Faculty Bibliography

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.

BACKGROUND: Thyroid storm (TS) constitutes an endocrine emergency with an incidence of up to 10% of all admissions for thyrotoxicosis. Cardiogenic shock (CS) is a rare complication of TS and very limited data exists on its incidence and outcomes. We aimed to estimate the national trends in incidence and outcomes of CS among patients admitted to US hospitals with TS. MATERIALS AND METHODS: We queried the nationwide inpatient sample for patients with the discharge diagnosis of TS between the years of 2003 and 2011. RESULTS: Based on a weighted estimate, we identified 41,835 patients with a diagnosis of TS, of which 1% developed CS. Patients with CS were more likely to have history of atrial fibrillation, alcohol abuse, preexisting congestive heart failure, coagulopathy, drug use, liver disease, pulmonary circulation disorders, valvular disorders, weight loss, renal failure, fluid and electrolyte disorders as compared to those who did not develop CS (P < 0.001 for all). We observed an increase in incidence of CS from 0.5% in 2003 to 3% in 2011 and a decrease in mortality from 60.5% in 2003 to 20.9% in 2011 (Ptrend < 0.001 for both). CONCLUSIONS: We observed that CS is a rare complication of TS, which occurs more commonly in male patients with preexisting structural and atherosclerotic heart disease, and carries a very poor prognosis. Although incidence has increased over the years, mortality from CS has steadily declined.

Von Willebrand disease (VWD) is an inherited bleeding disorder that often manifests clinically with hemorrhage after invasive procedures. We investigated the association between a diagnosis of VWD and bleeding and thrombotic outcomes following major non-cardiac surgery in a large national database from the United States. Patients age >/=45 years requiring major non-cardiac surgery were identified from Healthcare Cost and Utilization Project's National Inpatient Sample data. Von Willebrand disease, perioperative major adverse cardiovascular events (MACE), thrombotic events, and hemorrhage were defined by ICD9 diagnosis codes. From 2004 to 2013, a total of 10,581,621 hospitalizations for major non-cardiac surgery met study inclusion criteria and VWD was identified in 3765 (0.036%). In adjusted analyses, patients with VWD were significantly more likely to develop post-operative hemorrhage than patients without VWD (5.5 vs. 1.9%, p < 0.001; adjusted OR 3.49, 95% CI 3.03-4.03), but had similar odds of perioperative MACE and thrombotic events. Thus, a diagnosis of VWD was associated with increased risks of bleeding with non-cardiac surgery, without a corresponding reduction in perioperative thrombosis in comparison to patients without VWD. Perioperative management of patients with hereditary bleeding disorders and mitigation of thrombotic risks requires further study.

Background/UNASSIGNED:Venous thromboembolism (VTE) is a common vascular complication of non-cardiac surgery. Methods/UNASSIGNED:We evaluated national trends in perioperative in-hospital VTE incidence, management, and outcomes using a large database of hospital admissions from the United States. Patients aged ≥ 45 years undergoing major non-cardiac surgery from 2005 to 2013 were identified from the National Inpatient Sample. In-hospital perioperative VTE was defined as lower extremity deep vein thrombosis (DVT) or pulmonary embolism (PE), and the incidence was evaluated over time. Multivariable regression models with demographics and comorbidities as covariates were generated to estimate adjusted odds ratios (aOR). Results/UNASSIGNED:Major non-cardiac surgery was performed in 9,431,442 hospitalizations that met inclusion criteria, and perioperative VTE occurred in 99,776 patients (1,057 per 100,000), corresponding to an annual incidence of ≈53,000 after applying sample weights. Over time, perioperative VTE per 100,000 surgeries increased by 135 (95% CI 107 - 163), from 925 in 2005 to 1,060 in 2013 (p for trend <0.001; aOR [for 2013 versus 2005] 1.22, 95% CI 1.19 - 1.26), due to increases in non-fatal VTE rates (from 840 [per 100,000 surgeries] in 2005 to 987 in 2013; p for trend <0.001). Perioperative VTE occurred most frequently in patients undergoing thoracic (2.0%) and vascular surgery (1.8%). Mortality was higher in patients with VTE than those without VTE (aOR 3.12, 95% CI 3.05 - 3.20). Conclusions/UNASSIGNED:Perioperative VTE occurs in approximately 1% of patients ≥45 years undergoing major non-cardiac surgery, with increasing incidence of non-fatal VTE over time.

Background: Acute myocardial infarction (AMI) is a significant cardiovascular complication following non-cardiac surgery. We evaluated national trends in perioperative AMI, management, and outcomes using a large administrative database of United States hospital admissions. Methods: Patients who underwent non-cardiac surgery from 2005 to 2013 were identified using the National Inpatient Sample. Perioperative AMI was evaluated over time. Propensity score matching was used to compile cohorts of patients with perioperative AMI matched on their baseline characteristics who were managed invasively (defined as cardiac catheterization, percutaneous coronary intervention [PCI], or coronary artery bypass graft surgery [CABG]) versus conservatively. The primary outcome was in-hospital all-cause mortality. Results: 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% 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 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: 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

Importance: Major adverse cardiovascular and cerebrovascular events (MACCE) are a significant source of perioperative morbidity and mortality following noncardiac surgery. Objective: To evaluate national trends in perioperative cardiovascular outcomes and mortality after major noncardiac surgery and to identify surgical subtypes associated with cardiovascular events using a large administrative database of United States hospital admissions. Design, Setting, Participants: Patients who underwent major noncardiac surgery from January 2004 to December 2013 were identified using the National Inpatient Sample. Main Outcomes and Measures: Perioperative MACCE (primary outcome), defined as in-hospital, all-cause death, acute myocardial infarction (AMI), or acute ischemic stroke, were evaluated over time. Results: Among 10581621 hospitalizations (mean [SD] patient age, 65.74 [12.32] years; 5975798 female patients 56.60%]) for major noncardiac surgery, perioperative MACCE occurred in 317479 hospitalizations (3.0%), corresponding to an annual incidence of approximately 150000 events after applying sample weights. Major adverse cardiovascular and cerebrovascular events occurred most frequently in patients undergoing vascular (7.7%), thoracic (6.5%), and transplant surgery (6.3%). Between 2004 and 2013, the frequency of MACCE declined from 3.1% to 2.6% (P for trend <.001; adjusted odds ratio [aOR], 0.95; 95% CI, 0.94-0.97) driven by a decline in frequency of perioperative death (aOR, 0.79; 95% CI, 0.77-0.81) and AMI (aOR, 0.87; 95% CI, 0.84-0.89) but an increase in perioperative ischemic stroke from 0.52% in 2004 to 0.77% in 2013 (P for trend <.001; aOR 1.79; CI 1.73-1.86). Conclusions and Relevance: Perioperative MACCE occurs in 1 of every 33 hospitalizations for noncardiac surgery. Despite reductions in the rate of death and AMI among patients undergoing major noncardiac surgery in the United States, perioperative ischemic stroke increased over time. Additional efforts are necessary to improve cardiovascular care in the perioperative period of patients undergoing noncardiac surgery.

A 48-year-old man with hypertension presented with heart failure and reduced left ventricular systolic function. Coronary angiography revealed a non-dominant right coronary artery and a long anomalous branch of the proximal left anterior descending coronary artery that coursed inferiorly to give rise to the posterior descending artery. No epicardial coronary artery disease was visualized. The highly unusual anomalous branch was considered to be an incidental finding, with no pathological contribution to the clinical presentation.

BACKGROUND: Chronic kidney disease (CKD) is associated with cardiovascular disease and acute myocardial infarction (AMI). Contemporary management and outcomes of AMI in patients with CKD have not been reported. METHODS: We analyzed United States National Inpatient Sample data for patients admitted with AMI with or without CKD from 2007 to 2012. Propensity score matching was used to identify patients with AMI and CKD with similar baseline characteristics who were managed invasively (cardiac catheterization, percutaneous coronary intervention [PCI], or coronary artery bypass graft surgery [CABG]) or conservatively. The primary outcome was in-hospital all-cause mortality. RESULTS: Among 753,782 patients admitted with AMI, 17.8% had a diagnosis of CKD. Patients with CKD had lower odds of invasive management (49.9% vs. 73.1%; adjusted OR 0.57, 95% CI 0.57-0.58), were less likely to undergo revascularization (adjusted OR 0.60, 95% CI 0.59-0.61), and had higher in-hospital mortality (8.4% vs. 5.0%; adjusted OR 1.55, 95% CI 1.51-1.59) than those without CKD. In a propensity-matched cohort of 89,630 CKD patients treated for AMI with invasive vs. conservative management, invasive management was associated with lower in-hospital mortality overall (5.9% vs. 10.9%, p<0.001; OR=0.51 (0.49-0.54)) as well as in subgroups by MI type and severity of CKD. CONCLUSIONS: Patients with AMI and CKD are less likely to receive invasive management, coronary revascularization, and have higher in-hospital mortality than patients without CKD. Invasive management of AMI was associated with lower in-hospital mortality versus conservative management in all patients, regardless of CKD severity.

STUDY OBJECTIVE: Perioperative thrombotic complications after orthopedic surgery are associated with significant morbidity and mortality. The use of aspirin to reduce perioperative cardiovascular complications in certain high-risk cohorts remains controversial. Few studies have addressed aspirin use, bleeding, and cardiovascular outcomes among high-risk patients undergoing joint and spine surgery. DESIGN/SETTING/PATIENTS: We performed a retrospective comparison of adults undergoing knee, hip, or spine surgery at a tertiary care center during 2 periods between November 2008 and December 2009 (reference period) and between April 2013 and December 2013 (contemporary period). MEASUREMENTS: Patient demographics, comorbidities, management, and outcomes were ascertained using hospital datasets. MAIN RESULTS: A total of 5690 participants underwent 3075 joint and spine surgeries in the reference period and 2791 surgeries in the contemporary period. Mean age was 61+/-13 years, and 59% were female. In the overall population, incidence of myocardial injury (3.1% vs 5.8%, P<.0001), hemorrhage (0.2% vs 0.8%, P=.0009), and red blood cell transfusion (17.2% vs 24.8%, P<.001) were lower in the contemporary period. Among 614 participants with a preoperative diagnosis of coronary artery disease (CAD), in-hospital aspirin use was significantly higher in the contemporary period (66% vs 30.7%, P<.0001); numerically, fewer participants developed myocardial injury (13.5% vs 19.3%, P=.05), had hemorrhage (0.3% vs 2.1%, P=.0009), and had red blood cell transfusion (37.2% vs 44.2%, P<.001) in the contemporary vs reference period. CONCLUSIONS: In a large tertiary care center, the incidence of perioperative bleeding and cardiovascular events decreased over time. In participants with CAD, perioperative aspirin use increased and appears to be safe.