Does invasive management reduce in-hospital all-cause mortality in patients with perioperative acute myocardial infarction following non-cardiac surgery?
Invasive management of perioperative AMI following non-cardiac surgery is associated with significantly lower in-hospital mortality compared to conservative management.
AIMS: Acute myocardial infarction (AMI) is a significant cardiovascular complication following non-cardiac surgery. We sought to evaluate national trends in perioperative AMI, its management, and outcomes. METHODS AND RESULTS: Patients who underwent non-cardiac surgery from 2005 to 2013 were identified using the United States National Inpatient Sample. Perioperative AMI was evaluated over time. Propensity score matching was used to compile a cohort of AMI patients managed invasively (defined as cardiac catheterization or coronary revascularization) vs. conservatively. The primary outcome was in-hospital all-cause mortality. Among 9 566 277 hospitalizations for major non-cardiac surgery, perioperative AMI occurred in 84 093 (0.88%). Over time, the rate of perioperative AMI per 100 000 surgeries declined by 170 95% confidence intervals (95% CI) 158-181, from 898 in 2005 to 729 in 2013 (P for trend <0.0001). Perioperative AMI occurred most frequently in patients undergoing vascular (2.0%), transplant (1.6%), and thoracic (1.5%) surgery. In-hospital mortality was higher in patients with perioperative AMI than those without AMI 18.0% vs. 1.5%, P < 0.0001; adjusted odds ratio (OR) 5.76, 95% CI 5.65-5.88. Mortality associated with perioperative AMI declined over time (adjusted OR 0.86, 95% CI 0.84-0.88). In a propensity-matched cohort of 34 650 patients with perioperative AMI, invasive management was associated with lower mortality than conservative management (8.9% vs. 18.1%, P < 0.001; OR 0.44, 95% CI 0.41-0.47). CONCLUSION: In an observational cohort study from the USA, perioperative AMI occurs in 0.9% of patients undergoing major non-cardiac surgery and is strongly associated with in-hospital mortality. Invasive management of such patients may mitigate some of this excess risk, and further research on the management of perioperative AMI is warranted.
“I hope that [these findings] will increase attention to this topic, because people have ignored it. It's an iatrogenic complication, and of course we hate to talk about iatrogenic complications. And it's bad for business [since] surgeries are an important source of income for hospitals. In fact, I think patients and their caregivers would reconsider undergoing surgery if they would be aware of the true risk/benefit ratio of many operations.”
Smilowitz et al. (Wed,) studied this question.