Long-term Cardiac-Related Mortality Likely Predicted by 30-Day Postsurgical Outcomes

Following surgery for a non–cardiac-related matter, risk of long-term mortality was shown to nearly double due to perioperative adverse cardiac events (PACEs), reports Journal of the American Heart Association.

These outcomes were investigated among 202,584 consecutive patients who underwent noncardiac surgery between January 2011 and June 2019 at Samsung Medical Center in Seoul, Republic of Korea. For this study, PACEs were defined to be a composite end point comprising myocardial infarction, coronary revascularization, congestive heart failure, arrhythmic attack, acute pulmonary embolism, cardiac arrest, or stroke in the 30 days after surgery. Patients who died in the 30 days following their surgery were excluded from the final analysis.

“Cardiac complications are associated with perioperative mortality,” the authors wrote, “but PACEs that are associated with long-term mortality have not been clearly defined.”

Overall, there was a 90% greater risk of mortality (HR, 1.90; 95% CI, 1.74-2.09; P < .001) among the patients who experienced PACEs (n = 7994) compared with those who did not (n = 194,590). In addition, there was a 5.6-percentage-point difference in actual incidence of all-cause mortality when comparing outcomes among patients with PACEs and those without: 7.7% vs 2.1%.

The primary study end point was mortality in the first year, and it was also compared at the 3-year mark. Associations for variables—including male sex, age, diabetes status, current alcohol use, and European Society of Cardiology/European Society of Anaesthesiology intermediate‐to‐high surgical risk—and 1-year mortality were also determined.

The median (IQR) length of time between surgery and PACE was 2 (1-4) days, the mean (SD) patient ages were 62.2 (15.1) in the no-PACEs group and 64.8 (12.7) in the PACEs group, and rates of both hypertension and diabetes were higher in the PACEs group vs the no-PACEs group, at 48.6% vs 24.4% and 25.1% vs 11.0%, respectively. Follow-ups, meanwhile, were similar: The no-PACEs group had a median follow-up of 1125 (406-1959) days, and the PACEs group, 1063 (412-1824) days.

In addition to all-cause mortality, cardiovascular (CV) mortality was gauged at the 1-year mark. Again this was higher in the PACEs group: 0.9% vs 3.4% (HR, 1.81; 95% CI, 1.58-2.08; P < .001). And when 3-year rates for all-cause and CV mortality were evaluated, the trend of a higher rate is the PACEs group continued (both P < .001):

• All-cause mortality: 24.3% vs 9.0% (HR, 1.73; 95% CI, 1.62-1.84)
• CV mortality: 13.3% vs 4.7% (95% CI, 1.50-1.79)

Propensity-score matching, too, among 7839 patient pairs produced higher rates of both mortality outcomes, although the gap did close somewhat (all P < .001):

• At 1 year:
  • All-cause mortality: 7.9% vs 4.9% (HR, 1.64; 95% CI, 1.44-1.67)
  • CV mortality: 3.4% vs 2.1% (HR, 1..48; 95% CI, 1.38-2.04)
• At 3 years:
  • All-cause mortality: 24.4% vs 15.3% (HR, 1.51; 95% CI, 1.38-1.66)
  • CV mortality: 13.4% vs 8.5% (95% CI, 1.31-1.69)

Diabetes status was shown to have a significant interaction with mortality, too, in that an association for greater 1-year mortality was seen in the first 30 days after surgery among patients in the PACEs group who did not have diabetes (HR, 1.82; 95% CI, 1.56-2.13; P < .001) compared with those who had diabetes (HR, 1.25; 95% CI, 0.98-1.59; P = .08).

“Considering the enormous number of patients undergoing noncardiac surgery and the impact of cardiac complications n these patients, more clinical studies are necessary,” the authors emphasized. “The challenge is to select an optimal end point that is both clinically relevant and not too rare. Our results for incidence and association with long-term mortality may be helpful for selecting an end point in future studies.”

Reference

Oh AR, Park J, Lee JH, et al. Association between perioperative adverse cardiac events and mortality during one‐year follow‐up after noncardiac surgery. J Am Heart Assoc. Published online April 12, 2022. doi:10.1161/JAHA.121.024325