Incidence of major adverse cardiac events following non-cardiac surgery

Abstract

Aims: Major adverse cardiac events (MACE) triggered by non-cardiac surgery are prognostically important perioperative complications. However, due to often asymptomatic presentation, the incidence and timing of postoperative MACE are incompletely understood.

Methods and results: We conducted a prospective observational study implementing a perioperative screening for postoperative MACE [cardiovascular death (CVD), acute heart failure (AHF), haemodynamically relevant arrhythmias, spontaneous myocardial infarction (MI), and perioperative myocardial infarction/injury (PMI)] in patients at increased cardiovascular risk (≥65 years OR ≥45 years with history of cardiovascular disease) undergoing non-cardiac surgery at a tertiary hospital. All patients received serial measurements of cardiac troponin to detect asymptomatic MACE. Among 2265 patients (mean age 73 years, 43.4% women), the incidence of MACE was 15.2% within 30 days, and 20.6% within 365 days. CVD occurred in 1.2% [95% confidence interval (CI) 0.9-1.8] and in 3.7% (95% CI 3.0-4.5), haemodynamically relevant arrhythmias in 1.2% (95% CI 0.9-1.8) and in 2.1% (95% CI 1.6-2.8), AHF in 1.6% (95% CI 1.2-2.2) and in 4.2% (95% CI 3.4-5.1), spontaneous MI in 0.5% (95% CI 0.3-0.9) and in 1.6% (95% CI 1.2-2.2), and PMI in 13.2% (95% CI 11.9-14.7) and in 14.8% (95% CI 13.4-16.4) within 30 days and within 365 days, respectively. The MACE-incidence was increased above presumed baseline rate until Day 135 (95% CI 104-163), indicating a vulnerable period of 3-5 months.

Conclusion: One out of five high-risk patients undergoing non-cardiac surgery will develop one or more MACE within 365 days. The risk for MACE remains increased for about 5 months after non-cardiac surgery.

Trial registration: https://www.clinicaltrials.gov. Unique identifier: NCT02573532.

Keywords: Acute myocardial infarction; Arrhythmia; Death; Heart failure; Surgery.

Figure 1

Cumulative incidence of MACE within 365 days of follow-up. Kaplan–Meier curves displaying the cumulative incidence of MACE within 365 days of follow-up for (A) all patients (n = 2265, 464 events), and (B) split for patients with PMI (n = 274 with 90 events in red), and without PMI (n = 1989 with 190 events in green). Differences between groups (with, and without PMI) were assessed using the log-rank test. MACE, major adverse cardiac events; PMI, perioperative myocardial injury/infarction.

Figure 2

Cumulative incidence of the single components of MACE within 365 days of follow-up split for patients with and without PMI. Kaplan–Meier curves showing the cumulative incidence of the single components of MACE for (A) CVD (with PMI: n = 275, 23 events; without PMI: n = 1990; 60 events). (B) Haemodynamically relevant arrhythmias (with PMI: n = 274, 19 events; without PMI: n = 1989, 26 events). (C) AHF (with PMI: n = 275, 31 events; without PMI: n = 1990, 64 events). (D) Spontaneous MI (with PMI: n = 275; 9 events; without PMI: n = 1990, 28 events). Each split for patients with PMI (red line) and without PMI (green line). Differences between groups (with, and without PMI) were assessed using the log-rank test. Patients with initial PMI are more likely to suffer from CVD, haemodynamically relevant arrhythmias, AHF, and spontaneous MI during 365 days of follow-up. AHF, acute heart failure; CVD, cardiovascular death; MACE, major adverse cardiac events; MI, myocardial infarction; PMI, perioperative myocardial injury/infarction.

Figure 3

Time of occurrence of MACE within 365 days of follow-up. The time of occurrence of MACE within 365 days of follow-up shown for the entire patient cohort (n = 2265). Days after surgery on the x-axis, and pending events (in percent) on the y-axis. The green line was derived by linear regression of pending events from postoperative Day 300 to 365, the red line was derived by linear regression of pending events from postoperative Day 30 to 118. 95% confidence intervals (CIs) are shown as ribbons. The intersection area represents the overlap of the derived linear regression lines and their 95% CI. The intersection area is at 135 (95% CI 104–163) days of follow-up and is also shown by the orange coloured bar below with the label ‘Change in trend’. The steeper slope from postoperative Day 0 to 103 is illustrated by the red coloured bar with the label ‘MACE rate affected by the surgical procedure’, and the time period from postoperative Day 164 to 365 is illustrated by the green coloured bar with the label ‘stable event rate’. MACE, major adverse cardiac events.