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The incidence of perioperative myocardial infarction in general vascular surgery
L M Taylor1, R A Yeager, G L Moneta
1Department of Surgery, Oregon Health Sciences University, Portland 97201.
Insights
Extensive coronary artery disease screening before vascular surgery is unnecessary for most patients. Only those with severe symptoms require further cardiac evaluation, as routine screening does not improve outcomes.
Area of Science:
- Cardiology
- Vascular Surgery
- Perioperative Medicine
Background:
- Perioperative myocardial infarction is a significant concern in general vascular surgery.
- Current guidelines suggest selective coronary artery disease (CAD) testing based on symptoms.
Purpose of the Study:
- To evaluate the incidence of perioperative myocardial infarction (MI) in general vascular surgery patients.
- To assess the effectiveness of routine cardiac screening versus selective testing in this population.
Main Methods:
- A 1-year prospective study monitoring 491 patients undergoing 534 general vascular procedures.
- Creatine phosphokinase isoenzymes and electrocardiograms (ECG) were used for monitoring.
- Intensive CAD testing was reserved for patients with severe symptomatic CAD.
Main Results:
- Twenty-one (3.9%) perioperative MIs occurred, with 4 fatal MIs.
- All 12 operative deaths, including fatal MIs, were associated with urgent/emergent procedures.
- Elective procedures had no operative deaths or fatal MIs; 2.8% nonfatal MI rate.
- Selective CAD testing in severely symptomatic patients was confirmed as appropriate.
Conclusions:
- Widespread coronary screening before vascular surgery is not cost-effective or beneficial for most patients.
- Focusing invasive cardiac testing on patients with severe symptomatic CAD is the optimal strategy.
- Elective vascular surgery patients without severe CAD have a low risk of perioperative MI.
Abstract:
In a 1-year period all patients undergoing general vascular surgery (491 patients, 534 procedures) underwent monitoring by creatine phosphokinase isoenzymes and electrocardiograms (ECG) to detect perioperative myocardial infarction. Only those patients with severe symptomatic coronary artery disease (31 patients, 5.8%) characterized by unstable angina pectoris, uncontrolled arrhythmia, or severe congestive heart failure had any testing for coronary artery disease beyond history, physical examination, and ECG. Only three patients (0.5%) had prophylactic coronary artery bypass performed before general vascular procedures. Twenty-one (3.9%) myocardial infarctions (five asymptomatic, detected by enzymes only, and 16 symptomatic, four of which were fatal) were associated with the 534 procedures (aorta 105, carotid 87, infrainguinal bypass 207, extraanatomic 51, other 84). Eight noncardiac perioperative deaths occurred. All operative deaths (12 of 534, 2.2%) including all four fatal myocardial infarctions occurred associated with surgery on an urgent or emergency basis (12 of 249 procedures, urgent/emergent operative mortality rate 4.8%). No operative deaths and no fatal myocardial infarctions associated with the 285 elective procedures occurred. Nine of the 17 nonfatal myocardial infarctions (53%) also occurred after urgent/emergent procedures. The rate of perioperative myocardial infarctions (eight of 285, 2.8%) after elective surgery in this patient series is no different from that reported by multiple recent authors advocating widespread screening for and prophylactic treatment of coronary artery disease before general vascular surgery. Our experience confirms the therapeutic approach that expensive and invasive coronary screening programs in patients to undergo vascular operations should be limited to carefully selected patients with severely symptomatic coronary disease.