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    • Heart Mirror Journal Vol. 3, No. 1, 2009 From Affiliated Egyptian Universities and Cardiology Centers ISSN 1687-6652 ORIGINAL ARTICLE History of Arrhythmias is Significant Risk Factor for Perioperative Cardiac Complications in Coronary Patients Undergoing Abdominal Nonvascular Surgery Vesna M. Karapandžić1, Vitomir I. Rankovic2, Snezana N. Protic3 and Ivan G. Palibrk4 1 Department of Digestive Surgery, Institute of Digestive System Diseases, University, 2Department of Anaesthesia, University, 3Department of Anaesthesia, Institute of Digestive System Diseases, University and 4Department of Anaesthesia, Institute of Digestive System Diseases, University Clinical Center of Serbia, Belgrade, Serbia. Background History of arrhythmias is significant risk factor for perioperative cardiac complications in coronary patients undergoing open abdominal nonvascular surgery under general anesthesia. Methods Our prospective observational clinical study included 111 consecutive patients with angiographically verified coronary artery disease, operated on at the University Clinical Center. They were divided in two stratification subgroups, subgroup –I with a history of arrhythmias 43.2% (48/111) vs subgroup II-without a history of arrhythmias 57.6% (63/111) and were compared in relation to frequency of perioperative minor, major and fatal cardiac complications. All patients were monitored by continuous electrocardiogram during the surgery as well as in the immediate postoperative 72-hour period. All patients had 12-lead electrocardiography immediately after the surgery, and on postoperative days 1, 2 and 7 as well as a day before discharge from hospital. Cardiac biomarkers (CKMB and troponin) were evaluated at 6 h, 24 h and 96 hours following the surgery. The patients were monitored on daily basis during their stay in hospital and upon discharge till 30th postoperative day. Results Statistical design was presented by Pearson’s χ2 test and binomial logistic regression (Univariate and multivariate analysis). Perioperative mortality of cardiac etiology to 30th postoperative day was (3/48) 6.25% in patients with a history of arrhythmias vs (0/63) 0.0% patients without a history of arrhythmias (p<0.05). Causes of death in all three patients were malignant arrhythmias, acute heart failure and acute myocardial infarction. Conclusions History of arrhythmias significantly increases morbidity and mortality in patients with angiographically verified coronary artery disease undergoing open abdominal nonvascular surgery under general anesthesia. Keywords Arrhythmias, Risk factor, Coronary artery disease, Surgery, Perioperative complications. (Heart Mirror J 2009; 3(1): 24-31) INTROdUCTION Patients with current arrhythmias and/or history of Arrhythmias were initially identified as important predictors arrhythmias and conduction disturbances are at increased of perioperative cardiac complications, but subsequent risk of perioperative arrhythmias, heart failure, myocardial data indicate that this link is explained by the severity of ischemia and pulmonary embolism. Patients at the highest underlying cardiopulmonary disease, ongoing myocardial risk are those with structural heart disorders, older people ischemia or infarction and heart failure (1- 6). and patients undergoing major noncardiac surgery. (1-5) Downloaded from www.heartmirror.com
    • 25 Karapandžić et al. HMJ Vol. 3, No. 1, 2009 History of Arrhythmias is Significant Risk Factor May 2009: 24-31 Two scoring systems demonstrated that rhythm other than Criterion to enter the study was angiographically verified sinus, premature atrial contractions on last preoperative coronary artery disease. electrocardiogram, and more than five premature ventricular contractions documented at any time before operation was All patients from the selected group had preoperative independent predictors of poor prognosis (7, 8). and pre-hospital coronary angiography, irrelevant of noncardiac surgery along with decision made by According to the most recent literature data, major clinical cardiosurgical consultation team on further management predictors of increased perioperative cardiovascular risk of coronary disease (Myocardial medicamentous therapy). are significant arrhythmias [High-grade atrioventricular Angiographically verified severe stenosis of coronary block, symptomatic ventricular arrhythmias in the presence arteries and indication for myocardial revascularisation of underlying heart disease (Left ventricular dysfunction, had 31(64.6%) patient with a history of arrhythmias, and atrial enlargement, subcritical valvular stenoses and 24(38.1%) patients without a history of arrhythmias. Mild coronary artery disease) and supraventricular arrhythmias stenosis of coronary arteries with recommendation for with uncontrolled ventricular rate] (1-3). medicamentous therapy had 17(35.4%) patients with a history of arrhythmias, and 39(61.9%) patients without a Perioperative arrhythmias are often in noncardiac history of arrhythmias. The group of consecutive patients surgery, and if an etiological factor not corrected, they without coronary angiography performed was excluded might induce adverse cardiac events (4, 9). Their origin from the study, because their coronary disease was is most commonly extracardiac, caused by hypotension, diagnosed only by medical history, without any former hypovolemia, hypervolemia, hypoxemia, hemorrhage, diagnostic tests. infection, elevated body temperature, acid-base imbalance, electrolyte imbalance (Hypokalemia and hypomagnesemia), Diagnosis of history of arrhythmias was based on submitted drug toxicity, anxiousness, pain, pulmonary embolism, medical documentation from perihospital period (12-lead pneumonia, atelectasis, and higher activity of sympathetic electrocardiogram and/or 24-Holter electrocardiogram), nervous system (1, 3-6). including the electrocardiogram performed upon the admission to hospital. The aim of our study was to prove that a history of arrhythmias was significant risk factor for perioperative Diagnosis of newly developed perioperative arrhythmias cardiac complications in patients with angiographically was made comparing 12-lead electrocardiography and/or verified coronary artery disease undergoing open abdominal Holter electrocardiography from preoperative period with nonvascular surgery under general anesthesia. the same from intra - and postoperative period. SUBJECTS ANd METHOdS Perioperative management - risk reduction strategy: Perioperative monitoring and medicamentous therapy Study protocol were carried out in the line with American College of Our prospective observational clinical study included the Cardiology/American Heart Association (ACC/AHA) group of 111 consecutive patients with angiographically guidelines published in 2002 (3). verified coronary artery disease, operated on at the Department of Digestive Surgery, Institute of Digestive Coronary patients were monitored by continuous System Diseases, University Clinical Center of Serbia electrocardiogram during the surgery as well as in the (Tertiary level-teaching hospital), Belgrade, Serbia, immediate postoperative 72-hour period in the Intensive between July 2002 and December 2003. Care Unit, which recorded blood pressure and frequency values every hour, all kinds of electrocardiographic Risk assessment and preoperative preparation were changes as well as saturation. All patients had 12-lead completed according to American College of Cardiology/ electrocardiography immediately after the surgery, and American Heart Association (ACC/AHA) guidelines on postoperative days 1, 2 and 7 as well as a day before published in 2002 (3). discharge from hospital. Cardiac biomarkers (CKMB and troponin) were evaluated at 6 h, 24 h and 96 hours following Immediately upon admission, all patients were subjected the surgery according to ACC/AHA 2002 recommendations to complete physical/cardiological examination, involving (3). The patients were monitored on daily basis during their medical history, physical status, electrocardiogram (Schiller stay in hospital and upon discharge till 30th postoperative AT-1), X-ray of the heart and lungs (Shimadzu RS 50 A), day. During hospitalization, all patients were observed by transthoracic echocardiography (Siemens Sequoia 256) cardiologist every day. and complete laboratory analyses (Olympus 400). 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    • HMJ Vol. 3, No. 1, 2009 Karapandžić et al. 26 May 2009: 24-31 History of Arrhythmias is Significant Risk Factor Myocardial revascularisation prior to open abdominal 3. Acute heart failure-according to “Framingham Criteria nonvascular surgery was performed in 13(27.1%) patients for Heart Failure. with a history of arrhythmias and in 21(33.3%) patient without a history of arrhythmias. Indicated revascularisation 4. Cardiac arrest. was not performed in 21(38.2%) patient, because of emergency of surgery and/or poor general health status. 5. Cardiac death to the 30th postoperative day. Perioperative medicamentous therapy with beta blockers Statistical analysis was applied in 34(70.8%) coronary patients with a history of arrhythmias, and in 49(77.7%) patients without a history Coronary patients were divided in two stratification of arrhythmias. Fourteen (29.2%) coronary patients with a subgroups in relation to present and/or earlier history of history of arrhythmias did not receive beta blocker therapy arrhythmias. because drugs were contraindicated. Subgroup I included patients with a history of arrhythmias Perioperative cardiac complications: 43.2% (48/111) and subgroup II consisted of patients without a history of arrhythmias 57.6% (63/111). The following perioperative cardiac complications were observed: Two subgroups of patients were compared in relation to minor, major and fatal perioperative cardiac Minor perioperative cardiac complications: complications. 1. Hypertension (BP>160/100mmHg, Class II JNC VII)- according to criteria of the Joint National Committee. Statistical design was presented by Pearson’s χ2 test and binomial logistic regression. 2. Newly developed benign cardiac arrhythmias and conduction disturbances (Sinus tachycardia A non-parametrials Pearson’s χ2 test in the form of HR>100bpm, supraventricular tachyarrhythmias, atrial contingence tables were used for statistical analysis, fibrillation with rapid ventricular response, isolated considering that features were attributive categorical type premature ventricular contractions, nonsustained and significance level was at the limit of 0.05. ventricular tachycardia, newly developed bundle branch block right/left and AV block I and II)- Binomial (Or binary) logistic regression is a form of documented by 12-lead electrocardiography and/or regression which is used when the dependent is a dichotomy Holter electrocardiography. and the independents are of any type. Logistic logestic can be used to predict a dependent variable based on continuous 3. Transient myocardial ischemia with or without chest and/or categorical independents and to determine the pain (Transient and/or repeating ST ↑ ≥ 2mm in leads percent of variance in the dependent variable explained V1,V2,V3, ≥ 1mm in the other leads, ST ↓ ≥ 1mm in by the independents; to rank the relative importance at least 2 adjoining leads, and/or symmetric inversion of independents; to assess interaction effects; and to T waves ≥ 1mm) (10). understand the impact of covariate control variables. Major perioperative cardiac complications: RESULTS 1. Newly developed malignant cardiac arrhythmias and conduction disturbances (Sustained ventricular We analyzed the perioperative cardiac complications of 111 tachycardia, ventricular fibrillation, and AV block IIIo) consecutive coronary patients undergoing open abdominal -documented by 12-lead electrocardiography and/or nonvascular surgery under general anesthesia. Holter electrocardiography. Clinical characteristics of selected coronary patients was 2. Acute myocardial infarction (ESC/ACC 2000) (10). presented in Table (1). Downloaded from www.heartmirror.com
    • 27 Karapandžić et al. HMJ Vol. 3, No. 1, 2009 History of Arrhythmias is Significant Risk Factor May 2009: 24-31 Table 1: Clinical Characteristics of Selected Coronary Patients According To Hystory of Arrhythmias: Clinical characteristics With a history of arrhythmias Without a history of arrhythmias Total number of patients of selected coronary patients 48(43.2%) 63 (57.6%) n=111(100%) Severe stenosis (Angiographically verified) 31(64.6%) 24(38.1%) 55(49.5%) Heart failure chronic/acute 11(9.9%) 6(5.4%) 17(15.3%) Valvular heart diseases Valvular regurgitation 19(17.1%) 10(9.0%) 29(26.1%) Ostial stenoses 3(2.7%) 2(1.8%) 5(4.5%) Congenital heart disease (Non operated) 1(0.9%) 0(0.0%) 1(0.9%) Prosthetic heart valves 4(3.6%) 1(0.9%) 5(4.5%) Anuloplasty of heart valve 1(0.9%) 1(0.9%) 2(1.8%) Inflamatory myocardial diseases Viral myocarditis 1(0.9%) 0(0.0%) 1(0.9%) Infective endocarditis of prosthetic heart valves 2(1.8%) 1(0.9%) 3(2.7%) Pericarditis with effusion 2(1.8%) 1(0.9%) 3(2.7%) Echocardiographic paramethers Left ventricular ejection fraction <35% 9(8.1%) 6(5.4%) 15(13.5%) Mural thrombi in the left ventricle 1(0.9%) 1(0.9%) 2(1.8%) End-diastolic diameter of the left ventricle >5,7cm 35(31.5%) 10(9.0%) 45(40.5%) Risk factors for coronary disease Hypertension 31(27.9%) 39(35.1%) 70(63.1%) Diabetes mellitus 11(9.9%) 17(15.3%) 28(25.2%) Dyslipidemia 20(18.0%) 9(8.1%) 9(8.1%) Active smokers 20(18.0%) 8(7.2%) 28(25.2%) Family history of coronary disease 14(12.6%) 7(6.3%) 21(18.9%) Age >70 24(21.6%) 21(18.9%) 45(40.5%) Male 41(36.9%) 51(45.9%) 92(82.9%) Risk reduction strategy Myocardial revascularisation 13(27.1%) 21(33.3%) 34(30.6%) Beta blockers 34(70.8%) 49(77.7%) 83(74.7%) History of arrhythmias of selected coronary patients were Clinical characteristics of selected coronary patients shown in Table (2). according to the type of open abdominal nonvascular surgery were illustrated in Table (3). Downloaded from www.heartmirror.com
    • HMJ Vol. 3, No. 1, 2009 Karapandžić et al. 28 May 2009: 24-31 History of Arrhythmias is Significant Risk Factor Table 2: History of Arrhythmias in Selected Group of Coronary the subgroup without a history of arrhythmias – (53/132) Patients: 40.0% perioperative cardiac complications (p<0.01). The most common cardiac complications were newly developed History of arrhythmias Number of Patients arrhythmias and conduction disturbances. A total number and conduction disturbances 48 (43.2%) of cardiac/noncardiac deaths to 30th postoperative day Chronic atrial fibrillation 17(15.3%) were 5/111 (4.5%) and overall cardiac/noncardiac death 30 Permanent pacemaker 4(3.6%) days following the surgery was 6/111 (5.4%). A number Premature atrial contractions 8(7.2%) of cardiac deaths to the 30th postoperative day was 3/111 Premature ventricular (2.7%), and noncardiac death were 2/111 (1.8%). (see 34(30.6%) contractions Table 4). Ventricular tachycardia 4(3.6%) Ventricular fibrillation 4(3.6%) The main result of our study was statistically significant Left bundle branch block 10(9.0%) difference in relation to incidence of perioperative mortality of cardiac etiology to 30 th postoperative day between Right bundle branch block 14(12.6%) subgroup I – with a history of arrhythmias (3/48) 6.25% vs Left anterior hemiblock 3(2.7%) subgroup II - (0/63) 0.0% without history of arrhythmias History of transient AV block IIIo 2(1.8%) (p<0.05). Table 3: Clinical Characteristics of Selected Coronary Patients Our study also found statistically significant difference According to Type of Surgery: in relation incomplete sentence: With Without Total • Cardiac/noncardiac death till postoperative day 30 history of history of number of (p<0.01). arrhythmias arrhythmias patients • Overall cardiac/noncardiac death 30 days following Type of surgery 48(43.2%) 63(57.6%) n=111(100%) the surgery (p<0.05). Esophageal surgery 2(1.8%) 10(9.0%) 12(10.8%) • The number of patients with major cardiac Hepatobiliar 23(20.7%) 25(22.5%) 48(43.2%) complications (p<0.05). surgery • Acute myocardial infarction (p<0.05). Colorectal surgery 14(12.6%) 22(19.8%) 36(32.4%) • Transient myocardial ischemia (p<0.01). Ventral hernia 9(8.1%) 6(5.4%) 15(13.5%) • Newly developed arrhythmias and conduction repair disturbances (p<0.05). Duration of • A total number of patients with perioperative cardiac surgery complications (p<0.05). >3h 16(14.4%) 20(18.0%) 36(32.4%) • Furthermore, the number of patients assisted by <3h 32(28.8%) 43(38.7%) 75(67.5%) postoperative mechanical ventilation (p<0.01). Urgent surgery 18(16.2%) 13(11.7%) 3(27.9%) Elective surgery 30(27.0%) 50(45.0%) 80(72.1%) It failed to prove statistically significant difference in Malignant disease 22(19.8%) 30(27.0%) 52(46.8%) relation to incidence of newly developed perioperative heart Benign disease 26(23.4%) 33(29.7%) 59(53.1%) failure, but it did establish that percentage of complications was higher in patients with a history of arrhythmias. Using the Pearson’s χ2 test we fou nd: Using the univariate analysis we proved that a history of A total number of coronary patients with perioperative arrhythmias was a predictor of perioperative myocardial cardiac complications in both stratification subgroups ischemia and mechanical ventilation. was 66/111 (59.5%), and 45/111 (40.5%) patients had no cardiac complications. A total number of perioperative Using the multivariate analysis we didn’t prove that a cardiac complications was 132. The subgroup with a history of arrhythmias was an independent predictor of history of arrhythmias accounted for (79/132) 59.8% and perioperative cardiac complications. (See Table 5). Downloaded from www.heartmirror.com
    • 29 Karapandžić et al. HMJ Vol. 3, No. 1, 2009 History of Arrhythmias is Significant Risk Factor May 2009: 24-31 Table 4: Comparison of Coronary Patients With and Without History of Arrhythmias in Relation to Perioperative Cardiac Complications: With a history of Without a history Total number of cardiac arrhythmias of arrhythmias complications Perioperative Cardiac Complications P value n=48 n=63 n=111 43.2% 57.6% 100% Newly developed arrhythmias and conduction 20(41.2%) 17(26.9%) 37(33.3%) p<0.05 disturbances Transient myocardial ischemia 17(35.4%) 8(12.7%) 25(22.5%) p<0.01 Acute myocardial infarction 4(8.3%) 1(1.6%) 5(4.5%) p<0.05 ACC/ESC Newly developed heart failure 4(8.3%) 2(3.2%) 6(5.4%) p>0.05 Cardiac death until 30th postoperative day 3(6.3%) 0(0.0%) 3(2.7%) p<0.05 Total cardiac/noncardiac death until 30th 5(10.4%) 0(0.0%) 5(4.5%) p<0.01 postoperative day Total cardiac/noncardiac death 30 days 5(10.4%) 1(1.6%) 6(5.4%) p<0.05 following surgery Number of patients with major cardiac 7(14.6%) 3(4.8%) 10(9.0%) p<0.05 complications Total number of patients with cardiac 33(68.8%) 33(52.4%) 66(59.5%) p<0.05 complications Mechanical ventilation 8(16.7%) 1(1.6%) 9(8.1%) p<0.01 Table 5: Results of Logistic Regression of Coronary Patients With a History of Arrhythmias in Relation to Perioperative Cardiac Complications: Coronary patients with a history of Univariate Multivariate arrhythmias Perioperative cardiac complications analysis analysis n=48 (43.2%) p=0.162 / Newly developed arrhythmias and conduction disturbances p=0.006 p=0.237 Transient myocardial ischemia p=0.128 / Acute myocardial infarction ACC/ESC p=0.251 / Newly developed heart failure p=0.866 / Cardiac death until 30th postoperative day p=0.791 / Total cardiac/noncardiac death until 30th postoperative day p=0.076 / Total cardiac/noncardiac death 30 days following surgery p=0.088 / Number of patients with major cardiac complications p=0.084 / Total number of patients with cardiac complications p=0.020 p=0.506 Mechanical ventilation dISCUSSION Our prospective observational clinical study analyzed Cardiology/American Heart Association (ACC/AHA) perioperative cardiac complications in 111 consecutive guidelines published in 2002 (3). patients with angiographically verified coronary artery disease with vs without a history of arrhythmias The study verified that the incidence of all types of undergoing open abdominal nonvascular surgery under the observed perioperative cardiac complications was general anesthesia. significantly higher in patients with a history of arrhythmias ranging from 5.1%-22.7%. Risk assessment, preoperative preparation, postoperative monitoring and perioperative medicamentous therapy Overall incidence of new perioperative arrhythmias and were carried out in the line with American College of conduction disturbances was 33.3%, and it was higher by Downloaded from www.heartmirror.com
    • HMJ Vol. 3, No. 1, 2009 Karapandžić et al. 30 May 2009: 24-31 History of Arrhythmias is Significant Risk Factor 14.3% in the subgroup with a history of arrhythmias than under general anesthesia for reduction of morbidity and in the one without a history arrhythmias. New absolute mortality. tachyarrhythmia was developed in 2 patients, sinus tachycardia in 27 patients, supraventricular extrasystole CONCLUSIONS in 4 patients, ventricular extrasystole in 12 patients, nonsustained ventricular tachycardia in 4 cases, sustained History of arrhythmias significantly increases morbidity ventricular tachycardia in 2 patients, ventricular fibrillation and mortality in patients with angiographically verified in 2 patients and transient AV block IIIo in one case. No coronary artery disease undergoing open abdominal patient experienced pacemaker dysfunction. nonvascular surgery under general anesthesia. (p<0.01) The incidence of perioperative myocardial infarction was Considering the significantly higher percentage of 8.3% (With a history of arrhythmias) vs 1.6% (Without a perioperative cardiac complications in patients with a history of arrhythmias) (p<0.05), the number of patients history arrhythmias, it is advisable to treat perioperative with major cardiac complications was 14.6% (With a history arrhythmias with beta blockers for reduction of morbidity of arrhythmias) vs 4.8% (Without a history of arrhythmias) and mortality. (p<0.05), and cardiac death to postoperative day 30 was 6.25% (With a history of arrhythmias) vs 0.0% (Without a Corresponding Author: history of arrhythmias) (p<0.05). Vesna M. Karapandžić MD Internist-cardiologist-consultant, Intensive Care Unit, Elevated troponin-T level over 1.0 micro g/l had 4 patients Department of Digestive Surgery, University Clinical with a history of arrhythmias, and 1 patient without a Center of Serbia, Koste Todorovica 6, Belgrade, Serbia history of arrhythmias. Phone business: ++381.11.3663756 Fax: ++381.11.3065967 Direct cause of death in all three patients was the newly E-mail: vemika@eunet.rs developed malignant arrhythmias (Ventricular tachycardia and ventricular fibrillation), newly developed heart failure REFERENCES and acute myocardial infarction. Cardiac cause of death was confirmed by postmortem examination. One patient died on 1. Goldman L. Cardiovascular disease in special populations. General day 2, and other two on postoperative day 3. All three dead anesthesia in noncardiac surgery in patients with heart disease. 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