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A Prospective International Multicentre Cohort Study of Intraoperative Heart Rate and Systolic Blood Pressure and Myocardial Injury After Noncardiac Surgery: Results of the VISION Study

Abbott, Tom E. F. MRCP; Pearse, Rupert M. MD; Archbold, R. Andrew MD; Ahmad,, Tahania MPH; Niebrzegowska, Edyta MSc; Wragg, Andrew FRCP; Rodseth, Reitze N. PhD; Devereaux, Philip J. PhD; Ackland, Gareth L. PhD
doi: 10.1213/ANE.0000000000002560
Research Report: PDF Only

BACKGROUND:

The association between intraoperative cardiovascular changes and perioperative myocardial injury has chiefly focused on hypotension during noncardiac surgery. However, the relative influence of blood pressure and heart rate (HR) remains unclear. We investigated both individual and codependent relationships among intraoperative HR, systolic blood pressure (SBP), and myocardial injury after noncardiac surgery (MINS).

METHODS:

Secondary analysis of the Vascular Events in Noncardiac Surgery Cohort Evaluation (VISION) study, a prospective international cohort study of noncardiac surgical patients. Multivariable logistic regression analysis tested for associations between intraoperative HR and/or SBP and MINS, defined by an elevated serum troponin T adjudicated as due to an ischemic etiology, within 30 days after surgery. Predefined thresholds for intraoperative HR and SBP were: maximum HR >100 beats or minimum HR <55 beats per minute (bpm); maximum SBP >160 mm Hg or minimum SBP <100 mm Hg. Secondary outcomes were myocardial infarction and mortality within 30 days after surgery.

RESULTS:

After excluding missing data, 1197 of 15,109 patients (7.9%) sustained MINS, 454 of 16,031 (2.8%) sustained myocardial infarction, and 315 of 16,061 patients (2.0%) died within 30 days after surgery. Maximum intraoperative HR >100 bpm was associated with MINS (odds ratio [OR], 1.27 [1.07–1.50]; P < .01), myocardial infarction (OR, 1.34 [1.05–1.70]; P = .02), and mortality (OR, 2.65 [2.06–3.41]; P < .01). Minimum SBP <100 mm Hg was associated with MINS (OR, 1.21 [1.05–1.39]; P = .01) and mortality (OR, 1.81 [1.39–2.37]; P < .01), but not myocardial infarction (OR, 1.21 [0.98–1.49]; P = .07). Maximum SBP >160 mm Hg was associated with MINS (OR, 1.16 [1.01–1.34]; P = .04) and myocardial infarction (OR, 1.34 [1.09–1.64]; P = .01) but, paradoxically, reduced mortality (OR, 0.76 [0.58–0.99]; P = .04). Minimum HR <55 bpm was associated with reduced MINS (OR, 0.70 [0.59–0.82]; P < .01), myocardial infarction (OR, 0.75 [0.58–0.97]; P = .03), and mortality (OR, 0.58 [0.41–0.81]; P < .01). Minimum SBP <100 mm Hg with maximum HR >100 bpm was more strongly associated with MINS (OR, 1.42 [1.15–1.76]; P < .01) compared with minimum SBP <100 mm Hg alone (OR, 1.20 [1.03–1.40]; P = .02).

CONCLUSIONS:

Intraoperative tachycardia and hypotension are associated with MINS. Further interventional research targeting HR/blood pressure is needed to define the optimum strategy to reduce MINS.

This is an open-access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Accepted for publication September 8, 2017.

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Funding: T.E.F.A. is supported by a Medical Research Council and British Journal of Anaesthesia clinical research training fellowship (MR/M017974/1). R.M.P. is supported by an NIHR research professorship and BJA/Royal College of Anaesthetists (RCoA) career development fellowship. G.L.A. is supported by a BJA and RCoA basic science fellowship and the British Oxygen Company research grant. R.N.R. is supported by the National Research Foundation of South Africa. P.J.D. is supported by a Tier 1 Canada Research Chair in Perioperative Medicine and the Yusuf Chair in Cardiology. The Vascular Events in Noncardiac Surgery Cohort Evaluation (VISION) study was funded by over 50 grants, listed below. Roche Diagnostics provided the troponin T assays and some financial support for the VISION study. P.J.D. has received other funding from Roche Diagnostics and Abbott Diagnostics for investigator initiated studies. Funding for this study comes from more than 50 grants for VISION and its substudies: Canadian Institutes of Health Research (6 grants), Heart and Stroke Foundation of Ontario (2 grants), Academic Health Science Centres Alternative Funding Plan Innovation Fund Grant, Population Health Research Institute Grant, Clarity Research Group Grant, McMaster University, Department of Surgery, Surgical Associates Research Grant, Hamilton Health Science New Investigator Fund Grant, Hamilton Health Sciences Grant, Ontario Ministry of Resource and Innovation Grant, Stryker Canada, McMaster University, Department of Anesthesiology (2 grants), Saint Joseph’s Healthcare—Department of Medicine (2 grants), Father Sean O’Sullivan Research Centre (2 grants), McMaster University—Department of Medicine (2 grants), Hamilton Health Sciences Summer Studentships (6 grants), McMaster University—Department of Clinical Epidemiology and Biostatistics Grant, McMaster University—Division of Cardiology Grant, and Canadian Network and Centre for Trials International Grant; Winnipeg Health Sciences Foundation Operating Grant; Diagnostic Services of Manitoba Research Grant; University of Manitoba, Faculty of Dentistry Operational Fund; Projeto Hospitais de Excelencia a Servic o do SUS grant from the Brazilian Ministry of Health in Partnership with Hcor (Cardiac Hospital Sao Paulo-SP); School of Nursing, Universidad Industrial de Santander; Grupo de Cardiologı a Preventiva, Universidad Autó noma de Bucaramanga; Fundació n Cardioinfantil Instituto de Cardiologı a; Alianza Diagnóstica SA; University of Malaya Research Grant; and University of Malaya, Penyelidikan Jangka Pendek Grant. Roche Diagnostics provided the troponin T assays and some financial support for the VISION study. The VISION study funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation or approval of the article.

Conflicts of Interest: See Disclosures at the end of the article.

Reprints will not be available from the authors.

Address correspondence to Gareth L. Ackland, PhD, William Harvey Research Institute, Queen Mary University of London, John Vane Science Centre, London, EC1M 6BQ, United Kingdom. Address e-mail to g.ackland@qmul.ac.uk.

© 2017 International Anesthesia Research Society