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An Observational Study

Carisi A. Polanczyk, MD,ScD; Luis E. Rohde, MD,ScD; Lee Goldman, MD,MPH; E. Francis Cook, ScD; Eric J. Thomas, MD; Edward R. Marcantonio, MD; Carol M. Mangione, MD; Thomas H. Lee, MD,MSc

JAMA. 2001;286:309-314.

Context  Right heart catheterization (RHC) is commonly performed before high-risk noncardiac surgery, but the benefit of this strategy remains unproven.

Objective  To evaluate the relationship between use of perioperative RHC and postoperative cardiac complication rates in patients undergoing major noncardiac surgery.

Design  Prospective, observational cohort study.

Setting  Tertiary care teaching hospital in the United States.

Patients  Patients (n = 4059 aged 50 years) who underwent major elective noncardiac procedures with an expected length of stay of 2 or more days between July 18, 1989, and February 28, 1994. Two hundred twenty one patients had RHC and 3838 did not.

Main Outcome Measure  Combined end point of major postoperative cardiac events, including myocardial infarction, unstable angina, cardiogenic pulmonary edema, ventricular fibrillation, documented ventricular tachycardia or primary cardiac arrest, and sustained complete heart block, classified by a reviewer blinded to preoperative data.

Results  Major cardiac events occurred in 171 patients (4.2%). Patients who underwent perioperative RHC had a 3-fold increase in incidence of major postoperative cardiac events (34 [15.4%] vs 137 [3.6%]; P<.001). In multivariate analyses, the adjusted odds ratios (ORs) for postoperative major cardiac and noncardiac events in patients undergoing RHC were 2.0 (95% confidence interval [CI], 1.3-3.2) and 2.1 (95% CI, 1.2-3.5), respectively. In a case-control analysis of a subset of 215 matched pairs of patients who did and did not undergo RHC, adjusted for propensity of RHC and type of procedure, patients who underwent perioperative RHC also had increased risk of postoperative congestive heart failure (OR, 2.9; 95% CI, 1.4-6.2) and major noncardiac events (OR, 2.2; 95% CI, 1.4-4.9).

Conclusions  No evidence was found of reduction in complication rates associated with use of perioperative RHC in this population. Because of the morbidity and the high costs associated with RHC, the impact of this intervention in perioperative care should be evaluated in randomized trials.

Author Affiliations: Section for Clinical Epidemiology, Division of General Medicine (Drs Polanczyk, Cook, Thomas, Marcantonio, and Lee), and Cardiovascular Division (Drs Polanczyk, Rohde, and Lee), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass; Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco (Dr Goldman); and Department of Medicine, University of California, Los Angeles, School of Medicine, Los Angeles (Dr Mangione).

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