Severe Angina is Significant Risk Factor in Patients Undergoing the Abdominal Nonvascular Surgery




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Vesna Karapandzic


Severe Angina is Significant Risk Factor in Patients Undergoing the Abdominal Nonvascular Surgery

Severe Angina is Significant Risk Factor

V.M. Karapandzic 1,2, M.V. Boricic 3, S.M. Knezevic 2, V.I. Rankovic 1,4, I.G. Palibrk 1,4


Abstract


Background: Severe angina is significant risk factor in patients undergoing the abdominal nonvascular surgery.

Aims: The aim of our study was to prove that the incidence of expected perioperative cardiac complications was significantly higher in the group of severe than in the group of mild angina.

Methods: Our prospective observational clinical study included the group of 78 consecutive patients with angiographically verified coronary arterial disease who had angina. Coronary patients underwent open abdominal nonvascular surgery during general anaesthesia in University Clinical Center. The patients were classified into stratification subgroups, using the “Canadian Cardiovascular Society” grading of the angina. This subgroups were compared in relation to frequency of perioperative cardiac complications. During operation, and in the following 72 postoperative hours, the patients were monitored by continuous ST-T segment recording. Twelve-lead electrocardiography was performed immediately after the surgery, and on postoperative days 1, 2 and 7 as well as one day before discharge. Cardiac biomarkers were evaluated at 6h, 24h and 96 hours following the surgery.

A non-parametrical Pearson's hi-square test using the contingency tables was used to analyze the data from two subgroups with the level of significance set at 95% (p<0.05).



Results: Significant difference of the the incidence of perioperative cardiac death was found between two evaluated stratification subgroups 15.0%(severe angina) vs 0.0%(mild angina)(p<0.01).

Conclusions: We found high statistical significance of the incidence of perioperative cardiac death between the subgroup of severe angina and the subgroup of mild angina in patients having undergone open abdominal nonvascular surgery during general anesthesia.
KEYWORDS

angina pectoris • coronary artery disease • risk factors • surgery • complications



INTRODUCTION


Coronary patients experience significantly more major perioperative cardiac complications, compared with noncardiac population in the similar type of operation and anaesthesia. 1 More than 50% perioperative deaths are direct result of cardiovascular event. 2 Patients with verified coronary artery disease accounted for about one third of a total number of cases undergoing non cardiac surgery annualy, on what basis the majority of studies have analyzed risk evaluation and perioperative cardiac complications in coronary patients. 1-29

The objective of our prospective observational clinical study was:

To prove that the incidence of perioperative cardiac death is significantly higher in the subgroup of severe angina than in the subgroup of mild angina in patients undergoing the open abdominal nonvascular surgery during general anesthesia.



METHODS

Study protocol


Our prospective observational clinical study included the group of 78 consecutive patients with angiographically verified coronary arterial disease who had symptomatic angina. Coronary patients underwent the open abdominal nonvascular surgery during general anaesthesia at the Department of Digestive Surgery, Institute of Digestive System Diseases, University Clinical Center of Serbia, (tertiary-level teaching hospital), Belgrade, Serbia, between July 2002 and December 2003.

Preoperative cardiac evaluation was carried out in the line with American College of Cardiology/ American Heart Assotiation 2002 guidelines. 3,4

Within preoperative preparation, all patients were subjected to complete physical and cardiological examination, and in relation to their associated diseases, other necessary specialist and subspecialist examinations. Preoperative twelve-lead electrocardiography (Schiller AT-1, Schiller Corp, Austria), heart and chest X ray (Shimadzu RS-50 A, Shimadzu Corp, Kyoto, Japan), transthoracic echocardiography (Siemens Sequoia 256, Siemens Corp, Mountain View, CA ) and complete laboratory tests (Olympus 400, Olympus, Tokyo, Japan) were carried out in all patients.

Criterion to be enrolled in the study was angiographically verified coronary arterial disease. The group of consecutive patients without coronary angiography performed was excluded from the study, because their coronary disease was diagnosed only by medical history, without any former diagnostic tests.

All patients underwent preoperative and pre-hospital coronary angiography, irrelevant of noncardiac surgery along with decision made by cardiosurgical consultation on further management of coronary artery disease (medicamentous therapy or myocardial revascularisation-coronary artery bypass grafting).

Angiographically verified mild stenosis (<75% blood vessel stenosis) of coronary arteries with recommendation for medicamentous therapy (beta blocker, aspirin, statin) had 50 (64.1%) patients with angina. Severe stenosis (>75% blood vessel stenosis) of coronary arteries and indication for myocardial revascularisation had 28 (35.9%) patients with angina.

The patients were classified into stratification subgroups according to “Canadian Cardiovascular Society” classification of angina pectoris, published by Lucien Campeau as a Letter under the title “Grading of Angina Pectoris”, in Circulation 1976. 5 (see Table 1)

Perioperative management - risk reduction strategy

Perioperative monitoring and medicamentous therapy were carried out in the line with American College of Cardiology/American Heart Association guidelines published in 2002. 3,4

Coronary patients were monitored by continuous electrocardiogram during the surgery as well as in the immediate postoperative 72-hour period in the Intensive Care Unit, which recorded blood pressure and frequency values every hour, all kinds of electrocardiographic changes as well as saturation. All patients had twelve-lead electrocardiography immediately after the surgery, and on postoperative days 1, 2 and 7 as well as a day before discharge from hospital. Cardiac biomarkers (CKMB and troponin) were evaluated at 6 h, 24 h and 96 hours following the surgery according to American College of Cardiology/American Heart Association 2002 recommendations. 3,4 The patients were monitored on daily basis during their stay in hospital and upon discharge till 30th postoperative day. During hospitalization, all patients were observed by cardiologist every day.

Perioperative medicamentous therapy with beta-blockers was applied in 55 (70.5%) patients with angina, and 23 (29.5%) patients with angina did not receive beta-blocker therapy because the drugs were contraindicated.

Aspirin was terminated 3 days preoperatively, and returned in therapy on the 4 th postoperative day. Low molecular weight heparin in profilactic doses was applied twice a day in all patients before and after surgery.

Indicated myocardial revascularisation prior to open abdominal nonvascular surgery was performed only in 7 (1.3%) patients with angina, and was not performed in 21 (26.2%) patient, because of emergency of surgery and/or poor general health status.


Perioperative cardiac complications




The following perioperative cardiac complications were evaluated:


  1. cardiac death until 30th postoperative day;

  2. cardiac arrest;

  3. acute myocardial infarction - according to criteria of European Society of Cardiology/ American College of Cardiology 2000); 6

  4. transient myocardial ischemia with or without anginose pains (transient and/or repeating ST ↑ ≥ 2mm in leads V1,V2,V3, and ≥ 1 mm in other leads, ST ↓ ≥ 1 mm in at least 2 adjacent leads or symmetric inversion T waves ≥ 1 mm) - documented by continuous ST-T segment monitoring and/or twelve-lead electrocardiography; 7

  5. newly developed heart failure and pulmonary edema - according to “Framingham Criteria for Heart Failure” ;

  6. newly developed arrhythmias and conduction disturbances (sinus tachycardia heart rate >100/min, supraventricular tachyarrhythmias, atrial fibrillation with rapid ventricular response, isolated premature ventricular contractions, non sustained ventricular tachycardia, sustained ventricular tachycardia, ventricular fibrillation, atrioventricular block I, II and IIIo and new bundle branch block left/right)-documented by continuous ST-T segment monitoring and/or twelve-lead electrocardiography;

  7. hypertension (blood pressure >160/100 mgHg, Class II JNC VII) - according to criteria of the Joint National Committee.


STATISTICAL ANALYSIS
Two stratification subgroups were compared: mild angina (“Canadian Cardiovascular Society” class I and II) 58/78 (74.3%), and severe angina (“Canadian Cardiovascular Society” class III, IV, and unstable angina) 20/78 (25.6%), in relation to minor, major and fatal perioperative cardiac complications.

A non-parametrical Pearson's hi-square test using the contingency tables was used to analyze the data from 2 subgroups with the level of significance set at 95% (p<0.05).




RESULTS

Comparison of severe angina subgroup – 20/78 (25.6%) and mild angina subgroup – 58/78 (74.3%) revealed statistically significant difference in relation to incidence of all types of the expected perioperative cardiac complications.


Table 2 presents the characteristics of selected patients with angina in relation to significance of coronary artery stenosis, number of stenosed blood vessels and myocardial revascularization.

Table 3 illustrates the characteristics of selected coronary patients in relation to type of angina.

Table 4 shows characteristics of selected patients with angina in relation to medicamentous therapy, echocardiographic parameters, nature of digestive tract diseases and type of surgery.
A total number of patients with angina who experienced perioperative cardiac complications was 52/78 (66.7%), while 26/78 (33.3%) had no cardiac complication. A total number of minor, major and fatal perioperative cardiac complications was 113. The most perioperative cardiac complication was hypertension, and the least frequent was myocardial infarction. Perioperative death of cardiac origin was 3/78 (3.8%). (see Table 5)

The main result of our study was high statistically significant difference in relation to incidence of cardiac death until 30th postoperative day (p<0.01).

The study also found high statistically significant difference in relation to incidence of:



  • a total number of patients with cardiac complications (p<0.01);

  • number of patients with major cardiac complications (p<0.01);

  • total cardiac/noncardiac death 30 days after surgery (p<0.01);

  • acute myocardial infarction (p<0.01);

  • transient myocardial ischemia (p<0.01);

  • newly developed heart failure (p<0.05);

  • newly developed arrhythmia and conduction disturbances (p<0.01);

  • and number of patients assisted by mechanical ventilation (p<0.01).

There was no significant difference of the incidence of perioperative hypertension, but the percentage of complications was higher in the subgroup of severe angina.

Discussion


Our prospective observational clinical study analyzed the perioperative cardiac complications of 78 consecutive patients with angiographically verified coronary arterial disease who had symptomatic angina, and underwent the open abdominal nonvascular surgery during general anesthesia.

The patients were classified into stratification subgroups according to “Canadian Cardiovascular Society” classification of angina pectoris. 5


Preoperative cardiac preparation, perioperative monitoring and medicamentous therapy was carried out in the line with American College of Cardiology/ American Heart Assotiation 2002 guidelines. 3,4

Perioperative cardioprotection with beta-blockers was applied in 55 (70.5%) patients and myocardial revascularisation was performed in 7 (8.9%) patients.

According to American College of Cardiology/ American Heart Assotiation 2002 guidelines, “Canadian Cardiovascular Society” angina pectoris class I and II are intermediate, and “Canadian Cardiovascular Society” angina pectoris class III, IV and unstable angina are major predictors of the increased perioperative morbidity and mortality. 3,4

Two stratification subgroups were compared: mild angina (“Canadian Cardiovascular Society” angina pectoris class I and II), and severe angina (“Canadian Cardiovascular Society” angina pectoris class III, IV, and unstable angina), in relation to minor, major and fatal perioperative cardiac complications.

Comparing these two subgroups, our study found high statistical significance of frequency of all types of the expected perioperative cardiac complications, in coronary patients having undergone open abdominal nonvascular surgery during general anaesthesia.

Risk factors affecting the major cardiac complications were severe angina (class III, IV and unstable angina pectoris), angiographically verified significant stenosis of coronary arteries (>75% blood vessel stenosis) and dependence of preoperative use of nitrates. Five patients had typical chest pain 7 days before surgery. Elevated troponin-T level over 1,0 micro g/l after surgery had 5 patients with severe angina.

Direct causes of cardiac death until 30 th postoperative day in all three patients were the acute myocardial infarction, newly developed heart failure and malignant arrhythmias. One patient died on day 2, and other two on postoperative day 3. Cardiac cause of all death was confirmed by postmortem examination. All died patients belonged to the subgroup of patients with severe angina and angiographically verified significant stenosis of coronary arteries with indication for coronary revascularisation irrelevant of noncardiac surgery. In this group of patients, myocardial revascularization prior to noncardiac surgery was not performed either because of emergency of surgical intervention or because of poor general medical status of patients.

The incidence of major cardiac complications in our study was 3.4% to 40%. The latest literature data have reported the incidence of major postoperative cardiac events (combined incidence of nonfatal myocardial infarction, unstable angina pectoris, congestive heart failure and cardiac death) to be from 5.5% to 53%. 6

The obtained results of our study met the American College of Cardiology/ American Heart Assotiation 2000 criteria. 3

We concluded that “Canadian Cardiovascular Society” classification of angina pectoris is adequate for assessing the cardiac risk in open abdominal nonvascular surgery during general anaesthesia.

Using the “Canadian Cardiovascular Society” angina pectoris classification during the following 30 years, its value has been proved in clinical practice, independent from surgical intervention, and therefore, it is still widely used nowadays. One study compared four scoring systems for assessing the risk in noncardiac surgery, including “Canadian Cardiovascular Society” angina pectoris classification; this study has established that there is no statistical significance between them, and no index is significantly superior over another. 8

The results of the study cannot be compared with those of previous studies since no study has been published so far using the “Canadian Cardiovascular Society” angina pectoris classification in patients with angiographically verified coronary arterial disease having undergone open abdominal nonvascular surgery during general anesthesia.




CONCLUSIONS

In conclusion, the study established the following:



  1. High statistical significance of the incidence of perioperative cardiac death between the subgroup of severe angina and the subgroup of mild angina in patients having undergone open abdominal nonvascular surgery during general anesthesia;

  2. Statistically significant difference of the incidence of all expected perioperative minor, major and fatal cardiac complications between the subgroup of severe angina and the subgroup of mild angina;

  3. Patients with angiographically verified significant stenosis of coronary arteries belonged to class of severe angina according to “Canadian Cardiovascular Society” angina pectoris classification;

  4. “Canadian Cardiovascular Society” classification of angina pectoris is adequate for assessing the cardiac risk in open abdominal nonvascular surgery during general anaesthesia.



REFERENCES


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Table 1 Grading of Angina of Effort by the “Canadian Cardiovascular Society”


GRADING


ANGINA BY EFFORT

NUMBER OF PATIENTS WITH STABLE ANGINA


I

“Ordinary physical activity does not cause…angina,” such as walking and climbing stairs. Angina with strenuous or rapid or prolonged exertion at work or recreation.

43

55.1%





II

“Slight limitation of ordinary activity”. Walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, or in cold, or in wind, or under emotional stress, or only during the few hours after awakening. Walking more than 2 blocks on the level and climbing more than one flight of ordinary stairs at a normal pace and in normal conditions.

15

19.2%




III

“Marked limitation of ordinary physical activity.” Walking one to two blocks on the level and climbing one flight of stairs in normal conditions and at normal pace.

10

12.8%




IV

“Inability to carry on any physical activity without discomfort-anginal syndrome may be present at rest”

2

2.6%


Table 2 Angiographic characteristics of selected patients with angina pectoris

Clinical characteristics of selected patients with angina pectoris

according to coronary angiography

*CCS AP

I+II

n=58 (74.4%)

*CCS AP III+IV

+ Unstable AP

n=20 (25.6%)

Total number of patients with AP

78 (100%)

Coronary angiography

58 (100%)

20 (100%)

78 (100%)

Mild stenosis

51 (87.9%)

0 (0.0%)

51 (45.9%)

Severe stenosis

7 (12.1%)

20 (100%)

27 (34.6%)

Non-revascularized myocardium

3 (5.2%)

18 (90.0%)

21 (26.9%)

Single-vessel coronary disease

2

9

11

Two-vessel coronary disease

1

5

6

Two-vessel coronary disease with the left main stem stenosis

0

1

1

Three-vessel coronary disease

0

3

3

Revascularized myocardium

0

6

6 (7.7%)


* CCS AP - Canadian Cardiovascular Society” grading of angina pectoris

Table 3 Characteristics of selected patients according to type of angina pectoris

Characteristics of selected patients according to type of angina pectoris

Number of patients

Total number of selected patients

with angina pectoris



78 (100%)

Angina pectoris after

coronary artery revascularization



6 (7.7%)

Angina pectoris without

coronary artery revascularization



72 (92.3%)

Postinfarction angina pectoris

51 (65.4%)

Angina pectoris without

previous myocardial infarction



27 (34.6%)

Unstable angina pectoris

Stable angina pectoris



8 (10.2%)

70 (89.7%)




Table 4 Other characteristics of selected patients with angina pectoris

Other clinical characteristics of selected patients with angina pectoris


*CCS AP

I+II
n=58 (74.4%)

*CCS AP III+IV+

Unstable AP

n=20 (25.6%)

Total number of patients with AP

n=78 (100%)

Medicamentous therapy










Beta-blockers

45 (77.6%)

10 (50.0%)

55 (70.5%)

Nitrates

58 (100%)

20 (100%)

78 (100%)

Aspirin

27 (46.5%)

15 (75.0%)

42 (53.8%)

Echocardiographic parameters










End-diastolic diameter of the

left ventricle > 5.7cm



26 (44.8%)

16 (80.0%)

42 (53.8%)

Left ventricular ejection fraction <35%

Segmental wall motion abnormalities



6 (10.3%)

33 (56.9%)



7 (35.0%)

15 (75.0%)



13 (16.7%)

48 (61.5%)



Nature of digestive illness










Malignant disease of digestive system

30 (51.7%)

11 (55.0%)

41(52.6%)

Benign disease of digestive system

Esophageal surgery

Hepatobiliary surgery

Colorectal surgery

Ventral hernia repair




28 (48.3%)

8 (13.8%)

20 (34.5%)

22 (37.9%)

8 (13.8%)


9 (45.0%)

1 (5.0%)


10 (50.0%)

6 (30.0%)

3 (15.0%)


37 (47.4%)

9 (11.5%)

30 (38.5%)

28 (35.9%)

11 (14.1%)


Type of surgery










Emergency surgery

9 (15.5%)

11 (55.0%)

20 (25.6%)

Elective surgery

49 (84.5%)

9 (45.0%)

58 (74.3%)


Table 5 Comparison of patients according to CCS AP in relation to incidence of minor, major and fatal cardiac complications


PERIOPERATIVE

CARDIAC COMPLICATIONS


*CCS AP

I+II
n=58

74.3%


*CCS AP III+IV+

Unstable AP

n=20

25.6%


Total number of patients with AP

n=78

100%


P value

Total number of patients with cardiac complications

33

56.9%


19

95.0%


52

66.7%


p<0.01

Number of patients with major cardiac complications

2

3.4%


8

40.0%


10

12.8%


p<0.01

Total cardiac/noncardiac death 30 days after surgery

1

1.7%


4

20.0%


5

6.4%


p<0.01

Cardiac death until 30th postoperative day

0

0.0%

3

15.0%

3

3.8%

p<0.01

Acute myocardial infarction

ESC/ACC


0

0.0%


5

25.0%


5

6.4%


p<0.01

Transient myocardial ischaemia

7

12.1%


18

90.0%


25

32.0%


p<0.01

Newly developed heart failure

2

3.4%


4

20.0%


6

7.7%


p<0.05

Newly developed arrhythmia and conduction

disturbances



19

32.7%


12

60.0%


31

39.7%



p<0.01



Hypertension

BP>160/100 mmHg



25

43.1%


11

55.0%


36

46.1%


p>0.05

Mechanical ventilation

1

1.7%


7

35.0%


8

10.2%


p<0.01

Covering letter

Severe Angina is Significant Risk Factor in Patients Undergoing the Abdominal Nonvascular Surgery

V.M. Karapandzic 1,2, M.V. Boricic 3, S.M. Knezevic 2, V.I. Rankovic 1,4 , I.G. Palibrk 1,4


This work is not under active consideration for publication, has not been accepted for publication, nor has it been published, in full or in part. I confirm that the study has been approved by Institute of Digestive System Diseases, University Clinical Center of Serbia an institutional ethics committee.”

This article is original because no study on analysis of patients with angiographicaly verified coronary arterial disease, classified according to original “Canadian Cardiovascular Society” classification of angina pectoris, and having undergone open abdominal nonvascular surgery during general anesthesia, has been published to date.

Each author has been contributed to the design and conduct of the work, the manuscript has been written, read, and approved by all the authors.
Contributions all coauthors to the study:
Vesna M.Karapandzic, the author – she completed preoperative cardiological examinations for all patients of the selected group, the evaluation of cardiological risk, preoperative cardiological preparation, perioperative medicamentous therapy, according to ACC/AHA 2002, as well as everyday cardiological examinations during the entire perioperative period and outpatient cardiological controls of all survived patients after 30 days of surgery
Marija V. Boricic - she performed transthoracic echocardiography in 56 patients of the selected group
Srbislav M. Knezevic – he operated 11 patients of the selected group and evaluated the surgical risk according to American College of Cardiology/American Heart Association published in 2002.
Vitomir I. Rankovic – he performed 12 anesthesias for the selected group of patients and evaluated the operative risk according to scoring system of the American Society of Anesthesiologists –ASA
Ivan G. Palibrk - he controled continuous electrocardiogram monitoring in the immediate postoperative 72-hour period and observed all patients every day in the Intensive Care Unit


Vesna M. Karapandzic MD

Marija V. Boricic MD

Srbislav M. Knezevic MD PhD

Vitomir I. Rankovic MD PhD

Ivan G. Palibrk MD






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