TY - JOUR
T1 - Predicting major adverse cardiac events in spine fusion patients
T2 - Is the revised cardiac risk index sufficient?
AU - Carabini, Louanne M.
AU - Zeeni, Carine
AU - Moreland, Natalie C.
AU - Gould, Robert W.
AU - Hemmer, Laura B.
AU - Bebawy, John F.
AU - Koski, Tyler R.
AU - McClendon, Jamal
AU - Koht, Antoun
AU - Gupta, Dhanesh K.
PY - 2014/8/1
Y1 - 2014/8/1
N2 - STUDY DESIGN.: Observational cohort study. OBJECTIVE.: To determine the accuracy of the Revised Cardiac Risk Index (RCRI) in predicting major adverse cardiac events in patients undergoing spine fusion surgery of 3 levels or more. SUMMARY OF BACKGROUND DATA.: Preoperative cardiac testing is extensively guided by the RCRI, which was developed and validated in thoracic, abdominal, and orthopedic surgical patients. Because multilevel spine fusion surgery is often associated with major transfusion, we hypothesize that the RCRI may not accurately characterize the risk of cardiovascular morbidity in these patients. METHODS.: After institutional review board approval, perioperative data were collected from 547 patients who underwent 3 or more levels of spinal fusion with instrumentation. Postoperative cardiac morbidity was defined as any combination of the following: arrhythmia requiring medical treatment, myocardial infarction (either by electrocardiographic changes or troponin elevation), or the occurrence of demand ischemia. The surgical complexity was categorized as anterior surgery only, posterior cervical and/or thoracic fusion, posterior lumbar fusion, or any surgery that included transpedicular osteotomies. Logistic regression analysis was performed to determine RCRI performance. RESULTS.: The RCRI performed no better than chance (area under the curve = 0.54) in identifying the 49 patients (9%) who experienced cardiac morbidity. CONCLUSION.: The RCRI did not predict cardiac morbidity in our patients undergoing major spine fusion surgery, despite being extensively validated in low-risk noncardiac surgical patients. Preoperative testing and optimization decisions, previously based on the RCRI, may need to be revised to include more frequent functional cardiac imaging and more aggressive implementation of pharmacologic modalities that may mitigate cardiac morbidity, similar to the preoperative evaluation for major vascular surgery.
AB - STUDY DESIGN.: Observational cohort study. OBJECTIVE.: To determine the accuracy of the Revised Cardiac Risk Index (RCRI) in predicting major adverse cardiac events in patients undergoing spine fusion surgery of 3 levels or more. SUMMARY OF BACKGROUND DATA.: Preoperative cardiac testing is extensively guided by the RCRI, which was developed and validated in thoracic, abdominal, and orthopedic surgical patients. Because multilevel spine fusion surgery is often associated with major transfusion, we hypothesize that the RCRI may not accurately characterize the risk of cardiovascular morbidity in these patients. METHODS.: After institutional review board approval, perioperative data were collected from 547 patients who underwent 3 or more levels of spinal fusion with instrumentation. Postoperative cardiac morbidity was defined as any combination of the following: arrhythmia requiring medical treatment, myocardial infarction (either by electrocardiographic changes or troponin elevation), or the occurrence of demand ischemia. The surgical complexity was categorized as anterior surgery only, posterior cervical and/or thoracic fusion, posterior lumbar fusion, or any surgery that included transpedicular osteotomies. Logistic regression analysis was performed to determine RCRI performance. RESULTS.: The RCRI performed no better than chance (area under the curve = 0.54) in identifying the 49 patients (9%) who experienced cardiac morbidity. CONCLUSION.: The RCRI did not predict cardiac morbidity in our patients undergoing major spine fusion surgery, despite being extensively validated in low-risk noncardiac surgical patients. Preoperative testing and optimization decisions, previously based on the RCRI, may need to be revised to include more frequent functional cardiac imaging and more aggressive implementation of pharmacologic modalities that may mitigate cardiac morbidity, similar to the preoperative evaluation for major vascular surgery.
KW - acute myocardial infarction
KW - acute myocardial ischemia
KW - cardiac events
KW - perioperative cardiac morbidity
KW - perioperative mortality
KW - preoperative assessment
KW - preoperative cardiac risk assessment
KW - preoperative cardiac testing
KW - preoperative risk
KW - spine fusion
KW - spine surgery
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U2 - 10.1097/BRS.0000000000000405
DO - 10.1097/BRS.0000000000000405
M3 - Article
C2 - 24825150
AN - SCOPUS:84905438168
SN - 0362-2436
VL - 39
SP - 1441
EP - 1448
JO - Spine
JF - Spine
IS - 17
ER -
