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Ventricular Arrhythmias in Patients Undergoing Noncardiac Surgery
Brian O'Kelly, MB, MRCPI, FRCPC;
Warren S. Browner, MD, MPH;
Barry Massie, MD;
Julio Tubau, MD;
Long Ngo, MS;
Dennis T. Mangano, PhD, MD;
the Study of Perioperative Ischemia Research Group;
Dennis T. Mangano, PhD, MD;
Martin J. London, 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;
Diane Beatty;
Winifred von Ehrenburg;
Brian F. O'Kelly, MB, MRCPI, FRCPC;
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;
Ida M. Tateo, MS;
Jeffrey Tice;
Cary Fox, MA;
Angela Heithaus;
Jonathan Showstack, MPH;
Diana C. Nicoll, MD, PhD;
Paul Heinekin, MD;
Barry Massie, D;
Kanu Chatterjee, MB, FRCP;
H. Barrie Fairley, MD;
Lawrence W. Way, MD;
Warren Winkelstein, MD, MPH
JAMA. 1992;268(2):217-221.
Abstract
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Objective.
—To determine the incidence, clinical predictors and prognostic importance of perioperative ventricular arrhythmias.
Design.
—Prospective cohort study (Study of Perioperative Ischemia).
Setting.
—University-affiliated Department of Veterans Affairs Medical Center, San Francisco, Calif.
Subjects.
—A consecutive sample of 230 male patients, with known coronary artery disease (46%) or at high risk of coronary artery disease (54%), undergoing major noncardiac surgical procedures.
Measurements.
—We recorded cardiac rhythm throughout the preoperative (mean=21 hours), intraoperative (mean=6 hours), and postoperative (mean=38 hours) periods using continuous ambulatory electrocardiographic monitoring. Adverse cardiac outcomes were noted by physicians blinded to information about arrhythmias.
Main Results.
—Frequent or major ventricular arrhythmias (>30 ventricular ectopic beats per hour, ventricular tachycardia) occurred in 44% of our patients: 21% preoperatively, 16% intraoperatively, and 36% postoperatively. Compared with the preoperative baseline, the severity of arrhythmia increased in only 2% of patients intraoperatively but in 10% postoperatively. Preoperative ventricular arrhythmias were more common in smokers (odds ratio [OR], 4.1; 95% confidence interval [Cl], 1.2 to 15.0), those with a history of congestive heart failure (OR, 4.1; 95% Cl, 1.9 to 9.0), and those with electrocardiographic evidence of myocardial ischemia (OR, 2.2; 95% Cl, 1.1 to 4.7). Preoperative arrhythmias were associated with the occurrence of intraoperative and postoperative arrhythmias (OR, 7.3; 95% CI, 3.3 to 16.0, and OR, 6.4; 95% Cl, 2.7 to 15.0, respectively). Nonfatal myocardial infarction or cardiac death occurred in nine men; these outcomes were not significantly more frequent in those with prior perioperative arrhythmias, albeit with wide Cls (OR, 1.6; 95% CI, 0.4 to 6.2).
Conclusion.
—Almost half of all high-risk patients undergoing noncardiac surgery have frequent ventricular ectopic beats or nonsustained ventricular tachycardia. Our results suggest that these arrhythmias, when they occur without other signs or symptoms of myocardial infarction, may not require aggressive monitoring or treatment during the perioperative period.
(JAMA. 1992;268:217-221)
Author Affiliations
From the Departments of Medicine (Drs O'Kelly, Browner, Massie, and Tubau), Anesthesia (Drs Browner and Mangano and Mr Ngo), and Epidemiology and Biostatistics (Dr Browner), the Department of Veterans Affairs Medical Center and University of California, San Francisco.
Footnotes
A complete list of the participants in the research study group appears at the end of this article.
Reprint requests to Department of Anesthesia, Veterans Affairs Medical Center, 4150 Clement St (129), San Francisco, CA 94121 (Dr Mangano).
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