Surgical Apgar score is associated with myocardial injury after noncardiac surgery.
OBJECTIVE
To assess the impact of intraoperative hemodynamics in the development of perioperative myocardial infarction (MI) and myocardial ischemia after noncardiac surgery.


METHODS
Single-center retrospective cohort study of surgical patients from 2007 to 2012.


METHODS
Postanesthesia care unit, intensive care unit, and medical-surgical ward at an academic tertiary medical center.


METHODS
A total of 46,799 adult noncardiac, nonthoracic surgery patients, for which 2290 peak cardiac troponin (cTn) levels were available.


METHODS
The 10-point Surgical Apgar Score (SAS) was calculated from intraoperative heart rate, blood pressure, and blood loss. Peak troponin (cTn) levels, hospital length of stay, 7- and 30-day postoperative mortality, patient demographics, and prior medical conditions were gathered. Troponin leak was defined as cTn-I 0.6 to 1.5 ng/mL or cTn-T 0.1 to 0.3 ng/mL; perioperative MI criteria were cTn-I greater than 1.5 ng/mL or cTn-T greater than 0.30 ng/mL.


RESULTS
Of 46,799 noncardiac surgical cases, 209 (0.4%) and 192 (0.4%) suffered cTn leak and MI, respectively. Low SAS (0-4) was associated with increased risk of cTn leak and perioperative MI (univariate odds ratio, 2.76 and 2.06; 95% confidence interval, 2.20-3.45 and 1.57-2.70, respectively). In multivariable analysis, Surgical Apgar Score, age 65 years or older, American Society of Anesthesiologists physical status greater than or equal to III, emergency surgery, history of MI or hypertension, prolonged intraoperative tachycardia (heart rate >100 beats/min for >59 minutes), and prolonged hypotension (mean arterial pressure <40 mm Hg for >2 minutes) were independently associated with cTn leak and perioperative MI.


CONCLUSIONS
Low SAS scores (0-4) may be associated with cTn elevation after noncardiac surgery. SAS-based risk stratification may guide perioperative cTn surveillance in lieu of routine postoperative screening.
Department of Anesthesia & Perioperative Care, University of California, San Francisco, San Francisco, CA, USA. Electronic address: lmclhouse2@gmail.com.
L McLean
LM
House
Department of Anesthesiology & Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.
Khensani N
KN
Marolen
Department of Anesthesiology & Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.
Paul J
PJ
St Jacques
Department of Anesthesiology & Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.
Matthew D
MD
McEvoy
Department of Anesthesiology & Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.
Jesse M
JM
Ehrenfeld
D000328:Adult; D000368:Aged; D005260:Female; D006439:Hemodynamics; D006801:Humans; D007022:Hypotension / Q000209:etiology; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D009203:Myocardial Infarction / Q000453:epidemiology* / Q000209:etiology; D017202:Myocardial Ischemia / Q000453:epidemiology* / Q000209:etiology; D011183:Postoperative Complications / Q000453:epidemiology*; D011184:Postoperative Period; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D013514:Surgical Procedures, Operative / Q000009:adverse effects* / Q000401:mortality; D013714:Tennessee / Q000453:epidemiology; D019210:Troponin I / Q000097:blood; D020107:Troponin T / Q000097:blood
D019210:Troponin I; D020107:Troponin T
Ischemia; Myocardial injury; Non-cardiac surgery; Perioperative myocardial infarction; Surgical Apgar Score; Troponin elevation