Eve E. Slater

Multifactorial Index of Cardiac Risk in Noncardiac Surgical Procedures

To determine which preoperative factors might affect the development of cardiac complications after major noncardiac operations, we prospectively studied 1001 patients over 40 years of age. By multivariate discriminant analysis, we identified nine independent significant correlates of life-threatening and fatal cardiac complications: preoperative third heart sound or jugular venous distention; myocardial infarction in the preceding six months; more than five premature ventricular contractions per minute documented at any time before operation; rhythm other than sinus or presence of premature atrial contractions on preoperative electrocardiogram; age over 70 years; intraperitoneal, intrathoracic or aortic operation; emergency operation; important valvular aortic stenosis; and poor general medical condition. Patients could be separated into four classes of significantly different risk. Ten of the 19 postoperative cardiac fatalities occurred in the 18 patients at highest risk. If validated by prospective application, the multifactorial index may allow preoperative estimation of cardiac risk independent of direct surgical risk.

Cardiac risk factors and complications in non-cardiac surgery.

In an attempt to assess cardiac risk in non-cardiac surgery, 1001 patients over 40 years of age who underwent major operative procedures were examined preoperatively, observed through surgery, studied with at least one postoperative electrocardiogram, and followed until hospital discharge or death. Documented postoperative myocardial infarction occurred in only 18 patients; though most of these patients had some pre-existing heart disease, there were few preoperative factors which were statistically correlated with postoperative infarction. Postoperative pulmonary edema was strongly correlated with preoperative heart failure, but 21 of the 36 patients who developed pulmonary edema did not have any prior history of heart failure. Nearly all of these 21 patients were elderly, had abnormal preoperative electrocardiograms, and had intraabdominal or intrathoracic surgery. In the absence of an acute infarction, bifascicular conduction defects, with or without PR interval prolongation, never progressed to complete heart block. Spinal anesthesia protected against postoperative heart failure but not against other cardiac complication. By multivariate regression analysis, postoperative cardiac death was significantly correlated with (a) myocardial infarction in the previous 6 months; (b) third heart sound or jugular venous distention immediately preoperatively; (c) more than five premature ventricular contractions per minute documented at any time preoperatively; (d) rhythm other than sinus, or premature atrial contractions on preoperative electrocardiogram; (e) age over 70 years; (f) significant valvular aortic stenosis; (g) emergency operation; (h) a 33% or greater fall in systolic blood pressure for more than 10 minutes intraoperatively. Notably unimportant factors included smoking, glucose intolerance, hyperlipidemia, hypertension, peripheral atherosclerotic vascular disease, angina, and distant myocardial infarction.

Long-term survival of patients with treated aortic dissection

Retrospective data on the treatment of aortic dissection at the Massachusetts General Hospital from 1963 to 1978 are reported. During this period, 160 patients with spontaneous aortic dissection were treated by definitive medical or definitive surgical therapy. Patients were classified according to type (proximal versus distal) and duration (acute versus chronic) of dissection. Long-term follow-up (mean 48 months, range 1 to 147) was available in 156 cases. Hospital and late survival in each of the categories of dissection were evaluated in relation to those features of the dissection itself and of the subsequent therapy that correlated with ultimate survival. Results show that: 1) chronic presentation was the most significant determinant of both hospital and late survival; 2) in acute dissection, prognosis was determined largely by the presence or absence of major complications, regardless of ultimate therapy; the only complication without adverse effect on survival was aortic insufficiency; 3) late survival after discharge from the hospital was similar for patients with all types of dissection and modes of therapy; and 4) the incidence of late complications from aortic dissection was lower than previously reported. Thus, the success of early definitive medical and surgical treatment was sustained on long-term follow-up.

Dissection of the Aorta

Our approach to management, both initial and definitive, is summarized in Table 2. Patients with proximal dissection require surgical intervention after medical stabilization, unless prior debilitating illness precludes general anesthesia or prolonged vascular surgery. If myocardial infarction or cerebrovascular accidents has complicated the dissection, results are extremely poor, regardless of therapy. Patients with distal dissection have a good prognosis with medical therapy alone, unless aortic rupture or impending rupture, hematoma progression despite a maximal drug program, vital organ compromise, or inability to control pain or blood pressure medically supervene. Dissecting aneurysm of the aorta, while potentially a promptly fatal event, is amenable to aggressive therapy provided that one is alert to the possibility of this disease. Despite all technical advances, the single most important factor in making the diagnosis of dissecting aortic aneurysm is a strong index of suspicion on the part of the physician.

Inactive Renin — Through a Glass Darkly

Many enzymes (e.g., pepsin) and endocrine hormones (e.g., insulin) are synthesized first in the form of an inactive zymogen, which is then subject to proteolytic cleavage before eventual secretion ...

Case 43-1978

Presentation of Case A 28-year-old man was admitted to the hospital because of hypertension. He was well until seven years previously, when mild hypertension was found; no treatment was prescribed....

Percutaneous transluminal angioplasty of the renal artery: a hypertensiologist's view.

Wide acceptance of PTRA also demands documentation of its long-term duration of effect. This has been well established for surgical procedures, and only time and further experience will establish this aspect of PTRA. Undoubtedly, restenosis will occur, but its incidence has yet to be established. The early experience of Schwarten and others suggests that redilatation may well be feasible and successful, but again this requires further documentation. It is imperative that further investigation of this potentially valuable technique be carried out as a cooperative effort involving the physician, surgeon, and angiographer. It is important that criteria for patient selection be established, probably similar to those utilized for selection of patients for surgery, and that the procedure not be haphazardly applied to any patient with a renal artery stenosis. Ideally, a randomized trial comparing PTRA and surgery could answer many questions, but may not be feasible in practical terms. Most important, this technique should only be carried out by those experienced with percutaneous transluminal angioplasty in other arterial beds; otherwise I suspect many more kidneys will be lost than hypertensive patients cured.