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Late survival after perioperative myocardial infarction complicating vascular surgery
R A Yeager1, G L Moneta, J M Edwards
1Department of Surgery, Oregon Health Sciences University, Portland.
Purpose:
Although early death from perioperative myocardial infarction (PMI) after vascular surgery is well established, long-term outcome in patients surviving PMI is unknown. This prospective study was designed to determine cardiac outcome and survival rates in patients with symptomatic and asymptomatic nonfatal PMI associated with peripheral vascular surgery.
Methods:
During a 36-month period for 1989 to 1992, all patients undergoing vascular surgery at our institution were monitored for PMI with serial creatine kinase and myocardial band isoenzymes and electrocardiography. PMIs were classified as symptomatic (associated with chest pain, arrhythmia, congestive heart failure, or hypotension) or asymptomatic (electrocardiographic changes and/or elevated creatine kinase and myocardial band isoenzymes). Patients with PMI were then prospectively monitored and compared for late survival, with control patients undergoing vascular surgery without PMI during the same interval.
Results:
During the study period 1561 major peripheral vascular procedures were performed. There were 47 PMIs (3.0%). Eleven (0.7%) PMIs were fatal, 31 were nonfatal, and five other patients with PMI died during operation of non-heart-related causes. Eight of 31 patients with nonfatal PMI had a "chemical PMI" with creatine kinase and myocardial band isoenzyme elevation as the sole indicator of PMI. During follow-up (mean 27.7 months), there was a higher incidence of both subsequent myocardial infarction and coronary artery revascularization among the patients with nonfatal PMI compared with control subjects (p < 0.05); however, survival for patients with nonfatal PMI at 1 and 4 years (80% and 51%) did not differ from that of control patients (90% and 60%) (p > 0.05). Patients with "chemical PMI" had similar patterns of subsequent myocardial infarction and coronary intervention as control patients.
Conclusions:
Patients surviving nonfatal PMI after peripheral vascular surgery have a higher incidence of subsequent adverse cardiac events and coronary artery revascularization than patients undergoing vascular surgery without PMI, but they have similar survival rates at 1 and 4 years. Patients in the enzyme-only PMI group have a similar outcome compared with control subjects suggesting that a perioperative "chemical MI" may not be a significant clinical event.
Insights
Patients surviving perioperative myocardial infarction (PMI) after vascular surgery face more cardiac events but have similar survival rates. An enzyme-only "chemical MI" may not be clinically significant.
Area of Science:
- Cardiology
- Vascular Surgery
- Critical Care Medicine
Background:
- Perioperative myocardial infarction (PMI) is a known cause of early mortality after vascular surgery.
- Long-term outcomes for patients who survive PMI are not well-established.
- Understanding the long-term cardiac prognosis after nonfatal PMI is crucial for patient management.
Purpose of the Study:
- To determine the cardiac outcome and survival rates in patients who experienced symptomatic and asymptomatic nonfatal PMI following peripheral vascular surgery.
- To compare the long-term prognosis of PMI survivors with a control group of vascular surgery patients without PMI.
Main Methods:
- Prospective monitoring of patients undergoing peripheral vascular surgery over a 36-month period.
- Serial electrocardiography and cardiac enzyme (creatine kinase and myocardial band isoenzymes) monitoring to detect PMI.
- Classification of PMIs as symptomatic or asymptomatic, with subsequent long-term follow-up for survival and cardiac events.
Main Results:
- Out of 1561 procedures, 47 (3.0%) PMIs occurred, with 31 being nonfatal.
- Patients with nonfatal PMI showed a higher incidence of subsequent myocardial infarction and coronary artery revascularization compared to controls (p < 0.05).
- Survival rates at 1 and 4 years were similar between nonfatal PMI survivors and controls (80% vs. 90% at 1 year, 51% vs. 60% at 4 years).
Conclusions:
- Survivors of nonfatal PMI after peripheral vascular surgery experience more adverse cardiac events and interventions but maintain similar long-term survival rates as those without PMI.
- A perioperative "chemical MI" (enzyme elevation only) appears to have a similar clinical outcome to patients without PMI, suggesting it may not be a significant clinical event.