Changing risk of perioperative myocardial infarction

Years ago, patients with recent myocardial infarction (MI) were reported to be at high risk of reinfarction (27%) and death after surgery. Therapy has changed in the 3 decades since those reports, so we reexamined that risk as well as other cardiac comorbidities and surgical work values in predicting adverse outcome.

We used the National Surgical Quality Improvement Program Participant Use Data File for 2005 to 2009. We included all patients of all included specialties, for outpatient and inpatient surgery. Cardiac comorbidities included history of congestive heart failure (30 days) or MI (6 months), percutaneous coronary intervention, previous cardiac surgery, and history of angina (30 days). Other predictors included a frailty index and American Society of Anesthesiologists (ASA) class. Adverse cardiac events included cardiac arrest requiring cardiopulmonary resuscitation, MI, and death. Cases were stratified according to surgical work units. Univariate χ(2) analysis and multivariate logistic regression established simple relationships and interactions, with p < 0.05 significant.

Of patients who had recent MI, 2.1% had reinfarction perioperatively and 26% of those died. The odds ratio for infarction with vs without recent MI in inpatients age 40 years and older was 4.6. Frailty and ASA class were stronger predictors of perioperative MI and cardiac arrest than was history of MI, and risk increased as surgical work increased.

The risk caused by preoperative MI has improved by an order of magnitude in the last 30 years. The ASA class and especially frailty are better predictors of adverse cardiac events.