Prediction of Major Adverse Cardiac Events in Vascular Surgery: Are Cardiac Risk Scores of Any Practical Value?

Abstract

Background: Disease-specific preoperative scoring systems are often used to predict postoperative cardiac complications. We retrospectively evaluated the accuracy of 2 cardiac risk scores in the prediction of major adverse cardiac events (MACE) after vascular surgery.

Methods: Consecutive procedures were ‘‘scored’’ according to the Revised Cardiac Risk Index (RCRI) and the Eagle criteria. Two ‘‘generic’’ risk scoring systems, ASA (American Society of Anesthesiology) grade and the physiology Portsmouth POSSUM (P-POSSUM) score, were also documented for comparison.

Results: After 344 surgical procedures, 18 patients suffered a MACE (5.2%; 95% CI = 2.8-7.58-4 fatal). The RCRI (AUC 95% CI = 0.68 [0.57-0.83], P = .009) and the Eagle criteria (AUC 95% CI = 0.73 [0.57-0.8], P = .001) were no better than P-POSSUM (AUC 95% CI = 0.82 [0.73-0.91], P < .001) and ASA grade (AUC 95% CI = 0.67 (0.56-0.78), P = 0.016) in predicting MACE. Of the variables included in the 2 cardiac scoring systems, only age and history of ischemic heart disease were associated with MACE in our patients.

Conclusion: Cardiac risk scores were no better than generic risk scoring systems in predicting MACE. Poor performance may be due to differences between our patient population and those in which the scores were developed and to improved perioperative management of cardiac risk.

Keywords

cardiac risk scores major adverse cardiac events vascular surgery

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References

Goldman L. , Caldera DL , Nussbaum SR , et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977;297(16):845-850.

Detsky AS , Abrams HB , Forbath N. , Scott JG , Hilliard JR Predicting cardiac complications in patients undergoing noncardiac surgery . J Gen Intern Med. 1986;1(14):211-219.

Eagle KA , Coley CM , Newell JB , et al. Combining clinical and thallium data optimizes preoperative assessment of cardiac risk before major vascular surgery. Ann Intern Med. 1989;110(11): 859-866.

L’Italien GJ , Paul SD , Hendel RC , et al. Development and validation of a Bayesian model for perioperative cardiac risk assessment in a cohort of 1,081 vascular surgical candidates. J Am Coll Cardiol. 1996 ;27(4):779-786.

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(10): 1043-1049.

Copeland G. , Jones D. , Walters M. POSSUM: a scoring system for surgical audit. Br J Surg. 1991;78(3):356-360.

Whiteley MS , Prytherch DR , Higgins B. , Weaver PC , Prout WG An evaluation of the POSSUM surgical scoring system. Br J Surg. 1996;83(6):812-815.

Dripps RD , Lamont A. , Eckenhoff JE The role of anaesthesia in surgical mortality. JAMA. 1961;178:261-266.

Keats AS The ASA classification of physical status-a recapitulation. Anesthesiology. 1978;49(4):233-236.

10.

Hanley JA , McNeil BJ The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology. 1982; 143(1):29-36.

11.

Durazzo AE , Machado FS , Ikeoka DT , et al. Reduction in cardiovascular events after vascular surgery with atorvastatin: a randomized trial. J Vasc Surg. 2004;39(5):967-975.

12.

Schouten O. , Hoeks SE , Welten GM , et al. Effect of statin withdrawal on frequency of cardiac events after vascular urgery. Am J Cardiol. 2007;100(2):316-320.

13.

Feringa HH , Schouten O. , Karagiannis SE , et al. Intensity of statin therapy in relation to myocardial ischemia, troponin T release, and clinical cardiac outcome in patients undergoing major vascular surgery. J Am Coll Cardiol. 2007;50(17): 1649-1656.

14.

Welten GM , Schouten O. , van Domburg RT , et al. The influence of aging on the prognostic value of the revised cardiac risk index for postoperative cardiac complications in vascular surgery patients. Eur J Vasc Endovasc Surg. 2007;34(6):632-638.

15.

Mangano DT , Layug EL , Wallace A. , Tateo I. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. N Engl J Med. 1996;335(23):1713-1720.

16.

Devereaux PJ , Yang H. , Yusuf S. , et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008; 371(9627):1839-1847.