Rates of death, acute MI decrease among those undergoing major noncardiac surgery

Between 2004 and 2013, the rates of death and acute MI decreased and the rate of ischemic stroke increased among patients undergoing in-hospital major noncardiac surgery in the U.S., according to a database analysis.

Overall, the rate of perioperative major adverse cardiovascular and cerebrovascular events (MACCE) decreased from 3.1 percent in 2004 to 2.6 percent in 2013. The researchers defined MACCE as in-hospital all cause death, acute MI or ischemic stroke.

Lead researcher Nathaniel R. Smilowitz, MD, of the New York University School of Medicine in New York, and colleagues published their results online in JAMA Cardiology on Dec. 28.

“The observed reductions in overall perioperative MACCE are encouraging,” the researchers wrote. “These may be due to improved surgical case selection, advances in the management of cardiovascular risk factors and disease, improved surgical techniques, including increased use of minimally invasive surgical interventions, improved an- esthetic techniques, enhanced intraoperative monitoring, and advanced postoperative critical care.”

The researchers identified more than 10.5 million hospitalizations for major noncardiac surgery between January 2004 and December 2013. The patients were at least 45 years old and were enrolled in the Healthcare Cost and Utilization Project’s National Inpatient Sample, which is a database containing information on approximately 8 million hospitalizations per year in the U.S.

The researchers considered the following 13 major surgical subtypes: breast, endocrine, otolaryngology, general, genitourinary, gynecologic, neurosurgery, obstetrics, orthopedic, skin and burn, thoracic, noncardiac transplant and vascular surgery.

They found that MACCE occurred in 3 percent of the surgeries. Nonfatal acute MI occurred in 0.76 percent of procedures, nonfatal stroke occurred in 0.54 percent of procedures, death occurred in 1.67 percent of procedures and both nonfatal MI and nonfatal stroke occurred in 0.03 percent of procedures.

From 2004-2005 to 2012-2013, the rate of perioperative death declined from 1.9 percent to 1.4 percent and the rate of perioperative acute MI decreased from 0.98 percent to 0.86 percent. Both differences were statistically significant.

During that same time period, the rate of perioperative ischemic stroke significantly increased from 0.54 percent to 0.78 percent.

Patients who had a MACCE were older and were more likely to be male and have cardiovascular risk factors compared with those who did not have a MACCE. The rates of MACCE were 3.8 percent in non-Hispanic black patients and 2.9 percent in non-Hispanic white patients. The rates of perioperative death and stroke were also higher in non-Hispanic black patients compared with non-Hispanic white patients.

The proportion of patients with a MACCE was highest in those undergoing vascular (7.7 percent), thoracic (6.5 percent) and transplant (6.3 percent) surgery. The lowest risks were observed in patients undergoing obstetric and gynecologic surgery.

The researchers mentioned a few limitations of the study, including that they relied on administrative coding data, which could have been subject to reporting bias or coding errors. They also only analyzed adults who were 45 years old or older. In addition, they could not establish the timing of nonfatal acute MI or ischemic stroke after noncardiac surgery. Further, they did not have information on the use of medical therapy such as beta blockers, antiplatelet agents and other cardiovascular medications.

“Cardiovascular complications after noncardiac surgery remain a major source of morbidity and mortality,” the researchers wrote. “Despite improvements in perioperative outcomes over the past decade, the significant increase in the rate of ischemic stroke in this analysis requires confirmation and further study. Additional efforts are necessary to improve perioperative cardiovascular care of patients undergoing noncardiac surgery.”