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Association between Intraoperative Hypotension and Myocardial Injury after Vascular Surgery
Judith A R van Waes1, Wilton A van Klei, Duminda N Wijeysundera
1From the Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands (J.A.R.v.W., W.A.v.K., L.v.W.); Department of Anesthesia, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada (D.N.W., W.S.B.); Department of Health Policy Management and Evaluation; Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (D.N.W.); and Division of Vascular Surgery, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada (T.F.L.).
Insights
Intraoperative hypotension (IOH), defined as a 40% drop in blood pressure for over 30 minutes, significantly increases the risk of postoperative myocardial injury in elderly vascular surgery patients. This finding highlights the importance of vigilant blood pressure monitoring during surgery.
Area of Science:
- Cardiology
- Anesthesiology
- Vascular Surgery
Background:
- Postoperative myocardial injury is common after noncardiac surgery and linked to increased mortality.
- Intraoperative hypotension (IOH) is a suspected contributor to postoperative myocardial injury.
Purpose of the Study:
- To investigate the association between intraoperative hypotension and postoperative myocardial injury in elderly patients undergoing vascular surgery.
Main Methods:
- A cohort study of 890 patients aged 60+ undergoing vascular surgery.
- Myocardial injury assessed via postoperative troponin levels.
- IOH defined using various thresholds of mean arterial blood pressure; analyzed using Poisson regression.
Main Results:
- A 40% decrease in mean arterial blood pressure from preinduction levels, lasting over 30 minutes, was significantly associated with postoperative myocardial injury (RR 1.8, 99% CI 1.2-2.6).
- Shorter durations of hypotension were not associated with injury.
- Patients with IOH (MAP < 60 mmHg) had higher rates of myocardial injury (29% vs 20%).
Conclusions:
- In elderly vascular surgery patients, IOH defined as a 40% decrease in MAP for >30 minutes is associated with postoperative myocardial injury.
- This specific definition of IOH provides a clinically relevant target for prevention strategies.
Background:
Postoperative myocardial injury occurs frequently after noncardiac surgery and is strongly associated with mortality. Intraoperative hypotension (IOH) is hypothesized to be a possible cause. The aim of this study was to determine the association between IOH and postoperative myocardial injury.
Methods:
This cohort study included 890 consecutive patients aged 60 yr or older undergoing vascular surgery from two university centers. The occurrence of myocardial injury was assessed by troponin measurements as part of a postoperative care protocol. IOH was defined by four different thresholds using either relative or absolute values of the mean arterial blood pressure based on previous studies. Either invasive or noninvasive blood pressure measurements were used. Poisson regression analysis was used to determine the association between IOH and postoperative myocardial injury, adjusted for potential clinical confounders and multiple comparisons.
Results:
Depending on the definition used, IOH occurred in 12 to 81% of the patients. Postoperative myocardial injury occurred in 131 (29%) patients with IOH as defined by a mean arterial pressure less than 60 mmHg, compared with 87 (20%) patients without IOH (P = 0.001). After adjustment for potential confounding factors including mean heart rates, a 40% decrease from the preinduction mean arterial blood pressure with a cumulative duration of more than 30 min was associated with postoperative myocardial injury (relative risk, 1.8; 99% CI, 1.2 to 2.6, P < 0.001). Shorter cumulative durations (less than 30 min) were not associated with myocardial injury. Postoperative myocardial infarction and death within 30 days occurred in 26 (6%) and 17 (4%) patients with IOH as defined by a mean arterial pressure less than 60 mmHg, compared with 12 (3%; P = 0.08) and 15 (3%; P = 0.77) patients without IOH, respectively.
Conclusions:
In elderly vascular surgery patients, IOH defined as a 40% decrease from the preinduction mean arterial blood pressure with a cumulative duration of more than 30 min was associated with postoperative myocardial injury.
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