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Ambulatory Cardiology or General Internal Medicine Assessment Before Scheduled Major Vascular Surgery Is Associated
Charles de Mestral1,2,3, Husam M Abdel-Qadir1,4,5,6, Peter C Austin1
1Cardiovascular Program, ICES, Toronto, ON, Canada.
Insights
Pre-surgery assessment by cardiology or general internal medicine (GIM) physicians is linked to better outcomes for major vascular surgery patients. This evaluation improves patient survival rates and reduces complications.
Area of Science:
- Cardiology
- Vascular Surgery
- Internal Medicine
- Health Services Research
Background:
- Cardiovascular risk assessment and management before high-risk surgery is crucial but evolving.
- Optimizing pre-operative care for major vascular surgery patients is essential for improving outcomes.
Purpose of the Study:
- To determine the association between pre-operative ambulatory cardiology or general internal medicine (GIM) assessment and outcomes in patients undergoing major vascular surgery.
- To evaluate the impact of specialist pre-surgical evaluation on patient mortality and morbidity.
Main Methods:
- Population-based retrospective cohort study of adults undergoing scheduled major vascular surgery in Ontario, Canada (2004-2019).
- Comparison of patients with and without ambulatory cardiology/GIM assessment within 6 months pre-surgery.
- Cox proportional hazard regression with inverse probability of treatment weighting (IPTW) to adjust for confounding factors.
Main Results:
- Over 50,000 patients were analyzed; 40.8% received pre-operative assessment.
- Patients with assessment had higher comorbidity scores but lower 30-day mortality (2.7% vs. 3.3%).
- IPTW analysis confirmed that cardiology or GIM assessment was associated with significantly lower 30-day mortality (HR 0.73; 95% CI 0.65-0.82) and improved secondary outcomes.
Conclusions:
- Pre-operative assessment by cardiology or GIM physicians is associated with improved outcomes for major vascular surgery patients.
- Further research is warranted to elucidate the specific mechanisms driving these improved outcomes.
Objective:
To characterize the association between ambulatory cardiology or general internal medicine (GIM) assessment before surgery and outcomes after scheduled major vascular surgery.
Background:
Cardiovascular risk assessment and management before high-risk surgery remains an evolving area of care.
Methods:
This is a population-based retrospective cohort study of all adults who underwent scheduled major vascular surgery in Ontario, Canada, from April 1, 2004 to March 31, 2019. Patients who had an ambulatory cardiology and/or GIM assessment within 6 months before surgery were compared with those who did not. The primary outcome was 30-day mortality. Secondary outcomes included: composite of 30-day mortality, myocardial infarction or stroke, 30-day cardiovascular death, 1-year mortality, composite of 1-year mortality, myocardial infarction or stroke, and 1-year cardiovascular death. Cox proportional hazard regression using inverse probability of treatment weighting was used to mitigate confounding by indication.
Results:
Among 50,228 patients, 20,484 (40.8%) underwent an ambulatory assessment before surgery: 11,074 (54.1%) with cardiology, 8071 (39.4%) with GIM, and 1339 (6.5%) with both. Compared with patients who did not, those who underwent an assessment had a higher Revised Cardiac Risk Index [N with Index over 2 = 4989 (24.4%) vs 4587 (15.4%), P < 0.001] and more frequent preoperative cardiac testing [N = 7772 (37.9%) vs 6113 (20.6%), P < 0.001], but lower 30-day mortality [N = 551 (2.7%) vs 970 (3.3%), P < 0.001]. After the application of inverse probability of treatment weighting, cardiology or GIM assessment before surgery remained associated with a lower 30-day mortality [weighted hazard ratio (95% CI) = 0.73 (0.65-0.82)] and a lower rate of all secondary outcomes.
Conclusions:
Major vascular surgery patients assessed by a cardiology or GIM physician before surgery have better outcomes than those who are not. Further research is needed to better understand potential mechanisms of benefit.
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