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Coronary revascularization and adverse events in joint arthroplasty
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Coronary revascularization and adverse events in joint arthroplasty Reza Mostafavi Tabatabaee, MD, Mohammad R. Rasouli, MD, Maryam Rezapoor, MS, Mitchell G. Maltenfort, PhD, Alvin C. Ong, MD, and Javad Parvizi, MD, FRCS* Rothman Institute of Orthopaedics, Thomas Jefferson University, Philadelphia, Pennsylvania
article info
abstract
Article history:
Background: There is a paucity of literature about outcome of total joint arthroplasty in
Received 4 January 2015
patients with the history of angioplasty and/or stent or coronary artery bypass graft
Received in revised form
(CABG). The present study aimed to evaluate perioperative complications and mortality in
24 April 2015
these patients.
Accepted 7 May 2015
Methods: We used the Nationwide Inpatient Sample data from 2002e2011. Using the Ninth
Available online 14 May 2015
Revision of the International Classification of Disease, Clinical Modification codes for disorders and procedures, we identified patients with a history of coronary revascularization
Keywords:
(angioplasty and/or stent or CABG) and compared the inhospital adverse events in these
Coronary artery bypass graft
patients with patients without a history of coronary revascularization.
Coronary angioplasty/stent
Results: Cardiac complications occurred in 1.06% patients with a history of CABG; 0.95% of
Total joint arthroplasty
patients with a coronary angioplasty and/or stent and 0.82% of the control patients. In the
Adverse events
multivariate analysis, neither the history of CABG (P ¼ 0.07) nor the history of angioplasty
Mortality
and/or stenting (P ¼ 0.86) was associated with a higher risk of cardiac complications.
Nationwide Inpatient Sample
However, myocardial infarction occurred in a significantly higher proportion of patients with the history of CABG (0.66%, odds ratio, 1.24, P ¼ 0.001) and coronary angioplasty and/or stenting (0.67%, odds ratio, 1.96, P < 0.001) compared with that in the controls (0.27%). History of coronary revascularization did not increase the risk of respiratory, renal, and wound complications, surgical site infection, and mortality. Conclusions: Based on the findings of this study, it appears that there is no increased risk of inhospital mortality and complications (except for myocardial infarction) in patients with a history of coronary artery revascularization undergoing total joint arthroplasty. We also found perioperative cardiac arrhythmia, particularly atrial fibrillation, to be an independent predictor of inhospital adverse events. ª 2015 Elsevier Inc. All rights reserved.
1.
Introduction
Coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) have arisen as the predominant coronary artery revascularization strategies, with an estimated
397,000 inpatient CABG procedures and 954,000 inpatient PCI procedures performed in 2010 in the United States [1]. Although the development of revascularization therapies has been a major breakthrough in the treatment of coronary artery disease (CAD), enthusiasm has been mitigated by the
* Corresponding author. Rothman Institute at Thomas Jefferson University Hospital, Sheridan Building, Suite 1000, 125 South 9th Street, Philadelphia, PA 19107. Tel.: þ1 267 339 7813; fax: þ1 215 503 5651. E-mail address: [email protected] (J. Parvizi). 0022-4804/$ e see front matter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2015.05.013
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potentially fatal complications of subsequent coronary thrombosis [2]. Moreover, these patients are more susceptible to adverse cardiac events compared with those of the general population, particularly at the time of later surgeries [3e5]. The extent of catastrophe can be seen in documented cases, where the incidences of a major adverse cardiac event and mortality are 2.1%e9.8% and 1.2%e5.2% within 30 de1 y, respectively, after the surgery [5]. Approximately 5%e23% of patients with a history of revascularization procedure undergo noncardiac surgeries within 1e2 y of revascularization [4,6]. Total hip arthroplasty (THA) and total knee arthroplasty (TKA), with an annual number of over 750,000 cases in the United States, have been considered as the most common orthopedic procedures. By 2030, this number is expected to increase exponentially to 0.57 million and 3.48 million procedures for THA and TKA, respectively [7]. Given the high prevalence of CABG and stent placement on the one hand, and the increasing proportion of patients in need of total joint arthroplasty (TJA) on the other, it is expected that a larger number of patients with a history of coronary revascularization will require TJA. However, there is a paucity of literature about major adverse events after TJA in patients with a history of coronary stenting or CABG. Although some evidence of adverse cardiac events after noncardiac surgery in patients with a history of stent placement has been found [4], less is known about TJA in particular. This study focuses on the relation between a history of revascularization procedures (CABG and stent placement) and the inhospital major adverse events and the mortality after TJA. Moreover, we evaluate if cardiac arrhythmias affect the rate of complications and mortality in this population.
2.
Methods and materials
We used the Nationwide Inpatient Sample (NIS) database, the largest all-payer inpatient database in the United States, which contains information on about 8 million hospital admissions per year. Because the NIS database has been sufficiently deidentified, this study was exempt from the institutional review board review. NIS data from 2002e2011 were queried to identify those patients with a history of either CABG or coronary angioplasty and/or stenting who were also coded for primary or revision TJA. For this purpose, the following codes from the Ninth Revision of the International Classification of Diseases, Clinical Modification (ICD-9-CM) were used:
81.51 and 81.53 for primary and revision THA, respectively. 81.54 and 81.55 for primary and revision TKA, respectively. V45.81 for CABG. V45.82 for percutaneous transluminal coronary angioplasty and stenting.
Patients with a history of both CABG and cardiac stent were excluded, and the remaining patients were divided into three groups as follows: CABG, coronary angioplasty and/or stent, and controls (patients without a history of CABG or coronary angioplasty and/or stenting).
Because dysrhythmias are common in patients with ischemic heart diseases and may affect the outcome of patients undergoing TJA [8], we also ran a query based on the ICD-9-CM codes for dysrhythmias (427.0e427.9) to determine postoperative dysrhythmias. We further categorized postoperative dysrhythmias as atrial fibrillation (427.31) or other dysrhythmias. The same coding system was used to identify postoperative adverse events including cardiac, respiratory, renal, wound complications, and surgical site infection (SSI) and/or periprosthetic joint infection (PJI). These ICD-9-CM codes are listed in Table 1. For all patients, demographics, hospital characteristics, type of payer, and comorbidities were obtained in addition to inhospital complications and mortality. The Elixhauser comorbidity measure was used in our study to extract patients’ comorbidities. The Elixhauser comorbidity index was developed to determine the overall risk of comorbidity, using a list of 30 comorbidities based on the ICD-9-CM coding system [9]. Previous studies demonstrated that the Elixhauser comorbidity measure is a reliable index to predict the outcome of patients [10,11].
2.1.
Statistical analysis
Multivariate analysis (logistic regression) was performed to determine if a history of CABG and coronary stenting is an independent predictor of mortality and complications, controlling for confounders including Elixhauser comorbidities, type of TJA, type of insurance, age, gender, race, year of surgery, cardiac dysrhythmias (atrial fibrillation and other arrhythmias), and hospital size, type, and setting. All analyses were performed using R 3.0.2 (R Foundation for Statistical Computing, Vienna, Austria) using the “rms” package to perform the logistic regression. P values <0.05 were considered to be statistically significant.
3.
Results
From 2002e2011, there was an increase in the percent of patients with coronary angioplasty and/or stent that underwent TJA, whereas during the same period, the percent of cases with history of CABG that underwent TJA declined (Fig. 1). A total of 47,351 cases with a history of CABG and 44,017 cases with a history of coronary angioplasty and/or stent placement
Table 1 e Major adverse events evaluated and their related ICD-9M-CM codes. Study variables MI Cardiac Respiratory Hematoma/seroma PE Venous thrombotic events SSI/PJI Renal
ICD-9-CM code 410-xx 997.1 997.3 998.1 4151 4511, 4512, 4518, 4519, 4532, 4538, 4539 998.31, 998.32, 998.5x, 996.66, 996.67 997.5
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Fig. 1 e Trends in percent of patients who underwent TJA with a history of CABG or coronary stent.
were included in the final analysis and compared with 1,537,394 control patients. The outcome in terms of the inhospital mortality and complications was assessed. The characteristics of these cases have been summarized in Table 2.
3.1.
Risk of cardiopulmonary complications
There was a significant decrease in the rate of cardiopulmonary complications over time (P < 0.001). Cardiac complications occurred slightly more frequently in patients with a history of CABG (1.06%) and coronary angioplasty and/or stent (0.95%) compared with those in the control group (0.82%). In the multivariate analysis, controlling for confounders, neither a history of CABG (P ¼ 0.07) nor a history of angioplasty and/or stenting (P ¼ 0.86) was associated with a higher risk of cardiac complications. However, myocardial infarction (MI) occurred in a significantly higher proportion of patients with the history of CABG (0.66%, odds ratio (OR), 1.24; 95% confidence interval (CI), 1.09e1.42, P ¼ 0.001), the coronary angioplasty and/or stenting (0.67%, OR, 1.96; 95% CI, 1.71e2.24, P < 0.001) compared with that in the control group, in which MI occurred in 0.27% of cases. Patients who underwent revision surgery (OR, 1.19; 95% CI, 1.00e1.40, P ¼ 0.04) were at an increased risk of MI compared with those who underwent primary TJA. Multivariate analysis showed a decrease in the rate of respiratory complications over the study period. Respiratory complications were observed less frequently in the CABG (0.61%) and angioplasty and/or stent (0.61%) groups compared with those in the control (0.64%). In the multivariate analysis, a history of CABG was associated with a significantly lower risk of respiratory complications (OR, 0.79; 95% CI, 0.69e0.90, P < 0.001); however, a history of angioplasty and/or stenting was not an independent predictor of respiratory complications (P ¼ 0.12).
3.2.
Risk of venous thromboembolism
Pulmonary embolism (PE) occurred in 0.30% and 0.33% of the CABG and angioplasty and/or stent groups, respectively, whereas the PE rate was slightly higher in the control group at 0.38%. In the multivariate analysis, a history of CABG was associated with a lower risk of PE (OR, 0.80; 95% CI, 0.64e0.98, P < 0.03). Knee surgery was another predictor of the risk of PE in the multivariate analysis (OR, 2.23; 95% CI, 2.04e2.42, P < 0.001). Deep vein thrombosis (DVT) occurred in 0.42% of the CABG group, 0.49% of the angioplasty and/or stent cases and 0.58% of the control group. In the multivariate analysis, both CABG (OR, 0.69; 95% CI, 0.59e0.81, P < 0.001) and angioplasty and/or stenting (OR, 0.80; 95% CI, 0.68e0.94, P ¼ 0.007) were associated with a lower risk of DVT.
3.3.
Risk of renal complications
Renal complications occurred more frequently in the CABG group compared with those in other two groups (Fig. 2). However, using multivariate analysis, a history of CABG was not an independent risk factor for postoperative renal complications, whereas history of angioplasty and/or stenting was associated with a lower risk of renal complications (OR, 0.80; 95% CI, 0.70e0.91, P < 0.001).
3.4.
Risk of wound complications
Wound complications (SSI and/or PJI and hematoma and/or seroma) declined significantly over time in the multivariate analysis (P < 0.001). The rate of wound hematoma and/or seroma was slightly lower in the CABG (0.091%) and angioplasty and/or stent (0.91%) groups compared with that in the controls (0.96%). Multivariate analysis indicated that hematoma and/or seroma is less likely to occur in the CABG group
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Table 2 e Characteristics of patients in the CABG, coronary stent, and controls. Characteristics
Control
CABG
Stent
Number 1,537,394 47,351 44,017 Age (mean SD) 65.81 11.49 72.57 8.42 70.16 9.16 Female (%) 62.97 28.30 39.48 Ethnicity, % White 64.77 71.42 70.98 African-American 5.60 2.18 3.29 Hispanic 3.57 2.39 2.37 Asian 0.82 0.54 0.56 Native American/other 1.87 1.65 1.68 Unspecified 23.37 21.83 21.12 Insurance type, % Medicare 54.83 78.01 69.46 Medicaid 2.98 1.06 1.39 Private 38.46 19.05 26.47 Self-pay/NC/other 3.74 1.88 2.69 Hospital setting, % Rural 12.06 11.79 10.09 Urban academic 46.42 48.02 47.90 Urban private 41.52 40.19 42.01 Region, % Northeast 17.45 16.66 17.06 Midwest 26.83 28.13 29.67 South 35.86 38.73 36.21 West 19.86 16.48 17.05 Hospital size, % Small 16.56 13.34 13.83 Medium 24.50 24.74 23.94 Large 58.93 61.92 62.23 Type of TJA, % Primary THA 94.50 2.93 2.57 Primary TKA 94.45 2.81 2.75 Revision THA 94.54 3.40 2.06 Revision TKA 93.99 3.58 2.43 NC ¼ non-covered; SD ¼ standard deviation.
(OR, 0.81; 95% CI, 0.72e0.91, P < 0.001); however, a history of coronary angioplasty and/or stenting was not an independent predictor. SSI and/or PJI also was observed less frequently in the angioplasty and/or stent (0.18%) and CABG (0.20%) groups compared with that in the control (0.26%). In the multivariate analysis, CABG (OR, 0.73; 95% CI, 0.56e0.89, P ¼ 0.03) and coronary angioplasty and/or stenting (OR, 0.67; 95% CI,
0.52e0.86, P ¼ 0.001) were associated with a lower risk of SSI compared with that in the control group. As expected, revision surgery was an independent predictor for the risk of hematoma and/or seroma (OR, 1.66; 95% CI, 1.52e1.82, P < 0.001) and SSI and/or PJI (OR, 4.41; 95% CI, 3.76e5.18, P < 0.001). Hematoma and/or seroma was less likely to occur in TKA (OR, 0.73; 95% CI, 0.70e0.76, P < 0 0.001), and SSI and/or PJI was more frequent in TKA compared with THA (OR, 1.62; 95% CI, 1.48e1.77, P < 0.001).
3.5.
Although the rates of inhospital mortality were slightly higher in the CABG (0.21%) and angioplasty and/or stenting (0.18%) groups compared with those in the control (0.15%), neither a history of CABG (P ¼ 0.41) nor a history of coronary angioplasty and/or stenting was associated with higher risk of inhospital mortality.
3.6. Effect of cardiac dysrhythmias on mortality and complication rates The incidence rates of new onset arrhythmia in CABG, angioplasty and/or stenting, and control groups were 14.98%, 12.09%, and 8.44%, respectively. The incidence rate of new onset atrial fibrillation was 11.19, 8.37, and 5.29 for CABG, angioplasty and/or stenting, and control groups successively. Figure 3 shows the incidence rates of the atrial fibrillation and other dysrhythmia in each group. To evaluate the potential effects of cardiac arrhythmias on the rates of mortality and complications in the study groups, cardiac arrhythmias were divided into atrial fibrillation and other dysrhythmias. Cardiac complications occurred in 5.36% of patients with atrial fibrillation and 8.48% of cases with other arrhythmia, which were much higher than the rate of cardiac complications in patients without arrhythmia at 0.28% (Fig. 4). In all multivariate models, atrial fibrillation was an independent predictor of adverse events. Other dysrhythmias were also found to be independent predictors of mortality and all complications except for renal complications and SSI and/or PJI (Table 3). The mortality rate in patients with dysrhythmia was higher than the no arrhythmia group (0.63 and 1.35 for atrial fibrillation and other dysrhythmia, respectively, versus 0.08 for the no arrhythmia group).
4.
Fig. 2 e Rates of renal complications in study groups.
Risk of inhospital mortality
Discussion
The need for TJA has increased and will continue to increase in the United States, as has the number of CAD patients who require coronary revascularization [1,7]. Therefore, it is important to be mindful of the rates of complications in these patients for better assessment and management of morbidity and mortality as well as better identification of at-risk patients. These findings are very helpful to the health care providers for decision making and to adequately inform patients of the related. However, there is a paucity of available literature on the perioperative morbidity and mortality in patients with a history of coronary revascularization undergoing TJA. The present study aimed to determine the inhospital adverse
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Fig. 3 e The incidence rates of the atrial fibrillation and other dysrhythmia have been shown in each group.
events in patients with a history of coronary revascularization undergoing TJA, using nationally representative data. Moreover, we evaluated if cardiac arrhythmias may affect the rate of complications and mortality in this population. Using the NIS data from 2002e2011, this study noted that there has been a decrease in the rates of most inhospital complications, except MI, in patients who received coronary revascularization compared with the control patients undergoing TJA. Although cardiac complications and mortality were higher in the coronary revascularization group, none of them were statistically significant in the multivariate analysis. MI was significantly higher in the CABG and cardiac stent patients compared with that in the controls. Previous studies indicated a similar mortality rate of 1%e2% for patients with or without the history of CABG undergoing noncardiac surgeries [12,13]. These rates are lower compared to the reported rate of perioperative mortality in patients with a diagnosis of CAD receiving no revascularization intervention before noncardiac surgeries [12,13]. Supporting our findings,
previous studies have shown a higher rate of perioperative nonefatal MI after noncardiac surgery in patients with a history of CABG at 1.9% compared with 1.6% in patients with no risk factors [14,15]. Recently, Hawn et al. [4] performed a study to determine the incidence of adverse cardiac events in patients undergoing noncardiac surgeries, including musculoskeletal surgeries, using the Veterans Affairs database. In that study, adverse cardiac events occurred in 4.2% of patients with a history of coronary stenting who underwent musculoskeletal surgery within 30 d after the surgery. The authors did not evaluate the rate of adverse cardiac events specifically in those cases that underwent TJA. In comparison, in our study, in which we only considered inhospital cardiac adverse events, the rate of adverse cardiac events after TJA was much lower at 0.95% in the coronary angioplasty and/or stenting group. According to our findings, it seems that TJA in patients with a history of coronary angioplasty and/or stenting might be associated with a lower risk of adverse cardiac events compared with the
Fig. 4 e Perioperative complication rates in patients with or without cardiac arrhythmia.
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Table 3 e Association of cardiac arrhythmias, mortality, and complications in study patients. Complications
Atrial fibrillation, Other arrhythmia, OR (95% CI) OR (95% CI)
Cardiac complications
15.78 (14.97e16.65) P < 0.0001 2.01 (1.84e2.20) P < 0.0001 1.12 (1.03e1.22) P ¼ 0.007 1.19 (1.07e1.32) P ¼ 0.002 1.38 (1.26e1.50) P < 0.0001 1.12 (1.03e1.21) P ¼ 0.006 1.30 (1.22e1.40) P < 0.0002 1.37 (1.20e1.56) P < 0.0001 2.52 (2.21e2.87) P < 0.0001
MI Respiratory complications PE DVT Renal complications Wound hematoma/ seroma SSI Inhospital mortality
29.92 (28.44e31.48) P < 0.0001 3.86 (3.49e4.27) P < 0.0001 1.50 (1.36e1.65) P < 0.0001 2.60 (2.30e2.92) P < 0.0001 1.44 (1.29e1.61) P < 0.0001 1.00 (0.89e1.13) P ¼ 0.96 1.37 (1.25e1.49) P < 0.0001 1.09 (0.91e1.31) P ¼ 0.33 11.50 (10.29e12.86) P < 0.0001
general orthopedic procedures. However, our findings need to be confirmed by future studies with longer term follow-up. Another reason for the higher rate of adverse cardiac events in the study by Hawn et al. is that emergency surgeries were taken included in their analysis. History of CABG and coronary angioplasty and/or stenting was associated with a decreased risk of developing thromboembolic events after TJA. One potential explanation for this finding might be related to administration of antiplatelet therapy to these patients, particularly those with a history of recent coronary stenting, to avoid stent thrombosis. However, we did not have data on the type of postoperative DVT prophylaxis and the time interval from stent placement to TJA in the current cohort. This study also indicated that history of PCI with or without stenting, but not the history of CABG, is associated with a lower risk of renal complications. Renal artery stenosis is a frequent comorbidity in patients with CAD, and its reported prevalence varies from 6.2%e28%. Multivessel CAD or a history of CABG has been suggested as independent predictors of significant renal artery stenosis [16]. Therefore, a lower rate of renal complications in the PCI and/or stent compared with that in the CABG group might be explained in the light of possible lower prevalence of severe renal artery stenosis in the PCI and/or stent group compared with that in the CABG group. Severe renal artery stenosis could predispose patients to acute kidney injury because of the high volume of blood loss during a TJA procedure and administration of potentially nephrotoxic drugs. In addition, the presence of renal artery stenosis and possible stenting of renal artery in these patients may have also influenced the incidence of renal complications. However, there is not a specific ICD-9-CM code for the history of renal artery stenosis. Thus, we could not determine whether patients had undergone renal artery stenting. Perioperative supraventricular tachyarrhythmia (SVT) including atrial fibrillation has long been known as a predictor of poor outcome after major surgery [17]; however, the
incidence and influence of atrial fibrillation after major noncardiac surgery have been less evaluated. In the present study, we also found that postoperative cardiac dysrhythmias, particularly atrial fibrillation, were independent risk factors for the inhospital complications and mortality, which is consistent with previous reports [8]. In the study by Aggarwal et al. [8], the presence of atrial fibrillation compromised the outcome of TJA patients by increasing the length of hospital stay, the transfusion requirements, the risk of PJI, and the unplanned hospital readmission. Only patients with chronic atrial fibrillation were evaluated, which differs from our study where we mainly focused on the new-onset postoperative atrial fibrillation. However, the adverse effect of anticoagulation usage may still apply to our study patients. Moreover, postoperative atrial fibrillation may be a proxy for postoperative complications such as MI, which may increase the rate of inhospital morbidity and mortality. In another study, Kahn et al. [18] studied 1210 TJA patients to determine the incidence of new onset atrial fibrillation and/or SVT. The authors found an incidence of 3.1% for new onset atrial fibrillation and/or SVT, which is less than the rate of new onset atrial fibrillation in the present study (5.29% for control group). The authors found the history of atrial fibrillation, the increasing age, the atrial premature depolarizations, and the left anterior hemi-block on the preoperative electrocardiogram to be independent predictors of the perioperative occurrence of atrial fibrillation and/or SVT [17]. The difference between these two studies might be related to the design and the demographics of the cohorts. We used the NIS database, which collects data from hospitals with different protocols for detection of perioperative arrhythmias. However, in the study by Kahn et al., data were reported from a single institution with rigorous protocol for detection of perioperative arrhythmias. Regardless of the difference between these two studies, both studies found that the rate of perioperative arrhythmias after TJA is high and the development of these arrhythmias compromises the outcome of TJA in these patients. Additionally, we found an even greater risk of arrhythmias in postrevascularization patients. Thus, these patients should be closely monitored perioperatively for development of SVTs, particularly atrial fibrillation, and the arrhythmias treated promptly and appropriately. The use of nationally representative database and analysis on a large number of patients with a history of coronary artery revascularization are the main strengths of the present study. However, the present study has some limitations, which are mostly related to the limitations of the NIS database and the ICD-9-CM coding system. The NIS data only contain inhospital complications and mortality. Therefore, we were not able to determine the long-term complication and mortality rates after TJA in patients with a history of previous coronary revascularization. Moreover, the time interval between the coronary revascularization procedure and TJA was not available in the database. Because of the increased risk of cardiac complications after coronary revascularization, particularly within 3 mo after the revascularization procedure [19], the time interval between coronary revascularization and arthroplasty is important. As mentioned earlier, data on antiplatelet therapy,
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unfortunately missing from the NIS database, could have been helpful in interpreting our results. It was also impossible to determine the type of the coronary stent used in this patient population using the ICD-9-CM codes for history of stenting. However, Hawn et al. [4] indicated that the stent type, particularly for those patients in whom TJAs were performed 6 mo after the revascularization procedure, was not a strong predictor of adverse cardiac events. Thus, we believe that the lack of data on the type of stent is less likely to change our findings. It also should be highlighted that there have been some improvements in the surgical delivery of care in orthopedics over the last decade or so. In fact, the latter is also true for PCI and/or CABG techniques, coronary stent designs, and the introduction of better antiplatelet agents. Outcome of TJA is multifactorial and influenced by factors other than the surgical approach. Demographic factors and preexistent comorbidities are some of the important factors. It appears that with improvements in surgical and anesthesia techniques, patients with higher number of comorbidities have been allowed to undergo TJA. Thus, it is possible that the improvements in the outcome of TJA, that are to be expected as a result of improvements in technique, may have been offset by the unfavorable changes in the demographics of the TJA patients. Unfortunately, this study could not answer how improvement in TKA and THA surgical approaches has influenced the study findings given the limitations of the NIS database. The NIS is an administrative database that does not provide details about surgical and/or anesthetic techniques, type of stents, and antiplatelet therapy, and many other important factors that could have influenced the outcome of TJA.
5.
Conclusions
The present study demonstrated that there is no increased risk of inhospital mortality and complications (except for MI) in patients with a history of coronary artery revascularization undergoing TJA. We also found that postoperative cardiac arrhythmias, particularly atrial fibrillation, are an independent predictor for inhospital adverse events. Therefore, preventing perioperative arrhythmias in TJA patients, and appropriate management of the arrhythmia, may reduce the rate of inhospital complications and mortality in the TJA patients. Further studies need to be performed to compare the long-term outcome of patients with history of coronary revascularization undergoing TJA to those without a history of these procedures.
Acknowledgment Authors’ contributions: R.M.T., M.R.R., and M.R. contributed to the drafting of the article. M.R.R., A.C.O., and J.P. contributed to the study design. M.G.M. did the statistical analysis. A.C.O. and J.P. did the revision of the article for critically important intellectual content. There is no external source of funding for this study.
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Disclosure One of the authors (J.P.) has a board membership with the Journal of Arthroplasty, the Journal of Bone and Joint Surgery, the Bone and Joint Journal, Philadelphia Orthopaedics, the Eastern Orthopaedic Association, United Healthcare, Jaypee Publishers, ForMD and 3M. He is a consultant for Zimmer, Smith & Nephew, ConvaTec, TissueGene, CeramTec, PRN, and Medtronic. He receives royalties from Elsevier, Wolters Kluwer, Slack, and Datatrace. He has stock options with Hip Innovation Technology and CD Diagnostics. One of the authors (A.C.O.) is a paid consultant for Stryker and Smith & Nephew and has received research support from Zimmer and Genzyme. Other authors certify that they have no funding or commercial associations that may pose a conflict of interest relevant to the topic of the submitted article.
references
[1] Go AS, Mozaffarian D, Roger VL, et al. American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statisticsd2014 update: a report from the American Heart Association. Circulation 2014;129:e28. [2] Iakovou I, Schmidt T, Bonizzoni E, et al. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA 2005;293:2126. [3] To AC, Armstrong G, Zeng I, Webster MW. Noncardiac surgery and bleeding after percutaneous coronary intervention. Circ Cardiovasc Interv 2009;2:213. [4] Hawn MT, Graham LA, Richman JS, Itani KMF, Henderson WG, Maddox TM. Risk of major adverse cardiac events following noncardiac surgery in patients with coronary stents. JAMA 2013;310:1462. [5] Wijeysundera DN, Wijeysundera HC, Yun L, et al. Risk of elective major noncardiac surgery after coronary stent insertion: a population-based study. Circulation 2012;126: 1355. [6] Chassot PG, Delabays A, Spahn DR. Perioperative antiplatelet therapy: the case for continuing therapy in patients at risk of myocardial infarction. Br J Anaesth 2007;99:316. [7] Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89:780. [8] Aggarwal VK, Tischler EH, Post ZD, Kane I, Orozco FR, Ong A. Patients with atrial fibrillation undergoing total joint arthroplasty increase hospital burden. J Bone Joint Surg Am 2013;95:1606. [9] Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care 1998; 36:8. [10] van Walraven C, Austin PC, Jennings A, Quan H, Forster AJ. A modification of the Elixhauser comorbidity measures into a point system for hospital death using administrative data. Med Care 2009;47:626. [11] Sharabiani MT, Aylin P, Bottle A. Systematic review of comorbidity indices for administrative data. Med Care 2012; 50:1109. [12] Foster ED, Davis KB, Carpenter JA, Abele S, Fray D. Risk of noncardiac operation in patients with defined coronary disease: the Coronary Artery Surgery Study (CASS) registry experience. Ann Thorac Surg 1986;41:42.
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[13] Gersh BJ, Rihal CS, Rooke TW, Ballard DJ. Evaluation and management of patients with both peripheral vascular and coronary artery disease. J Am Coll Cardiol 1991;18:203. [14] Eagle KA, Rihal CS, Mickel MC, Holmes DR, Foster ED, Gersh BJ. Cardiac risk of noncardiac surgery: influence of coronary disease and type of surgery in 3368 operations. CASS Investigators and University of Michigan Heart Care Program. Coronary Artery Surgery Study. Circulation 1997;96: 1882. [15] Vanzetto G, Machecourt J, Blendea D, et al. Additive value of thallium single-photon emission computed tomography myocardial imaging for prediction of perioperative events in clinically selected high cardiac risk patients having abdominal aortic surgery. Am J Cardiol 1996;77:143.
[16] Ghaffari S, Sohrabi B, Siahdasht RB, Pourafkari L. Prevalence and predictors of renal artery stenosis in hypertensive patients undergoing coronary angiography. Hypertens Res 2009;32:1009. [17] Basilico FC, Sweeney G, Losina E, et al. Risk factors for cardiovascular complications following total joint replacement surgery. Arthritis Rheum 2008;58:1915. [18] Kahn RL, Hargett MJ, Urquhart B, Sharrock NE, Peterson MG. Supraventricular tachyarrhythmias during total joint arthroplasty. Incidence and risk. Clin Orthop Relat Res 1993; 296:265. [19] Chassot PG, Delabays A, Spahn DR. Preoperative evaluation of patients with, or at risk of, coronary artery disease undergoing non-cardiac surgery. Br J Anaesth 2002;89:747.
Available online at www.sciencedirect.com
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Coronary revascularization and adverse events in joint arthroplasty Reza Mostafavi Tabatabaee, MD, Mohammad R. Rasouli, MD, Maryam Rezapoor, MS, Mitchell G. Maltenfort, PhD, Alvin C. Ong, MD, and Javad Parvizi, MD, FRCS* Rothman Institute of Orthopaedics, Thomas Jefferson University, Philadelphia, Pennsylvania
article info
abstract
Article history:
Background: There is a paucity of literature about outcome of total joint arthroplasty in
Received 4 January 2015
patients with the history of angioplasty and/or stent or coronary artery bypass graft
Received in revised form
(CABG). The present study aimed to evaluate perioperative complications and mortality in
24 April 2015
these patients.
Accepted 7 May 2015
Methods: We used the Nationwide Inpatient Sample data from 2002e2011. Using the Ninth
Available online 14 May 2015
Revision of the International Classification of Disease, Clinical Modification codes for disorders and procedures, we identified patients with a history of coronary revascularization
Keywords:
(angioplasty and/or stent or CABG) and compared the inhospital adverse events in these
Coronary artery bypass graft
patients with patients without a history of coronary revascularization.
Coronary angioplasty/stent
Results: Cardiac complications occurred in 1.06% patients with a history of CABG; 0.95% of
Total joint arthroplasty
patients with a coronary angioplasty and/or stent and 0.82% of the control patients. In the
Adverse events
multivariate analysis, neither the history of CABG (P ¼ 0.07) nor the history of angioplasty
Mortality
and/or stenting (P ¼ 0.86) was associated with a higher risk of cardiac complications.
Nationwide Inpatient Sample
However, myocardial infarction occurred in a significantly higher proportion of patients with the history of CABG (0.66%, odds ratio, 1.24, P ¼ 0.001) and coronary angioplasty and/or stenting (0.67%, odds ratio, 1.96, P < 0.001) compared with that in the controls (0.27%). History of coronary revascularization did not increase the risk of respiratory, renal, and wound complications, surgical site infection, and mortality. Conclusions: Based on the findings of this study, it appears that there is no increased risk of inhospital mortality and complications (except for myocardial infarction) in patients with a history of coronary artery revascularization undergoing total joint arthroplasty. We also found perioperative cardiac arrhythmia, particularly atrial fibrillation, to be an independent predictor of inhospital adverse events. ª 2015 Elsevier Inc. All rights reserved.
1.
Introduction
Coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) have arisen as the predominant coronary artery revascularization strategies, with an estimated
397,000 inpatient CABG procedures and 954,000 inpatient PCI procedures performed in 2010 in the United States [1]. Although the development of revascularization therapies has been a major breakthrough in the treatment of coronary artery disease (CAD), enthusiasm has been mitigated by the
* Corresponding author. Rothman Institute at Thomas Jefferson University Hospital, Sheridan Building, Suite 1000, 125 South 9th Street, Philadelphia, PA 19107. Tel.: þ1 267 339 7813; fax: þ1 215 503 5651. E-mail address: [email protected] (J. Parvizi). 0022-4804/$ e see front matter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2015.05.013
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potentially fatal complications of subsequent coronary thrombosis [2]. Moreover, these patients are more susceptible to adverse cardiac events compared with those of the general population, particularly at the time of later surgeries [3e5]. The extent of catastrophe can be seen in documented cases, where the incidences of a major adverse cardiac event and mortality are 2.1%e9.8% and 1.2%e5.2% within 30 de1 y, respectively, after the surgery [5]. Approximately 5%e23% of patients with a history of revascularization procedure undergo noncardiac surgeries within 1e2 y of revascularization [4,6]. Total hip arthroplasty (THA) and total knee arthroplasty (TKA), with an annual number of over 750,000 cases in the United States, have been considered as the most common orthopedic procedures. By 2030, this number is expected to increase exponentially to 0.57 million and 3.48 million procedures for THA and TKA, respectively [7]. Given the high prevalence of CABG and stent placement on the one hand, and the increasing proportion of patients in need of total joint arthroplasty (TJA) on the other, it is expected that a larger number of patients with a history of coronary revascularization will require TJA. However, there is a paucity of literature about major adverse events after TJA in patients with a history of coronary stenting or CABG. Although some evidence of adverse cardiac events after noncardiac surgery in patients with a history of stent placement has been found [4], less is known about TJA in particular. This study focuses on the relation between a history of revascularization procedures (CABG and stent placement) and the inhospital major adverse events and the mortality after TJA. Moreover, we evaluate if cardiac arrhythmias affect the rate of complications and mortality in this population.
2.
Methods and materials
We used the Nationwide Inpatient Sample (NIS) database, the largest all-payer inpatient database in the United States, which contains information on about 8 million hospital admissions per year. Because the NIS database has been sufficiently deidentified, this study was exempt from the institutional review board review. NIS data from 2002e2011 were queried to identify those patients with a history of either CABG or coronary angioplasty and/or stenting who were also coded for primary or revision TJA. For this purpose, the following codes from the Ninth Revision of the International Classification of Diseases, Clinical Modification (ICD-9-CM) were used:
81.51 and 81.53 for primary and revision THA, respectively. 81.54 and 81.55 for primary and revision TKA, respectively. V45.81 for CABG. V45.82 for percutaneous transluminal coronary angioplasty and stenting.
Patients with a history of both CABG and cardiac stent were excluded, and the remaining patients were divided into three groups as follows: CABG, coronary angioplasty and/or stent, and controls (patients without a history of CABG or coronary angioplasty and/or stenting).
Because dysrhythmias are common in patients with ischemic heart diseases and may affect the outcome of patients undergoing TJA [8], we also ran a query based on the ICD-9-CM codes for dysrhythmias (427.0e427.9) to determine postoperative dysrhythmias. We further categorized postoperative dysrhythmias as atrial fibrillation (427.31) or other dysrhythmias. The same coding system was used to identify postoperative adverse events including cardiac, respiratory, renal, wound complications, and surgical site infection (SSI) and/or periprosthetic joint infection (PJI). These ICD-9-CM codes are listed in Table 1. For all patients, demographics, hospital characteristics, type of payer, and comorbidities were obtained in addition to inhospital complications and mortality. The Elixhauser comorbidity measure was used in our study to extract patients’ comorbidities. The Elixhauser comorbidity index was developed to determine the overall risk of comorbidity, using a list of 30 comorbidities based on the ICD-9-CM coding system [9]. Previous studies demonstrated that the Elixhauser comorbidity measure is a reliable index to predict the outcome of patients [10,11].
2.1.
Statistical analysis
Multivariate analysis (logistic regression) was performed to determine if a history of CABG and coronary stenting is an independent predictor of mortality and complications, controlling for confounders including Elixhauser comorbidities, type of TJA, type of insurance, age, gender, race, year of surgery, cardiac dysrhythmias (atrial fibrillation and other arrhythmias), and hospital size, type, and setting. All analyses were performed using R 3.0.2 (R Foundation for Statistical Computing, Vienna, Austria) using the “rms” package to perform the logistic regression. P values <0.05 were considered to be statistically significant.
3.
Results
From 2002e2011, there was an increase in the percent of patients with coronary angioplasty and/or stent that underwent TJA, whereas during the same period, the percent of cases with history of CABG that underwent TJA declined (Fig. 1). A total of 47,351 cases with a history of CABG and 44,017 cases with a history of coronary angioplasty and/or stent placement
Table 1 e Major adverse events evaluated and their related ICD-9M-CM codes. Study variables MI Cardiac Respiratory Hematoma/seroma PE Venous thrombotic events SSI/PJI Renal
ICD-9-CM code 410-xx 997.1 997.3 998.1 4151 4511, 4512, 4518, 4519, 4532, 4538, 4539 998.31, 998.32, 998.5x, 996.66, 996.67 997.5
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Fig. 1 e Trends in percent of patients who underwent TJA with a history of CABG or coronary stent.
were included in the final analysis and compared with 1,537,394 control patients. The outcome in terms of the inhospital mortality and complications was assessed. The characteristics of these cases have been summarized in Table 2.
3.1.
Risk of cardiopulmonary complications
There was a significant decrease in the rate of cardiopulmonary complications over time (P < 0.001). Cardiac complications occurred slightly more frequently in patients with a history of CABG (1.06%) and coronary angioplasty and/or stent (0.95%) compared with those in the control group (0.82%). In the multivariate analysis, controlling for confounders, neither a history of CABG (P ¼ 0.07) nor a history of angioplasty and/or stenting (P ¼ 0.86) was associated with a higher risk of cardiac complications. However, myocardial infarction (MI) occurred in a significantly higher proportion of patients with the history of CABG (0.66%, odds ratio (OR), 1.24; 95% confidence interval (CI), 1.09e1.42, P ¼ 0.001), the coronary angioplasty and/or stenting (0.67%, OR, 1.96; 95% CI, 1.71e2.24, P < 0.001) compared with that in the control group, in which MI occurred in 0.27% of cases. Patients who underwent revision surgery (OR, 1.19; 95% CI, 1.00e1.40, P ¼ 0.04) were at an increased risk of MI compared with those who underwent primary TJA. Multivariate analysis showed a decrease in the rate of respiratory complications over the study period. Respiratory complications were observed less frequently in the CABG (0.61%) and angioplasty and/or stent (0.61%) groups compared with those in the control (0.64%). In the multivariate analysis, a history of CABG was associated with a significantly lower risk of respiratory complications (OR, 0.79; 95% CI, 0.69e0.90, P < 0.001); however, a history of angioplasty and/or stenting was not an independent predictor of respiratory complications (P ¼ 0.12).
3.2.
Risk of venous thromboembolism
Pulmonary embolism (PE) occurred in 0.30% and 0.33% of the CABG and angioplasty and/or stent groups, respectively, whereas the PE rate was slightly higher in the control group at 0.38%. In the multivariate analysis, a history of CABG was associated with a lower risk of PE (OR, 0.80; 95% CI, 0.64e0.98, P < 0.03). Knee surgery was another predictor of the risk of PE in the multivariate analysis (OR, 2.23; 95% CI, 2.04e2.42, P < 0.001). Deep vein thrombosis (DVT) occurred in 0.42% of the CABG group, 0.49% of the angioplasty and/or stent cases and 0.58% of the control group. In the multivariate analysis, both CABG (OR, 0.69; 95% CI, 0.59e0.81, P < 0.001) and angioplasty and/or stenting (OR, 0.80; 95% CI, 0.68e0.94, P ¼ 0.007) were associated with a lower risk of DVT.
3.3.
Risk of renal complications
Renal complications occurred more frequently in the CABG group compared with those in other two groups (Fig. 2). However, using multivariate analysis, a history of CABG was not an independent risk factor for postoperative renal complications, whereas history of angioplasty and/or stenting was associated with a lower risk of renal complications (OR, 0.80; 95% CI, 0.70e0.91, P < 0.001).
3.4.
Risk of wound complications
Wound complications (SSI and/or PJI and hematoma and/or seroma) declined significantly over time in the multivariate analysis (P < 0.001). The rate of wound hematoma and/or seroma was slightly lower in the CABG (0.091%) and angioplasty and/or stent (0.91%) groups compared with that in the controls (0.96%). Multivariate analysis indicated that hematoma and/or seroma is less likely to occur in the CABG group
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Table 2 e Characteristics of patients in the CABG, coronary stent, and controls. Characteristics
Control
CABG
Stent
Number 1,537,394 47,351 44,017 Age (mean SD) 65.81 11.49 72.57 8.42 70.16 9.16 Female (%) 62.97 28.30 39.48 Ethnicity, % White 64.77 71.42 70.98 African-American 5.60 2.18 3.29 Hispanic 3.57 2.39 2.37 Asian 0.82 0.54 0.56 Native American/other 1.87 1.65 1.68 Unspecified 23.37 21.83 21.12 Insurance type, % Medicare 54.83 78.01 69.46 Medicaid 2.98 1.06 1.39 Private 38.46 19.05 26.47 Self-pay/NC/other 3.74 1.88 2.69 Hospital setting, % Rural 12.06 11.79 10.09 Urban academic 46.42 48.02 47.90 Urban private 41.52 40.19 42.01 Region, % Northeast 17.45 16.66 17.06 Midwest 26.83 28.13 29.67 South 35.86 38.73 36.21 West 19.86 16.48 17.05 Hospital size, % Small 16.56 13.34 13.83 Medium 24.50 24.74 23.94 Large 58.93 61.92 62.23 Type of TJA, % Primary THA 94.50 2.93 2.57 Primary TKA 94.45 2.81 2.75 Revision THA 94.54 3.40 2.06 Revision TKA 93.99 3.58 2.43 NC ¼ non-covered; SD ¼ standard deviation.
(OR, 0.81; 95% CI, 0.72e0.91, P < 0.001); however, a history of coronary angioplasty and/or stenting was not an independent predictor. SSI and/or PJI also was observed less frequently in the angioplasty and/or stent (0.18%) and CABG (0.20%) groups compared with that in the control (0.26%). In the multivariate analysis, CABG (OR, 0.73; 95% CI, 0.56e0.89, P ¼ 0.03) and coronary angioplasty and/or stenting (OR, 0.67; 95% CI,
0.52e0.86, P ¼ 0.001) were associated with a lower risk of SSI compared with that in the control group. As expected, revision surgery was an independent predictor for the risk of hematoma and/or seroma (OR, 1.66; 95% CI, 1.52e1.82, P < 0.001) and SSI and/or PJI (OR, 4.41; 95% CI, 3.76e5.18, P < 0.001). Hematoma and/or seroma was less likely to occur in TKA (OR, 0.73; 95% CI, 0.70e0.76, P < 0 0.001), and SSI and/or PJI was more frequent in TKA compared with THA (OR, 1.62; 95% CI, 1.48e1.77, P < 0.001).
3.5.
Although the rates of inhospital mortality were slightly higher in the CABG (0.21%) and angioplasty and/or stenting (0.18%) groups compared with those in the control (0.15%), neither a history of CABG (P ¼ 0.41) nor a history of coronary angioplasty and/or stenting was associated with higher risk of inhospital mortality.
3.6. Effect of cardiac dysrhythmias on mortality and complication rates The incidence rates of new onset arrhythmia in CABG, angioplasty and/or stenting, and control groups were 14.98%, 12.09%, and 8.44%, respectively. The incidence rate of new onset atrial fibrillation was 11.19, 8.37, and 5.29 for CABG, angioplasty and/or stenting, and control groups successively. Figure 3 shows the incidence rates of the atrial fibrillation and other dysrhythmia in each group. To evaluate the potential effects of cardiac arrhythmias on the rates of mortality and complications in the study groups, cardiac arrhythmias were divided into atrial fibrillation and other dysrhythmias. Cardiac complications occurred in 5.36% of patients with atrial fibrillation and 8.48% of cases with other arrhythmia, which were much higher than the rate of cardiac complications in patients without arrhythmia at 0.28% (Fig. 4). In all multivariate models, atrial fibrillation was an independent predictor of adverse events. Other dysrhythmias were also found to be independent predictors of mortality and all complications except for renal complications and SSI and/or PJI (Table 3). The mortality rate in patients with dysrhythmia was higher than the no arrhythmia group (0.63 and 1.35 for atrial fibrillation and other dysrhythmia, respectively, versus 0.08 for the no arrhythmia group).
4.
Fig. 2 e Rates of renal complications in study groups.
Risk of inhospital mortality
Discussion
The need for TJA has increased and will continue to increase in the United States, as has the number of CAD patients who require coronary revascularization [1,7]. Therefore, it is important to be mindful of the rates of complications in these patients for better assessment and management of morbidity and mortality as well as better identification of at-risk patients. These findings are very helpful to the health care providers for decision making and to adequately inform patients of the related. However, there is a paucity of available literature on the perioperative morbidity and mortality in patients with a history of coronary revascularization undergoing TJA. The present study aimed to determine the inhospital adverse
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Fig. 3 e The incidence rates of the atrial fibrillation and other dysrhythmia have been shown in each group.
events in patients with a history of coronary revascularization undergoing TJA, using nationally representative data. Moreover, we evaluated if cardiac arrhythmias may affect the rate of complications and mortality in this population. Using the NIS data from 2002e2011, this study noted that there has been a decrease in the rates of most inhospital complications, except MI, in patients who received coronary revascularization compared with the control patients undergoing TJA. Although cardiac complications and mortality were higher in the coronary revascularization group, none of them were statistically significant in the multivariate analysis. MI was significantly higher in the CABG and cardiac stent patients compared with that in the controls. Previous studies indicated a similar mortality rate of 1%e2% for patients with or without the history of CABG undergoing noncardiac surgeries [12,13]. These rates are lower compared to the reported rate of perioperative mortality in patients with a diagnosis of CAD receiving no revascularization intervention before noncardiac surgeries [12,13]. Supporting our findings,
previous studies have shown a higher rate of perioperative nonefatal MI after noncardiac surgery in patients with a history of CABG at 1.9% compared with 1.6% in patients with no risk factors [14,15]. Recently, Hawn et al. [4] performed a study to determine the incidence of adverse cardiac events in patients undergoing noncardiac surgeries, including musculoskeletal surgeries, using the Veterans Affairs database. In that study, adverse cardiac events occurred in 4.2% of patients with a history of coronary stenting who underwent musculoskeletal surgery within 30 d after the surgery. The authors did not evaluate the rate of adverse cardiac events specifically in those cases that underwent TJA. In comparison, in our study, in which we only considered inhospital cardiac adverse events, the rate of adverse cardiac events after TJA was much lower at 0.95% in the coronary angioplasty and/or stenting group. According to our findings, it seems that TJA in patients with a history of coronary angioplasty and/or stenting might be associated with a lower risk of adverse cardiac events compared with the
Fig. 4 e Perioperative complication rates in patients with or without cardiac arrhythmia.
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Table 3 e Association of cardiac arrhythmias, mortality, and complications in study patients. Complications
Atrial fibrillation, Other arrhythmia, OR (95% CI) OR (95% CI)
Cardiac complications
15.78 (14.97e16.65) P < 0.0001 2.01 (1.84e2.20) P < 0.0001 1.12 (1.03e1.22) P ¼ 0.007 1.19 (1.07e1.32) P ¼ 0.002 1.38 (1.26e1.50) P < 0.0001 1.12 (1.03e1.21) P ¼ 0.006 1.30 (1.22e1.40) P < 0.0002 1.37 (1.20e1.56) P < 0.0001 2.52 (2.21e2.87) P < 0.0001
MI Respiratory complications PE DVT Renal complications Wound hematoma/ seroma SSI Inhospital mortality
29.92 (28.44e31.48) P < 0.0001 3.86 (3.49e4.27) P < 0.0001 1.50 (1.36e1.65) P < 0.0001 2.60 (2.30e2.92) P < 0.0001 1.44 (1.29e1.61) P < 0.0001 1.00 (0.89e1.13) P ¼ 0.96 1.37 (1.25e1.49) P < 0.0001 1.09 (0.91e1.31) P ¼ 0.33 11.50 (10.29e12.86) P < 0.0001
general orthopedic procedures. However, our findings need to be confirmed by future studies with longer term follow-up. Another reason for the higher rate of adverse cardiac events in the study by Hawn et al. is that emergency surgeries were taken included in their analysis. History of CABG and coronary angioplasty and/or stenting was associated with a decreased risk of developing thromboembolic events after TJA. One potential explanation for this finding might be related to administration of antiplatelet therapy to these patients, particularly those with a history of recent coronary stenting, to avoid stent thrombosis. However, we did not have data on the type of postoperative DVT prophylaxis and the time interval from stent placement to TJA in the current cohort. This study also indicated that history of PCI with or without stenting, but not the history of CABG, is associated with a lower risk of renal complications. Renal artery stenosis is a frequent comorbidity in patients with CAD, and its reported prevalence varies from 6.2%e28%. Multivessel CAD or a history of CABG has been suggested as independent predictors of significant renal artery stenosis [16]. Therefore, a lower rate of renal complications in the PCI and/or stent compared with that in the CABG group might be explained in the light of possible lower prevalence of severe renal artery stenosis in the PCI and/or stent group compared with that in the CABG group. Severe renal artery stenosis could predispose patients to acute kidney injury because of the high volume of blood loss during a TJA procedure and administration of potentially nephrotoxic drugs. In addition, the presence of renal artery stenosis and possible stenting of renal artery in these patients may have also influenced the incidence of renal complications. However, there is not a specific ICD-9-CM code for the history of renal artery stenosis. Thus, we could not determine whether patients had undergone renal artery stenting. Perioperative supraventricular tachyarrhythmia (SVT) including atrial fibrillation has long been known as a predictor of poor outcome after major surgery [17]; however, the
incidence and influence of atrial fibrillation after major noncardiac surgery have been less evaluated. In the present study, we also found that postoperative cardiac dysrhythmias, particularly atrial fibrillation, were independent risk factors for the inhospital complications and mortality, which is consistent with previous reports [8]. In the study by Aggarwal et al. [8], the presence of atrial fibrillation compromised the outcome of TJA patients by increasing the length of hospital stay, the transfusion requirements, the risk of PJI, and the unplanned hospital readmission. Only patients with chronic atrial fibrillation were evaluated, which differs from our study where we mainly focused on the new-onset postoperative atrial fibrillation. However, the adverse effect of anticoagulation usage may still apply to our study patients. Moreover, postoperative atrial fibrillation may be a proxy for postoperative complications such as MI, which may increase the rate of inhospital morbidity and mortality. In another study, Kahn et al. [18] studied 1210 TJA patients to determine the incidence of new onset atrial fibrillation and/or SVT. The authors found an incidence of 3.1% for new onset atrial fibrillation and/or SVT, which is less than the rate of new onset atrial fibrillation in the present study (5.29% for control group). The authors found the history of atrial fibrillation, the increasing age, the atrial premature depolarizations, and the left anterior hemi-block on the preoperative electrocardiogram to be independent predictors of the perioperative occurrence of atrial fibrillation and/or SVT [17]. The difference between these two studies might be related to the design and the demographics of the cohorts. We used the NIS database, which collects data from hospitals with different protocols for detection of perioperative arrhythmias. However, in the study by Kahn et al., data were reported from a single institution with rigorous protocol for detection of perioperative arrhythmias. Regardless of the difference between these two studies, both studies found that the rate of perioperative arrhythmias after TJA is high and the development of these arrhythmias compromises the outcome of TJA in these patients. Additionally, we found an even greater risk of arrhythmias in postrevascularization patients. Thus, these patients should be closely monitored perioperatively for development of SVTs, particularly atrial fibrillation, and the arrhythmias treated promptly and appropriately. The use of nationally representative database and analysis on a large number of patients with a history of coronary artery revascularization are the main strengths of the present study. However, the present study has some limitations, which are mostly related to the limitations of the NIS database and the ICD-9-CM coding system. The NIS data only contain inhospital complications and mortality. Therefore, we were not able to determine the long-term complication and mortality rates after TJA in patients with a history of previous coronary revascularization. Moreover, the time interval between the coronary revascularization procedure and TJA was not available in the database. Because of the increased risk of cardiac complications after coronary revascularization, particularly within 3 mo after the revascularization procedure [19], the time interval between coronary revascularization and arthroplasty is important. As mentioned earlier, data on antiplatelet therapy,
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unfortunately missing from the NIS database, could have been helpful in interpreting our results. It was also impossible to determine the type of the coronary stent used in this patient population using the ICD-9-CM codes for history of stenting. However, Hawn et al. [4] indicated that the stent type, particularly for those patients in whom TJAs were performed 6 mo after the revascularization procedure, was not a strong predictor of adverse cardiac events. Thus, we believe that the lack of data on the type of stent is less likely to change our findings. It also should be highlighted that there have been some improvements in the surgical delivery of care in orthopedics over the last decade or so. In fact, the latter is also true for PCI and/or CABG techniques, coronary stent designs, and the introduction of better antiplatelet agents. Outcome of TJA is multifactorial and influenced by factors other than the surgical approach. Demographic factors and preexistent comorbidities are some of the important factors. It appears that with improvements in surgical and anesthesia techniques, patients with higher number of comorbidities have been allowed to undergo TJA. Thus, it is possible that the improvements in the outcome of TJA, that are to be expected as a result of improvements in technique, may have been offset by the unfavorable changes in the demographics of the TJA patients. Unfortunately, this study could not answer how improvement in TKA and THA surgical approaches has influenced the study findings given the limitations of the NIS database. The NIS is an administrative database that does not provide details about surgical and/or anesthetic techniques, type of stents, and antiplatelet therapy, and many other important factors that could have influenced the outcome of TJA.
5.
Conclusions
The present study demonstrated that there is no increased risk of inhospital mortality and complications (except for MI) in patients with a history of coronary artery revascularization undergoing TJA. We also found that postoperative cardiac arrhythmias, particularly atrial fibrillation, are an independent predictor for inhospital adverse events. Therefore, preventing perioperative arrhythmias in TJA patients, and appropriate management of the arrhythmia, may reduce the rate of inhospital complications and mortality in the TJA patients. Further studies need to be performed to compare the long-term outcome of patients with history of coronary revascularization undergoing TJA to those without a history of these procedures.
Acknowledgment Authors’ contributions: R.M.T., M.R.R., and M.R. contributed to the drafting of the article. M.R.R., A.C.O., and J.P. contributed to the study design. M.G.M. did the statistical analysis. A.C.O. and J.P. did the revision of the article for critically important intellectual content. There is no external source of funding for this study.
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Disclosure One of the authors (J.P.) has a board membership with the Journal of Arthroplasty, the Journal of Bone and Joint Surgery, the Bone and Joint Journal, Philadelphia Orthopaedics, the Eastern Orthopaedic Association, United Healthcare, Jaypee Publishers, ForMD and 3M. He is a consultant for Zimmer, Smith & Nephew, ConvaTec, TissueGene, CeramTec, PRN, and Medtronic. He receives royalties from Elsevier, Wolters Kluwer, Slack, and Datatrace. He has stock options with Hip Innovation Technology and CD Diagnostics. One of the authors (A.C.O.) is a paid consultant for Stryker and Smith & Nephew and has received research support from Zimmer and Genzyme. Other authors certify that they have no funding or commercial associations that may pose a conflict of interest relevant to the topic of the submitted article.
references
[1] Go AS, Mozaffarian D, Roger VL, et al. American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statisticsd2014 update: a report from the American Heart Association. Circulation 2014;129:e28. [2] Iakovou I, Schmidt T, Bonizzoni E, et al. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA 2005;293:2126. [3] To AC, Armstrong G, Zeng I, Webster MW. Noncardiac surgery and bleeding after percutaneous coronary intervention. Circ Cardiovasc Interv 2009;2:213. [4] Hawn MT, Graham LA, Richman JS, Itani KMF, Henderson WG, Maddox TM. Risk of major adverse cardiac events following noncardiac surgery in patients with coronary stents. JAMA 2013;310:1462. [5] Wijeysundera DN, Wijeysundera HC, Yun L, et al. Risk of elective major noncardiac surgery after coronary stent insertion: a population-based study. Circulation 2012;126: 1355. [6] Chassot PG, Delabays A, Spahn DR. Perioperative antiplatelet therapy: the case for continuing therapy in patients at risk of myocardial infarction. Br J Anaesth 2007;99:316. [7] Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89:780. [8] Aggarwal VK, Tischler EH, Post ZD, Kane I, Orozco FR, Ong A. Patients with atrial fibrillation undergoing total joint arthroplasty increase hospital burden. J Bone Joint Surg Am 2013;95:1606. [9] Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care 1998; 36:8. [10] van Walraven C, Austin PC, Jennings A, Quan H, Forster AJ. A modification of the Elixhauser comorbidity measures into a point system for hospital death using administrative data. Med Care 2009;47:626. [11] Sharabiani MT, Aylin P, Bottle A. Systematic review of comorbidity indices for administrative data. Med Care 2012; 50:1109. [12] Foster ED, Davis KB, Carpenter JA, Abele S, Fray D. Risk of noncardiac operation in patients with defined coronary disease: the Coronary Artery Surgery Study (CASS) registry experience. Ann Thorac Surg 1986;41:42.
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[13] Gersh BJ, Rihal CS, Rooke TW, Ballard DJ. Evaluation and management of patients with both peripheral vascular and coronary artery disease. J Am Coll Cardiol 1991;18:203. [14] Eagle KA, Rihal CS, Mickel MC, Holmes DR, Foster ED, Gersh BJ. Cardiac risk of noncardiac surgery: influence of coronary disease and type of surgery in 3368 operations. CASS Investigators and University of Michigan Heart Care Program. Coronary Artery Surgery Study. Circulation 1997;96: 1882. [15] Vanzetto G, Machecourt J, Blendea D, et al. Additive value of thallium single-photon emission computed tomography myocardial imaging for prediction of perioperative events in clinically selected high cardiac risk patients having abdominal aortic surgery. Am J Cardiol 1996;77:143.
[16] Ghaffari S, Sohrabi B, Siahdasht RB, Pourafkari L. Prevalence and predictors of renal artery stenosis in hypertensive patients undergoing coronary angiography. Hypertens Res 2009;32:1009. [17] Basilico FC, Sweeney G, Losina E, et al. Risk factors for cardiovascular complications following total joint replacement surgery. Arthritis Rheum 2008;58:1915. [18] Kahn RL, Hargett MJ, Urquhart B, Sharrock NE, Peterson MG. Supraventricular tachyarrhythmias during total joint arthroplasty. Incidence and risk. Clin Orthop Relat Res 1993; 296:265. [19] Chassot PG, Delabays A, Spahn DR. Preoperative evaluation of patients with, or at risk of, coronary artery disease undergoing non-cardiac surgery. Br J Anaesth 2002;89:747.