Perioperative cardiac evaluation: assessment, risk reduction, and complication management

Changing risk of perioperative myocardial infarction

INTRODUCTION

Years ago, patients with recent myocardial infarction (MI) were reported to be at high risk of reinfarction (27%) and death after surgery. Therapy has changed in the 3 decades since those reports, so we reexamined that risk as well as other cardiac comorbidities and surgical work values in predicting adverse outcome.

METHODS

We used the National Surgical Quality Improvement Program Participant Use Data File for 2005 to 2009. We included all patients of all included specialties, for outpatient and inpatient surgery. Cardiac comorbidities included history of congestive heart failure (30 days) or MI (6 months), percutaneous coronary intervention, previous cardiac surgery, and history of angina (30 days). Other predictors included a frailty index and American Society of Anesthesiologists (ASA) class. Adverse cardiac events included cardiac arrest requiring cardiopulmonary resuscitation, MI, and death. Cases were stratified according to surgical work units. Univariate χ(2) analysis and multivariate logistic regression established simple relationships and interactions, with p < 0.05 significant.

RESULTS

Of patients who had recent MI, 2.1% had reinfarction perioperatively and 26% of those died. The odds ratio for infarction with vs without recent MI in inpatients age 40 years and older was 4.6. Frailty and ASA class were stronger predictors of perioperative MI and cardiac arrest than was history of MI, and risk increased as surgical work increased.

DISCUSSION

The risk caused by preoperative MI has improved by an order of magnitude in the last 30 years. The ASA class and especially frailty are better predictors of adverse cardiac events.

Implementing public health in secondary care: a Rotherham perspective on strategy development and implementation

AIMS

This paper reports an approach to develop and implement a public health strategy in secondary care and uses smoking cessation as a means for measuring success.

METHODS

Rotherham Foundation Hospital Trust recognized its unique role to promote, prevent and protect health and well-being in Rotherham. Following consultation across key departments, the trust developed a public health strategy encompassing five priorities.

RESULTS

We report ongoing commitment and engagement following the launch of the public health strategy. Over a period of one year (April 2008 to March 2009) 269 front-line staff were trained on smoking cessation brief interventions. We report 890 referrals to smoking cessation, resulting in 414 setting a quit date and 143 four-week quitters (35% conversion rate). Despite progress in implementing smoking cessation, more communication is required to ensure that GPs and hospital staff continue to maximize patient outcomes through brief interventions.

CONCLUSIONS

The paper provides an approach to implement public health in secondary care. The Commissioning for Quality and Innovation (CQUIN) payment framework would be a useful tool to ensure key public health areas such as smoking cessation are systemized in secondary care.

Aortic valve stenosis

Calcific aortic stenosis (AS) is primarily a disease of the elderly, possessing features that are biomechanical as well as systemic and inflammatory in nature, with risk factors and histopathology similar to atherosclerosis. To date no medical therapy has been shown to conclusively alter the progression of the disease, and for those with symptomatic AS, aortic valve replacement (AVR) is advocated. Factors that may alert the physician to an accelerated progression of calcific aortic valvular disease toward severe symptomatic AS include moderate aortic valve calcification, chronically dialyzed patients, and patients 80 years and older. There remains significant morbidity and mortality associated with AVR, and new techniques and technologies for AVR are being developed. For those who undergo successful AVR the long-term prognosis is good. A substantial number of patients with symptomatic AS present for anesthesia care for a variety of procedures. A thorough, modern understanding of AS and its course are necessary for the anesthesiologist to guide the patient through the perioperative period.