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Northwestern Medicine Grayslake Outpatient Center. Bluhm Cardiovascular Institute at Kishwaukee Hospital. Northwestern Medicine Cardiology Sandwich. To exclude cases in which MACCE may have preceded the primary noncardiac surgery, a sensitivity analysis was performed excluding patients who were hospitalized urgently or emergently. Similarly, a sensitivity analysis was performed in the cohort of patients who underwent noncardiac surgery within the first 72 hours of hospital admission.

Finally, due to the established risks of perioperative stroke in patients undergoing major vascular surgery, 15 a sensitivity analysis was performed excluding this high-risk cohort. The odds of MACCE over time, after multivariable adjustment for demographics, clinical covariates, and surgical type are shown in eFigure 3 in the Supplement. Similar trends in perioperative MACCE, death, AMI, and stroke were observed in a sensitivity analysis of patients who were electively hospitalized for noncardiac surgery, as well as in a sensitivity analysis of patients who underwent the principal noncardiac surgery within the first 72 hours of hospital admission eFigure 4A and B in the Supplement.

After excluding patients who underwent major vascular surgery, similar trends in perioperative MACCE and the individual endpoints were also observed eFigure 4C in the Supplement. The lowest risks were observed in patients undergoing obstetric and gynecologic surgery. After multivariable adjustment, thoracic surgery OR, 2. Black patients also had higher rates of perioperative death aOR, 1. In this analysis of In contrast, rates of perioperative ischemic stroke increased during the study timeframe. Men had higher risk of perioperative MACCE than women in unadjusted and multivariable adjusted models.

In analyses of perioperative events by race and ethnicity, non-Hispanic black patients had the highest rates of perioperative death and ischemic stroke in comparison to other racial groups. Since the publication of the initial Goldman multifactorial index of cardiac risk in , 6 adverse cardiovascular events have been recognized as a major cause of perioperative morbidity and mortality. Nearly 40 years later, efforts to identify patients at the greatest risk for perioperative MACCE and to reduce morbidity and mortality following noncardiac surgery remain ongoing. To our knowledge, this is the first study to report national data on the cardiovascular outcomes of in-hospital major noncardiac surgery in the modern era, with multivariable adjusted predictors of perioperative death, ischemic stroke, AMI, and the composite of MACCE.

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Furthermore, this is the largest analysis of time trends in perioperative cardiovascular outcomes in the United States. These may be due to improved surgical case selection, advances in the management of cardiovascular risk factors and disease, improved surgical techniques, including increased use of minimally invasive surgical interventions, improved anesthetic techniques, enhanced intraoperative monitoring, and advanced postoperative critical care.

Reductions in myocardial infarction during the study are surprising, given the increase in the sensitivity of modern cardiac biomarkers necessary for the diagnosis of myocardial infarction during the study timeframe. Stroke incidence rates have declined steadily over the past decades in the United States. The rising rates of stroke in the perioperative period may be attributable to an increased prevalence of cardiovascular risk factors of surgical patients, carotid stenosis or cerebrovascular disease, atrial arrhythmias, or changes in intraoperative hemodynamic management.


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While vascular surgery patients are likely to have the highest atherosclerotic burden and the greatest risk for ischemic complications following surgery, this strong association also raises the possibility that perhaps some patients in this cohort underwent a major vascular procedure or surgery as a consequence of ischemic stroke. After excluding patients who underwent vascular surgery, an increase in the rate of perioperative ischemic stroke over time was still observed.

This trend also persisted in sensitivity analyses of patients who were electively hospitalized for surgery, and among patients who underwent the principal noncardiac surgery within the first 72 hours of hospital admission. In these sensitivity analyses, patients were unlikely to have presented with an acute stroke prior to the primary noncardiac surgery.

There are some notable limitations of this study. First, analyses are based on administrative coding data, which may be subject to reporting bias or coding errors. Second, the analysis was limited to adults age 45 years or older, the population at risk for cardiovascular complications of noncardiac surgery. Rates of perioperative AMI are lower in this analysis than in some previously published studies, likely due to the inclusion of larger numbers of low-risk patients from the NIS data set.

However, because major noncardiac surgery is contraindicated early after AMI or stroke, patients presenting with these acute cardiovascular conditions were unlikely to undergo major noncardiac surgery during the index hospital admission. Furthermore, trends in perioperative outcomes were similar in sensitivity analyses of patients undergoing surgery during elective hospitalization. Fifth, although a history of heart failure was included in modeling, left ventricular function and other important markers of cardiovascular risk were not available for inclusion in this analysis.

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Finally, results of perioperative laboratory testing, including cardiac biomarkers, were not available from this administrative data set. Myocardial injury after noncardiac surgery, a well-described independent risk factor for short and long-term mortality, could not be ascertained and was not included in the composite outcome. To our knowledge, this is the largest analysis of perioperative MACCE in patients undergoing major noncardiac surgery in the United States. Cardiovascular complications after noncardiac surgery remain a major source of morbidity and mortality.

Despite improvements in perioperative outcomes over the past decade, the significant increase in the rate of ischemic stroke in this analysis requires confirmation and further study. Additional efforts are necessary to improve perioperative cardiovascular care of patients undergoing noncardiac surgery.

Published Online: December 28, Author Contributions: Dr Smilowitz had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Berger and Bangalore are cosenior authors and contributed equally to this article. Critical revision of the manuscript for important intellectual content: All authors.

All Rights Reserved. Figure 1. View Large Download. Table 1. Patient selection flow diagram eFigure 2. Risks of major adverse cardiovascular and cerebrovascular events over time, adjusted for demographics, clinical covariates, and surgical subtypes eFigure 4. Trends in perioperative major adverse cardiovascular and cerebrovascular events Panel A , perioperative mortality Panel B , perioperative myocardial infarction Panel C , and perioperative ischemic stroke Panel D by sex eFigure 6.

Estimate of the global volume of surgery in an assessment supporting improved health outcomes. PubMed Google Scholar Crossref. Perioperative management to reduce cardiovascular events. Cardiac complications in patients undergoing major noncardiac surgery. N Engl J Med.