Effect of bundle branch block patterns on mortality in hospitalized patients with heart failure

A widened QRS interval is associated with increased mortality in patients with heart failure (HF). However, the prognostic significance of the type of bundle branch block (BBB) pattern in these patients is unclear. The data of 4,102 patients with HF hospitalized during a prospective national survey were analyzed to investigate the association between BBB type and 1-year mortality in 3,737 patients without pacemakers. Right BBB (RBBB) was present in 381 patients (10.2%) and left BBB (LBBB) in 504 patients (13.5%). RBBB and LBBB were associated with increased 1-year mortality on univariate analysis (odds ratio [OR] 1.44, 95% confidence interval [CI] 1.15 to 1.81, and OR 1.20, 95% CI 0.97 to 1.47, respectively). In patients with systolic HF, after adjusting for multiple risk factors, only RBBB was found to be an independent predictor of mortality (RBBB vs no BBB OR 1.62, 95% CI 1.12 to 2.33, and RBBB vs LBBB OR 1.71, 95% CI 1.09 to 2.69). This correlation was stronger in patients with lower left ventricular ejection fractions and was also maintained in patients without acute myocardial infarctions. Analyzing the data for all patients with HF, there was a trend for increased mortality in the RBBB group only (adjusted OR 1.21, 95% CI 0.94 to 1.56). LBBB was not related to mortality in patients with either systolic HF or preserved ejection fractions. In conclusion, RBBB rather than LBBB is an independent predictor of mortality in hospitalized patients with systolic HF. This prognostic marker could be used for risk stratification and the selection of treatment.     

Electrocardiographic characteristics in patients with pulmonary sarcoidosis indicating cardiac involvement

ECG Characteristics of Cardiac Sarcoidosis. Introduction: Sarcoidosis is a multisystem granulomatous disease that can affect the heart. Early identification of cardiac sarcoidosis (CS) is critical because sudden death can be the initial presentation. We sought to evaluate the potential role of the ECG for identification of cardiac involvement in a cohort of patients with biopsy‐proven pulmonary sarcoidosis. Methods: Our cohort consisted of referred patients with biopsy‐proven pulmonary sarcoidosis who demonstrated symptoms consistent with cardiac involvement. The ECG characteristics collected were PR, QRS duration, QT interval, rate, bundle branch block (BBB), fragmented QRS (fQRS). QRS fragmentation was defined as 2 anatomically contiguous leads demonstrating RSR’ patterns in the absence of BBB. Results: There were 112 subjects included in the cohort. Of the 52 subjects eventually diagnosed with CS, 39 had an ECG demonstrating fQRS while 21 of the 60 of non‐CS patients had fQRS (75% vs 33.9%, P < 0.01). A RBBB or LBBB pattern were both more prevalent in the CS population (RBBB: 23.1% vs 6.7%, P = 0.016; LBBB: 3.8% vs 1.7%, P = 0.6). QRS duration remained significantly associated with CS after exclusion of those with BBB (93.5 +/− 10.6 vs 88 +/− 11 ms; P = 0.04). When fQRS and bundle branch block were combined, 90.4% of CS patient's ECGs contained at least one of the features, compared to 36.7% of noncardiac CS (P < 0.01). Conclusions: The presence of fQRS or BBB pattern in patients with pulmonary sarcoidosis is associated with cardiac involvement and therefore should prompt further evaluation. (J Cardiovasc Electrophysiol, Vol. pp. 1‐6)     

Bundle Branch Block after Myocardial Infarction—A Long Term Follow-up*

Summary: Bundle branch block after myocardial infarction-a long term follow-up. K. S. Woo and R. M. Norris. Aust. N.Z. J. Med., 1979,9, pp. 411–416. Fifty-two patients with myocardial infarction complicated by bundle branch block (27 RBBB and 25 LBBB) survived the hospital period (1967–1972), and were followed up to December 1976. Actuarial survival curves revealed a worse mortality up to five years (P < 0·05) for LBBB (68%) than for RBBB (33%). All deaths occurred in the first four years. In RBBB, additional hemiblock (seven patients) did not increase the risk of heart block nor worsen the prognosis—one death in seven patients (14%) compared to eight in 20 patients with isolated RBBB (40%). The previous literature on long term survival of BBB was reviewed. Recommended treatment for BBB, a marker of severe myocardial damage, includes antiarrhythmic prophylaxis for anteroseptal infarction with RBBB, aneurysmectomy in selected subsets of patients, and possibly prevention of RBBB or its complications by treatment for reduction of infaret size during the very early phase after onset of infarction.     

Relation of bundle branch block to long-term (four-year) mortality in hospitalized patients with systolic heart failure

There is controversy regarding type of bundle branch block (BBB) that is associated with increased mortality risk in patients with heart failure (HF). The present study was designed to explore the association between BBB pattern and long-term mortality in hospitalized patients with systolic HF. Risk of 4-year all-cause mortality was assessed in 1,888 hospitalized patients with systolic HF (left ventricular ejection function <50%) without a pacemaker in a prospective national survey. Cox proportional hazards regression modeling was used to compare mortality risk in patients with right BBB (RBBB; 10%), left BBB (LBBB; 14%), and no BBB (76%) on admission electrocardiogram. At 4 years of follow up, mortality rates were highest in patients with RBBB (69%), intermediate in those with LBBB (63%), and lowest in those without BBB (50%, p <0.001). Multivariate analysis demonstrated a significant 36% increased mortality risk in patients with RBBB versus no BBB (p = 0.002) but no significant difference in mortality risk for patients with LBBB versus no BBB (hazard ratio 1.04, p = 0.66). RBBB versus LBBB was associated with a 29% (p = 0.035) increased risk for 4-year mortality in the total population and with a 58% (p = 0.015) increased risk in patients with ejection fraction <30%. In conclusion, RBBB but not LBBB on admission electrocardiogram is associated with a significant increased long-term mortality risk in hospitalized patients with systolic HF. Deleterious effects of RBBB compared to LBBB appear to be more pronounced in patients with more advanced left ventricular dysfunction.     

Prognostic differences between different types of bundle branch block during the early phase of acute myocardial infarction: insights from the Hirulog and Early Reperfusion or Occlusion (HERO)-2 trial.

AIMS: Bundle branch block (BBB) early during acute myocardial infarction (AMI) is often considered high risk for mortality. Little is known about how different BBB types influence prognosis. METHODS AND RESULTS: The HERO-2 trial recruited 17 073 patients with ischaemic symptoms lasting >30 min and either ST elevation with or without right bundle branch block (RBBB) or presumed-new left bundle branch block (LBBB). Electrocardiograms were performed before and 60 min after the start of fibrinolytic therapy. Using patients with normal intraventricular conduction as a reference, odds ratios (ORs) for 30-day mortality were calculated for different BBB types (LBBB, RBBB with anterior AMI, and RBBB with inferior AMI) present at randomization and/or 60 min, with adjustment for recruitment region, pre-infarction characteristics, time to randomization, hemodynamics, and Killip class. At randomization, the 873 patients (5.11%) with BBB had worse baseline characteristics than patients without BBB. In patients presenting with LBBB (n=300), the ORs for 30-day mortality were 1.90 (95% CI 1.39-2.59) before and 0.68 (0.48-0.99) after adjustment for other prognosticators. In patients presenting with RBBB (n=415) and anterior AMI, the ORs were 3.52 (2.82-4.38) before and 2.48 (1.93-3.19) after adjustment. In patients presenting with RBBB and inferior AMI (n=158), the ORs were 1.74 (1.06-2.86) before and 1.22 (0.71-2.08) after adjustment. Within 60 min, 143 patients (0.92%) developed new BBB. The adjusted ORs for 30-day mortality were 2.97 (1.16-7.57) in the 25 patients with new LBBB, 3.84 (2.38-6.22) in the 100 with new RBBB and anterior AMI, and 2.23 (0.54-9.21) in the 18 with new RBBB and inferior AMI. CONCLUSION: RBBB accompanying anterior AMI at presentation and new BBB (including LBBB) early after fibrinolytic therapy are independent predictors of high 30-day mortality. These electrocardiographic features should be considered in risk stratification to identify high-risk patients.     

Long-term cardiovascular outcomes in patients with angina pectoris presenting with bundle branch block

Long-term outcomes of unselected patients with angina pectoris and bundle branch block (BBB) on initial electrocardiogram are not well established. The Olmsted County Chest Pain Study is a community-based cohort of 2,271 consecutive patients presenting to 3 Olmsted County emergency departments with angina from 1985 through 1992. Patients were followed for major adverse cardiovascular events (MACEs) including death, myocardial infarction, stroke, and revascularization at 30 days and over a median follow-up period of 7.3 years and for mortality only through a median of 16.6 years. Cox models were used to estimate associations between BBB and cardiovascular outcomes. Mean age of the cohort on presentation was 63 years, and 58% were men. MACEs at 30 days occurred in 11% with right BBB (RBBB), 8.8% with left BBB (LBBB), and 6.4% in patients without BBB (p = 0.17). Over a median follow-up of 7.3 years, patients with BBB were at higher risk for MACEs (RBBB, hazard ratio [HR] 1.85, 95% confidence interval [CI] 1.44 to 2.38, p <0.001; LBBB, HR 2.04, 95% CI 1.62 to 2.56, p <0.001) compared to those without BBB. Over a median of 16.6 years, the 2 BBB groups had lower survival rates than patients without BBB (RBBB, HR 2.19, 95% CI 1.73 to 2.78, p <0.001; LBBB, HR 3.32, 95% CI 2.67 to 4.13, p ≤0.001), but after adjustment for multiple risk factors an increased risk of mortality for LBBB remained significant. In conclusion, appearance of LBBB or RBBB in patients presenting with angina predicts adverse long-term cardiovascular outcomes compared to patients without BBB.     

Is Wider Worse? QRS Duration Predicts Cardiac Mortality in Patients with Right Bundle Branch Block

Background: Increasing QRS duration may be of prognostic significance in patients with right bundle branch block (RBBB) and may assist in predicting overall cardiovascular risk. Methods: To test this hypothesis, we examined the Computerized Patient Records of patients with complete and persistent RBBB. Primary and secondary end points were all‐cause and cardiac mortality. The effects of QRS duration on death rates were analyzed using the Cox proportional hazards regression model (P < 0.05). We identified 52,852 patients with EKGs and selected all those with diagnosis of RBBB (QRS ≥ 120 ms) between January 2000 and January 2004. Some patients had EKG records confirming RBBB since 1987. The QRS durations were categorized into four groups: 120–129, 130–139, 140–149, and ≥ 150 ms. Results: A total of 997 (1.9%) patients (mean age 68.9 ± 10 years) with RBBB were followed for 1–226 (median 45) months. All‐cause mortality occurred in 344 (34.5%), cardiac deaths in 59 (5.9%), noncardiac in 191 (19.2%), and unknown causes in 94 (9.4%) patients. Mean left ventricular EF for cardiac patients was 38 ± 15%. In patients with cardiac deaths, QRS duration was associated with increased morality (P < 0.007). For every 10 ms increase in QRS duration, the risk of death rose by 26.6%. The effect of QRS duration on all cause mortality was not statistically significant (P < 0.43). Conclusion: Increasing QRS duration was an independent predictor of cardiac mortality in patients with RBBB, but had no influence on all‐cause mortality. QRS duration has added prognostic information to the presence of right bundle branch block.     

Aortic stenosis: an underestimated risk factor for perioperative complications in patients undergoing noncardiac surgery

PURPOSE: To determine the incidence of perioperative events in patients with aortic stenosis undergoing noncardiac surgery. METHODS: We studied 108 patients with moderate (mean gradient, 25 to 49 mm Hg) or severe (mean gradient, > or =50 mm Hg) aortic stenosis and 216 controls who underwent noncardiac surgery between 1991 and 2000 at Erasmus Medical Center. Controls were selected based on calendar year and type of surgery. Details of clinical risk factors, type of surgery, and perioperative management were retrieved from medical records. The main outcome measure was the composite of perioperative mortality and nonfatal myocardial infarction. RESULTS: There was a significantly higher incidence of the composite endpoint in patients with aortic stenosis than in patients without aortic stenosis (14% [15/108] vs. 2% [4/216], P <0.001). This rate of perioperative complications was also substantially higher in patients with severe aortic stenosis compared with patients with moderate aortic stenosis (31% [5/16] vs. 11% [10/92], P = 0.04). After adjusting for cardiac risk factors, aortic stenosis remained a strong predictor of the composite endpoint (odds ratio = 5.2; 95% confidence interval: 1.6 to 17.0). CONCLUSION: Aortic stenosis is a risk factor for perioperative mortality and nonfatal myocardial infarction, and the severity of aortic stenosis is highly predictive of these complications.     

Bundle branch block as a predictor of long-term survival after acute myocardial infarction

Using a community-based population of patients with acute myocardial infarction (AMI), we sought to: (1) determine the prevalence of bundle branch block (BBB) on the presenting electrocardiogram (ECG), (2) compare the clinical characteristics and the treatment administered to patients with and without BBB, and (3) determine the association of BBB with mortality. We analyzed the admission ECGs of 894 consecutive patients with AMI from Olmsted County, Minnesota, seen at our institution from January 1988 to March 1998. Of these, 53 had left BBB (LBBB) (5.9%) and 60 had right BBB (RBBB) (6.7%). Patients with BBB were more likely to be older, have a history of AMI or hypertension, and to be in Killip class >I at presentation. They were less likely to receive primary reperfusion therapy, beta blockers, or heparin, but more likely to receive angiotensin-converting enzyme inhibitors. They had lower mean predischarge ejection fractions (38 +/- 16% vs 50 +/- 15%, p <0.0001). In-hospital mortality was 13.3%, 17.0%, and 9.1% for patients with RBBB, LBBB, and no BBB, respectively (p = 0.11). Respective postdischarge survival at 1, 3, and 5 years was 80%, 60%, and 50% in the RBBB group, 78%, 56%, and 51% in the LBBB group, and 92%, 85%, and 76% in the group without BBB (p <0.0001). Although BBB was not an independent predictor of mortality on multivariate analysis, the presence of transient or persistent BBB with AMI is an easily recognized clinical marker of increased mortality. Our conclusion from this study is that in a community-based population, patients who had LBBB or RBBB at the time of AMI had lower predischarge ejection fractions and higher in-hospital and long-term unadjusted mortality.     

Usefulness of hypotension during dobutamine echocardiography in predicting perioperative cardiac events

This study was undertaken to determine the prognostic significance of hypotension induced during preoperative dobutamine stress echocardiography (DSE) before vascular and noncardiac thoracic surgery. Wall motion abnormality during DSE predicts perioperative risk. Although hypotension during DSE has not been shown to correlate with the presence or severity of coronary artery disease, its significance in perioperative risk assessment is unknown. We retrospectively studied 300 patients who had DSE within 6 months of noncardiac surgery. Perioperative events including death, myocardial infarction, ischemia, and arrhythmias were recorded. Odds ratios with 95% confidence intervals were used to examine the association between clinical and echocardiographic variables and perioperative events. A hypotensive response during DSE was seen in 85 patients (28%). Forty-eight patients (16%) had 54 perioperative complications including 4 cardiac-related deaths, 10 myocardial infarctions, 12 myocardial ischemic events, and 28 arrhythmias. Hypotension during DSE was predictive of the combined end point of perioperative cardiac mortality, myocardial infarction, and ischemia (odds ratio 4.04, 95% confidence interval 1.72 to 9.51). In a multivariate logistic regression model, hypotension during DSE remained a significant predictor (odds ratio 4.10, p<0.01). DSE-related hypotension was predictive of perioperative cardiac events and therefore may have a role in risk stratification before vascular or noncardiac thoracic surgery.     

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

BACKGROUND: Major surgical procedures are performed with increasing frequency in elderly persons, but the impact of age on resource use and outcomes is uncertain. OBJECTIVE: To evaluate the influence of age on perioperative cardiac and noncardiac complications and length of stay in patients undergoing noncardiac surgery. DESIGN: Prospective cohort study. SETTING: Urban academic medical center. PATIENTS: Consecutive sample of 4315 patients 50 years of age or older who underwent nonemergent major noncardiac procedures. MEASUREMENTS: Major perioperative complications (cardiac and noncardiac), in-hospital mortality, and length of stay. RESULTS: Major perioperative complications occurred in 4.3% (44 of 1015) of patients 59 years of age or younger, 5.7% (93 of 1646) of patients 60 to 69 years of age, 9.6% (129 of 1341) of patients 70 to 79 years of age, and 12.5% (39 of 313) of patients 80 years of age or older (P < 0.001). In-hospital mortality was significantly higher in patients 80 years of age or older than in those younger than 80 years of age (0.7% vs. 2.6%, respectively). Multivariate analyses indicated an increased odds ratio for perioperative complications or in-hospital mortality in patients 70 to 79 years of age (1.8 [95% CI, 1.2 to 2.7]) and those 80 years of age or older (OR, 2.1 [CI, 1.2 to 3.6]) compared with patients 50 to 59 years of age. Patients 80 years of age or older stayed an average of 1 day more in the hospital, after adjustment for other clinical data (P = 0.001). CONCLUSIONS: Elderly patients had a higher rate of major perioperative complications and mortality after noncardiac surgery and a longer length of stay, but even in patients 80 years of age or older, mortality was low.     

QRS Axis and the Benefit of Cardiac Resynchronization Therapy in Patients with Mildly Symptomatic Heart Failure Enrolled in MADIT‐CRT

Cardiac Resynchronization Therapy and QRS Axis . Background: Mildly symptomatic heart failure (HF) patients derive substantial clinical benefit from cardiac resynchronization therapy with defibrillator (CRT‐D) as shown in MADIT‐CRT. The presence of QRS axis deviation may influence response to CRT‐D. The objective of this study was to determine whether QRS axis deviation will be associated with differential benefit from CRT‐D. Methods : Baseline electrocardiograms of 1,820 patients from MADIT‐CRT were evaluated for left axis deviation (LAD: quantitative QRS axis ‐30 to ‐90) or right axis deviation (RAD: QRS axis 90–180) in left bundle branch block (LBBB), right bundle branch block (RBBB), and nonspecific interventricular conduction delay QRS morphologies. The primary endpoints were the first occurrence of a HF event or death and the separate occurrence of all‐cause mortality as in MADIT‐CRT. Results: Among LBBB patients, those with LAD had a higher risk of primary events at 2 years than non‐LAD patients (20% vs 16%; P = 0.024). The same was observed among RBBB patients (20% vs 10%; P = 0.05) but not in IVCD patients (22% vs 23%; P = NS). RAD did not convey any increased risk of the primary combined endpoint in any QRS morphology subgroup. When analyzing the benefit of CRT‐D in the non‐LBBB subgroups, there was no significant difference in hazard ratios for CRT‐D versus ICD for either LAD or RAD. However, LBBB patients without LAD showed a trend toward greater benefit from CRT therapy than LBBB patients with LAD (HR for no LAD: 0.37, 95% CI: 0.26–0.53 and with LAD: 0.54, 95% CI: 0.36–0.79; P value for interaction = 0.18). Conclusions: LAD in non‐LBBB patients (RBBB or IVCD) is not associated with an increased benefit from CRT. In LBBB patients, those without LAD seem to benefit more from CRT‐D than those with LAD. (J Cardiovasc Electrophysiol, Vol. 24, pp. 442‐448, April 2013)     

Preoperative plasma N-terminal pro-brain natriuretic peptide concentration and perioperative cardiovascular risk in elderly patients.

BACKGROUND: The prediction of perioperative cardiovascular complications is important in the medical management of patients undergoing noncardiac surgery. Several indices have been developed, but a simpler, more practical and accurate method is needed. The purpose of this study was to determine whether the N-terminal pro-brain natriuretic peptide (NT-proBNP) concentration before operation can be used to predict perioperative cardiovascular complications in elderly patients undergoing noncardiac surgery. METHODS AND RESULTS: The study group comprised 279 patients older than 60 years who were scheduled for elective surgery. The plasma NT-proBNP concentration, clinical cardiac indices and left ventricular ejection fraction were measured prior to operation. The postoperative cardiac outcomes were followed and predictors for postoperative cardiac risk were identified. Cardiovascular complications occurred in 25 patients (9.0%). Age, the incidence of prior ischemic heart disease or congestive heart failure, and the plasma NT-proBNP concentration were significantly higher in patients with perioperative cardiovascular complications than in those without. Using receiver operating characteristic analysis to predict perioperative cardiovascular events, a cut-off value of 201 pg/ml was identified as the optimal predictor of perioperative complications, showing a sensitivity of 80.0% and specificity of 81.1%. Multivariate analysis revealed that NT-proBNP >201 pg/ml (odds ratio (OR) 7.6, 95% confidence interval (CI) 2.2-26.6, p=0.003) and revised cardiac index > or =2 (OR 6.3, 95% CI 1.7-23.8, p=0.007) were independent predictors for perioperative cardiovascular complications. CONCLUSIONS: Elevated NT-proBNP levels are independently associated with an increase in the risk of perioperative cardiovascular complications in elderly patients undergoing noncardiac and nonvascular operations.     

Beta-blockers and statins are individually associated with reduced mortality in patients undergoing noncardiac, nonvascular surgery

BACKGROUND: Patients undergoing noncardiac, nonvascular surgery are at risk for perioperative mortality owing to underlying (a)symptomatic coronary artery disease. We hypothesized that beta-blocker and statin use are associated with reduced perioperative mortality. METHODS: We performed a case-control study in 75 581 patients who underwent 108 593 noncardiac, nonvascular surgery at the Erasmus Medical Center between 1991 and 2001. Cases were the 989 patients who died during hospital stay after surgery. From the remaining patients, 1879 matched controls (age, sex, calendar year and type of surgery) were selected. Information was then obtained regarding the use of beta-blockers and statins and the presence of cardiac risk factors. RESULTS: The median age of the study population was 63 years; 61% were men. beta-blockers were less often used in cases than in controls (6.2 vs. 8.2%; P=0.05), as were statins (2.4 vs. 5.5%; P<0.001). After adjustment for the propensity of beta-blocker use and cardiovascular risk factors, beta-blockers were associated with a 59% mortality reduction (odds ratio 0.41; 95% confidence interval 0.28-0.59). Statins were associated with a 60% mortality reduction (adjusted odds ratio 0.40; 95% confidence interval 0.24-0.68). A significant interaction between beta-blockers and statins was observed (P<0.001). In the presence of each other, statins and beta-blockers were not associated with reduced mortality (adjusted odds ratio 2.0 and 95% confidence interval 0.74-5.7 and adjusted odds ratio 1.3 and 95% confidence interval 0.52-3.2). It should be, however, noted that only nine cases and 29 controls used both agents simultaneously. CONCLUSION: This case-control study provides evidence that beta-blockers and statins are individually associated with a reduction of perioperative mortality in patients undergoing noncardiac, nonvascular surgery.     

Predicting medical and surgical complications of carotid endarterectomy: comparing the risk indexes

BACKGROUND: Several generic cardiac risk assessment tools predict perioperative cardiac complications, but their ability to predict a broader range of medical, neurologic, and surgical complications is unknown. METHODS: A multicenter retrospective observational cohort study of 1998 patients undergoing carotid endarterectomy (CEA). Complications within 30 days of surgery were assessed by medical record review, including death or nonfatal stroke and cardiac, noncardiac medical, minor neurologic, and wound complications. Logistic regression and receiver operating characteristic curve analyses assessed the predictive abilities of the Goldman, Detsky, Revised Cardiac Risk, and American Society of Anesthesiologists indexes and of 2 CEA-specific risk models (the Halm and Tu scores). RESULTS: Death or stroke occurred in 3.2% of patients, cardiac complications in 4.0%, noncardiac medical complications in 3.2%, minor neurologic complications in 6.9%, and wound complications in 6.0%. All risk models (except the Tu score) significantly predicted cardiac complications equally well (P<.05). All 6 risk models were equivalent in predicting noncardiac medical complications. Only the Revised Cardiac Risk Index and the 2 CEA-specific risk models (Halm and Tu scores) predicted death or stroke and minor neurologic and wound complications. The Halm score was superior in predicting death or stroke compared with the Tu score and the Revised Cardiac Risk Index (area under the receiver operating characteristic curve, 0.72 vs 0.62 and 0.61, respectively; P<.05). Patients with cardiac, noncardiac medical, minor neurologic, or wound complications had 3- to 16-fold increased odds of death or stroke. CONCLUSION: The Halm score CEA-specific risk model and the generic Revised Cardiac Risk Index predicted a broad range of medical, neurologic, and surgical complications following CEA.     

Usefulness of transthoracic echocardiography as a tool for risk stratification of patients undergoing major noncardiac surgery

Transthoracic echocardiography (TTE) is frequently ordered before noncardiac surgery, although its ability to predict perioperative cardiac complications is uncertain. To evaluate the incremental information provided by TTE after consideration of clinical data for prediction of cardiac complications after noncardiac surgery, 570 patients who underwent TTE before major noncardiac surgery at a university hospital were studied. Preoperative clinical data and clinical outcomes were collected prospectively according to a structured protocol. TTE data included left ventricular (LV) function, hypertrophy indexes, and Doppler-derived measurements. In univariate analyses, preoperative systolic dysfunction was associated with postoperative myocardial infarction (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.1 to 7.0), cardiogenic pulmonary edema (OR 3.2, 95% CI 1.4 to 7.0), and major cardiac complications (OR 2.4, 95% Cl 1.3 to 4.5). Moderate to severe LV hypertrophy, moderate to severe mitral regurgitation, and increased aortic valve gradient were also associated with major cardiac events (OR 2.3, 95% CI 1.2 to 4.6; OR 2.2, 95% CI 1.1 to 4.3; OR 2.1, 95% CI 1.0 to 4.5, respectively). In logistic regression analysis, models with echocardiographic variables predicted major cardiac complications significantly better than those that included only clinical variables (c statistic 0.73 vs 0.68; p <0.05). Echocardiographic data added significant information for patients at increased risk for cardiac complications by clinical criteria, but not in otherwise low-risk patients. In conclusion, preoperative TTE before noncardiac surgery can provide independent information about the risk of postoperative cardiac complications in selected patients.     

Utilization efficacy of noninvasive and invasive cardiac testing among stable cardiac patients undergoing noncardiac surgery.

BACKGROUND: Patients with coronary artery disease are at increased risk from noncardiac surgery. We examined a population of cardiac patients undergoing noncardiac surgery to determine whether coronary angiography was successfully utilized to identify and treat ischemic heart disease. Our hypothesis was that cardiac complications would not differ between the group of patients who underwent coronary angiography and the group that did not. METHODS: We conducted a secondary analysis from a prospective, cohort study of 314 patients with stable cardiac disease undergoing elective noncardiac surgery. The cohort was stratified by history of coronary arteriography. Follow-up extended postoperatively for a minimum of 30 days or until discharge if later. RESULTS: Of this cohort, 37.9% of the patients had a coronary angiogram at a median interval of 19 months (range, 1 day-13 years) before surgery. Among the 15 cardiac deaths (4.8%), 14 patients had compensated congestive heart failure and/or diabetes. The two arms were similar by surgical risk. Despite a higher clinical risk (P<.001), the catheterized vs. noncatheterized arm exhibited a similar cardiac morbidity and a lower cardiac mortality (0.8% vs. 7.2%, P=.01). The lower cardiac mortality persisted whether the patients were recently or remotely catheterized and whether revascularized or not. CONCLUSION: Coronary arteriography is associated with mortality risk-reduction among stable cardiac patients undergoing intermediate-to-high-risk noncardiac surgery, but is unwarranted for low-risk procedures. A higher risk linked to diabetes and congestive heart failure suggests underutilization of noninvasive testing and coronary arteriography among patients with these diagnoses and stable cardiac disease.     

Prediction of cardiac and pulmonary complications related to elective abdominal and noncardiac thoracic surgery in geriatric patients

PURPOSE: Major cardiac and pulmonary complications associated with abdominal and noncardiac thoracic surgery are a common cause of mortality and serious morbidity in elderly patients. We postulated that a simple, inexpensive bicycle exercise test could provide objective documentation of cardiopulmonary reserve and, therefore, predict perioperative pulmonary as well as cardiac complications. PATIENTS AND METHODS: Prior to elective surgery, 177 patients aged 65 years or older had assessment of the clinical history, results of physical examination, electrocardiogram, chest radiograph, blood chemistries, pulmonary function test findings, supine exercise test results, Dripps classification, and Goldman cardiac risk factors. Observations in patients with and without major perioperative cardiac and/or pulmonary complications were compared using univariate analysis followed by a multivariate logistic regression procedure. RESULTS: Major perioperative complications were pulmonary in 24 patients, cardiac in 25 patients, and either cardiac or pulmonary in 39 patients. By multivariate analysis, inability to perform two minutes of supine bicycle exercise raising the heart rate above 99 beats/minute was the best predictor of perioperative pulmonary, cardiac, and combined cardiopulmonary complication (p less than 0.0005). Among 108 patients who were able to achieve these exercise criteria, cardiac or pulmonary complications occurred in 10 patients (9.3%), with one death (0.9%). Among 69 patients unable to exercise satisfactorily, cardiac or pulmonary complications occurred in 29 patients (42%), with five total deaths (7.2%). CONCLUSION: Objective measurement of exercise capacity by supine bicycle ergometry appears to be of clinical value for preoperative risk stratification for both pulmonary and cardiac complications prior to major elective abdominal or noncardiac thoracic surgery in elderly patients.     

Electromechanical coupling, uncoupling, and ventricular function in patients with bundle branch block: a tissue-Doppler echocardiographic study

BACKGROUND: Left bundle branch block (LBBB) is associated with impaired left ventricular (LV) function and increased morbidity and mortality, especially in patients with structural heart diseases. The mechanisms are poorly understood. Subjects and METHODS: Subjects with isolated LBBB (n=20), right bundle branch block (RBBB, n=20), and controls (C, n=20) were studied with standard two-dimensional (2D), and color-encoded tissue-Doppler echocardiography (TDE). Inter- and intraventricular systolic and diastolic coordination were assessed from the TDE velocity profiles. LV function was assessed by 2D echocardiography, by TDE-derived peak systolic velocities, and the atrioventricular (AV) plane displacement. RESULTS: Subjects with LBBB had longer electromechanical delays and longer isovolumic relaxation times than did the C and RBBB groups (P <0.001). For the LBBB subjects compared with the RBBB and C groups, ejection times were shorter, peak systolic velocities and AV plane displacements were lower, they had larger LV end-systolic volumes and lower LV ejection fraction (all P <0.001), and the atrial contribution to A-V plane displacement was higher (P <0.01). There were no differences in diastolic or filling times among the groups. CONCLUSIONS: In patients with LBBB, delayed regional electromechanical coupling and uncoupling leads to generalized intra- and interventricular asynchrony, thereby explaining the depressed regional and global LV functions. Assessment of the electromechanical coupling and uncoupling processes and their consequences on cardiac function in patients with BBB and structural heart diseases may be possible using TDE.     

Association between cardiac and noncardiac complications in patients undergoing noncardiac surgery: outcomes and effects on length of stay

PURPOSE: To determine the relation between cardiac and noncardiac complications and their effects on length of stay in patients undergoing noncardiac surgery. METHODS: We collected detailed information from the history, physical examination, and preoperative tests of 3970 patients aged > or =50 years who were undergoing major noncardiac procedures. Serial electrocardiograms and cardiac enzyme measurements were performed perioperatively, and cardiac and noncardiac complications were recorded prospectively. Multivariate logistic regression analysis was used to determine the association between cardiac and noncardiac complications, and linear regression was used to assess their effects on length of stay. RESULTS: Cardiac complications occurred in 84 patients (2%), and noncardiac complications developed in 510 patients (13%). Both types of complications occurred in 40 patients (1%). The most common cardiac complications were pulmonary edema (n = 42) and myocardial infarction (n = 41). The most common noncardiac complications were wound infection (n = 291), confusion (n = 87), respiratory failure requiring intubation (n = 62), deep venous thrombosis (n = 48), and bacterial pneumonia (n = 46). Patients with cardiac complications were more likely to suffer a noncardiac complication than were those without cardiac complications, even after adjustment for preoperative clinical factors (odds ratio = 6.4; 95% confidence interval [CI]: 3.9 to 10.6). Mean length of stay was markedly increased in patients who experienced cardiac (11 days; 95% CI: 9 to 12 days) or noncardiac (11 days; 95% CI: 10 to 12 days) complications, or both (15 days; 95% CI: 12 to 18 days), as compared with patients without complications (4 days; 95% CI: 3 to 4 days), even after adjustment for procedure type and clinical factors. CONCLUSION: Cardiac and noncardiac complications were strongly linked in patients undergoing noncardiac surgery. Patients who experienced one type of complication were at increased risk of developing the other type of complication as well as prolonged perioperative length of stay.