Authors: Jason B. Liu, M.D., M.S. et al
Anesthesiology 2 2018, Vol.128, 283-292.
Background: Current preoperative cardiac risk stratification practices group operations into broad categories, which might inadequately consider the intrinsic cardiac risks of individual operations. We sought to define the intrinsic cardiac risks of individual operations and to demonstrate how grouping operations might lead to imprecise estimates of perioperative cardiac risk.
Methods: Elective operations (based on Common Procedural Terminology codes) performed from January 1, 2010 to December 31, 2015 at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program were studied. A composite measure of perioperative adverse cardiac events was defined as either cardiac arrest requiring cardiopulmonary resuscitation or acute myocardial infarction. Operations’ intrinsic cardiac risks were derived from mixed-effects models while controlling for patient mix. Resultant risks were sorted into low-, intermediate-, and high-risk categories, and the most commonly performed operations within each category were identified. Intrinsic operative risks were also examined using a representative grouping of operations to portray within-group variation.
Results: Sixty-six low, 30 intermediate, and 106 high intrinsic cardiac risk operations were identified. Excisional breast biopsy had the lowest intrinsic cardiac risk (overall rate, 0.01%; odds ratio, 0.11; 95% CI, 0.02 to 0.25) relative to the average, whereas aorto-bifemoral bypass grafting had the highest (overall rate, 4.1%; odds ratio, 6.61; 95% CI, 5.54 to 7.90). There was wide variation in the intrinsic cardiac risks of operations within the representative grouping (median odds ratio, 1.40; interquartile range, 0.88 to 2.17).
Conclusions: A continuum of intrinsic cardiac risk exists among operations. Grouping operations into broad categories inadequately accounts for the intrinsic cardiac risk of individual operations.
What We Already Know about This Topic
- The intrinsic risk of cardiac adverse events after surgery has historically been attributed to broad categories of surgeries based upon anatomical region (g., intraperitoneal) or surgical service (e.g., plastic surgery)
- Detailed procedure-specific risks, independent of underlying patient comorbidities, have not been robustly analyzed or reported
What This Article Tells Us That Is New
- An analysis of 3 million surgeries in the American College of Surgeons National Surgical Quality Improvement Program registry demonstrated a broad range of procedure-specific cardiac adverse event risk for 200 commonly performed procedures
- These data may advance our patient-specific risk/benefit analyses and medical decision-making