becuse of preopertive MI hs improved by n order of mgnitude in the lst 30 yers. The ASA clss nd especilly frilty re better predictors of dverse crdic events. Introduction Hlf of periopertive mortlity is sid to be becuse of mjor dverse crdic events. 1 Numerous efforts hve been mde to identify who is t risk nd to wht degree. For exmple, Goldmn et l 2 prospectively studied 1001 ptients older thn ge 40 yers who were undergoing noncrdic surgery. Of those who hd myocrdil infrction (MI) in the 6 months preceding surgery, 27.3% hd periopertive MI or crdic deth. Of those ptients who hd n MI more thn 6 months before surgery or hd no previous MI (there ws no difference in outcome for the 2 groups), 2.8% hd periopertive MI or crdic deth. Numerous studies from the 1960s through the 1980s found similr risk of preexisting crdic disese, with mortlity becuse of periopertive MI t bout 50%, s reviewed by Mngno. 3 On the bsis of this risk, nesthesiologists recommended ginst ll but urgent surgery until 6 months elpsed fter n MI. Some studies in the 1980s, however, found less risk of previous MI. For exmple, Ro et l 4 found tht of 195 ptients with previous infrct, 10 (5.1%) hd periopertive MI. However, they monitored most of their ptients (except minor surgery lsting less thn 30 minutes) with n rteril line nd pulmonry rtery ctheter nd ggressively treted them in the intensive cre unit for severl dys postopertively, n expensive therpy tht is not stndrd of cre nd hs not been duplicted in subsequent reserch. During the lst 30 yers, medicl therpy hs chnged, with sttins, β-blockers, nd spirin becoming more stndrd; interventionl therpy hs dvnced with coronry rtery stents nd coronry rtery bypss using the internl mmmry rtery; nesthetic prctice hs chnged; nd surgeons hve dopted less invsive pproches. Periopertive MI remins contributor to periopertive morbidity nd mortlity, yet we found only one study in recent yers exmining the risk of previous MI on postopertive mortlity. 5 As the demogrphics of the surgicl popultion chnge, ge or single risk fctors such s MI lone s cuity djustors re indequte. Clinicins re ssessing risk in incresingly stndrdized wys. 6-9 For exmple, 50-yer-old ptient with congestive hert filure (CHF) nd dibetes with renl filure is more worrisome thn n octogenrin still working nd living independently. A frilty index is single score bsed on stndrdized ssessment of multiple mesures, but the Americn Society of Anesthesiologists (ASA) clss incorportes similr informtion except in subjective wy. The ASA clss is useful becuse it is simple nd widely known, but it suffers from interuser vribility. 10 Frilty is proving to be powerful predictor of surgicl morbidity nd mortlity. 11 Dt from the Ntionl Surgicl Qulity Improvement Progrm (NSQIP) hve been used extensively to evlute surgicl risk nd improve outcomes. 12,13 NSQIP collects dt in uniform wy from more thn 250 hospitls round the US nd Cnd. Trined nurse reviewers submit ll of the dt, nd sites re reviewed to ensure interrter relibility. A vlidted smpling method is used to collect dt on brod vriety of cses, nd outcomes re trcked for 30 dys. It represents highly relible dtset tht llows us to reexmine the risk of previous MI on postopertive outcome, to determine whether tht risk hs chnged, nd to mesure the role of other crdic comorbidities. Kenneth D Lrsen, MD, PhD, is n Anesthesiologist t the Kiser Sunnyside Medicl Center in Clckms, OR. E-mil: kenneth.lrsen@kp.org. Iln S Rubinfeld, MD, MBA, is n Attending Physicin in Trum nd Criticl Cre nd Acute Cre Surgery t Henry Ford Hospitl in Detroit, MI. He is lso Assistnt Professor of Surgery, Wyne Stte University School of Medicine; Associte Progrm Director, Generl Surgery Residency, Henry Ford Hospitl; nd Associte Medicl Director, Surgicl Intensive Cre, Henry Ford Hospitl. E-mil: irubinfeld@yhoo.com. 4 The Permnente Journl/ Fll 2012/ Volume 16 No. 4

2 Chnging Risk of Periopertive Myocrdil Infrction ORIGINAL RESEARCH & CONTRIBUTIONS Methods We developed dtset using five yers of NSQIP Prticipnt Use Dt (2005 to 2009). Vribles from the comorbidites tht were most consistent with crdic history were identified nd re listed in Tble 1. Adverse events relted to the hert were similrly identified (Tble 1). Univrite nlysis using χ 2 test ws performed with ll comorbidities predicting ech dverse event. Multivrite logistic regression nlysis ws performed to ccount for preopertive conditions tht my hve ffected outcomes, s well s to look for interctions between the crdic risk vribles. Vribles known from the NSQIP seminnul reports to be highly predictive of crdic risk were included in the model. These vribles were preopertive lbumin level, emergency sttus of the opertion, ASA clssifiction, nd wound clss. We lso used simplified frilty index, which ws recently developed nd described elsewhere, 14 nd ws modified from the Cndin Study of Helth nd Aging Frilty Index 15 to use NSQIP dt. This index included the following: 1) nonindependent functionl sttus; 2) history of dibetes mellitus; 3) history of either chronic obstructive pulmonry disese or pneumoni; 4) history of CHF; 5) history of MI; 6) history of percutneous coronry intervention, crdic surgery, or ngin; 7) hypertension requiring the use of medictions; 8) peripherl vsculr disese or rest pin ; 9) impired sensorium; 10) trnsient ischemic ttck or cerebrovsculr ccident without residul deficit; nd 11) cerebrovsculr ccident with deficit. Finlly, we strtified ptients ccording to surgicl work (in reltive vlue units, [RVUs]), 16 divided into groups of fewer thn 10, 10 to 20, nd more thn 20 RVUs, nd we exmined the incidence of periopertive MI nd deth. All sttisticl nlysis ws performed using SPSS version 20 (IBM SPSS, Armonk, NY). A p vlue of <0.05 ws considered sttisticlly significnt. The study ws done with the pprovl Tble 1. Comorbidities nd dverse events Comorbidities nd dverse events Comorbidity CHF in 30 dys before surgery Definition YES is entered for ptients with CHF, which is the inbility of the hert to pump sufficient quntity of blood to meet the metbolic needs of the body or the bility to do so only t incresed ventriculr filling pressure. Only newly dignosed CHF within the previous 30 dys or dignosis of chronic CHF with new signs or symptoms in the 30 dys before surgery fulfills this definition. History of MI 6 months before surgery Previous PCI Previous crdic surgery History of ngin in one month before surgery Common mnifesttions re bnorml limittion in exercise tolernce becuse of dyspne or ftigue; orthopne (dyspne on lying supine); proxysml nocturnl dyspne (wkening from sleep with dyspne); incresed jugulr venous pressure; pulmonry rles on physicl exmintion; crdiomegly; nd pulmonry vsculr engorgement. YES is entered for ptients with history of non-q-wve or Q-wve infrct in the 6 months before surgery s dignosed in the ptient s medicl record. YES is entered for ptients who hve undergone PCI t ny time (including ny ttempted PCI). This includes either blloon diltion or stent plcement. This does not include vlvuloplsty procedures. YES is entered if the ptient hs hd ny mjor crdic surgicl procedures (performed either s n off-pump repir or using crdiopulmonry bypss). This includes coronry rtery bypss grft surgery, vlve replcement or repir, repir of tril or ventriculr septl defects, gret thorcic vessel repir, crdic trnsplnt, left ventriculr neurysmectomy, insertion of left ventriculr ssist devices, etc. Not included re pcemker insertions or AICD insertions. YES is entered if ptient reports pin or discomfort between the diphrgm nd the mndible resulting from myocrdil ischemi. Typiclly, ngin is dull, diffuse (fistsized or lrger) substernl chest discomfort precipitted by exertion or emotion nd relieved by rest or nitroglycerine. Rdition to the rms nd shoulders often occurs, nd occsionlly to the neck, jw (mndible, not mxill), or interscpulr region. Adverse event MI Crdic rrest requiring CPR Deth For ptients receiving ntinginl medictions, YES is entered only if the ptient hs hd ngin t ny time within one month before surgery. A new trnsmurl cute MI occurring during surgery or within 30 dys s mnifested by new Q wves on ECG The bsence of crdic rhythm or presence of chotic crdic rhythm tht results in loss of consciousness requiring the initition of ny component of bsic nd/or dvnced crdic life support within 30 dys of the opertion. Any ptient with n AICD tht fires but the ptient hs no loss of consciousness should be excluded. Deth within 30 dys of index opertion AICD = utomtic implntble crdioverter defibrilltor; CHF = congestive hert filure; CPR = crdiopulmonry resuscittion; ECG = electrocrdiogrm; MI = myocrdil infrction; PCI = percutneous coronry intervention. The Permnente Journl/ Fll 2012/ Volume 16 No. 4 5

3 ORIGINAL RESEARCH & CONTRIBUTIONS Chnging Risk of Periopertive Myocrdil Infrction Figure 1. Age Distribution of inptients ge 40 yers nd older. of Henry Ford Hospitl s internl review bord s well s under the Dt Use Agreement of the Americn College of Surgeons. Results The NSQIP study popultion collected between 2005 nd 2009 includes 971,455 ptients. The frequencies of comorbidities were s follows: 1% CHF in the previous 30 dys, 0.7% recent MI (in the 6 months before surgery), 5.4% previous percutneous coronry intervention, 5.9% previous mjor crdic surgery, nd 1% ngin in previous 30 dys. Adverse events within 30 dys fter surgery were 0.3% MI, 0.4% crdic rrest requiring crdiopulmonry resuscittion, nd 1.7% deth. To nlyze postopertive morbidity, we selected 2 subpopultions: 1) ptients ged 40 yers nd older nd (2) inptients ged 40 yers nd older. The ge distribution of the inptients ged 40 yers nd older is illustrted in Figure 1, with ptients ged 80 yers nd older in one of the ctegories. The ASA clss of these inptients ws s follows: 3.0% ASA Clss 1, 35.6% ASA 2, 49.7% ASA 3, 11.0% ASA 4, nd 0.5% ASA 5. Of 782,240 ptients ged 40 yers nd older, 775,165 hd no MI within 6 months before surgery, nd 2540 (pproximtely 0.3%) of those hd n MI periopertively (Tble 2). Of the 7075 ptients who hd recent MI, 148 (2.1%) hd periopertive MI. The odds rtio (OR) for periopertive MI given recent preopertive MI ws 6.5 (confidence intervl [CI], 5.5 to 7.7). For 525,469 inptients ged 40 yers nd older 2462 of 518,819 (0.5%) with no recent MI hd periopertive MI, wheres 142 of 6650 (2.1%) with recent MI hd periopertive MI (Tble 2). The OR of periopertive MI given recent preopertive MI ws 4.6 (CI, ). In the group of inptients ged 40 yers nd older, 2604 hd n MI nd 674 (25.9%) of them died within 30 dys of surgery vs 14,995 (2.9%) who died within 30 dys but did not hve n MI. Tble 2. Periopertive myocrdil infrction with or without history of recent myocrdil infrction Ptient popultion History of MI No history of MI b Totl OR (95% CI) Totl NSQIP popultion 149/7198 (2.0) 2665/964,257 (0.3) 2814/971,455 (0.3) 8.2 ( ) Age 40 yers 148/7075 (2.1) 2540/775,165 (0.3) 2688/782,240 (0.3) 6.5 ( ) Inptients ged 40 yers 142/6650 (2.1) 2462/518,819 (0.5) 2604/525,469 (0.5) 4.6 ( ) Ptients with MI within six months preceding surgery. Vlues re the number of periopertive MIs/number in grouop (percentge). b Ptients with no MI within six months preceding surgery. Vlues re the number of periopertive MIs/number in group (percentge). CI = confidence intervl; MI = myocrdil infrction; NSQIP = Ntionl Surgicl Qulity Improvement Progrm; OR = odds rtio. Tble 3. Logistic regression of risk fctors for crdic rrest Risk fctor B SE Wld χ 2 df p vlue b Exp(B) Lower CI Upper CI CHF Recent MI PCI PCS History of ngin ASA Clss Emergency surgery Frilty c Wld χ 2 test of the null hypothesis tht the coefficient equls zero. b Sttisticl significnce is p < c See Methods for description of frilty index. ASA = Americn Society of Anesthesiologists; B = coefficient for the logistic regression eqution for predicting the dependent vrible from the independent vrible: log (p/1 p) = B 0 + B 1 x X 1 + B 2 x X 2 + B 3 x X 3 + B n x X n where p is the probbility of crdic rrest; CHF = congestive hert filure; CI = confidence intervl; df = degrees of freedom for the Wld χ 2 test; Exp(B) exponentition of the B coefficient, n odds rtio; MI = myocrdil infrction; PCI = percutneous coronry intervention; PCS = previous crdic surgery; SE = stndrd error round the coefficient. 6 The Permnente Journl/ Fll 2012/ Volume 16 No. 4

4 Chnging Risk of Periopertive Myocrdil Infrction ORIGINAL RESEARCH & CONTRIBUTIONS Tble 4. Logistic regression of risk fctors for periopertive myocrdil infrction Risk fctor B SE Wld χ 2 df p vlue b Exp(B) Lower CI Upper CI CHF Recent MI PCI PCS History of ngin ASA Clss Emergency surgery Frilty c Wld χ 2 test of the null hypothesis tht the coefficient equls zero. b Sttisticl significnce is p < c See Methods for description of frilty index. ASA = Americn Society of Anesthesiologists; B = coefficient for the logistic regression eqution for predicting the dependent vrible from the independent vrible: log (p/1 p) = B 0 + B 1 x X 1 + B 2 x X 2 + B 3 x X 3 + B n x X n where p is the probbility of crdic rrest; CHF = congestive hert filure; CI = confidence intervl; df = degrees of freedom for the Wld χ 2 test; Exp(B) exponentition of the B coefficient, n odds rtio; MI = myocrdil infrction; PCI = percutneous coronry intervention; PCS = previous crdic surgery; SE = stndrd error round the coefficient. The OR of ptient dying whether or not s/he hd periopertive MI ws We lso did logistic regression nlysis of possible risk fctors for periopertive crdic rrest (Tble 3) nd periopertive MI (Tble 4), including recent CHF, recent MI, history of percutneous coronry intervention, history of previous mjor crdic surgery, recent ngin, ASA clss, emergency surgery, nd frilty index. Frilty nd ASA clss were the strongest predictors of crdic rrest; the OR Exp(B) for frilty ws 26.4, nd the ORs for ASA Clsses 3, 4, nd 5 were 1.2, 3.5, nd 7.5, respectively. For periopertive MI, frilty nd ASA clss lso were the most powerful predictors, with the OR for frilty being 41.8, nd the ORs for ASA Clsses 3, 4, nd 5 being 6.9, 12.3, nd 14.9, respectively. Finlly, we exmined outcomes (periopertive MI nd deth) in inptients ged 40 yers or older strtified by surgicl complexity (RVUs). As surgicl RVUs incresed, the incidence of periopertive MI incresed in ptients with nd without history of recent MI, but the incidence ws greter in those with recent MI (Tble 5). Also, s surgicl RVUs incresed, the incidence of deth incresed (Tble 5). The incidence of deth ws greter in those with history of recent MI; however, mny deths were noncrdic. For exmple, in the highest RVU group there were 73 periopertive MIs nd 408 deths (Tble 5) in the ptients with recent MI. In the mid- nd high-rvu ctegories, 14% to 16% of ptients with recent MI died even though only 1.9% to 2.5% of them hd nother MI fter surgery. In ll RVU ctegories except the lowest RVUs with no history of recent MI, the incidence of deth ws severl-fold greter thn the incidence of periopertive MI. Discussion In the decdes since the study by Goldmn et l, 2 our dt show the bsolute nd reltive risk of periopertive MI nd deth hs decresed. The bsolute risk of periopertive MI for ptients with recent MI hs decresed by n order of mgnitude from 27.3% to 2.1%. The risk of periopertive MI for ptients with recent MI hs improved, but so hs the risk for ptients without recent MI by n order of mgnitude from 2.8% to 0.3%. Our dt do not llow us to nlyze wht ccounts for this improvement, but the reson is likely multifctoril. Goldmn et l 2 did not report n OR, but we clculted this rtio from their dt. Of 22 ptients with recent preopertive MI, 6 hd periopertive MI or crdic deth, nd of 973 without recent preopertive MI, 26 hd periopertive MI or crdic deth. The OR, therefore, ws 9.7 for risk of periopertive MI or crdic deth given preopertive MI. The OR of periopertive MI for ptients with vs without recent MI hs decresed from the 9.7 clculted from the dt by Goldmn et l. Which popultion one chooses to compre could be either ll ptients ged 40 yers nd older or inptients ged 40 yers nd older. Surgicl prctice hs chnged so tht some ptients who would hve been inptients in the 1970s would now be outptients. Nonetheless, n OR between 4.7 (inptients only) nd 6.5 (inptients nd outptients) in our dt seems n pproprite comprison nd is substntilly less thn 9.7. Not only is the bsolute risk improved but lso the reltive risk for ptients with preexisting crdic disese is reduced by t lest one third, if not one hlf. The risk of periopertive MI for ptient who hd recent preopertive MI hs fllen from 9.7 times greter thn tht of ptient who hd no recent MI to 4.7 to 6.5 times greter. The inhospitl mortlity for periopertive MI ws pproximtely 50% in the erlier studies. 3 In our dt, 30-dy mortlity fter periopertive MI ws 25.9%. Although this number is n improvement, it is still high nd remins serious concern. Also, The Permnente Journl/ Fll 2012/ Volume 16 No. 4 7

5 ORIGINAL RESEARCH & CONTRIBUTIONS Chnging Risk of Periopertive Myocrdil Infrction delyed morbidity for this popultion remins high. Ptients surviving n inhospitl MI hd 28-fold increse in crdic complictions within 6 months of surgery. 17 Recent studies of ptients undergoing vsculr surgery hve lso reported mortlity from periopertive MI s below 50%, finding 16% to 21% mortlity. 18,19 Previous coronry rtery bypss grfting, even more thn yer before vsculr surgery, hs been reported to reduce the risk of crdic mortlity, 19 but McFll et l 20 found tht bypss grfting did not decrese reinfrction or mortlity in mjor vsculr surgery. We focused on recent MI s predictor of outcome for historicl comprison nd found tht 2% of ptients with recent MI will experience reinfrction, but others hve used known coronry rtery disese (CAD) or CAD risk fctors s predictors of outcome. Mngno et l 21 showed tht those with risk fctors who were treted with tenolol hd 6-month mortlity of 0% wheres those not treted hd 8% mortlity. At-risk ptients of Wllce et l 22 hd 2% 30-dy mortlity when treted with tenolol. Bdner et l 23 found t-risk ptients hd 5.6% periopertive MI (17% ftl). Lee et l 6 reported 2% of t-risk ptients hd mjor crdic events periopertively. Most impressively, Wllce et l 22 illustrted reduction in 30-dy ll-cuse mortlity fter surgery from 1% in 1996 to 0.4% in 2008 (vs 1.7% in our totl popultion), wheres 1-yer mortlity fell from 16% to 4% in their study popultion, which included t-risk nd low-risk ptients. All mesures of periopertive morbidity nd mortlity for ptients with history of MI (preexisting CAD) hve improved in the bove cited studies compred with those from the 1970s. In ddition, crdic events seem no longer to ccount for hlf of periopertive morbidity since our inptients 40 yers of ge nd older hd 2604 periopertive MIs nd 15,669 deths. Nonetheless, recent preopertive MI still must be viewed s serious risk fctor. 1,3 An OR greter thn 1 signifies elevted risk, nd the much-improved risk we report is still considerble nd requires continuing diligent cre. The improvement in outcomes we mesured is not mtched by tht observed by Livhits et l, 5 who collected dt in Cliforni between 1999 nd When MI occurred in the 1 month before surgery, they found 33% reinfrction, with nerly hlf of those ptients dying (14% mortlity), similr to 1970s outcomes. Our dt recorded MI in the 6 months before surgery, but not in 30-dy increments so we cnnot compre with tht finding. At 3 to 6 months fter MI, Livhits et l found 6% reinfrction, showing decrese in risk with time from preopertive MI, lthough still higher thn wht we observed. 5 Even when we nlyzed outcomes by surgicl RVU, ptients in the highest RVU ctegory with history of recent MI hd reinfrction rte of only 2.5%. The selected study popultion of Livhits et l, composed of ptients hving 5 mjor opertions, seems not the sme s ours becuse 2.9% of their ptients hd n MI in the yer before surgery wheres 1.2% of our inptients ge 40 yers nd older hd n MI in the preceding 6 months, nd their ptients men ge ws 69 yers wheres tht of our group of inptients ged 40 nd older ws 63 yers. For the purpose of evluting chnge in outcomes compred with older studies, we believe our popultion of inptients ged 40 yers nd older is more suitble. Livhits et l ppropritely recommend delying elective surgery fter MI by t lest 8 weeks, using temporizing mesures if necessry. Frilty, other indexes, nd screening procedures hve been proposed s wys to strtify periopertive risk. 6-9,14 We found tht risk incresed s surgicl RVUs incresed, but ptient fctors ccount for opertive mortlity in ll but the most complex cses. 24 In our dt the multifctoril mesures of frilty nd ASA clss were better predictors of dverse outcome thn single fctors such s history of MI. In summry, we exmined the risk of previous MI nd other risk fctors on periopertive crdic morbidity using the NSQIP dtbse. The risk of periopertive mjor crdic events hs improved by n order of mgnitude during the lst 30 yers. Crdic events remin mjor contributor to morbidity nd mortlity, but now re closer to one fifth rther thn the previously reported one hlf of periopertive mortlity. Frilty nd ASA clss re the more powerful predictors of dverse outcome. v Tble 5. Periopertive myocrdil infrction nd deth by reltive vlue units ctegory nd history of recent myocrdil infrction Surgicl RVU Recent history No Periop MI no. (%) Periop MI no. (%) c 2 OR (95% CI) No Deth no. (%) Deth no. (%) c 2 OR (95% CI) <10 No MI 63,265 (99.8) 149 (0.2) ,384 (98.4) 103 (1.6) (n = 64,119) MI 693 (98.3) 12 (1.7) ( ) 639 (90.6) 66 (9.4) ( ) No MI 235,321 (99.6) 871 (0.4) ,187 (97.5) 6005 (2.5) (n = 239,234) MI 2985 (98.1) 57 (1.9) ( ) 2566 (84.4) 476 (15.6) ( ) >20 No MI 217,771 (99.3) 1442 (0.7) ,529 (96.5) 7684 (3.5) (n = 222,116) MI 2830 (97.5) 73 (2.5) ( ) 2495 (85.9) 408 (14.1) ( ) Totl No MI 516,357 (99.5) 2462 (0.5) ,100 (97.2) 14,719 (2.8) (N = 525,469) MI 6508 (97.9) 142 (2.1) ( ) 5700 (85.7) 950 (14.3) ( ) Periopertive indictes during or within 30 dys fter surgery, deth ws for tht occurring within 30 dys fter surgery, nd recent indictes within 6 months before surgery. CI = confidence intervl; MI = myocrdil infrction; OR = odds rtio; Periop = periopertive; RVU = reltive vlue units. 8 The Permnente Journl/ Fll 2012/ Volume 16 No. 4

6 Chnging Risk of Periopertive Myocrdil Infrction ORIGINAL RESEARCH & CONTRIBUTIONS Disclosure Sttement The uthor(s) hve no conflicts of interest to disclose. Acknowledgment Kthleen Louden, ELS, of Louden Helth Communictions provided editoril ssistnce. References 1. Devereux PJ, Goldmn L, Cook DJ, Gilbert K, Leslie K, Guytt GH. Periopertive crdic events in ptients undergoing noncrdic surgery: review of the mgnitude of the problem, the pthophysiology of the events nd methods to estimte nd communicte risk. CMAJ 2005 Sep 13;173(6): DOI: 2. Goldmn L, Clder DL, Southwick FS, et l. Crdic risk fctors nd complictions in non-crdic surgery. Medicine (Bltimore) 1978 Jul;57(4): Mngno DT. Periopertive crdic morbidity. Anesthesiology 1990 Jn;72(1): DOI: Ro TK, Jcobs KH, El-Etr AA. Reinfrction following nesthesi in ptients with myocrdil infrction. Anesthesiology 1983 Dec;59(6): DOI: 5. Livhits M, Ko CY, Leonrdi MJ, Zingmond DS, Gibbons MM, de Virgillo C. Risk of surgery following recent myocrdil infrction. Ann Surg 2011 My; 253(5): DOI: 6. Lee TH, Mrintonio ER, Mngione CM, et l. Derivtion nd prospective vlidtion of simple index for prediction of crdic risk of mjor noncrdic surgery. Circultion 1999 Sep 7;100(10): DOI: org/ / 01.CIR Sxton A, Velnovich V. Preopertive frilty nd qulity of life s predictors of postopertive complictions. Ann Surg 2011 Jun;253(6): DOI: 8. Willims FM, Bergin JD. Crdic screening before noncrdic surgery. Surg Clin North Am 2009;89(4):747-62,vii. DOI: suc Muck KF, Mnjrrez EC, Cohn SL. Periopertive crdic evlution: ssessment, risk reduction, nd compliction mngement. Clin Geritr Med 2008 Nov;24(4): ,vii. DOI: cger Owens WD, Felts JA, Spitzngel EL. ASA physicl sttus clssifictions: study of consistency of rtings. Anesthesiology 1978 Oct;49(4): DOI: Frhrt JS, Velnovich V, Flvo AJ, et l. Are the fril destined to fil? Frilty index s predictor of surgicl morbidity nd mortlity in the elderly. J Trum Acute Cre Surg 2012;72(6): DOI: TA.0b013e fb. 12. Webb S, Rubinfeld I, Velnovich V, Horst HM, Reickert C. Using Ntionl Surgicl Qulity Improvement Progrm (NSQIP) dt for risk djustment to compre Clvien 4 nd 5 complictions in open nd lproscopic colectomy. Surg Endosc 2012 Mr;26(3): DOI: s Itni KM. Fifteen yers of the Ntionl Surgicl Qulity Improvement Progrm in review. Am J Surg 2009 Nov;198(5 Suppl):S9-S18. org/ /j.mjsurg Obeid N, Azuh O, Reddy S, et l. Predictors of criticl cre-relted complictions in colectomy ptients using the Ntionl Surgicl Qulity Improvement Progrm: exploring frilty nd ggressive lproscopic pproches. J Trum Acute Cre Surg 2012 Apr;72(4): DOI: TA.0b013e31824d0f Rockwood K, Song X, McKnight C, et l. A globl clinicl mesure of fitness nd frilty in elderly people. CMAJ 2005 Aug 30;173(5): DOI: Ntionl physicin fee schedule reltive vlue file. Wshington, DC: Centers for Medicre nd Medicid Services, US Deprtment of Helth nd Humn Services; Mngno DT, Bowner Ws, Hollenberg M, et l. Long-term crdic prognosis following non-crdic surgery: The Study of Periopertive Ischemi Reserch Group. JAMA 1992 Jul 8;268(2): DOI: jm Bode RH Jr, Lewis KP, Zrick SW, et l. Crdic outcome fter peripherl vsculr surgery: Comprison of generl nd regionl nesthesi. Anesthesiology 1996 Jn;84(1):3-13. DOI: Sprung J, Abdelmlk B, Gottlieb A, et l. Anlysis of risk fctors for myocrdil infrction nd crdic mortlity fter mjor vsculr surgery. Anesthesiology 2000 Jul;93(1): DOI: org/ / McFll ED, Wrd HB, Moritz TE, et l. Coronry rtery revsculriztion before elective mjor vsculr surgery. N Engl J Med 2004 Dec 30;351(27): DOI: Mngno DT, Lyug EL, Wllce A, Tteo I. Effect of tenolol on mortlity nd crdiovsculr morbidity fter non-crdic surgery: Multicenter Study of Periopertive Ischemi Reserch Group. New Engl J Med 1996 Dec 5; 335(23): DOI: Wllce AW, Au S, Cson BA. Assocition of the pttern of use of periopertive β-blockde nd postopertive mortlity. Anesthesiology 2010 Oct;113(4): DOI: ALN.0b013e3181f1c Bdner NH, Knill RL, Brown JE, Novick TV, Gelb AW. Myocrdil infrction fter noncrdic surgery. Anesthesiology 1998 Mr;88(3): DOI: dx.doi.org/ / Errtum in: Anesthesiology 1999 Feb;90(2): Aust JB, Henderson W, Khuri S, Pge CP. The impct of opertive complexity on ptient risk fctors. Ann Surg 2005 Jun; 241(6): DOI: dx.doi.org/ /01.sl dd. The Permnente Journl/ Fll 2012/ Volume 16 No. 4 9