A Prospective International Multicentre Cohort Study of Intraoperative Heart Rate and Systolic Blood Pressure and Myocardial Injury After Noncardiac Surgery: Results of the VISION Study

Tom E F Abbott, Rupert M Pearse, R Andrew Archbold, Tahania Ahmad, Edyta Niebrzegowska, Andrew Wragg, Reitze N Rodseth, Philip J Devereaux, Gareth L Ackland, Tom E F Abbott, Rupert M Pearse, R Andrew Archbold, Tahania Ahmad, Edyta Niebrzegowska, Andrew Wragg, Reitze N Rodseth, Philip J Devereaux, Gareth L Ackland

Abstract

Background: The association between intraoperative cardiovascular changes and perioperative myocardial injury has chiefly focused on hypotension during noncardiac surgery. However, the relative influence of blood pressure and heart rate (HR) remains unclear. We investigated both individual and codependent relationships among intraoperative HR, systolic blood pressure (SBP), and myocardial injury after noncardiac surgery (MINS).

Methods: Secondary analysis of the Vascular Events in Noncardiac Surgery Cohort Evaluation (VISION) study, a prospective international cohort study of noncardiac surgical patients. Multivariable logistic regression analysis tested for associations between intraoperative HR and/or SBP and MINS, defined by an elevated serum troponin T adjudicated as due to an ischemic etiology, within 30 days after surgery. Predefined thresholds for intraoperative HR and SBP were: maximum HR >100 beats or minimum HR <55 beats per minute (bpm); maximum SBP >160 mm Hg or minimum SBP <100 mm Hg. Secondary outcomes were myocardial infarction and mortality within 30 days after surgery.

Results: After excluding missing data, 1197 of 15,109 patients (7.9%) sustained MINS, 454 of 16,031 (2.8%) sustained myocardial infarction, and 315 of 16,061 patients (2.0%) died within 30 days after surgery. Maximum intraoperative HR >100 bpm was associated with MINS (odds ratio [OR], 1.27 [1.07-1.50]; P < .01), myocardial infarction (OR, 1.34 [1.05-1.70]; P = .02), and mortality (OR, 2.65 [2.06-3.41]; P < .01). Minimum SBP <100 mm Hg was associated with MINS (OR, 1.21 [1.05-1.39]; P = .01) and mortality (OR, 1.81 [1.39-2.37]; P < .01), but not myocardial infarction (OR, 1.21 [0.98-1.49]; P = .07). Maximum SBP >160 mm Hg was associated with MINS (OR, 1.16 [1.01-1.34]; P = .04) and myocardial infarction (OR, 1.34 [1.09-1.64]; P = .01) but, paradoxically, reduced mortality (OR, 0.76 [0.58-0.99]; P = .04). Minimum HR <55 bpm was associated with reduced MINS (OR, 0.70 [0.59-0.82]; P < .01), myocardial infarction (OR, 0.75 [0.58-0.97]; P = .03), and mortality (OR, 0.58 [0.41-0.81]; P < .01). Minimum SBP <100 mm Hg with maximum HR >100 bpm was more strongly associated with MINS (OR, 1.42 [1.15-1.76]; P < .01) compared with minimum SBP <100 mm Hg alone (OR, 1.20 [1.03-1.40]; P = .02).

Conclusions: Intraoperative tachycardia and hypotension are associated with MINS. Further interventional research targeting HR/blood pressure is needed to define the optimum strategy to reduce MINS.

Conflict of interest statement

Conflicts of Interest: See Disclosures at the end of the article.

Figures

Figure 1.
Figure 1.
Patient flow diagram showing the number of cases included and excluded from each analysis.
Figure 2.
Figure 2.
Forest plot summarizing multivariable logistic regression models for highest and lowest intraoperative heart rate (HR) and systolic blood pressure (SBP). Dependent variables are myocardial injury after noncardiac surgery (MINS), myocardial infarction, and mortality within 30 d after surgery. Highest intraoperative HR was dichotomized according to a threshold of >100 beats per minute (bpm) with HR ≤100 bpm as the reference category. Lowest intraoperative HR was dichotomized according to the threshold of 160 mm Hg with SBP ≤160 mm Hg as the reference category. Lowest intraoperative SBP was dichotomized according to the threshold of http://links.lww.com/AA/C70.
Figure 3.
Figure 3.
Forest plot summarizing multivariable logistic regression models for the duration of high/low intraoperative heart rate (HR) and systolic blood pressure (SBP). The dependent variable was myocardial injury after noncardiac surgery (MINS) within 30 d after surgery. There were 4 separate regression models for duration of intraoperative HR >100 beats per minute (bpm), intraoperative HR 160 mm Hg, and intraoperative SBP 100 bpm, the reference group was patients with HR ≤100 bpm. The x-axis shows odds ratios and the error bars show 95% confidence intervals. The full multivariable regression models are presented in Supplemental Digital Content, Tables 3, 4, 7, and 8, http://links.lww.com/AA/C70.
Figure 4.
Figure 4.
Forest plot summarizing multivariable logistic regression models for combinations of highest/lowest intraoperative systolic blood pressure (SBP) and heart rate (HR). The dependent variable was myocardial injury after noncardiac surgery (MINS) within 30 d after surgery. The sample was categorized according to highest intraoperative SBP >160 mm Hg, lowest intraoperative SBP 100 beats per minute (bpm), and lowest intraoperative HR http://links.lww.com/AA/C70.

References

    1. Devereaux PJ, Chan MT, Alonso-Coello P; Vascular Events In Noncardiac Surgery Patients Cohort Evaluation Study Investigators. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. J Am Med Assoc. 2012;307:2295–2304..
    1. Gillies MA, Shah AS, Mullenheim J, et al. Perioperative myocardial injury in patients receiving cardiac output-guided haemodynamic therapy: a substudy of the OPTIMISE Trial. Br J Anaesth. 2015;115:227–233..
    1. Weiser TG, Haynes AB, Molina G, et al. Estimate of the global volume of surgery in 2012: an assessment supporting improved health outcomes. Lancet. 2015;385suppl 2S11.
    1. Pearse RM, Moreno RP, Bauer P, et al. ; European Surgical Outcomes Study (EuSOS) group for the Trials groups of the European Society of Intensive Care Medicine and the European Society of Anaesthesiology. Mortality after surgery in Europe: a 7 day cohort study. Lancet. 2012;380:1059–1065..
    1. Abbott TEF, Fowler AJ, Dobbs TD, Harrison EM, Gillies MA, Pearse RM. Frequency of surgical treatment and related hospital procedures in the UK: a national ecological study using hospital episode statistics. Br J Anaesth. 2017;119:249–257..
    1. Nathoe HM, van Klei WA, Beattie WS. Perioperative troponin elevation: always myocardial injury, but not always myocardial infarction. Anesth Analg. 2014;119:1014–1016..
    1. Bijker JB, van Klei WA, Kappen TH, van Wolfswinkel L, Moons KG, Kalkman CJ. Incidence of intraoperative hypotension as a function of the chosen definition: literature definitions applied to a retrospective cohort using automated data collection. Anesthesiology. 2007;107:213–220..
    1. Sessler DI, Sigl JC, Kelley SD, et al. Hospital stay and mortality are increased in patients having a “triple low” of low blood pressure, low bispectral index, and low minimum alveolar concentration of volatile anesthesia. Anesthesiology. 2012;116:1195–1203..
    1. Landesberg G, Beattie WS, Mosseri M, Jaffe AS, Alpert JS. Perioperative myocardial infarction. Circulation. 2009;119:2936–2944..
    1. Devereaux PJ, Sessler DI, Leslie K, et al. ; POISE-2 Investigators. Clonidine in patients undergoing noncardiac surgery. N Engl J Med. 2014;370:1504–1513..
    1. Abbott TE, Ackland GL, Archbold RA, et al. Preoperative heart rate and myocardial injury after non-cardiac surgery: results of a predefined secondary analysis of the VISION study. Br J Anaesth. 2016;117:172–181..
    1. Devereaux PJ, Yang H, Yusuf S, et al. ; POISE Study Group. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008;371:1839–1847..
    1. Wijeysundera DN, Duncan D, Nkonde-Price C, et al. ; ACC/AHA Task Force Members. Perioperative beta blockade in noncardiac surgery: a systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:2246–2264..
    1. Foëx P, Higham H. Preoperative fast heart rate: a harbinger of perioperative adverse cardiac events. Br J Anaesth. 2016;117:271–274..
    1. Reich DL, Bennett-Guerrero E, Bodian CA, Hossain S, Winfree W, Krol M. Intraoperative tachycardia and hypertension are independently associated with adverse outcome in noncardiac surgery of long duration. Anesth Analg. 2002;95:273–277..
    1. van Waes JA, van Klei WA, Wijeysundera DN, van Wolfswinkel L, Lindsay TF, Beattie WS. Association between intraoperative hypotension and myocardial injury after vascular surgery. Anesthesiology. 2016;124:35–44..
    1. Walsh M, Devereaux PJ, Garg AX, et al. Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery: toward an empirical definition of hypotension. Anesthesiology. 2013;119:507–515..
    1. Abbott TEF, Pearse RM, Archbold RA, et al. Association between preoperative pulse pressure and perioperative myocardial injury: an international observational cohort study of patients undergoing non-cardiac surgery. Br J Anaesth. 2017;119:78–86..
    1. Botto F, Alonso-Coello P, Chan MT, et al. ; Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Writing Group, on behalf of The Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Investigators; Appendix 1. The Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Study Investigators Writing Group; Appendix 2. The Vascular events In noncardiac Surgery patIents cOhort evaluatioN Operations Committee; Vascular events In noncardiac Surgery patIents cOhort evaluatioN VISION Study Investigators. Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology. 2014;120:564–578..
    1. Vandenbroucke JP, von Elm E, Altman DG, et al. ; STROBE Initiative. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. Int J Surg. 2014;12:1500–1524..
    1. Jammer I, Wickboldt N, Sander M, et al. ; European Society of Anaesthesiology (ESA) and the European Society of Intensive Care Medicine (ESICM); European Society of Anaesthesiology; European Society of Intensive Care Medicine. Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions: a statement from the ESA-ESICM joint taskforce on perioperative outcome measures. Eur J Anaesthesiol. 2015;32:88–105..
    1. Thygesen K, Alpert JS, Jaffe AS, et al. ; Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction. Third universal definition of myocardial infarction. Circulation. 2012;126:2020–2035..
    1. Hawn MT, Graham LA, Richman JS, Itani KM, Henderson WG, Maddox TM. Risk of major adverse cardiac events following noncardiac surgery in patients with coronary stents. JAMA. 2013;310:1462–1472..
    1. Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100:1043–1049..
    1. O’Connor ME, Kirwan CJ, Pearse RM, Prowle JR. Incidence and associations of acute kidney injury after major abdominal surgery. Intensive Care Med. 2016;42:521–530..
    1. Bijker JB, van Klei WA, Vergouwe Y, et al. Intraoperative hypotension and 1-year mortality after noncardiac surgery. Anesthesiology. 2009;111:1217–1226..
    1. Hartmann B, Junger A, Röhrig R, et al. Intra-operative tachycardia and peri-operative outcome. Langenbecks Arch Surg. 2003;388:255–260..
    1. Bouri S, Shun-Shin MJ, Cole GD, Mayet J, Francis DP. Meta-analysis of secure randomised controlled trials of β-blockade to prevent perioperative death in non-cardiac surgery. Heart. 2014;100:456–464..
    1. Abbott TEF, Minto G, Lee AM, Pearse RM, Ackland G. Elevated preoperative heart rate is associated with cardiopulmonary and autonomic impairment in high-risk surgical patients. Br J Anaesth. 2017;119:87–94..
    1. Pearse RM, Harrison DA, MacDonald N, et al. ; OPTIMISE Study Group. Effect of a perioperative, cardiac output-guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: a randomized clinical trial and systematic review. JAMA. 2014;311:2181–2190..
    1. Pearse RM, Holt PJ, Grocott MP. Managing perioperative risk in patients undergoing elective non-cardiac surgery. BMJ. 2011;343:d5759.
    1. Anderson JL, Morrow DA. Acute myocardial infarction. N Engl J Med. 2017;376:2053–2064..
    1. Assmann G, Cullen P, Evers T, Petzinna D, Schulte H. Importance of arterial pulse pressure as a predictor of coronary heart disease risk in PROCAM. Eur Heart J. 2005;26:2120–2126..
    1. Landesburg G, Zhou W, Aversano T. Tachycardia-induced subendocardial necrosis in acutely instrumented dogs with fixed coronary stenosis. Anesth Analg. 1999;88:973–979..
    1. Fowler AJ, Ahmad T, Phull MK, Allard S, Gillies MA, Pearse RM. Meta-analysis of the association between preoperative anaemia and mortality after surgery. Br J Surg. 2015;102:1314–1324..
    1. Manfrini O, Pizzi C, Trerè D, Fontana F, Bugiardini R. Parasympathetic failure and risk of subsequent coronary events in unstable angina and non-ST-segment elevation myocardial infarction. Eur Heart J. 2003;24:1560–1566..
    1. Whelton SP, Narla V, Blaha MJ, et al. Association between resting heart rate and inflammatory biomarkers (high- sensitivity C-reactive protein, interleukin-6, and fibrinogen) (from the Multi-Ethnic Study of Atherosclerosis). Am J Cardiol. 2014;113:644–649..
    1. Whittle J, Nelson A, Otto JM, et al. Sympathetic autonomic dysfunction and impaired cardiovascular performance in higher risk surgical patients: implications for perioperative sympatholysis. Open Heart. 2015;2:e000268.
    1. Abbott TE, Vaid N, Ip D, et al. A single-centre observational cohort study of admission National Early Warning Score (NEWS). Resuscitation. 2015;92:89–93..
    1. Dierckx R, Cleland JG, Parsons S, et al. Prescribing patterns to optimize heart rate: analysis of 1,000 consecutive outpatient appointments to a single heart failure clinic over a 6-month period. JACC Heart Fail. 2015;3:224–230..
    1. Nagele P, Brown F, Gage BF, et al. High-sensitivity cardiac troponin T in prediction and diagnosis of myocardial infarction and long-term mortality after noncardiac surgery. Am Heart J. 2013;166:325–332.e1..

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