Surgical Apgar score is associated with myocardial injury after noncardiac surgery

• Published in: Journal of clinical anesthesia 2016-11, Vol.34, p.395-402
• Main Authors: House, L. McLean, MD, Marolen, Khensani N., MPH, St. Jacques, Paul J., MD, McEvoy, Matthew D., MD, Ehrenfeld, Jesse M., MD, MPH
• Format: Article
• Language: English
• Subjects: Adult; Aged; Anesthesia & Perioperative Care; Apgar score; Blood pressure; Cardiac arrhythmia; Chronic obstructive pulmonary disease; Data warehouses; Diabetes; Electronic health records; Family medical history; Female; Health risk assessment; Heart attacks; Heart failure; Heart rate; Hemodynamics; Humans; Hypertension; Hypotension - etiology; Ischemia; Male; Medical records; Middle Aged; Monitoring, Intraoperative; Mortality; Myocardial Infarction - epidemiology; Myocardial Infarction - etiology; Myocardial injury; Myocardial Ischemia - epidemiology; Myocardial Ischemia - etiology; Non-cardiac surgery; Pain Medicine; Patients; Perioperative myocardial infarction; Postoperative Complications - epidemiology; Postoperative Period; Retrospective Studies; Risk Assessment - methods; Surgery; Surgical Apgar Score; Surgical Procedures, Operative - adverse effects; Surgical Procedures, Operative - mortality; Surveillance; Tennessee - epidemiology; Troponin elevation; Troponin I - blood; Troponin T - blood; Ventilation
• ISSN: 0952-8180; 1873-4529
• DOI: 10.1016/j.jclinane.2016.05.009

Abstract Study Objective To assess the impact of intraoperative hemodynamics in the development of perioperative myocardial infarction (MI) and myocardial ischemia after noncardiac surgery. Design Single-center retrospective cohort study of surgical patients from 2007 to 2012. Setting Postanesthesia care unit, intensive care unit, and medical-surgical ward at an academic tertiary medical center. Patients A total of 46,799 adult noncardiac, nonthoracic surgery patients, for which 2290 peak cardiac troponin (cTn) levels were available. Measurements The 10-point Surgical Apgar Score (SAS) was calculated from intraoperative heart rate, blood pressure, and blood loss. Peak troponin (cTn) levels, hospital length of stay, 7- and 30-day postoperative mortality, patient demographics, and prior medical conditions were gathered. Troponin leak was defined as cTn-I 0.6 to 1.5 ng/mL or cTn-T 0.1 to 0.3 ng/mL; perioperative MI criteria were cTn-I greater than 1.5 ng/mL or cTn-T greater than 0.30 ng/mL. Main results Of 46,799 noncardiac surgical cases, 209 (0.4%) and 192 (0.4%) suffered cTn leak and MI, respectively. Low SAS (0-4) was associated with increased risk of cTn leak and perioperative MI (univariate odds ratio, 2.76 and 2.06; 95% confidence interval, 2.20-3.45 and 1.57-2.70, respectively). In multivariable analysis, Surgical Apgar Score, age 65 years or older, American Society of Anesthesiologists physical status greater than or equal to III, emergency surgery, history of MI or hypertension, prolonged intraoperative tachycardia (heart rate > 100 beats/min for > 59 minutes), and prolonged hypotension (mean arterial pressure < 40 mm Hg for > 2 minutes) were independently associated with cTn leak and perioperative MI. Conclusions Low SAS scores (0-4) may be associated with cTn elevation after noncardiac surgery. SAS-based risk stratification may guide perioperative cTn surveillance in lieu of routine postoperative screening.