Newly Published
Perioperative Medicine  |   March 2019
Relationship between Perioperative Hypotension and Perioperative Cardiovascular Events in Patients with Coronary Artery Disease Undergoing Major Noncardiac Surgery
Author Notes
  • From the Lilibeth Caberto London Kidney Clinical Research Unit, London Health Sciences Centre, London, Canada (P.S.R.); the Department of Medicine (P.S.R., T.S., E.D., V.T., P.J.D.) and Department of Health Research Methods, Evidence and Impact (P.S.R., E.D., P.J.D.), McMaster University, Hamilton, Canada; the Population Health Research Institute, Hamilton, Canada (E.D., P.J.D.); the Division of General Internal Medicine, McGill University Health Center, Montreal, Canada (A.B.); the Department of Anesthesia and Intensive Care, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China (M.T.V.C.); the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (C.B.); the Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada (B.J.W.C.); the Department of Radiology, University of Ottawa, Ottawa, Canada (B.J.W.C.); and the Department of Anesthesia, University of Toronto, Toronto, Canada (J.S.K).
  • Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • Submitted for publication April 12, 2017. Accepted for publication January 21, 2019.
    Submitted for publication April 12, 2017. Accepted for publication January 21, 2019.×
  • Correspondence: Address correspondence to Dr. Roshanov: Lilibeth Caberto London Kidney Clinical Research Unit, Room ELL-101, Westminster, London Health Sciences Centre, 800 Commissioners Road East, London, Ontario, Canada N6A 4G5. roshanp@mcmaster.ca. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Perioperative Medicine / Cardiovascular Anesthesia
Perioperative Medicine   |   March 2019
Relationship between Perioperative Hypotension and Perioperative Cardiovascular Events in Patients with Coronary Artery Disease Undergoing Major Noncardiac Surgery
Anesthesiology Newly Published on March 8, 2019. doi:10.1097/ALN.0000000000002654
Anesthesiology Newly Published on March 8, 2019. doi:10.1097/ALN.0000000000002654
Abstract

Editor’s Perspective:

What We Already Know about This Topic:

  • Perioperative hypotension is associated with cardiovascular events in patients having noncardiac surgery, but it is unknown if the severity of preexisting coronary artery disease determines susceptibility to the cardiovascular risks of perioperative hypotension

What This Article Tells Us That Is New:

  • In patients who had risk factors for, or known, coronary artery disease and were having noncardiac surgery, perioperative hypotension and degree of coronary artery disease on preoperative coronary computed tomographic angiography were independently associated with perioperative cardiovascular death and myocardial infarction

  • Perioperative hypotension was associated with cardiovascular events regardless of the degree of coronary artery disease on preoperative coronary computed tomographic angiography

Background: Perioperative hypotension is associated with cardiovascular events in patients having noncardiac surgery. It is unknown if the severity of preexisting coronary artery disease determines susceptibility to the cardiovascular risks of perioperative hypotension.

Methods: In this retrospective exploratory analysis of a substudy of an international prospective blinded cohort study, 955 patients 45 yr of age or older with history or risk factors for coronary artery disease underwent coronary computed tomographic angiography before elective inpatient noncardiac surgery. The authors evaluated the potential interaction between angiographic findings and perioperative hypotension (defined as systolic blood pressure less than 90 mmHg for a total of 10 min or more during surgery or for any duration after surgery and for which intervention was initiated) on the composite outcome of time to myocardial infarction or cardiovascular death up to 30 days after surgery. Angiography assessors were blinded to study outcomes; patients, treating clinicians, and outcome assessors were blinded to angiography findings.

Results: Cardiovascular events (myocardial infarction or cardiovascular death within 30 days after surgery) occurred in 7.7% of patients (74/955), including in 2.7% (8/293) without obstructive coronary disease or hypotension compared to 6.7% (21/314) with obstructive coronary disease but no hypotension (hazard ratio, 2.51; 95% CI, 1.11 to 5.66; P = 0.027), 8.8% (14/159) in patients with hypotension but without obstructive coronary disease (hazard ratio, 3.85; 95% CI, 1.62 to 9.19; P = 0.002), and 16.4% (31/189) with obstructive coronary disease and hypotension (hazard ratio, 7.34; 95% CI, 3.37 to 15.96; P < 0.001). Hypotension was independently associated with cardiovascular events (hazard ratio, 3.17; 95% CI, 1.99 to 5.06; P < 0.001). This association remained in patients without obstructive disease and did not differ significantly across degrees of coronary disease (P value for interaction, 0.599).

Conclusions: In patients having noncardiac surgery, perioperative hypotension was associated with cardiovascular events regardless of the degree of coronary artery disease on preoperative coronary computed tomographic angiography.