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The influence of perioperative myocardial infarction on long-term prognosis following elective vascular surgery
E O McFalls1, H B Ward, S Santilli
1Cardiology Section, VA Medical Center, University of Minnesota, Minneapolis 55417, USA.
Insights
Perioperative myocardial infarction impacts 1-year mortality after elective vascular surgery. However, the extent of vascular disease is a stronger predictor of long-term survival in these patients.
Area of Science:
- Cardiology
- Vascular Surgery
- Outcomes Research
Background:
- Elective vascular surgery carries significant perioperative risks.
- Cardiac events are a leading cause of mortality following these procedures.
Purpose of the Study:
- To investigate the long-term impact of perioperative myocardial infarction on mortality in patients undergoing elective vascular surgery.
Main Methods:
- A 4-year follow-up study of 115 patients undergoing elective vascular procedures (abdominal aortic aneurysm or lower extremity revascularization).
- Data collected included preoperative evaluation, perioperative events, and vital status at 4 years post-surgery.
Main Results:
- Overall 4-year mortality was 39%, with cardiac causes being the most frequent (40%).
- Perioperative myocardial infarction was a marginally significant predictor of 1-year mortality.
- Non-AAA surgery and diabetes mellitus were significant predictors of 4-year mortality.
Conclusions:
- Cardiac mortality is the primary cause of late death after elective vascular surgery.
- While perioperative myocardial infarction and coronary artery disease indicators predict early mortality, the severity of vascular disease is crucial for long-term survival.
- Further research, including randomized trials, is needed to optimize treatment strategies for patients with combined coronary and vascular disease.
Study Objective:
The present study was performed to determine the influence of a perioperative myocardial infarction on long-term mortality in patients who have undergone elective vascular surgery.
Study Design:
This was a 4-year follow-up of patients who had undergone elective vascular procedures at a Veterans Affairs Medical Center. Between January 1989 and December 1990, 115 consecutive patients underwent surgery for either an expanding abdominal aortic aneurysm (AAA) (38%) or for pain in the lower extremities (62%).
Results:
Vital status at 4 years postsurgery was determined for all patients. Thirty-day postoperative mortality was 3%, while estimates at 1, 2, 3, and 4 years were 19%, 26%, 35%, and 39%, respectively. Of the 45 patients who died within 4 years following surgery, the major causes of death were cardiac (40%), cancer (18%), cerebrovascular (13%), and peripheral vascular disease (11%). Univariate predictors of 1-year mortality on preoperative evaluation were an abnormal ECG, moderate or greater sized exercise thallium defect and left ventricular ejection fraction < or =40%, and a perioperative myocardial infarction. Univariate predictors of 4-year mortality were non-AAA surgery and diabetes mellitus. Perioperative myocardial infarction was a marginally significant independent predictor of 1-year mortality (p=0.06), while the need for non-AAA surgery was a strong independent predictor at 4 years.
Conclusions:
Cardiac mortality is the major cause of late death among patients undergoing elective vascular surgery. Although preoperative indicators of symptomatic coronary artery disease and nonfatal perioperative myocardial infarction identified those individuals at increased mortality in the first postoperative year, the extent of vascular disease at presentation may be a more important determinant of long-term survival. A randomized trial in such patients is needed to assess the best strategy for treating patients with coexistent coronary artery and vascular diseases.
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