Postoperative Cardiac Ischemia Detection by Continuous 12-Lead Electrocardiographic Monitoring in Vascular Surgery Patients: A Prospective, Observational Study

• Published in: Journal of cardiothoracic and vascular anesthesia 2017-06, Vol.31 (3), p.950-956
• Main Authors: Ollila, Aino, MD, Virolainen, Juha, MD, PhD, Vanhatalo, Joonas, MSc (Tech), Vikatmaa, Pirkka, MD, PhD, Tikkanen, Ilkka, MD, PhD, Venermo, Maarit, MD, PhD, Salmenperä, Markku, MD, PhD, Pettilä, Ville, MD, PhD, Vikatmaa, Leena, MD, PhD
• Format: Article
• Language: English
• Subjects: Aged; Anesthesia & Perioperative Care; cardiac ischemia; Critical Care; Electrocardiography - methods; Electrocardiography - trends; Female; Finland - epidemiology; high-sensitive troponin T; Holter electrocardiography; Humans; Intraoperative Neurophysiological Monitoring - methods; Intraoperative Neurophysiological Monitoring - trends; Male; myocardial infarction; Myocardial Ischemia - diagnosis; Myocardial Ischemia - etiology; Myocardial Ischemia - physiopathology; perioperative complications; Postoperative Complications - diagnosis; Postoperative Complications - etiology; Postoperative Complications - physiopathology; postoperative monitoring; Prospective Studies; vascular surgery; Vascular Surgical Procedures - adverse effects; Vascular Surgical Procedures - trends
• ISSN: 1053-0770; 1532-8422
• DOI: 10.1053/j.jvca.2016.09.027

Objectives Elderly patients undergoing vascular surgery are at major risk for perioperative cardiac complications. The authors investigated continuous electrocardiographic Holter monitoring in a postoperative setting to determine the degree of postoperative ischemic load and its possible associations with perioperative myocardial infarction. Design A prospective, observational study. Setting One university hospital. Participants The study comprised 51 patients aged 65 years or older undergoing peripheral arterial surgery. Interventions Continuous electrocardiographic monitoring with a Holter device was started postoperatively and continued for 72 hours or until discharge. Postural changes were recorded using a 3-axis accelerometer. Standard 12-lead electrocardiography, high-sensitive troponin T measurements, and an inquiry of ischemic symptoms were performed 4 times perioperatively. Measurements and Main Results The primary outcomes were ischemic load (area under the function of ischemic ST-segment deviation and ischemic time) and perioperative myocardial infarction. During 3,262.7 patient-hours of monitoring, 17 patients (33.3%) experienced 608 transient ischemic events, all denoted by ST-segment depression. Of these 17 patients, 5 experienced perioperative myocardial infarction. The mean ischemic load in all patients was 913.2±2,797.3 µV×minute. Ischemic load predicted perioperative myocardial infarction, with an area under receiver operating characteristics curve (95% confidence interval) of 0.87 (0.75-0.99). Ischemic changes occurred most frequently during hours 24 to 60 of monitoring. Ischemia was asymptomatic in 14 of 17 patients (82.4%). Conclusion Postoperative myocardial ischemia was common in peripheral vascular surgery patients and may progress to perioperative myocardial infarction. Ischemic load was a good predictor of perioperative myocardial infarction. Ambulatory electrocardiographic monitoring solutions for continuous postoperative ischemia detection are warranted in the surgical ward.