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CARDIOVASCULAR ANESTHESIA

Adverse Cardiac Outcomes After Noncardiac Surgery in Patients with Prior Percutaneous Transluminal Coronary Angioplasty

Department of Anesthesiology, University of Washington, Seattle, Washington

Address correspondence and reprint requests to Karen L. Posner, PhD, Department of Anesthesiology, University of Washington, Box 356540, Seattle, WA 98195-6540. Address e-mail to posner{at}u.washington.edu

	Abstract

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In this retrospective cohort study, we compared adverse cardiac outcomes after noncardiac surgery among patients with prior percutaneous transluminal coronary angioplasty (PTCA), patients with nonrevascularized coronary artery disease (CAD), and normal controls. Inpatient hospital discharge abstracts from all nonfederal acute care hospitals in Washington State linked to death certificates were evaluated. Patients 45 yr old with prior PTCA who underwent noncardiac surgery from 1987 to 1993 were matched by age, sex, surgery type, and discharge year to 686 patients with CAD and to 2155 normal controls (no CAD). We compared risk for adverse cardiac outcomes (death, myocardial infarction, angina, congestive heart failure, malignant dysrhythmia, cardiogenic shock, coronary artery bypass graft, or PTCA) within 30 days. Patients with PTCA had twice the risk of adverse cardiac outcome as normal controls (odds ratio [OR] 1.98;

P < 0.001), with a higher risk of angina (OR 7.84), congestive heart failure (OR 2.06), and myocardial infarction (OR 3.86) but a lower risk of death (OR 0.46; P < 0.001). Patients with PTCA had half the risk of adverse cardiac outcome as patients with CAD (OR 0.50; P < 0.001), including less risk of angina (OR 0.51) and congestive heart failure (OR 0.40; P < 0.001), but no difference in myocardial infarction (P = 0.304) or death (P = 0.436). No difference was found between 142 patients with recent PTCA (90 days before noncardiac surgery) matched to patients with CAD (OR 0.90; P = 0.396). Patients revascularized by PTCA >90 days before noncardiac surgery seem to have a lower risk of poor outcome than nonrevascularized patients, although not as low as normal controls. For recent PTCA patients, the lack of difference compared with CAD patient outcomes requires a larger sample size for verification. Present findings do not lend support to a role for prophylactic PTCA to improve noncardiac surgery outcomes. This investigation did not control for CAD severity, medical management, or comorbidities. Study of these factors is needed before the clinical implications of PTCA for noncardiac surgical risk can be completely assessed.

Implications: Hospital records showed patients with prior percutaneous transluminal coronary angioplasty were twice as likely as healthy patients to have an adverse cardiac outcome after noncardiac surgery, although their risk was reduced by half compared with patients with untreated coronary artery disease. Further study of the role of percutaneous transluminal coronary angioplasty in modulating noncardiac surgery risk is needed.

	Introduction

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Perioperative myocardial infarction is a major source of morbidity and mortality after noncardiac surgery. An estimated 1 million patients in the United States present for noncardiac surgery with a history of coronary artery disease (CAD) and 7–8 million of the 25 million annual noncardiac surgical procedures in the United States are performed on patients at high risk of perioperative cardiac complications (1). Although it has been recommended that patients with significant CAD undergo prophylactic percutaneous transluminal coronary angioplasty (PTCA) (2,3) or coronary artery bypass graft (CABG) before noncardiac surgery, there has been little research to support this approach (4), or to compare the noncardiac surgery outcomes of patients with prior PTCA, CABG, medical treatment, or no treatment of CAD before noncardiac surgery. Although the cost and outcomes associated with various CAD treatment methods have been the focus of recent research, the cardiac risks faced by patients with CAD undergoing noncardiac surgery have not been adequately assessed (5). There are little data concerning the relative risk of an adverse cardiac event after noncardiac surgery for revascularized patients with CAD compared with nonrevascularized patients with CAD or patients without CAD (1).

This study used Washington State hospital discharge abstract and vital statistics data to compare the rate of adverse cardiac events after noncardiac surgery among patients with CAD revascularized by PTCA with nonrevascularized patients with CAD and with patients without CAD. Two hypotheses were investigated:

1.PTCA-revascularized patients are more likely to have an adverse cardiac event after noncardiac surgery than patients without CAD.

2.PTCA-revascularized patients are less likely to have an adverse cardiac event after noncardiac surgery than nonrevascularized patients with CAD.

	Methods

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The Washington State episode of illness database was the primary data source. This database contains discharge abstract data for all patients hospitalized in nonfederal acute care hospitals in Washington State from 1987 to 1993. Discharge abstracts include a maximum of nine diagnosis codes and six procedure codes. These data were linked to date and cause of death from the death and illness database. After human subjects review board approval, the Department of Health provided three data files:

1.All records of patients with a noncardiac surgical admission after an admission for PTCA (PTCA group). The first noncardiac surgery admission after PTCA was tagged as the index admission. Noncardiac surgery on the same admission as PTCA was excluded.

2.Records of normal control patients matched by age, sex, and year of index noncardiac surgery to the PTCA group. "Normal control" was defined as no diagnosis of CAD, PTCA, or CABG before or concurrent with the index noncardiac surgical admission.

3.Records of patients aged 45 yr with a diagnosis of CAD before or concurrent with an index noncardiac surgery admission but no history of prior or concurrent PTCA or CABG.

The matching of nonrevascularized patients with CAD to the PTCA group was performed by study staff.

Patients in the PTCA group (n = 2980) were matched on a 1:1 ratio to normal controls by age (within 10 yr), sex, type of noncardiac surgery, and year of index admission. Type of noncardiac surgery was defined by International Classification of Diseases (ICD)-9-CM procedure code grouped by body system into 14 noncardiac surgery groups. Type 7 (cardiovascular system) and Type 16 (miscellaneous diagnostic procedures) were excluded. The validity of this grouping for surgical risk matching was checked by repeating data analysis on the subsets of patients matched by Agency for Health Care Policy and Research Clinical Classification for Health Policy Research (CCHPR) code. The CCHPR coding system uses ICD-9-CM procedure codes to create 231 procedure classes grouped by surgical risk. PTCA patients who could not be successfully matched to normal controls (n = 825) were excluded from the analysis, resulting in a sample of 2155 matched patients.

The successfully matched patients in the PTCA group were then matched on a 1:1 ratio to nonrevascularized patients with CAD by age (within 10 yr), sex, type of noncardiac surgery, and year of index admission. Patients who could not be successfully matched (n = 1469) were excluded from the analysis of these two groups. The final matched group of prior PTCA and nonrevascularized patients with CAD consisted of 686 matched pairs.

The PTCA group consisted of all patients with an ICD-9-CM procedure code of 36.0–36.03 or 36.05–36.09 on any admission before the index admission. Patients with a CABG procedure code (36.1–36.99) or a status post-CABG diagnosis code (V45.81) in any position on a discharge abstract before or concurrent with the index admission were excluded from the study. The index admission was defined as the first noncardiac surgical admission after an admission for PTCA (by procedure code). Patients with PTCA who could not be matched to a patient in another group were excluded.

The index admission for normal controls was selected from all noncardiac surgery admissions. The noncardiac surgical admission of a normal control patient was tagged as the index admission if it occurred in the same year as a matched PTCA group patient's index admission. Patients with a history of CAD, status post-CABG, or status post-PTCA by diagnosis code before or concurrent with the index admission were excluded from the normal control group, as were patients with a history of PTCA, CABG, or any cardiac surgery by procedure code before or concurrent with the index admission. Normal controls whose noncardiac surgery admissions could not be matched to a PTCA group patient's index admission were excluded.

The index admission for nonrevascularized patients with CAD was selected from all noncardiac surgery admissions occurring concurrent with or after an admission with a diagnosis code of CAD but before any admission with a cardiac surgery procedure code (including CABG or PTCA) or a status post-CABG or PTCA diagnosis code. Nonrevascularized patients with CAD whose eligible noncardiac surgery admissions could not be matched to a PTCA patient's index admission were excluded.

Patients without an index admission 30 days before the last date in the database were excluded. This allowed for complete 30-day follow-up of outcomes for all patients.

An adverse cardiac outcome was defined as death or any adverse cardiac event occurring 30 days of the index admission or occurring during a subsequent admission having an admission date within 30 days of the index noncardiac surgery admission date. Death was defined by discharge status for the index admission or any subsequent admission within 30 days and by death certificate data. Adverse cardiac events were defined as any ICD-9-CM diagnosis code of myocardial infarction (MI; 410–410.9), angina (411.1, 411.89, 413–413.9), congestive heart failure (CHF; 428.0–428.10), malignant dysrhythmia (426.12–426.13, 426.54, 426.90, 427.1, 427.41–427.42), cardiogenic shock (785.51), or unspecified cardiac complication (997.10) on the discharge abstract. Adverse cardiac events also included ICD-9-CM procedure codes of CABG, PTCA, or cardiac thrombolysis (36.0–36.99) on any subsequent admission within 30 days of the index admission.

The PTCA group's outcomes were separately compared with the outcomes of each of the other two groups using McNemar's test for matched data with one-tailed probability calculated by permutation test (SPSS Exact Tests 7.0; SPSS Inc., Chicago, IL). Odds ratios with 95% confidence intervals were calculated by comparing the PTCA group (cases) with each of the other matched groups (controls) using Epi Info 6 (SPSS Inc.). The same analysis was repeated for the subset of PTCA group patients (and corresponding matched controls) undergoing noncardiac surgery within 90 days after PTCA (the period during which restenosis is most common) (6). The analysis was also repeated for the subset of PTCA and nonrevascularized patients with CAD with matching MI histories (MI or no MI before noncardiac surgery). Patients undergoing noncardiac surgery during the same admission as PTCA were excluded from the study. A P value of 0.01 was chosen for rejection of the null hypothesis. This was adjusted by Bonferroni method to P 0.002 for each test to account for the performance of six tests.

	Results

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Index admissions for 2155 PTCA group patients were successfully matched to an equal number of normal control index admissions. Index admissions for 686 PTCA group patients were successfully matched to index admissions of nonrevascularized patients with CAD. Noncardiac index surgical admissions consisted of a wide variety of procedures, including the digestive system (32% PTCA/normal groups, 52% PTCA/CAD groups), musculoskeletal system (23% normals, 20% CAD; mainly hip, knee, and other joint repairs), genitalia (18%, 14%; prostate, hysterectomy), and respiratory system (6%, 5%; larynx, lungs, and chest). Matching by CCHPR category produced results consistent with the broader ICD-9-CM system groupings but reduced the sample size of matched patients, consequently reducing statistical power. Results are based on the ICD-9-CM bodily system groupings. Table 1 provides a comparison of the study groups (PTCA, normal controls, nonrevascularized CAD).

Patients with PTCA matched to nonrevascularized patients with CAD by MI history had risks similar to the larger unmatched groups (Table 4). Risks of specific adverse cardiac events were also similar to the larger non-MI–matched set, although statistical significance was not achieved in the smaller sample for some outcomes (Table 4).

	Discussion

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This picture is strikingly different for the subset of patients undergoing noncardiac surgery within 90 days of PTCA. Patients with recent PTCA were nearly 3 times more likely to have an adverse cardiac outcome than normal controls, but they were not less likely to have a poor cardiac outcome than nonrevascularized patients with CAD. One fourth of patients undergoing noncardiac surgery within 90 days of PTCA had an adverse cardiac outcome within 30 days after surgery. This outcome does not differ from the outcome of nonrevascularized patients with CAD (Table 3). Although the small size (n = 142) of the matched recent PTCA-CAD sample makes any conclusions tentative due to lack of statistical power, the rate of adverse cardiac outcomes among these recent PTCA patients (26.1%) is consistent with the larger group of recent PTCA patients matched to normal controls (27.3%) (Table 3).

Some authors have recommended prophylactic revascularization (PTCA or CABG) before noncardiac surgery for patients with CAD (2,3). Because coronary restenosis most often occurs within 90 days of PTCA (6), it has been assumed that prophylactic PTCA should be performed within 90 days of anticipated noncardiac surgery. However, research shows that both endothelial disruption (such as may accompany PTCA) and surgical stress stimulate thrombosis (7,8). Patients undergoing noncardiac surgery relatively soon after PTCA may be at risk of coronary artery thrombosis from the combined prothrombotic effects of PTCA and noncardiac surgery. This may explain the relatively poor outcome of the patients in this study who had PTCA 90 days before noncardiac surgery compared with nonrevascularized patients with CAD (Table 3).

Patients who died during hospitalization for PTCA or who required emergency CABG or who sustained cardiac complications that precluded subsequent noncardiac surgery would have been excluded from selection for the PTCA group in the present study. This study included only PTCA survivors who went on to undergo noncardiac surgery. A measure of the true risk of prophylactic PTCA and noncardiac surgery would combine the risks of both procedures (9). Such a measure was beyond the scope of our study. However, because recent PTCA has not been shown to decrease the risk of poor cardiac outcome after noncardiac surgery below the risk of nonrevascularized patients with CAD, it is possible that the combined risk associated with prophylactic PTCA plus noncardiac surgery places patients at higher risk of poor outcome than that of patients proceeding directly to noncardiac surgery without PTCA. This warrants further study. Lack of evidence supporting prophylactic PTCA to improve noncardiac surgery outcomes led the American College of Cardiologists, the American Heart Association, and the American College of Physicians to adopt guidelines that recommend revascularization before noncardiac surgery only if PTCA would be indicated for the patient regardless of future surgical plans (4,10).

Our results must be interpreted with caution because of limitations of the study design. The results are based on discharge abstract data, which may be subject to miscoding and misclassification. Validity checks of the Washington State data used in this study were not available. Evaluation of similar data (Medicare claims) indicates that MI, angina, and CHF are accurately coded (11). It is possible that patients with CAD, PTCA, or CABG before the study period could have been misclassified if those diagnoses were not present on subsequent discharge abstracts. However, given that status post-CABG, status post-PTCA, and CAD may be coded on any discharge and that the Washington State data allow for nine discharge diagnosis codes, such misclassification is unlikely to have been a major problem in this study. The creation of a longitudinal patient claims history, such as used in this study to capture revascularization history, is a strategy recommended to improve coding accuracy (12).

A weakness of our retrospective design is lack of control over patient assignment to comparison groups and missing information on disease severity. For example, we did not know the relative proportion of patients in the nonrevascularized CAD group who had mild CAD not requiring intervention, severe CAD precluding intervention, or disease not anatomically amenable to PTCA. In the PTCA group, we did not know whether the procedure was performed for medical necessity (e.g., unstable status of patient) or for prophylaxis in anticipation of noncardiac surgery. We also lacked data on which coronary vessels were revascularized, although, during this period (1987–1993), it was common to revascularize only a single vessel with PTCA (13). It is possible that the cardiac events after noncardiac surgery in the PTCA group involved nonrevascularized vessels. Because of these limitations, the results of this study apply only generally to patient revascularization status, rather than to specific coronary pathology. Although analysis of the subset of PTCA-CAD patients matched by MI history yielded results consistent with the overall findings (Table 4), this matching only serves as a surrogate for disease severity and may not accurately reflect coronary disease status and PTCA efficacy. However, even the general level of information concerning risks of poor cardiac outcome after noncardiac surgery presented herein was not available previously.

The number of recent PTCA patients matched to nonrevascularized patients with CAD was relatively small (n = 142); therefore, the negative findings in that analysis may be an artifact of sample size. The same weakness applies to PTCA and nonrevascularized patients with CAD matched by MI history. Analysis of a larger sample is required to verify these results.

This study relies on data from a single state. We do not know whether Washington State data differ from those from other areas of the country. Previous studies of patients with nonrevascularized CAD undergoing noncardiac surgery have found similar rates of cardiac events and death, as occurred in the Washington State sample (1,5,14–19), which suggests that the latter sample may be reasonably representative of the national experience. For example, the 2.8% rate of postoperative MI in Washington State among nonrevascularized patients with CAD was relatively similar to the 4%–5% rate in other moderate to large studies (15,16). Likewise, the 2.9% mortality rate in Washington State nonrevascularized patients with CAD was within the 2%–14% range of other comparably sized studies (14–16,18). Although the 10% adverse cardiac outcome rate for normal controls in the present analysis may seem high, this result should be interpreted in the context of the matched study design. The selection of normal controls was determined by the PTCA patient sample, with a mean (±SD) age of 67 ± 10 years (Table 1). Fleisher et al. (20) reported a similar perioperative cardiac event rate in patients undergoing noncardiac surgery with normal preoperative electrocardiogram results.

Previous studies of cardiac events after noncardiac surgery in patients with prior PTCA have not yielded consistent results (3,21–23). Rates of perioperative MI varied from 0% (3,23) to 5.6% (18), whereas mortality rates were 0% (3,23) to 9.8% (21). This inconsistency may stem from the relatively small samples (14–148 patients per study group) (3,21–23) and a focus on specific surgical procedures in some studies (21,23). None of these studies included comparison groups. In contrast, our study involved comparatively large matched groups of patients differing in revascularization status (normal controls and nonrevascularized patients with CAD). A wide variety of surgical procedures was included, although vascular surgery was excluded.

Our most surprising result was the finding of similar outcomes between patients with recent PTCA and those with nonrevascularized CAD. The patients with recent PTCA did no better than nonrevascularized patients with CAD, with more than one fourth of each group having some adverse cardiac outcome after noncardiac surgery (Table 3). These results are consistent with recent findings by Lapuerta et al. (24) and Seeger et al. (25) who also found similar noncardiac surgery outcomes between patients revascularized prophylactically and patients with no cardiac intervention. Matched patients without CAD did much better, with a 12% complication rate (Table 3). Although patients with PTCA did have a lower risk of adverse cardiac outcomes after noncardiac surgery overall compared with nonrevascularized CAD patients, PTCA did not render these Washington State patients "as good as new" in terms of their noncardiac surgery risk. Further research on risks of noncardiac surgery for revascularized patients is required to fully evaluate the comparative advantages and disadvantages of revascularization and its implications for future medical care.

	Acknowledgments

 
This research was supported by the Washington State Society of Anesthesiologists and the University of Washington Department of Anesthesiology.

We thank Ian Wright for his assistance in this project and Dawn Bolgioni and Lynn Hubbard-Hamacher for their excellent secretarial work.

	Footnotes

 
Presented at the annual meeting of the American Heart Association, Orlando, FL, November 12, 1997.

	References

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