THE INFLUENCE OF PERIOPERATIVE MYOCARDIAL-INFARCTION ON LONG-TERM PROGNOSIS FOLLOWING ELECTIVE VASCULAR-SURGERY

Study objective: The present study was performed to determine the infl uence of a perioperative myocardial infarction on long-term mortality in patients who have undergone elective vascular surgery. Study design : This was a 4-year follow-up of patients who had undergone elective v ascular procedures at a Veterans Affairs Medical Center. Between Janua ry 1989 and December 1990, 115 consecutive patients underwent surgery for either an expanding abdominal aortic aneurysm (AAA) (38%) or for p ain in the lower extremities (62%). Results: Vital status at 4 years p ostsurgery was determined for all patients. Thirty-day postoperative m ortality was 3%, while estimates at 1, 2, 3, and 4 years were 19%, 26% , 35%, and 39%, respectively. Of the 45 patients who died within 4 yea rs following surgery, the major causes of death were cardiac (40%), ca ncer (18%), cerebrovascular (13%), and peripheral vascular disease (11 %). Univariate predictors of 1-year mortality on preoperative evaluati on were an abnormal ECG, moderate or greater sized exercise thallium d efect and left ventricular ejection fraction less than or equal to 40% , and a perioperative myocardial infarction. Univariate predictors of 4-year mortality were non-AAA surgery and diabetes mellitus. Periopera tive myocardial infarction was a marginally significant independent pr edictor of 1-year mortality (p=0.06), while the need for non-AAA surge ry was a strong independent predictor at 4 years. Conclusions: Cardiac mortality is the major cause of late death among patients undergoing elective vascular surgery. Although preoperative indicators of symptom atic coronary artery disease and nonfatal perioperative myocardial inf arction identified those individuals at increased mortality in the fir st postoperative year, the extent of vascular disease at presentation may be a more important determinant of long-term survival. A randomize d trial in such patients is needed to assess the best strategy for tre ating patients with coexistent coronary artery and vascular diseases.