Impact of age on perioperative complications and length of stay in patients undergoing noncardiac surgery

clinical risk factors) do not generally need any further testing and can proceed safely to surgery with perioperative beta-blockers, whereas DSE is most helpful in intermediateor high-risk groups (ⱖ3 risk factors) to identify patients at high likelihood of perioperative event during noncardiac surgery despite beta-blockers. Such patients may benefit from preoperative revascularization. RM

offered only to those patients where the procedure is justified irregardless of the noncardiac surgical issues. RM

Impact of Age on Perioperative Complications and Length of Stay in Patients Undergoing Noncardiac Surgery Polanczyk CA, Marcantonio E, Goldman L, et al. Ann Intern Med 2001;134:637– 43.

Outcomes of Noncardiac Surgery After Coronary Bypass Surgery or Coronary Angioplasty in the Bypass Angioplasty Revascularization Investigation (BARI)

Study Question: Does age have an impact on perioperative cardiac and noncardiac complications and length of stay in patients undergoing noncardiac surgery? Methods: Consecutive sample of 4315 patients ⱖ50 years of age who underwent nonemergent major noncardiac procedures at a large urban academic medical center were evaluated for major perioperative complications (cardiac and noncardiac), in-hospital mortality and length of stay. Results: Major perioperative complications occurred in 4.3% of patients ⱕ59 years of age, 5.7% of patients 60 to 69 years of age, 9.6% of patients 70 to 79 years of age and 12.5% (39 of 313) of patients ⱖ80 years of age; (p⬍0.001). Similarly, in-hospital mortality was significantly higher in patients ⱖ80 years of age than in those ⬍80 years of age (0.7% vs. 2.6%, respectively). Multivariate analyses indicated an increased risk for perioperative complications or in-hospital mortality in patients 70 to 79 years of age (Odds ratio [OR] 1.8 [95% CI, 1.2 to 2.7]) and those ⱖ80 years of age (OR, 2.1 [CI, 1.2 to 3.6]) compared with patients 50 to 59 years of age. Length of stay was an average of a day longer for patients ⱖ80 years of age as compared to the younger cohort (p⫽0.001). Conclusion: Elderly patients had a higher rate of major perioperative complications and mortality after noncardiac surgery and a longer length of stay. Perspective: More aggressive strategies are needed to minimize the risk of perioperative events in this high-risk cohort including a proper preoperative risk assessment, vigorous perioperative monitoring to identify adverse events and modifying risks in appropriate patients with the medical therapy (beta-blockers) and/or invasive therapy. RM

Hassan SA, Hlatky MA, Boothroyd DB, et al. Am J Med. 2001; 110:260 – 6. Study Question: Is coronary angioplasty as beneficial as coronary artery bypass surgery in reducing the risk of cardiac complications after noncardiac surgery? Methods: In the Bypass Angioplasty Revascularization Investigation (BARI) trial, patients with multivessel coronary artery disease and preserved left ventricular function, who were suitable for both coronary artery bypass surgery as well as angioplasty, were randomly assigned to undergo one or the other procedure. All subsequent noncardiac surgeries during a mean follow-up of 7.7 years were recorded among participants in the ancillary Study of Economics and Quality of Life. Comparisons were made among the two treatment groups with respect to mortality and nonfatal myocardial infarction rates, length of stay, and hospital costs. Results: Non-cardiac surgery was performed in 501 patients at a median of 29 months after their most recent coronary revascularization procedure. Mortality and nonfatal myocardial infarction within 30 days of the first noncardiac surgery occurred in 1.6% of the patients in each group. Mean length of hospital stay (6.3⫾6.7 vs. 6.2⫾6.8 days; p⫽0.47) and hospital cost ($8,920⫾$11,511 vs. $7,785 ⫾$7,643; p⫽0.33) were similar between the surgery and angioplasty groups. Inclusion of subsequent noncardiac procedures in the analysis also demonstrated equivalent outcomes for both treatment-assignment groups. Conclusion: Rates of myocardial infarction and death after noncardiac surgery are similarly low after bypass surgery or angioplasty in patients with multivessel coronary artery disease and preserved left ventricular function. Perspective: A new randomized trial currently under way in the Veterans’ Affairs Medical System will help to clarify the role of coronary revascularization as compared to medical therapy in risk reduction in patient undergoing noncardiac surgery. Until then, given the evidence of the beneficial effect of beta-blocker therapy in high-risk patients undergoing noncardiac surgery, such agents should be used for most higher risk patients undergoing noncardiac surgery. Revascularization (bypass surgery or angioplasty) should be

Temporal Aspects of Heparin-Induced Thrombocytopenia Warkentin TE, Kelton JG. N Engl J Med 2001;344:1286 –92. Study Question: What is the temporal relation between previous or current heparin therapy and the onset of heparininduced thrombocytopenia? Methods: In 243 patients with serologically confirmed heparin-induced thrombocytopenia, the time between the start of heparin therapy and the onset of thrombocytopenia as well as the persistence of circulating heparin-dependent antibodies detected by a platelet serotonin-release assay and an assay for antibodies against platelet factor 4 were investigated. Patients with a previous episode of heparin-in-

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