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Patients with coronary artery disease as a surgical risk∗
Patients Disease
with Coronarv as a Surgical THOMAS W.
Artery Risk*
MATTINGLY, M.D.
%‘ASHINGTON,D. C.
T
ODAY, the surgical risk is greater in patients with coronary disease than in other forms Roughly, it is two to three of heart disease. times that occurring in the total population operated upon. Comparisons of the mortality and morbidity rates for surgery in patients with arteriosclerotic heart disease and those with normal hearts, as reported in medical literature, show wide variations. The collected series recently compiled and published by Nachlas et al.’ and reproduced here (Table I) show a variation of mortality rate from 3.2 to 18.2 per cent and morbidity rate (complications) from 4.3 to 24.1. In the aggregate, the mortality was 6.6, and complications 10.1 with In the recent a 2.9 mortality in the controls. series of Nachlas et al.,’ the mortality rate for 200 operations in patients with coronary disease was 10.5 per cent against 3.5 in 6,059 controls. CLINICAL MANIFESTATIONS AND COMPLICATIONS OF CORONARY DISEASE AS SURGICAL RISK FACTORS The actual risk in a given patient depends upon multiple factors,2 the most important of which relate to the nature of the clinical manifestations and complications of the coronary Clinical manifestations of coronary disease. disease as surgical risk factors will be discussed (1) coronary under the following categories: insufficiency, (2) myocardial infarction, recent and old, (3) myocardial disease designated as arteriosclerotic heart disease, (4) asymptomatic and occult coronary disease, and (5) complications of coronary disease. CORONARYINSUFFICIENCY Coronary insufficiency, recognized either by the clinical syndrome of angina alone or by the additional electrocardiographic abnormalities
in the resting or postexercise electrocardiogram, represents an unpredictable risk. Patients with this condition are susceptible to sudden unexpected death with or without the development of a thrombotic occlusion. Ischemic or arrhythmic death can occur during the stress of surgery just as it does under the Conditions that usual stresses of daily living. induce or increase myocardial ischemia during surgery are added risk factors in this type of patient. In spite of this element of unpredictability, the clinical spectrum of coronary insufficiency and the relative risk factors are broad and can be subjected to preoperative evaluation and prognosis. Angina and a Xormal Electrocardiogram: The patient with clinical angina but with a normal resting and postexercise electrocardiogram usuCorally has localized coronary artery disease. onary occlusion in such a patient during surgery is not likely to be fatal except occasionally when it triggers a fatal arrhythmia. The patient with an occasional bout of exertional angina who has a normal resting and exercise electrocardiogram and no other cardiovascular abnormalities presents about the same surgical risk as a patient of same age without symptoms of angina.3 Angina and Abnormal Electrocardiogram: The patient with uncomplicated angina but demonstrating electrocardiographic abnormalities of myocardial ischemia usually has generalized as well as severe occlusive disease. This form is subject to troublesome or fatal arrhythmias, and thrombotic occlusions during or after surgery which are often fatal. Angina Decubitus: Angina decubitus or a pattern of angina of an increasing frequency and severity with clinical features of an impend-
* From the Departments of Medicine, Washington Hospital Center, Georgetown University and George \Vashington University Schools of Medicine, Washington, D. C. SEPTEMBER
1963
279
280
Mattingly TABLE
Comparison
of Mortality
Authors
and Morbitidy
Hospital Massachusetts General
Sprague
I
Rates in Normal and Arteriosclerotic
Year
---Controls-MorOperatality tions (“i;) (no.)
Patients (Collected ---Cardiac Operations (no.)
1929
Patients---_ MorComplicatality tions (o,‘o) (‘%) 18.2*
88
Butler et al.
Peter Bent Bri+m
1930
278
5.8t
Hickman
University of Chicago
1935
103
9.7*
Brumm and Willius
Mayo Clinic
1939
Morrison
New York
1948
et a1.Q
IIannigan
et al.
Memorial York)
J.ochhead
et al.
George Washington University
1954
New England Center
1954
Sinai of Baltimore
1959
Etsten et Nachlas
al.1j et al.
Combined
(New
1951
series
257 9,137 260
4,154
Series)’
12.6X
4.3*
2.8
485
14.8
4.3
3.4
58
5.2
24.1$
51
6.0
6.0
2.0
1,624
3.4
6,059
3.5
200
10.5
19,610
2.9
3>144
6.6
r Reproduced from Table III of Nachlas et al.’ with permission of authors and publisher. * Some authors indicated cardiac deaths only in their mortality figures. t These authors separated their deaths into expected and unexpected groups, rather than cardiac Their mortality rate includes only the expected deaths. $ These authors listed only the cardiorespiratory complications.
19 10.1
and noncardiac.
§ The data from Hickman and associates comprise all cases listed as myocardial disease, coronary thrombosis and Both major and minor operative procedures were included although there were only a small number angina pectoris. of the latter. /1The comparatively low mortality among the cardiac patients in this series may be due to the fact that only 60 per cent of the operations were considered major procedures. ing infarction creates as poor a surgical risk as any form of coronary disease, including an acute myocardial infarction. PREOPERATIVE
MYOCARDIAL
TABLE
II
Incidence of Postoperative Coronary Occlusion in Male Patients Over 50 Years of Age*
INFARCTION
The surgical risk offered by a well recognized preoperative coronary occlusion with a myocardial infarction has been carefully evaluated. Both the frequency and operative mortality of complicating postoperative occlusions have been Specific modifying factors and overstudied. all incidence is well shown in the recent excellent study of Knapp et al..,4 whose statistical tabulations are reproduced here (Table II). They show an incidence of 6 per cent for postoperative coronary occlusions in those with a history of previous coronary occlusion as compared with an incidence of 0.7 per cent in a large series operated upon without a history of a preThere is actually operative coronary occlusion. an eightfold increase in incidence, which is significant. Experience has demonstrated that the risk of a
Total
No previous history of coronary occlusion Previous history of coronary occlusion
8,557
No Postoperative Coronary Occlusion
Postoperative Coronary Occlusion
8,498
50(0.7%)
427
401
* Reproduced from Table I of Knapp permission of authors and publisher.
26(6%) et ah4 with
fatal or nonfatal complication as well as another postoperative occlusion in a patient who has a preoperative myocardial infarction is related to the interval between preoperative infarction and the time of the operation. Surgery During Acute State of Infarction: The THE
AMERICAN
JOURNAL
OF CARDIOLOGY
Coronary
Artery
Disease
risk of major surgery performed during an acute myocardial infarction is so great that any form of elective surgery is unjustified. Emergency lifesaving surgical procedures also involve of critical hemorrhage, great risks : control closure of a visceral perforation, relief of strangulated intestinal obstruction, removal of gangrenous intestine or other tissues and surgical treatment of a complication of the myocardial infarction itself (ruptured ventricular septum, pericardial tamponade, etc.). The justification for an acceptance of the risk in these situations must be weighed against the natural course without the benefit of surgery. Elective Surgery Following Recovery from Infarction: Less urgent surgery and elective surgery should not be performed until a myocardial infarction is well healed and the associated complications well controlled. How long after an acute infarction can elective surgery be performed with reasonable safety? Opinions vary, but the generally accepted period is from three to six months. My own policy has been to wait at least six months. Statistical studies from published reports indicate that the shorter the interval the greater the hazard of recurrence of occlusion. This is well demonstrated in the statistical study of Knapp et a1.l (Table III). At an interval of less than six months, the incidence of recurrence was 100 per cent. Thereafter at longer intervals, the incidence decreased until at a two year inter\.al the incidence of recurrence was no higher than that in the general population having an operation without a history of a previous coronary occlusion. .4n interesting and encouraging finding in ‘I’ABLE
Patients with Preoperative Coronary Occlusions 7 21
7(100%) 7(33%)
1 yr.-2 yr.
22
9(41%)
2 yr.-3 yr.
25
Over 3 yr.
352
302%) 0
427
* Reproduced from Table IV of Knapp permission of authors and publisher. SEPTEMBER
1963
their series was that the mortality rate did not parallel this relation to the interval from preThompson et al.5 operative coronary occlusion. recently reported a low incidence of only one fatal postoperative myocardial infarction among 23 transurethral prostatic resections performed less than six months after a myocardial infarction. Likewise, there were no deaths in a small group of six patients in whom it was considered necessary to perform resections less than three months after a myocardial infarction. The incidence of as well as the mortality from postoperative coronary occlusions was observed to increase in male patients over 50 years of age undergoing surgery. Table IV (reproduced here from Knapp et a1.4) demonstrates that this age factor increased the mortality from 19 to 58 per cent in those who developed occlusions. .4RTERIOSCLEROTIC
HEART
DISEASE
Too frequently the surgeon receives a vague and general diagnosis of arteriosclerotic heart disease from the physician who referred or evaluated the patient for surgery. Included in such a diagnosis are manifestations such as symtomatic and asymptomatic bundle branch block, A-V block, nondiagnostic electrocardiographic abnormalities compatible with but not diagnostic of myocardial infarction and cardiomegaly and myocardial failure without obvious cause in patients in the coronary age In the recent review by Nachlas et al.,’ group. it was shown that such patients provided a mortality and an incidence of postoperative cardiac complications equally as great as those with preoperative angina and myocardial infarctions. These observations indicate that
TABL.E
IV
Mortality from Postoperative Coronary Occlusion Male Surgical Patients Over 50 Years of Age*
Patients with Postoperative Coronary Occlusions
6 mo.-1 yr.
Total
281
Risk
III
Effect of Time Interval Between Coronary Occlusion and Operation on Incidence of Postoperative Occlusion in Men over 50 with Preoperative Coronary Occlusion*
Under 6 mo.
as a Surgical
26 et al.4 with
Total No previous history of coronary occlusion Previous history of coronary occlusion
8,557 427
in
Mortality Postfrom Postoperative operative Coronary Coronary OccluOcclusion sion -__ 59
11(19%)
26
15(58’S)
* Reproduced from Table II of Knapp permission of authors and publisher.
et al.4 with
282
Mattingly
the risk of surgery ignored.
A
fication
in such patients
plea
and
is made
evaluation,
be some patients
for
but
cannot
a better
there
in this indefinite
be
classi-
will
always
category.
diagnosis
spect,
that
fatal of
is usually
is, during
or nonfatal
coronary
coronary a
large
routine
with dence
In
50 years
Fifty
per cent
would
may
patients
have
of
it rose
and
to
missed
study
of
cent.
infarctions In
postoperative
Wroblewski
in
in those
the aid of the
electrocardiogram.
infarctions,
inci-
4.5 per
without
of chronic
a similar
and
the patient
with
vious with
left
angina
the
extent
of the surgical
asymptomatic
presents
is difficult
unknown
until
careful
postoperative age.
and will
remain
explained
this problem
and
over
monitoring
those
showing
In some
instances
has been reduced COMPLICATIONS which include
failure thrombus The
There the
surgery
abnormalities.
failure, only
when
or is the
DISEASE
presence
of
coronary
but
which
provokes
nocturnal
dyspnea
risk;
the
undergo
surgery
is undertaken.
left
maximal
diseases
SURGICAL RISK
additional
disease
The
that
following
factors modify
the
modifying
briefly:
(1)
of surgery;
procedure;
and
operative
than of
surgical
factors
presence
(4)
(5)
other
and complications
will
of associated
; (2) age of the patient;
duration
(3)
anesthetic
type agent
preoperative
and
and and post-
management.
ASSOCIATED DISEASES These well
include
as
associated
cardiovascular
noncardiovascular
the more important briefly
conditions.
as
latter
risk
pulmonary
ones will be enumerated
it induces
are
disease, and
the
more
diseases which
significantly with coronary
of an intra-
hypertensive
cardiovascular
megaly
failure
encountered
but
stenosis
medical
therapy
offers
of one or more
of the
valvular
disease
is less
the surgical
diseases.
Systemic
disease with
is favorable
com-
dis-
cardiovascular
increase
is the one
for embolic
and/or
myocardial
important
risk in patients and
diseases,
either
dis-
or ag-
systemic
vascular
noncoronary
and
complica-
and
Coexisting
hypertensive
valvular
insufficiency, ease
as Only
discussed.
aortic coronary
conduction
location
responsible
a pre-
should
Cardiovascular Conditions:
cardiomegaly
The
for
Likewise,
infarction
operative
manifestations
be discussed
or
considered
arrhythmias,
are many
risk.
of age and con-
for such studies
been
before
the
a patient
a procedure
preoperative
aneurysm.*
is important
plications.
operating
the age limit
have
myocardial
gravates
un-
electrocardio-
complications
orders,
cardiac
of
of the
recognized
during
OF CORONARY
failure
the clinical
to 40 years of age.
factors
ventricular
the
instituted 50 years
each
acute,
have
procedures
important
disease
to
40 years
and
in
centers
have
and
for some
and postoperative
in patients
tinuous
seen
medical
given
over
arrests
arrhythmias
of preoperative
The
patient accounts
circulatory
Many
grams
electrocardiograms
surgical
and
room.
tion
to evaluate
It undoubtedly
cardiac
in
patient
are
especially
is a poor
FACTORS MODIFYING
which
disease
evaluations
of an acute be given
or without
myocardial failure
a a
one
coronary
routine
clinical
risk problem
rest,
ventricular
third to be silent infarctions. The
at
angina,
that
with
and and
constitutes
surgery.
angina
ventricular
by symp-
failure
should
elective
effort presence
(angina)
in evaluating
recognizable
improvement
myocardial
and La Due7 found
consideration
than and
this
surgery
The
arrhythmia
infarction
if the
maximal
ventricular
to or greater
emergency
and
left
uncontrolled
same
emergency
insufficiency
by
improve-
disease manifested
coronary
complicated
these
to which
in all instances.
coronary
tomatic
with
to surgery
but
to
is to
preoperative
extent
when
risk
who
or maximal prior
is variable,
be made
risk equal
the
of these postoperative
been
postoperative detailed
age
indicated
should
careful
The
be accomplished
major
or
Patients
have
and correction
myocardial
infarctions
cent,
can
adds
disease
surgery. should
of the complication
how pre-
be masked
myocardial
major
occlusion
so studied,
series was 2.4 per
over
postoperative
coronary
infarction
of postoperative
the entire
patients
have demonstrated
496
silent
coronary
risk is to be reduced. is
Recent
surgical and
postoperative
myocardial
missed.
show
of
preoperative
and
a
routine
disease.
series
electrocardiograms operative
when
where
electrocardiograms
of
having
or
undergo
significantly
with
evaluation
or complication
occurs
complications
patient
ment
in retro-
surgery
manifestation
asymptomatic studies6
or after
disease
preoperative
recognized
the
complications
ASYMPTOMATIC OR OCCULT CORONARY DISEASE This
above
most in
that
improvement. frequent
cardio-
frequently
but
present Aortic is most
THE AMERICAN JOURNAL OF CARDIOLOGY
Coronary
Artery
Disease
likely to increase the risk and is very difficult to evaluate and to prognosticate or alleviate. Noncardiovascular Conditions: Associated noncardiovascular lesions requiring consideration in the evaluation of the patient with coronary disease as a surgical risk are (1) pulmonary insufficiency, acute and chronic, (2) hematological disorders, especially anemia and polycythemia, (3) renal diseases, (4) diabetes and its complications, (5) electrolytic disorders and (6) infections. Anxiety, fear and anger are possible factors dificult to evaluate. AGE
AND
CORONARY
DISEASE
Opinions are divided as to whether the elderly patient with coronary disease represents a poorer surgical risk than the younger one. There are factors which tend to neutralize each other such as the observation that those patients with the severest form of coronary disease die before they reach the age of 60 years; thus patients over 60 years undergoing surgery are the survivors with milder disease. This is countered by the increasing incidence of associated diseases, especially chronic pulmonary diseases, in patients over 60 years of age which adversely modify the surgical risk by aggravating the Likecoronary disease and its complications. wise, in the survivors beyond 60 years of age, with milder degrees of coronary disease, the severity of their disease gradually increases with age so that at subsequent years, they too have severe disease but at an age when it is less well tolerated. It has been my observation that, in general, age does not adversely affect the surgical risk of the patient with coronary disease. In the evaluation of the elderly patient with coronary disease for surgery it is most important to evaluate the age of the entire vascular system and the functional status of other systems. The age of the vascular system frequently differs from the chronologic age of the patient.” Earlier, in the discussion of the incidence and mortality of recurrent myocardial infarction during surgery, reference was made to significant differences in rates in patients over 50 years of a,ge.4 TYPE
AND
DURATION
OF
SURGERY
Emergency Versus Elective Surgery: In the patient with coronary disease the surgical risk of emergency surgery, in general, is two to threefold that of elective surgery in the patient undergoing a similar procedure but properly evaluated and prepared.iO This risk factor SEPTEMBER
1963
as a Surgical
Risk
283
again is modified by age as demonstrated in the collected series of Nachlas et al.’ (Table v). Location of Surgery: Laparotomies with operative procedures on the intestinal and biliary tract, thoracic procedures and major gynecologic and genitourinary procedures tend to provide a greater risk for the patient with coronary disease than other procedures of similar duration. They provide greater opportunities for shock, hemorrhage and attending hypotension which induce myocardial ischemia. However, with good operative technic, anesthetic management and preoperative and postoperative care, little difference exists in mortality and morbidity as compared to major surgery directed to other areas of the body. Duration of Surgery: Surgical procedures of two or more hours’ duration are usually considered a greater risk than procedures requiring less time. Today, this is a minor factor. We daily witness an uneventful course after prolonged vascular surgery and other major surgical procedures in the elderly patient with coronary disease who is well monitered and managed through many hours of surgery. On the other hand, one witnesses unexpected complications and fatalities in the coronary patient undergoing simple surgical procedures of short duration but under conditions where unexpected conditions developed during the anesthesia, or preoperative and postoperative surgery management. ANESTHETIC
AGENT
In previous years, the consulting or attending physician and the surgeon frequently debated at length on the relative risks of various anesthetic agents and procedures in a patient with coronary disease undergoing surgery. Today with an increasing number of well trained physician specialists in anesthesiology, there is less and less evidence to indicate that the type of anesthetic agent used significantly modifies the risk factor. The good anesthetist is capable of utilizing each agent, and selection should be left to his evaluation of the problem. The selection of the anesthetist is, therefore, more important than the agent or the procedure. In my many years of preoperative evaluation of cardiac patients, including those with coronary disease, I have never made specific recommendations as to the anesthetic agent but outlined the existing disease and the hazards to be avoided during surgery. Indirectly I hoped
284
Mattingly TABLE v Influence
of Age and Urgency
of Operation
on Surgical
Risk (Collected
Series)* Mortality (%)
Age Group
Over
Over
60 years
70 years
Operations (no.)
Authors
(%)
Elective Operations
Emergency Operations 16.4 12.5 17.4 21.9
Mortality Controls (‘;G)
Estes (1949) Parsons et al. (1949) Bosch et al. (1952) Haug and Dale (1952) Cole (1953) Combined series
400 322 500 354 1,099 2,675
6.5 9.4 9.6 9.0 5.1 7.2
5.0 5.0 8.8 5.7
Welch (1948) Childs and Mason (1949) Owen and Murphy (1952) Anglem and Bradford (1953) Stewart and Alfano (1954) Mithoefer and Mithorfer (1954) Parsons et al. (1956) Limbosch (1956) Nachlas et al. (1959) Combined series
609 99 434 621 290 240 146 336 77 2,852
10.2 17 2 27.2 10.0 13.0 8.3 8.2 20.5 14.3 14.3
13.81
39t
22.6 1o.ot
3j:; 19.ot
:.
6.6 16.6t
20:8 30.01
;:; 1.1
* Reproduced from Table v of Nachlas 5 These findings were based on elective
2.1 1.1 3.0
2.;
35
et al.’ with permission of authors and publisher. and emergency abdominal operations only.
that this would prompt the surgeon and the anesthetist to use their best tools and personnel. PREOPERATIVE
Mortality
ANDPOSTOPERATIVEMANAGEMENT
Preoperative medications are as important as the anesthetic agent itself as modifying factors. Excessive and inadequate sedation or antiarrhythmic medications create an additional Improper management of the risk factor. patient with hypertensive coronary artery disease treated with such drugs as reserpine, guanethedine or other blocking agents has created unnecessary risks. Likewise, hypokalemic states in the patient under therapy with chlorothiazides and digitalis furnish complications providing additional risks.
general condition of the patient, type and duration of surgery and anesthesia. Reduction or elimination of the risk requires the teamwork and diligence of the attending or consulting physician or both, the surgeon and the anesthesist in a well planned and executed program of preoperative, operative and postoperative management. REFERENCES
2. 3.
SUMMARY
In general, the surgical risk for the patient with coronary disease as measured by mortality and morbidity rates is two to three times that of the total population having operations and greater than that provided by other forms of heart disease. The risk factor for a given patient with coronary disease is variable and depends upon many factors; the most significant relate to the type of clinical manifestations and the presence or absence of complications. Less important modifying factors to be considered are age,
M. M., ABRAMS, S. J. and GOLDBERG, M. M. The influence of arteriosclerotic heart disease on surgical risk. Am. J. Szq., 101: 447, 1961. GILCHRIST, A. R. Cardiac patient as a surgical risk. J. Roy. Call. Surgeons, 6 : 159, 1961. MATTINGLY, T. IV. The postexercise electrocardiogram, its value in the diagnosis and prognosis of coronary arterial disease. .4m. J. Cardiol., 9: 395, 1962. KNAPP, R. B., TOPKINS, M. J. and ARTUSIO, J. T. The cerebral accident and coronary occlusion in anesthesia. J.A.M.A., 182: 332, 1962. THOMPSON, G. J., KELALIS, P. P. and CONNOLLY, D. C. Transurethral prostatic resection after myocardial infarction. J.A.M.A., 182: 110,1962. DRISCOLL, A. C , HOBIKA, ,J. H., ETSTEN, B. E. and PROGER. S. Clinically unrecognized myocardial infarction following surgery. Xew England J.
1. NACHLAS,
4.
5.
6.
Med., 264: 633,196l. 7. WROBLEWSKI, F. and as infarction majorsurgery. 8. WASSERMAN, F.,
LA DUE, J. S. Myocardial post-operative complication of
J.A.M.A.,150: BELLET, S. and
1212,1952. SAICHEK, R.
P.
THE AMERICAN JOURNAL OF CARDIOLOCY
Coronary
Artery
Disease
Postoperative myocardial infarction; report of 25 cases. New Ergland J. M
SEPTEMBER
1963
as a Surgical
Risk
285
10. DE PEYSTER, F..A.,PAUL, 0. and GILCHRIST, R. K. Risk of urgent surgery in the presence of myocardial infarction and angina pectoris. Arch Suy., (5: 448, 1952.
with Coronarv as a Surgical THOMAS W.
Artery Risk*
MATTINGLY, M.D.
%‘ASHINGTON,D. C.
T
ODAY, the surgical risk is greater in patients with coronary disease than in other forms Roughly, it is two to three of heart disease. times that occurring in the total population operated upon. Comparisons of the mortality and morbidity rates for surgery in patients with arteriosclerotic heart disease and those with normal hearts, as reported in medical literature, show wide variations. The collected series recently compiled and published by Nachlas et al.’ and reproduced here (Table I) show a variation of mortality rate from 3.2 to 18.2 per cent and morbidity rate (complications) from 4.3 to 24.1. In the aggregate, the mortality was 6.6, and complications 10.1 with In the recent a 2.9 mortality in the controls. series of Nachlas et al.,’ the mortality rate for 200 operations in patients with coronary disease was 10.5 per cent against 3.5 in 6,059 controls. CLINICAL MANIFESTATIONS AND COMPLICATIONS OF CORONARY DISEASE AS SURGICAL RISK FACTORS The actual risk in a given patient depends upon multiple factors,2 the most important of which relate to the nature of the clinical manifestations and complications of the coronary Clinical manifestations of coronary disease. disease as surgical risk factors will be discussed (1) coronary under the following categories: insufficiency, (2) myocardial infarction, recent and old, (3) myocardial disease designated as arteriosclerotic heart disease, (4) asymptomatic and occult coronary disease, and (5) complications of coronary disease. CORONARYINSUFFICIENCY Coronary insufficiency, recognized either by the clinical syndrome of angina alone or by the additional electrocardiographic abnormalities
in the resting or postexercise electrocardiogram, represents an unpredictable risk. Patients with this condition are susceptible to sudden unexpected death with or without the development of a thrombotic occlusion. Ischemic or arrhythmic death can occur during the stress of surgery just as it does under the Conditions that usual stresses of daily living. induce or increase myocardial ischemia during surgery are added risk factors in this type of patient. In spite of this element of unpredictability, the clinical spectrum of coronary insufficiency and the relative risk factors are broad and can be subjected to preoperative evaluation and prognosis. Angina and a Xormal Electrocardiogram: The patient with clinical angina but with a normal resting and postexercise electrocardiogram usuCorally has localized coronary artery disease. onary occlusion in such a patient during surgery is not likely to be fatal except occasionally when it triggers a fatal arrhythmia. The patient with an occasional bout of exertional angina who has a normal resting and exercise electrocardiogram and no other cardiovascular abnormalities presents about the same surgical risk as a patient of same age without symptoms of angina.3 Angina and Abnormal Electrocardiogram: The patient with uncomplicated angina but demonstrating electrocardiographic abnormalities of myocardial ischemia usually has generalized as well as severe occlusive disease. This form is subject to troublesome or fatal arrhythmias, and thrombotic occlusions during or after surgery which are often fatal. Angina Decubitus: Angina decubitus or a pattern of angina of an increasing frequency and severity with clinical features of an impend-
* From the Departments of Medicine, Washington Hospital Center, Georgetown University and George \Vashington University Schools of Medicine, Washington, D. C. SEPTEMBER
1963
279
280
Mattingly TABLE
Comparison
of Mortality
Authors
and Morbitidy
Hospital Massachusetts General
Sprague
I
Rates in Normal and Arteriosclerotic
Year
---Controls-MorOperatality tions (“i;) (no.)
Patients (Collected ---Cardiac Operations (no.)
1929
Patients---_ MorComplicatality tions (o,‘o) (‘%) 18.2*
88
Butler et al.
Peter Bent Bri+m
1930
278
5.8t
Hickman
University of Chicago
1935
103
9.7*
Brumm and Willius
Mayo Clinic
1939
Morrison
New York
1948
et a1.Q
IIannigan
et al.
Memorial York)
J.ochhead
et al.
George Washington University
1954
New England Center
1954
Sinai of Baltimore
1959
Etsten et Nachlas
al.1j et al.
Combined
(New
1951
series
257 9,137 260
4,154
Series)’
12.6X
4.3*
2.8
485
14.8
4.3
3.4
58
5.2
24.1$
51
6.0
6.0
2.0
1,624
3.4
6,059
3.5
200
10.5
19,610
2.9
3>144
6.6
r Reproduced from Table III of Nachlas et al.’ with permission of authors and publisher. * Some authors indicated cardiac deaths only in their mortality figures. t These authors separated their deaths into expected and unexpected groups, rather than cardiac Their mortality rate includes only the expected deaths. $ These authors listed only the cardiorespiratory complications.
19 10.1
and noncardiac.
§ The data from Hickman and associates comprise all cases listed as myocardial disease, coronary thrombosis and Both major and minor operative procedures were included although there were only a small number angina pectoris. of the latter. /1The comparatively low mortality among the cardiac patients in this series may be due to the fact that only 60 per cent of the operations were considered major procedures. ing infarction creates as poor a surgical risk as any form of coronary disease, including an acute myocardial infarction. PREOPERATIVE
MYOCARDIAL
TABLE
II
Incidence of Postoperative Coronary Occlusion in Male Patients Over 50 Years of Age*
INFARCTION
The surgical risk offered by a well recognized preoperative coronary occlusion with a myocardial infarction has been carefully evaluated. Both the frequency and operative mortality of complicating postoperative occlusions have been Specific modifying factors and overstudied. all incidence is well shown in the recent excellent study of Knapp et al..,4 whose statistical tabulations are reproduced here (Table II). They show an incidence of 6 per cent for postoperative coronary occlusions in those with a history of previous coronary occlusion as compared with an incidence of 0.7 per cent in a large series operated upon without a history of a preThere is actually operative coronary occlusion. an eightfold increase in incidence, which is significant. Experience has demonstrated that the risk of a
Total
No previous history of coronary occlusion Previous history of coronary occlusion
8,557
No Postoperative Coronary Occlusion
Postoperative Coronary Occlusion
8,498
50(0.7%)
427
401
* Reproduced from Table I of Knapp permission of authors and publisher.
26(6%) et ah4 with
fatal or nonfatal complication as well as another postoperative occlusion in a patient who has a preoperative myocardial infarction is related to the interval between preoperative infarction and the time of the operation. Surgery During Acute State of Infarction: The THE
AMERICAN
JOURNAL
OF CARDIOLOGY
Coronary
Artery
Disease
risk of major surgery performed during an acute myocardial infarction is so great that any form of elective surgery is unjustified. Emergency lifesaving surgical procedures also involve of critical hemorrhage, great risks : control closure of a visceral perforation, relief of strangulated intestinal obstruction, removal of gangrenous intestine or other tissues and surgical treatment of a complication of the myocardial infarction itself (ruptured ventricular septum, pericardial tamponade, etc.). The justification for an acceptance of the risk in these situations must be weighed against the natural course without the benefit of surgery. Elective Surgery Following Recovery from Infarction: Less urgent surgery and elective surgery should not be performed until a myocardial infarction is well healed and the associated complications well controlled. How long after an acute infarction can elective surgery be performed with reasonable safety? Opinions vary, but the generally accepted period is from three to six months. My own policy has been to wait at least six months. Statistical studies from published reports indicate that the shorter the interval the greater the hazard of recurrence of occlusion. This is well demonstrated in the statistical study of Knapp et a1.l (Table III). At an interval of less than six months, the incidence of recurrence was 100 per cent. Thereafter at longer intervals, the incidence decreased until at a two year inter\.al the incidence of recurrence was no higher than that in the general population having an operation without a history of a previous coronary occlusion. .4n interesting and encouraging finding in ‘I’ABLE
Patients with Preoperative Coronary Occlusions 7 21
7(100%) 7(33%)
1 yr.-2 yr.
22
9(41%)
2 yr.-3 yr.
25
Over 3 yr.
352
302%) 0
427
* Reproduced from Table IV of Knapp permission of authors and publisher. SEPTEMBER
1963
their series was that the mortality rate did not parallel this relation to the interval from preThompson et al.5 operative coronary occlusion. recently reported a low incidence of only one fatal postoperative myocardial infarction among 23 transurethral prostatic resections performed less than six months after a myocardial infarction. Likewise, there were no deaths in a small group of six patients in whom it was considered necessary to perform resections less than three months after a myocardial infarction. The incidence of as well as the mortality from postoperative coronary occlusions was observed to increase in male patients over 50 years of age undergoing surgery. Table IV (reproduced here from Knapp et a1.4) demonstrates that this age factor increased the mortality from 19 to 58 per cent in those who developed occlusions. .4RTERIOSCLEROTIC
HEART
DISEASE
Too frequently the surgeon receives a vague and general diagnosis of arteriosclerotic heart disease from the physician who referred or evaluated the patient for surgery. Included in such a diagnosis are manifestations such as symtomatic and asymptomatic bundle branch block, A-V block, nondiagnostic electrocardiographic abnormalities compatible with but not diagnostic of myocardial infarction and cardiomegaly and myocardial failure without obvious cause in patients in the coronary age In the recent review by Nachlas et al.,’ group. it was shown that such patients provided a mortality and an incidence of postoperative cardiac complications equally as great as those with preoperative angina and myocardial infarctions. These observations indicate that
TABL.E
IV
Mortality from Postoperative Coronary Occlusion Male Surgical Patients Over 50 Years of Age*
Patients with Postoperative Coronary Occlusions
6 mo.-1 yr.
Total
281
Risk
III
Effect of Time Interval Between Coronary Occlusion and Operation on Incidence of Postoperative Occlusion in Men over 50 with Preoperative Coronary Occlusion*
Under 6 mo.
as a Surgical
26 et al.4 with
Total No previous history of coronary occlusion Previous history of coronary occlusion
8,557 427
in
Mortality Postfrom Postoperative operative Coronary Coronary OccluOcclusion sion -__ 59
11(19%)
26
15(58’S)
* Reproduced from Table II of Knapp permission of authors and publisher.
et al.4 with
282
Mattingly
the risk of surgery ignored.
A
fication
in such patients
plea
and
is made
evaluation,
be some patients
for
but
cannot
a better
there
in this indefinite
be
classi-
will
always
category.
diagnosis
spect,
that
fatal of
is usually
is, during
or nonfatal
coronary
coronary a
large
routine
with dence
In
50 years
Fifty
per cent
would
may
patients
have
of
it rose
and
to
missed
study
of
cent.
infarctions In
postoperative
Wroblewski
in
in those
the aid of the
electrocardiogram.
infarctions,
inci-
4.5 per
without
of chronic
a similar
and
the patient
with
vious with
left
angina
the
extent
of the surgical
asymptomatic
presents
is difficult
unknown
until
careful
postoperative age.
and will
remain
explained
this problem
and
over
monitoring
those
showing
In some
instances
has been reduced COMPLICATIONS which include
failure thrombus The
There the
surgery
abnormalities.
failure, only
when
or is the
DISEASE
presence
of
coronary
but
which
provokes
nocturnal
dyspnea
risk;
the
undergo
surgery
is undertaken.
left
maximal
diseases
SURGICAL RISK
additional
disease
The
that
following
factors modify
the
modifying
briefly:
(1)
of surgery;
procedure;
and
operative
than of
surgical
factors
presence
(4)
(5)
other
and complications
will
of associated
; (2) age of the patient;
duration
(3)
anesthetic
type agent
preoperative
and
and and post-
management.
ASSOCIATED DISEASES These well
include
as
associated
cardiovascular
noncardiovascular
the more important briefly
conditions.
as
latter
risk
pulmonary
ones will be enumerated
it induces
are
disease, and
the
more
diseases which
significantly with coronary
of an intra-
hypertensive
cardiovascular
megaly
failure
encountered
but
stenosis
medical
therapy
offers
of one or more
of the
valvular
disease
is less
the surgical
diseases.
Systemic
disease with
is favorable
com-
dis-
cardiovascular
increase
is the one
for embolic
and/or
myocardial
important
risk in patients and
diseases,
either
dis-
or ag-
systemic
vascular
noncoronary
and
complica-
and
Coexisting
hypertensive
valvular
insufficiency, ease
as Only
discussed.
aortic coronary
conduction
location
responsible
a pre-
should
Cardiovascular Conditions:
cardiomegaly
The
for
Likewise,
infarction
operative
manifestations
be discussed
or
considered
arrhythmias,
are many
risk.
of age and con-
for such studies
been
before
the
a patient
a procedure
preoperative
aneurysm.*
is important
plications.
operating
the age limit
have
myocardial
gravates
un-
electrocardio-
complications
orders,
cardiac
of
of the
recognized
during
OF CORONARY
failure
the clinical
to 40 years of age.
factors
ventricular
the
instituted 50 years
each
acute,
have
procedures
important
disease
to
40 years
and
in
centers
have
and
for some
and postoperative
in patients
tinuous
seen
medical
given
over
arrests
arrhythmias
of preoperative
The
patient accounts
circulatory
Many
grams
electrocardiograms
surgical
and
room.
tion
to evaluate
It undoubtedly
cardiac
in
patient
are
especially
is a poor
FACTORS MODIFYING
which
disease
evaluations
of an acute be given
or without
myocardial failure
a a
one
coronary
routine
clinical
risk problem
rest,
ventricular
third to be silent infarctions. The
at
angina,
that
with
and and
constitutes
surgery.
angina
ventricular
by symp-
failure
should
elective
effort presence
(angina)
in evaluating
recognizable
improvement
myocardial
and La Due7 found
consideration
than and
this
surgery
The
arrhythmia
infarction
if the
maximal
ventricular
to or greater
emergency
and
left
uncontrolled
same
emergency
insufficiency
by
improve-
disease manifested
coronary
complicated
these
to which
in all instances.
coronary
tomatic
with
to surgery
but
to
is to
preoperative
extent
when
risk
who
or maximal prior
is variable,
be made
risk equal
the
of these postoperative
been
postoperative detailed
age
indicated
should
careful
The
be accomplished
major
or
Patients
have
and correction
myocardial
infarctions
cent,
can
adds
disease
surgery. should
of the complication
how pre-
be masked
myocardial
major
occlusion
so studied,
series was 2.4 per
over
postoperative
coronary
infarction
of postoperative
the entire
patients
have demonstrated
496
silent
coronary
risk is to be reduced. is
Recent
surgical and
postoperative
myocardial
missed.
show
of
preoperative
and
a
routine
disease.
series
electrocardiograms operative
when
where
electrocardiograms
of
having
or
undergo
significantly
with
evaluation
or complication
occurs
complications
patient
ment
in retro-
surgery
manifestation
asymptomatic studies6
or after
disease
preoperative
recognized
the
complications
ASYMPTOMATIC OR OCCULT CORONARY DISEASE This
above
most in
that
improvement. frequent
cardio-
frequently
but
present Aortic is most
THE AMERICAN JOURNAL OF CARDIOLOGY
Coronary
Artery
Disease
likely to increase the risk and is very difficult to evaluate and to prognosticate or alleviate. Noncardiovascular Conditions: Associated noncardiovascular lesions requiring consideration in the evaluation of the patient with coronary disease as a surgical risk are (1) pulmonary insufficiency, acute and chronic, (2) hematological disorders, especially anemia and polycythemia, (3) renal diseases, (4) diabetes and its complications, (5) electrolytic disorders and (6) infections. Anxiety, fear and anger are possible factors dificult to evaluate. AGE
AND
CORONARY
DISEASE
Opinions are divided as to whether the elderly patient with coronary disease represents a poorer surgical risk than the younger one. There are factors which tend to neutralize each other such as the observation that those patients with the severest form of coronary disease die before they reach the age of 60 years; thus patients over 60 years undergoing surgery are the survivors with milder disease. This is countered by the increasing incidence of associated diseases, especially chronic pulmonary diseases, in patients over 60 years of age which adversely modify the surgical risk by aggravating the Likecoronary disease and its complications. wise, in the survivors beyond 60 years of age, with milder degrees of coronary disease, the severity of their disease gradually increases with age so that at subsequent years, they too have severe disease but at an age when it is less well tolerated. It has been my observation that, in general, age does not adversely affect the surgical risk of the patient with coronary disease. In the evaluation of the elderly patient with coronary disease for surgery it is most important to evaluate the age of the entire vascular system and the functional status of other systems. The age of the vascular system frequently differs from the chronologic age of the patient.” Earlier, in the discussion of the incidence and mortality of recurrent myocardial infarction during surgery, reference was made to significant differences in rates in patients over 50 years of a,ge.4 TYPE
AND
DURATION
OF
SURGERY
Emergency Versus Elective Surgery: In the patient with coronary disease the surgical risk of emergency surgery, in general, is two to threefold that of elective surgery in the patient undergoing a similar procedure but properly evaluated and prepared.iO This risk factor SEPTEMBER
1963
as a Surgical
Risk
283
again is modified by age as demonstrated in the collected series of Nachlas et al.’ (Table v). Location of Surgery: Laparotomies with operative procedures on the intestinal and biliary tract, thoracic procedures and major gynecologic and genitourinary procedures tend to provide a greater risk for the patient with coronary disease than other procedures of similar duration. They provide greater opportunities for shock, hemorrhage and attending hypotension which induce myocardial ischemia. However, with good operative technic, anesthetic management and preoperative and postoperative care, little difference exists in mortality and morbidity as compared to major surgery directed to other areas of the body. Duration of Surgery: Surgical procedures of two or more hours’ duration are usually considered a greater risk than procedures requiring less time. Today, this is a minor factor. We daily witness an uneventful course after prolonged vascular surgery and other major surgical procedures in the elderly patient with coronary disease who is well monitered and managed through many hours of surgery. On the other hand, one witnesses unexpected complications and fatalities in the coronary patient undergoing simple surgical procedures of short duration but under conditions where unexpected conditions developed during the anesthesia, or preoperative and postoperative surgery management. ANESTHETIC
AGENT
In previous years, the consulting or attending physician and the surgeon frequently debated at length on the relative risks of various anesthetic agents and procedures in a patient with coronary disease undergoing surgery. Today with an increasing number of well trained physician specialists in anesthesiology, there is less and less evidence to indicate that the type of anesthetic agent used significantly modifies the risk factor. The good anesthetist is capable of utilizing each agent, and selection should be left to his evaluation of the problem. The selection of the anesthetist is, therefore, more important than the agent or the procedure. In my many years of preoperative evaluation of cardiac patients, including those with coronary disease, I have never made specific recommendations as to the anesthetic agent but outlined the existing disease and the hazards to be avoided during surgery. Indirectly I hoped
284
Mattingly TABLE v Influence
of Age and Urgency
of Operation
on Surgical
Risk (Collected
Series)* Mortality (%)
Age Group
Over
Over
60 years
70 years
Operations (no.)
Authors
(%)
Elective Operations
Emergency Operations 16.4 12.5 17.4 21.9
Mortality Controls (‘;G)
Estes (1949) Parsons et al. (1949) Bosch et al. (1952) Haug and Dale (1952) Cole (1953) Combined series
400 322 500 354 1,099 2,675
6.5 9.4 9.6 9.0 5.1 7.2
5.0 5.0 8.8 5.7
Welch (1948) Childs and Mason (1949) Owen and Murphy (1952) Anglem and Bradford (1953) Stewart and Alfano (1954) Mithoefer and Mithorfer (1954) Parsons et al. (1956) Limbosch (1956) Nachlas et al. (1959) Combined series
609 99 434 621 290 240 146 336 77 2,852
10.2 17 2 27.2 10.0 13.0 8.3 8.2 20.5 14.3 14.3
13.81
39t
22.6 1o.ot
3j:; 19.ot
:.
6.6 16.6t
20:8 30.01
;:; 1.1
* Reproduced from Table v of Nachlas 5 These findings were based on elective
2.1 1.1 3.0
2.;
35
et al.’ with permission of authors and publisher. and emergency abdominal operations only.
that this would prompt the surgeon and the anesthetist to use their best tools and personnel. PREOPERATIVE
Mortality
ANDPOSTOPERATIVEMANAGEMENT
Preoperative medications are as important as the anesthetic agent itself as modifying factors. Excessive and inadequate sedation or antiarrhythmic medications create an additional Improper management of the risk factor. patient with hypertensive coronary artery disease treated with such drugs as reserpine, guanethedine or other blocking agents has created unnecessary risks. Likewise, hypokalemic states in the patient under therapy with chlorothiazides and digitalis furnish complications providing additional risks.
general condition of the patient, type and duration of surgery and anesthesia. Reduction or elimination of the risk requires the teamwork and diligence of the attending or consulting physician or both, the surgeon and the anesthesist in a well planned and executed program of preoperative, operative and postoperative management. REFERENCES
2. 3.
SUMMARY
In general, the surgical risk for the patient with coronary disease as measured by mortality and morbidity rates is two to three times that of the total population having operations and greater than that provided by other forms of heart disease. The risk factor for a given patient with coronary disease is variable and depends upon many factors; the most significant relate to the type of clinical manifestations and the presence or absence of complications. Less important modifying factors to be considered are age,
M. M., ABRAMS, S. J. and GOLDBERG, M. M. The influence of arteriosclerotic heart disease on surgical risk. Am. J. Szq., 101: 447, 1961. GILCHRIST, A. R. Cardiac patient as a surgical risk. J. Roy. Call. Surgeons, 6 : 159, 1961. MATTINGLY, T. IV. The postexercise electrocardiogram, its value in the diagnosis and prognosis of coronary arterial disease. .4m. J. Cardiol., 9: 395, 1962. KNAPP, R. B., TOPKINS, M. J. and ARTUSIO, J. T. The cerebral accident and coronary occlusion in anesthesia. J.A.M.A., 182: 332, 1962. THOMPSON, G. J., KELALIS, P. P. and CONNOLLY, D. C. Transurethral prostatic resection after myocardial infarction. J.A.M.A., 182: 110,1962. DRISCOLL, A. C , HOBIKA, ,J. H., ETSTEN, B. E. and PROGER. S. Clinically unrecognized myocardial infarction following surgery. Xew England J.
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4.
5.
6.
Med., 264: 633,196l. 7. WROBLEWSKI, F. and as infarction majorsurgery. 8. WASSERMAN, F.,
LA DUE, J. S. Myocardial post-operative complication of
J.A.M.A.,150: BELLET, S. and
1212,1952. SAICHEK, R.
P.
THE AMERICAN JOURNAL OF CARDIOLOCY
Coronary
Artery
Disease
Postoperative myocardial infarction; report of 25 cases. New Ergland J. M
SEPTEMBER
1963
as a Surgical
Risk
285
10. DE PEYSTER, F..A.,PAUL, 0. and GILCHRIST, R. K. Risk of urgent surgery in the presence of myocardial infarction and angina pectoris. Arch Suy., (5: 448, 1952.