Abstract
Background
Acute myocardial infarction (AMI) is a major cardiovascular complication of non-cardiac surgery. We sought to evaluate the frequency, causes, and outcomes of 30-day hospital readmission after perioperative AMI.
Methods
Patients who were diagnosed with AMI during hospitalization for major non-cardiac surgery were identified using the 2014 United States Nationwide Readmission Database. Rates, causes, and costs of 30-day readmissions after non-cardiac surgery with and without perioperative AMI were identified.
Results
Among 3,807,357 hospitalizations for major non-cardiac surgery, 8,085 patients with perioperative AMI were identified. A total of 1,135 perioperative AMI patients (14.0%) died in-hospital during the index admission. Survivors of perioperative AMI were more likely to be readmitted within 30-days than surgical patients without perioperative AMI (19.1% versus 6.5%, p<0.001). The most common indications for 30-day rehospitalization were management of infectious complications (30.0%), cardiovascular complications (25.3%), and bleeding (10.4%). In-hospital mortality during hospital readmission in the first 30 days after perioperative AMI was 11.3%. At 6 months, the risk of death was 17.6% and ≥1 hospital readmission was 36.2%.
Conclusions
Among patients undergoing non-cardiac surgery who develop a perioperative MI, approximately 1 in 3 suffer from in-hospital death or hospital readmission in the first 30 days after discharge. Strategies to improve outcomes of surgical patients early after perioperative AMI are warranted.
Keywords: Acute Coronary Syndrome, Hospital readmission, Myocardial Infarction, Noncardiac Surgery, Perioperative, Readmission, Surgery
Introduction
Perioperative acute myocardial infarction (AMI) is a potentially devastating cardiovascular complication for millions of patients undergoing major non-cardiac surgery each year.1–4 Among patients at increased risk for cardiovascular complications, perioperative AMI can occur in up to 5.0% of major non-cardiac inpatient surgeries and is strongly associated with morbidity, longer lengths of stay, and in-hospital mortality.5–7 Outcomes of patients with perioperative AMI after hospital discharge are less certain. Hospital readmission is a frequently-cited quality metric after non-cardiac surgery and in cardiovascular disease patients, with significant implications to costs of care, patient quality of life, and major adverse outcomes.8 The objective of the present study was to evaluate rates of hospital readmission in patients with and without perioperative AMI, and to identify causes of re-hospitalization using a large administrative database of United States hospital admissions.
Methods
Study Population
Adults ≥18 years old undergoing major non-cardiac surgery in 2014 were identified from the United States (US) Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project’s (HCUP) Nationwide Readmission Database (NRD). The 2014 NRD is a national administrative database of discharge-level data from community hospitals in 22 states that collectively represent 51.2% of the US population and 49.3% of all US hospitalizations.9 Patients undergoing major non-cardiac surgery were included in the analysis if they had a principal International Classification of Diseases, Ninth Revision (ICD-9) procedure code for a major therapeutic operating room procedure (HCUP Procedure Class 4) during the index hospital admission, as previously described.5 Principal Clinical Classifications Software (CCS) procedure codes, AHRQ-defined groups of related ICD-9 procedure codes, were used to identify cases by surgical subtype. Patients who underwent cardiac procedures, cardiac surgery and transplantation, bone marrow transplantation, ophthalmologic surgery, radiation therapy, dental surgery, and non-operating room procedures were excluded from the analysis. Major non-cardiac surgery CCS procedure codes were clustered into 9 major surgical subtypes: general, genitourinary, neurosurgery, orthopedic, otolaryngology, skin and breast, thoracic, vascular surgery, and other non-cardiac surgeries not classified elsewhere. Patients with perioperative AMI were identified using ICD-9 diagnosis codes for acute ST-segment elevation myocardial infarction (STEMI) (410.01 to 410.61, 410.81, and 410.91) and non-ST-segment elevation myocardial infarction (NSTEMI) (410.71).
The primary study outcome was 30-day hospital readmission. Patients who underwent major non-cardiac surgery and were discharged in December 2014 (n=354,953) were excluded from the analysis due to incomplete follow-up data from the calendar-year files. For patients with >1 perioperative AMI, only the first surgical hospitalization with perioperative AMI was included in the final analysis. In the cohort of patients without any perioperative AMI who underwent multiple surgeries, only the first hospitalization for surgery in the calendar year was included in the final analysis.
Patient Characteristics, Hospital Readmission & Outcomes
We included patient demographics and relevant comorbidities during the index hospitalization as defined by ICD-9 diagnosis codes. Thirty-day hospital readmissions were determined based on methodology outlined by HCUP.10 Among patients with multiple readmissions within 30-days, only the first readmission was included for analysis.
Primary ICD-9 diagnosis codes were used to determine the indication for hospital readmission and were clustered into the following clinically relevant categories: bleeding, cardiovascular disorders, endocrine disorders, gastrointestinal disorders, infectious complications, malignancy, metabolic disorders, musculoskeletal disorders, neurologic disorders, peripheral vascular disease, pulmonary disorders, renal disorders, wound or device complications, and other complications not classified elsewhere. Hospital length of stay, total costs, and in-hospital mortality were also evaluated. Health care costs were derived according to HCUP guidance by multiplying the total charge for each admission by the cost-to-charge ratios reported for each hospital.
Statistical Analysis
Continuous variables were reported as mean ± standard deviation (SD) and compared using the Student’s t test. Categorical variables were reported as percentages and compared by Chi-square tests. Multivariable logistic regression models were generated to estimate odds ratios adjusted for patient demographics, cardiovascular risk factors, and comorbidities. Models included age, sex, race/ethnicity, obesity, tobacco use, hypertension, hyperlipidemia, diabetes mellitus, chronic kidney disease, end stage renal disease, coronary artery disease, prior revascularization with either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), peripheral arterial disease, congestive heart failure, valvular heart disease, prior venous thromboembolism, chronic lung disease, malignancy, anemia, alcohol abuse, elective/urgent hospitalization, surgery type and year of hospitalization as covariates for adjustment. A sensitivity analysis of perioperative AMI patients who were discharged from the index hospitalization in January through June 2014 was also performed to determine 180-day hospital readmission. To exclude cases in which AMI may have preceded non-cardiac surgery, sensitivity analyses were performed after excluding patients who were urgently or emergently hospitalized for their index surgery, and in a cohort of patients who underwent the index non-cardiac surgery within the first 48 hours of hospital presentation.
Sampling weights were applied to determine national incidence estimates according to HCUP guidance.11 Statistical analyses were performed using SPSS 20 (IBM SPSS Statistics, Armonk, NY). Statistical tests are two-sided and P-values <0.05 were considered to be statistically significant. The NRD is a publicly available, de-identified dataset, and the study was exempt from institutional board review. The data, analytic methods, and study materials will not be made available to other researchers for purposes of reproducing the results or replicating the procedure.
Results
Study Population
Among the 29,699,157 adult hospitalizations recorded in the 2014 NRD, there were 4,162,310 hospitalizations for major non-cardiac surgery; after excluding discharges in December 2014, a total of 3,807,357 surgical hospitalizations met study inclusion criteria. Perioperative AMI occurred in 8,100 hospitalizations for surgery (0.2%), with 8,085 unique patients identified. Among 3,799,257 surgical hospitalizations without AMI, 3,653,144 unique patients were identified. Baseline characteristics of patients with and without perioperative AMI are shown in Table 1. Patients with AMI were older, more likely to be male, and had a greater burden of conventional risk factors for CAD. Among patients with perioperative AMI, STEMI occurred in 1,501 (18.6%) and NSTEMI in 6,584 (81.4%). Coronary revascularization was performed in 15.8% of patients with perioperative AMI (12.5% of NSTEMI and 30.4% of STEMI). During the index hospitalization, mortality was higher in patients undergoing non-cardiac surgery with perioperative AMI in comparison to patients without perioperative AMI (14.0% vs. 0.3%, p<0.001). Among patients with perioperative AMI, mortality was higher in patients with STEMI in comparison to NSTEMI (28.6% vs. 10.7%, p<0.001). Total hospital costs during the index surgical admission were higher among patients with perioperative AMI in comparison to those without perioperative AMI ($28,874 [Interquartile Range (IQR) $17,388 - $65,906] vs. $11,052 [IQR $6,878 - $16,798], p<0.001).
Table 1.
Baseline characteristics of patients undergoing major non-cardiac surgery with and without perioperative acute myocardial infarction.
| Perioperative AMI (n=8,085) |
No Perioperative AMI (n=3,653,144) |
|
|---|---|---|
| Age | 73.0 ± 12.9 | 53.2 ± 19.2 |
| Female Sex | 3809 (47.1%) | 2422127 (66.3%) |
| Primary Payer | ||
| Medicare | 6158 (76.2%) | 1295437 (35.5%) |
| Medicaid | 494 (6.1%) | 599752 (16.4%) |
| Private insurance | 1073 (13.3%) | 1473608 (40.3%) |
| Self-pay | 157 (1.9%) | 106639 (2.9%) |
| No charge | 16 (0.2%) | 17038 (0.5%) |
| Other | 160 (2%) | 152901 (4.2%) |
| No Data | 26 (0.3%) | 7769 (0.2%) |
| Comorbidities | ||
| Obesity | 1038 (12.8%) | 608636 (16.7%) |
| Tobacco (Current or Former) | 2301 (28.5%) | 813266 (22.3%) |
| Hypertension | 5700 (70.5%) | 1524962 (41.7%) |
| Hyperlipidemia | 3679 (45.5%) | 902900 (24.7%) |
| Diabetes Mellitus | 2870 (35.5%) | 600420 (16.4%) |
| Chronic Kidney Disease | 2327 (28.8%) | 197027 (5.4%) |
| End Stage Renal Disease | 440 (5.4%) | 22471 (0.6%) |
| Coronary Artery Disease | 4311 (53.3%) | 339440 (9.3%) |
| Prior PCI | 852 (10.5%) | 93445 (2.6%) |
| Prior CABG | 869 (10.7%) | 81142 (2.2%) |
| Peripheral Artery Disease | 1664 (20.6%) | 123991 (3.4%) |
| History of TIA/Stroke | 560 (6.9%) | 100913 (2.8%) |
| History of Heart Failure | 2400 (29.7%) | 109089 (3.0%) |
| History of Venous | ||
| Thromboembolism | 252 (3.1%) | 76492 (2.1%) |
| Chronic Pulmonary disease | 1820 (22.5%) | 477703 (13.1%) |
| Alcohol Abuse | 272 (3.4%) | 69661 (1.9%) |
| Malignancy | 557 (6.9%) | 113976 (3.1%) |
| Anemia | 2043 (25.3%) | 442537 (12.1%) |
| Elective Surgical Admission | 2006 (24.8%) | 2203440 (60.3%) |
| Surgery Type | ||
| General | 1706 (21.1%) | 837215 (22.9%) |
| Genitourinary | 448 (5.5%) | 174314 (4.8%) |
| Neurosurgery | 297 (3.7%) | 201025 (5.5%) |
| Orthopedic | 3227 (39.9%) | 1320320 (36.1%) |
| Otolaryngology | 80 (1.0%) | 33699 (0.9%) |
| Skin/Breast | 411 (5.1%) | 126763 (3.5%) |
| Thoracic | 299 (3.7%) | 28168 (0.8%) |
| Vascular | 1548 (19.1%) | 103965 (2.8%) |
| Other | 70 (0.9%) | 827677 (22.7%) |
| Hospital Characteristics | ||
| Hospital Bed Size | ||
| Small | 947 (11.7%) | 607076 (16.6%) |
| Medium | 1961 (24.3%) | 1004294 (27.5%) |
| Large | 5180 (64.0%) | 2041774 (55.9%) |
| Control/ownership of hospital | ||
| Government, nonfederal | 993 (12.3%) | 440415 (12.1%) |
| Private, not-profit | 6142 (76.0%) | 2703077 (74%) |
| Private, invest-own | 951 (11.8%) | 509653 (14%) |
| Hospital urban-rural designation | ||
| Large metropolitan areas | 4043 (50.0%) | 1992615 (54.5%) |
| Small metropolitan areas | 3323 (41.1%) | 1354739 (37.1%) |
| Micropolitan areas | 613 (7.6%) | 239756 (6.6%) |
| Rural | 106 (1.3%) | 66035 (1.8%) |
| Index Length of Stay | 9 days (IQR 6 - 19) | 3 days (IQR 2 - 4) |
| Index Total Charges | $28,874 (IQR $17,388 - $65,906) |
$11,052 (IQR $6,878 - $16,798) |
All P-values for comparison <0.001
Incidence, Causes, and Outcomes of 30-Day Hospital Readmission
The overall incidence of 30-day hospital readmission among survivors of perioperative AMI was 19.1% (1,324 readmissions) as compared to 6.5% (237,804 readmissions) among patients undergoing non-cardiac surgery without perioperative AMI (p<0.001; adjusted OR [aOR] 1.39 95% CI 1.31-1.48). Similar findings were observed after excluding patients who were urgently or emergently hospitalized for their index surgery or underwent the index non-cardiac surgery within the first 48 hours of hospital presentation (Supplemental Table 1). No difference in the frequency of hospital readmission was observed between survivors of perioperative STEMI and NSTEMI (20.0% vs. 18.9%, p=0.42). Among patients readmitted within 30-days, the median time to hospitalization after perioperative AMI was 15 days (IQR 9 – 22 days), as compared to 10 days (IQR 5 – 18 days) among surgical patients without AMI during the index hospitalization (p<0.001). Recurrent AMI during readmission were more common among patients with a prior perioperative AMI in comparison to those without recent perioperative AMI (10.9% versus 1.5%, p<0.001). Patients with recent perioperative AMI were less likely to undergo a second major non-cardiac surgery during hospital readmission than patients without perioperative AMI (6.7% versus 14.2%, p<0.001).
The most common indications for 30-day hospital readmission were management of infectious complications (30.0%), cardiovascular complications (25.3%), and bleeding complications (10.4%) among patients with perioperative AMI during the index surgical admission, and infectious complications (30.6%), gastrointestinal complications (12.0%), and cardiovascular complications (8.2%) among patients without perioperative AMI (Table 2). The most common primary ICD-9 diagnoses for 30-day hospital readmission in patients with recent perioperative AMI were septicemia in 11.2%, acute non-ST segment myocardial infarction in 5.1%, postoperative infection in 4.1%, acute kidney failure in 2.8%, acute on chronic systolic heart failure in 2.7%, acute on chronic diastolic heart failure in 2.6%, and pneumonia in 2.5% (see Supplemental Table 2 for specific ICD-9 codes). A diagnosis code for an acute cardiovascular complication was present in a non-primary position in 15.5% of patients readmitted with a non-cardiovascular primary diagnosis, including 17.9% of admissions for infectious complications, 11.1% of admissions for bleeding complications, and 9.2% of admissions for infectious complications. Among patients without perioperative AMI during their index surgical admission, the most common primary ICD-9 diagnoses for 30-day hospital readmission were postoperative infection in 9%, septicemia in 4.6%, digestive system complications in 2.9%, and acute kidney failure in 2% of patients without perioperative AMI.
Table 2.
Common Indications for 30-day hospital readmission among patients with and without perioperative AMI.
| Perioperative AMI during Index Surgical Hospitalization | No Perioperative AMI during Index Surgical Hospitalization |
|---|---|
| Infectious Complications (30.0%) | Infectious Complications (30.6%) |
| Cardiovascular Complications (25.3%) | Gastrointestinal Complications (12.0%) |
| Bleeding Complications (10.4%) | Cardiovascular Complications (8.2%) |
| Gastrointestinal Complications (5.6%) | Wound/Device Complication (6.9%) |
| Pulmonary Complications (5.0%) | Bleeding Complications (5.7%) |
| Renal Complications (4.4%) | Neurologic Complications (5.6%) |
| Other Complications (19.3%) | Musculoskeletal Complications (4.5%) |
| Renal Complications (3.6%) | |
| Other Complications (22.9%) |
Median length of stay during readmission was 5 days (IQR 3 – 8) among patients with perioperative AMI in comparison to 4 days (IQR 2 – 7) among patients without perioperative AMI (p<0.001). The median cost of hospital readmission within 30 days following perioperative AMI was $9,893 (IQR $5,712 - $17,398) in comparison to $8,083 (IQR $4,659 - $14,834) for readmissions among patients without recent perioperative AMI (p<0.001). Among patients who were readmitted within 30 days, 11.3% (150 patients) with a recent perioperative AMI died in-hospital during their first hospital readmission in comparison to 2.5% (5,867 patients) without recent perioperative AMI (p<0.001). Among the 150 patients with perioperative AMI who died during 30-day hospital readmission, infectious complications (51.6%), cardiovascular complications (17.2%), and pulmonary complications (9.6%) were the most common indications for hospitalization. Overall, 30-day in-hospital mortality (death during the index admission or during first hospital readmission within 30 days) was higher among patients with recent perioperative AMI in comparison to patients without perioperative AMI (15.9% versus 0.5%, p<0.001). Among patients with AMI, those with perioperative STEMI had a higher frequency of 30-day in-hospital mortality than patients with perioperative NSTEMI (29.6% vs. 12.8%, p<0.001).
Surgery-Specific Risks Associated with Perioperative AMI
Risks of death and 30-day readmission after perioperative AMI varied by the subtype of non-cardiac surgery performed during the index hospitalization (Figure 1). Risk of death during the index admission was highest among patients with AMI complicating thoracic (28.4%), general (20.3%), vascular surgery (15.3%) and neurosurgery (12.5%). Among patients with perioperative AMI who survived to discharge during the index hospitalization, 30-day readmission was common among all surgical subtypes (Figure 1). Thirty-day in-hospital mortality (death during the index admission or during first hospital readmission within 30 days) was highest among AMI patients undergoing thoracic (30.9%), general (22.4%), vascular surgery (17.2%) and neurosurgery (13.9%).
Figure 1.
Surgery specific risks for in-hospital death during the index hospitalization or 30-day hospital readmission among patients with perioperative AMI
180-Day Follow-Up
In a sensitivity analysis of patients with perioperative AMI who were discharged from the index surgical hospitalization from January through June 2014 with 180-day follow up data available (n=4,305), 637 patients died in-hospital (14.8%) and 1,557 survivors (42.4%) were readmitted within 6 months of follow up. Of those readmitted, an additional 122 patients (7.8%) died during the hospital readmission. The 180-day in-hospital mortality (death during the index admission or during first hospital readmission within 180 days) was 17.6%.
Discussion
In a large national readmission database of adults admitted for major non-cardiac surgery, nearly one-third of patients identified as having perioperative AMI died during the index hospitalization or were readmitted within 30 days of discharge, and half of patients died or were readmitted by 6 months. Among the 19% of patients who survived to discharge and had a hospital readmission within 30 days, infectious, cardiovascular, and bleeding complications were the most common primary diagnoses associated with hospital readmission. This is the first report to explore 30-day hospital readmissions in patients with perioperative AMI after non-cardiac surgery in the United States.
Despite recent declines in the incidence of perioperative AMI in high-risk patients, cardiovascular events continue to be a major source of morbidity and mortality after non-cardiac surgery.5 Analyses of the large American College of Surgeons National Surgical Quality Improvement Program previously identified associations between in-hospital cardiovascular complications and unplanned readmissions post-discharge, even when controlling for baseline patient risk and surgical complexity.8, 12 However, these analyses did not provide data on hospital readmission among patients with perioperative MI. In the present study, survivors of perioperative AMI had significantly higher 30-day rates of readmission than surgical patients without perioperative AMI, after adjustment for demographics, surgical subtype, and cardiovascular risk factors. Nearly 1 in every 3 patients with perioperative AMI died or required hospital readmission within 30 days, with a higher risk observed in patients with perioperative STEMI in comparison to NSTEMI. Among patients who survived the surgical hospitalization and were readmitted within 30 days, 1 in every 4 presented with another cardiovascular complication, and 11% of these patients had a recurrent AMI. In addition to recurrent cardiovascular complications associated with AMI, prolonged length of stay during the index hospitalization after AMI can lead to other hospital-acquired complications of surgery, including hospital-acquired infections, venous thromboembolism, and physical deconditioning. These factors may exacerbate adverse outcomes in this population and substantially increase risks of hospital readmission.
Reductions in readmissions after AMI and surgery have become major goals for both payers and providers in the US. In 2012, the US Centers for Medicare and Medicaid (CMS) launched the Hospital Readmission Reduction Program (HRRP), a program to reduce payments to hospitals with excess hospital readmissions. The HRRP has already demonstrated beneficial changes in clinical practice, with declines in readmissions in medical and surgical target and non-target conditions at hospitals subjected to penalties.13, 14 Despite these early successes, hospital readmissions in patients with perioperative AMI in the setting of non-cardiac surgery continue to burden the healthcare system, and additional efforts to improve outcomes in this high-risk population are necessary.
Unfortunately, the optimal prevention and management of patients with perioperative AMI remains uncertain, and medical interventions or systems of care to reduce death and hospital readmissions in this population have not been established.15 Complicating matters, perioperative AMI can represent either type 1 myocardial infarction (AMI due to unstable CAD and plaque rupture) or type 2 myocardial infarction (AMI due to mismatch in myocardial oxygen supply and demand that occurs in the absence of unstable CAD). Although both AMI subtypes are associated with adverse outcomes, optimal treatment may differ.16 Current clinical practice guidelines recommend management of perioperative AMI according to guidelines for the general population, but with ‘modifications based on the severity of NSTE-ACS and the limitations imposed by the noncardiac surgical procedure’.17 Increased prescribing of guideline-directed medical therapy (GDMT) for atherosclerotic cardiovascular disease and appropriate referral for invasive management of AMI may further reduce cardiovascular risks in this complex patient population.
Study Limitations
There are a few limitations of this analysis. First, NRD data are derived from diagnosis codes recorded in state administrative databases and are subject to errors in coding and/or reporting bias. Large numbers of relatively low-risk patients may contribute to the lower incidence of perioperative AMI observed in the NRD in comparison to other studies that restricted analyses to the highest-risk subgroups. The diagnosis of perioperative AMI may be under-reported or missed entirely. Many perioperative AMIs are clinically silent and may not be recognized by treating physicians without routine ECG and/or biomarker screening.18 In prior analyses, up to two-thirds of perioperative AMI can occur without overt ischemic symptoms.19 Even in the absence of overt AMI, “silent” perioperative elevations in troponin are associated with increased post-operative 30-day and long-term mortality.18–20 Providers in certain surgical subspecialties may be less inclined to measure serum biomarkers in the post-operative period, and rates of postoperative AMI diagnosis may vary based on the frequency of cardiac biomarker measurement. As results of perioperative laboratory testing were not available in this administrative dataset, the frequency of cardiac biomarker measurement in this cohort is unknown. As a consequence, readmission rates are uncertain for patients who developed myocardial injury after non-cardiac surgery without overt AMI. Furthermore, contemporary clinical practice guidelines recommend against routine postoperative troponin screening following non-cardiac surgery, and therefore silent AMI are likely to be routinely missed in clinical practice.15 Still, our findings are consistent with high-risk subsets of patients enrolled in prior prospective studies. Among patients who developed myocardial injury after noncardiac surgery with an ischemic feature consistent with AMI in the Vascular Events In Noncardiac Surgery Patients Cohort Evaluations (VISION) study, 30-day mortality rate was 13.5%;19–21 in this analysis, in-hospital mortality was 14%. Thus, our findings are consistent with the high-risk subset of patients enrolled in VISION and reflect the outcomes of a large, real-world, high-risk population of patients diagnosed with perioperative AMI.
Second, discrete clinical data, including the results of diagnostic coronary angiography and measurement of left ventricular function, were not captured in this administrative dataset. Differentiation of type 1 and type 2 AMI subtypes was not possible due to limitations of ICD-9 coding. However, only 16% of patients with AMI underwent coronary revascularization in this cohort, suggesting many cases may have been due to type 2 AMI. Third, in-hospital or discharge medications were not available for review and could not be determined. Fourth, the sequence of non-cardiac surgery preceding AMI cannot be confirmed in this administrative database. However, non-cardiac surgery is contraindicated early after AMI, and patients admitted to the hospital for AMI would be unlikely to undergo major non-cardiac surgery during the same hospital admission. Fifth, although in-hospital deaths within 30-days were identified from this in-hospital dataset, out-of-hospital mortality following perioperative AMI could not be determined. Due to limitations of calendar-year datasets, longer-term rates of hospital readmission could not be determined within the full cohort. The risk of readmission after AMI is highest immediately after hospital discharge,22 although prior studies suggest that perioperative myocardial injury and AMI are associated with long-term mortality in addition to the short-term risks of death and rehospitalization.23
Conclusions
Among patients undergoing non-cardiac surgery with a perioperative MI, approximately 1 in 7 patients died and 1 in 5 were readmitted within the first 30 days after discharge. Two thirds of hospital readmissions occurred due to infectious, cardiovascular, or bleeding complications. By 6 months, half of patients with a perioperative MI died or were re-hospitalized at least once. Strategies to improve outcomes of surgical patients early after perioperative AMI are warranted.
Supplementary Material
Clinical Perspectives.
What is New?
Perioperative acute myocardial infarction (AMI) after non-cardiac surgery is associated with high in-hospital mortality and a 19% risk of 30-day hospital readmission among survivors.
The majority of hospitalizations after perioperative AMI are due to infectious, cardiovascular, or bleeding complications.
Recurrent AMI occurs in 11% of patients rehospitalized after perioperative AMI.
At 6 months after perioperative AMI, 36.2% of patients were re-hospitalized and the overall risk of in-hospital death (during the index admission or first re-hospitalization) was 17.6%.
What are the clinical implications?
AMI is a major cardiovascular complication of non-cardiac surgery.
Hospital readmissions and mortality among perioperative AMI patients pose a significant burden to the healthcare system.
Strategies to improve outcomes of surgical patients early after perioperative AMI are warranted.
Acknowledgments
Sponsor/Funding: Dr. Smilowitz was supported by the NIH National Heart, Lung, and Blood Institute under award T32HL098129.
Abbreviations
- AMI
Acute Myocardial Infarction
- CCS
Clinical Classifications Software
- CABG
Coronary Artery Bypass Grafting
- HCUP
Healthcare Cost and Utilization Project’s
- NRD
Nationwide Readmission Database
- PCI
Percutaneous Coronary Intervention
Footnotes
Conflict of Interest Disclosures: None.
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