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Monitoring for Myocardial Ischemia During Noncardiac SurgeryA Technology Assessment of Transesophageal Echocardiography and 12-Lead Electrocardiography
Mark J. Eisenberg, MD, MPH;
Martin J. London, MD;
Jacqueline M. Leung, MD;
Warren S. Browner, MD, MPH;
Milton Hollenberg, MD;
Julio F. Tubau, MD;
Ida M. Tateo, MS;
Nelson B. Schiller, MD;
Dennis T. Mangano, PhD, MD;
the Study of Perioperative Ischemia Research Group;
Dennis T. Mangano, PhD, MD;
Warren S. Browner, MD, MPH;
Milton Hollenberg, MD;
Julio F. Tubau, MD;
Jacqueline M. Leung, MD;
William C. Krupski, MD;
Joseph A. Rapp, MD;
Marcus W. Hedgcock, MD;
Edward D. Verrier, MD;
Scott Merrick, MD;
M. Lou Meyer, MS;
Linda Levenson;
Martin G. Wong, RDMS;
Elizabeth Layug, MD;
Juliet Li, MD;
Maria E. Franks, RN;
Yuriko C. Wellington, MS;
Mara Balasubramanian, MD;
Evelyn Cembrano, MD;
Wilfredo Velasco, MD;
Nonato Pineda, MD;
Safiullah N. Katiby, MD;
Thea Miller;
Winifred von Ehrenburg;
Brian F. O'Kelly, MB;
Jadwiga Szlachcic, MD;
Andrew A. Knight, MD;
Virginia Fegert, MD;
Paul Goehner, MD;
David N. Harris, MD, FFARCS;
Deanna Siliciano, MD;
Nancy H. Mark, MD;
Randy Smith, MD;
James Helman, MD;
Ida M. Tateo, MS;
Jeffrey Tice;
Cary Fox, MA;
Angela Heithaus;
Jonathan Showstack, PhD;
Diana C. Nicoll, MD, PhD;
Paul Heineken, MD;
Barry Massie, MD;
Kanu Chatterjee, MB, FRCP;
H. Barrie Fairley, MD;
Lawrence W. Way, MD;
Warren Winkelstein, MD, MPH
JAMA. 1992;268(2):210-216.
Abstract
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Objective.
—Transesophageal echocardiography (TEE) and 12-lead electrocardiography (ECG) are sophisticated techniques that are increasingly being used to monitor for myocardial ischemia during noncardiac surgery. We examined whether the routine use of these techniques has incremental clinical value in identifying patients at high risk for perioperative ischemic outcomes when compared with preoperative clinical data and intraoperative monitoring using continuous two-lead bipolar ECG.
Design.
—Cohort study.
Setting.
—Veterans Affairs medical center.
Patients.
—A total of 332 men undergoing noncardiac surgery who had or were at high risk for coronary artery disease.
Interventions.
—TEE, 12-lead ECG, and two-lead ECG were performed continuously during noncardiac surgery (47% vascular, 53% nonvascular). Monitoring results were not available to anesthesiologists or surgeons, and data were blindly analyzed after surgery.
Main Outcome Measure.
—Perioperative ischemic outcomes (cardiac death, nonfatal myocardial infarction, unstable angina).
Results.
—In a subset of 285 patients who were adequately studied by all three techniques, 111 patients (39%) were identified as having intraoperative myocardial ischemia (by one or more monitoring techniques). By univariate analysis, intraoperative ischemia was associated with all perioperative cardiac outcomes, including ischemic outcomes, congestive heart failure, and ventricular tachycardia (P .02 for each of the three monitoring techniques). However, when monitoring results for TEE and 12-lead ECG were added to a multivariate model that included preoperative clinical data and continuous two-lead ECG results, the incremental value of TEE was small (odds ratio, 2.6; 95% confidence interval [Cl], 1.2 to 5.7; P=.02) and that of 12-lead ECG was not significant (odds ratio, 1.5; 95% Cl, 0.6 to 3.8). Furthermore, when the multivariate analysis was repeated with only ischemic outcomes, neither TEE nor 12-lead ECG retained significant associations (odds ratio, 2.2; 95% Cl, 0.5 to 9.4, and odds ratio, 1.1; 95% Cl, 0.2 to 6.1, respectively).
Conclusion.
—When compared with preoperative clinical data and intraoperative monitoring using two-lead ECG, routine monitoring for myocardial ischemia with TEE or 12-lead ECG during noncardiac surgery has little incremental clinical value in identifying patients at high risk for perioperative ischemic outcomes.
(JAMA. 1992;268:210-216)
Author Affiliations
From the Departments of Medicine (Drs Eisenberg, Browner, Hollenberg, Tubau, and Schiller), Anesthesiology (Drs London, Leung, Browner, and Mangano and Ms Tateo), Epidemiology and Biostatistics (Dr Browner and Ms Tateo), and Surgery of the University of California and the Veterans Affairs Medical Center, San Francisco.
Footnotes
A complete list of the participants in the research study group appears at the end of this article.
Reprint requests to Cardiology Division, Moffitt-Long Hospital, University of California, 505 Parnassus Ave, San Francisco, CA 94143-0214 (Dr Eisenberg).
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