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Warren S. Browner, MD, MPH; Juliet Li, MD; Dennis T. Mangano, PhD, MD; 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; Scot Merrick, MD; Marcus W. Hedgcock, MD; Edward Verrier, MD; Martin J. London, MD; Elizabeth Layug, MD; Juliet Li, MD; Linda Levenson; Maria Franks, RN; Martin G. Wong, RDMS; M. Lou Meyer, MS; Ida M. Tateo, MS; Thea Miller

JAMA. 1992;268(2):228-232.

Abstract
Objectives.
—To determine the causes of and risk factors for mortality following noncardiac surgery.

Design.
—Prospective cohort study.

Setting.
—A university-affiliated Veterans Affairs medical center.

Patients.
—Consecutive series of 474 men between the ages of 38 and 89 years (mean age, 68 years) who were undergoing major noncardiac surgery involving general anesthesia. All subjects had known coronary artery disease or were at high risk for coronary artery disease.

Measurements and Results.
—During the initial hospitalization, 26 patients (5%) died, most commonly from sepsis (n=6) or cardiac diseases (n=6). Deaths occurred from postoperative days 2 to 69; half occurred more than 3 weeks after surgery. Multivariable analysis disclosed that a history of hypertension (odds ratio [OR]=3.8; 95% confidence interval [Cl], 1.1 to 13), a severely limited activity level (OR=9.7; 95% Cl, 2.5 to 37), and a creatinine clearance of less than 0.83 mL/s (OR=6.8; 95% Cl, 2.8 to 16) were all independently associated with an increased risk of postoperative mortality. The mortality rate in patients with two or more of these risk factors was 20%, nearly eight times higher (95% Cl, 3.6 to 16) than those with one or no risk factors. An additional 82 patients died within the next 2 years; cancer, renal dysfunction, congestive heart failure, and obstructive pulmonary disease were independently associated with long-term mortality.

Conclusions.
—Even in patients at high risk of cardiac complications following surgery, noncardiac causes of death are more common. Patients with a history of hypertension, severely limited activity, and reduced renal function appear to be at especially high risk of in-hospital mortality after noncardiac surgery.

(JAMA. 1992;268:228-232)

Author Affiliations
From the Departments of Medicine (Dr Browner), Anesthesia (Drs Browner, Li, and Mangano), Epidemiology and Biostatistics (Dr Browner), and Surgery, Veterans Affairs Medical Center, 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 General Internal Medicine Section, Veterans Affairs Medical Center (111A1), San Francisco, CA 94121 (Dr Browner).

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