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Title: Implication of Major Adverse Postoperative Events and Myocardial Injury on Disability and Survival: A Planned Subanalysis of the ENIGMA-II Trial.
Austin Authors: Beattie, W Scott;Wijeysundera, Duminda N;Chan, Matthew T V;Peyton, Philip J ;Leslie, Kate;Paech, Michael J;Sessler, Daniel I;Wallace, Sophie;Myles, Paul S;Galagher, W;Farrington, C;Ditoro, A;Baulch, S;Sidiropoulos, Sofia ;Bulach, R;Bryant, D;O'Loughlin, E;Mitteregger, V;Bolsin, S;Osborne, C ;McRae, R;Backstrom, M;Cotter, R;March, S;Silbert, B;Said, S;Halliwell, R;Cope, J;Fahlbusch, D;Crump, D;Thompson, G;Jefferies, A;Reeves, M;Buckley, N;Tidy, T;Schricker, T;Lattermann, R;Iannuzzi, D;Carroll, J;Jacka, M;Bryden, C;Badner, N;Tsang, M W Y;Cheng, B C P;Fong, A C M;Chu, L C Y;Koo, E G Y;Mohd, N;Ming, L E;Campbell, D;McAllister, D;Walker, S ;Olliff, S;Kennedy, R;Eldawlatly, A;Alzahrani, T;Chua, N;Sneyd, R;McMillan, H;Parkinson, I;Brennan, A;Balaji, P;Nightingale, J;Kunst, G;Dickinson, M;Subramaniam, B;Banner-Godspeed, V;Liu, J;Kurz, A;Hesler, B;Fu, A Y;Egan, C;Fiffick, A N;Hutcherson, M T;Turan, A;Naylor, A;Obal, D;Cooke, E
Affiliation: Departments of Anesthesia
Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
From the Department of Anesthesia and Pain Management, University Health Network, University of Toronto, Toronto, Ontario, Canada
Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
Department of Anaesthesia and Perioperative Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
Department of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia
Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia
Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Victoria, Australia
Department of Anaesthesia, Perioperative and Pain Medicine Unit, Melbourne Medical School, Parkville, Victoria, Australia
Department of Pharmacology and Therapeutics, University of Melbourne, Melbourne, Victoria, Australia
Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
Issue Date: 2018
Publication information: Anesthesia and analgesia 2018; 127(5): 1118-1126
Abstract: Globally, >300 million patients have surgery annually, and ≤20% experience adverse postoperative events. We studied the impact of both cardiac and noncardiac adverse events on 1-year disability-free survival after noncardiac surgery. We used the study cohort from the Evaluation of Nitrous oxide in Gas Mixture of Anesthesia (ENIGMA-II) trial, an international randomized trial of 6992 noncardiac surgical patients. All were ≥45 years of age and had moderate to high cardiac risk. The primary outcome was mortality within 1 postoperative year. We defined 4 separate types of postoperative adverse events. Major adverse cardiac events (MACEs) included myocardial infarction (MI), cardiac arrest, and myocardial revascularization with or without troponin elevation. MI was defined using the third Universal Definition and was blindly adjudicated. A second cohort consisted of patients with isolated troponin increases who did not meet the definition for MI. We also considered a cohort of patients who experienced major adverse postoperative events (MAPEs), including unplanned admission to intensive care, prolonged mechanical ventilation, wound infection, pulmonary embolism, and stroke. From this cohort, we identified a group without troponin elevation and another with troponin elevation that was not judged to be an MI. Multivariable Cox proportional hazard models for death at 1 year and assessments of proportionality of hazard functions were performed and expressed as an adjusted hazard ratio (aHR) and 95% confidence intervals (CIs). MACEs were observed in 469 patients, and another 754 patients had isolated troponin increases. MAPEs were observed in 631 patients. Compared with control patients, patients with a MACE were at increased risk of mortality (aHR, 3.36 [95% CI, 2.55-4.46]), similar to patients who suffered a MAPE without troponin elevation (n = 501) (aHR, 2.98 [95% CI, 2.26-3.92]). Patients who suffered a MAPE with troponin elevation but without MI had the highest risk of death (n = 116) (aHR, 4.29 [95% CI, 2.89-6.36]). These 4 types of adverse events similarly affected 1-year disability-free survival. MACEs and MAPEs occur at similar frequencies and affect survival to a similar degree. All 3 types of postoperative troponin elevation in this analysis were associated, to varying degrees, with increased risk of death and disability.
DOI: 10.1213/ANE.0000000000003310
ORCID: 0000-0003-1185-2869
Journal: Anesthesia and analgesia
PubMed URL: 29533264
Type: Journal Article
Appears in Collections:Journal articles

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