Long-Term Outcomes of Perioperative MI/Injury After Surgery
- All perioperative myocardial infarction (PMI) etiologies were associated with an increased risk of MACE and death within 1 year compared to patients without PMI.
- MACE and death rate differed substantially among PMI etiologies: 5 of 10 patients with PMI due to acute heart failure or tachyarrhythmia developed at least one MACE within 1 year, vs. 4 of 10 with T1MI, and 1.5 in 10 in lT2MI.
- These findings underscore the urgent need for more intensive treatments in these high-risk patients.
What are the major adverse cardiac events (MACE) and all-cause mortality associated with different centrally adjudicated perioperative myocardial infarction/injury (PMI) etiologies within 1 year following noncardiac surgery?
The BASEL-PMI study investigators assessed etiologies of PMIs detected within an active surveillance and response program adjudicated by two independent physicians based on all information obtained during clinically indicated PMI workup including cardiac imaging among consecutive high-risk patients undergoing major noncardiac surgery in a prospective multicenter study. PMI etiologies were hierarchically classified into ‘extracardiac’ if caused by a primarily extracardiac disease such as severe sepsis or pulmonary embolism; and ‘cardiac’, further subtyped into type 1 myocardial infarction (T1MI), tachyarrhythmia, acute heart failure (AHF), or likely type 2 myocardial infarction (lT2MI). MACE including acute myocardial infarction, AHF (both only from day 3 to avoid inclusion bias), life-threatening arrhythmia, and cardiovascular death as well as all-cause death were assessed during 1-year follow-up. The primary endpoints were the occurrence of MACE and all-cause death following different PMI etiologies within 1 year. The authors performed multivariable Cox proportional hazards analysis for first MACE and all-cause mortality in patients with PMI adjusted for: age, sex, European Society of Cardiology/European Society of Anesthesiology surgery risk (low, medium, high risk of cardiac events), revised cardiac risk index class, urgency of surgery, postoperative complications (sepsis, stroke, bleeding), center, and surgical specialty.
Among 7,754 patients (ages 45–98 years, 45% women), PMI occurred in 1,016 (13.1%). At least one MACE occurred in 684/7,754 patients (8.8%) and 818/7,754 patients died (10.5%) within 1 year. Outcomes differed starkly according to etiology: in patients with extracardiac PMI, T1MI, tachyarrhythmia, AHF, and lT2MI 51%, 41%, 57%, 64%, and 25% had MACE, and 38%, 27%, 40%, 49%, and 17% patients died within 1 year, respectively, compared to 7% and 9% in patients without PMI. These associations persisted in multivariable analysis.
The authors report that at 1 year, most PMI etiologies have unacceptably high rates of MACE and all-cause death, highlighting the urgent need for more intensive treatments.
This prospective, multinational study reports that all PMI etiologies were associated with an increased risk of MACE and death within 1 year compared to patients without PMI. Of note, the MACE and death rate differed substantially among PMI etiologies: 5 of 10 patients with PMI due to AHF or tachyarrhythmia developed at least one MACE within 1 year, vs. 4 of 10 with T1MI, and 1.5 in 10 in lT2MI. Furthermore, the vast majority of patients with PMI did not experience typical ischemic symptoms, highlighting the need for active surveillance in order to reliably detect these events. These findings also underscore the urgent need for more intensive treatments in these high-risk patients.
Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Vascular Medicine, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure
Keywords: Acute Coronary Syndrome, Arrhythmias, Cardiac, Diagnostic Imaging, General Surgery, Heart Failure, Hemorrhage, Myocardial Infarction, Myocardial Ischemia, Patient Care Team, Perioperative Care, Postoperative Complications, Pulmonary Embolism, Risk, Secondary Prevention, Sepsis, Stroke, Tachycardia
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