A Study On The Significance Of Transthoracic Echocardiography Before Non-cardiac Surgery In Elderly Patients With Coronary Heart Disease

Background:Perioperative major adverse cardiac event(MACE)in noncardiac surgeries is associated with marked increase in morbidity and mortality in elderly patients with history of coronary heart disease(CHD).Previous studies have revealed that age and previous CHD are independent risk factors for MACE in noncardiac surgery.Elderly patients with CHD history are more prone to experience MACE in noncardiac surgery,due to the coexistence of both risk factors.Thoroughly evaluating the cardiac risk of the population preoperatively is of crucial importance,since it not only assists in clinical decision-making,but also in perioperative management.Currently,the Revised Cardiac Risk Index(RCRI)is the most widely adopted assessing tool of perioperative MACE.However,the predictive value of RCRI has been increasingly questioned.Preoperative transthoracic echocardiography(TTE),as a widely applied cardiac function assessment,has been a routine examination for elderly patients with CHD in many hospitals.Currently,the predictive value of preoperative TTE in assessing perioperative MACE in in noncardiac surgeries has not been reported in elderly patients with CHD.Objective:In this study,the clinical medical records of elderly patients with CHD undergoing noncardiac surgery during hospitalization in Peking Union Medical College Hospital(PUMCH)were reviewed,and three prediction models based on clinical variables,TTE variables and selected clinical+TTE variables models were constructed.Predictive values of three models were analyzed.Methods:A retrospective cohort study were conducted to screen eligible elderly patients with CHD undergoing noncardiac surgery in PUMCH.Perioperative data were recorded in a unified case report form(CRF).The primary end point of the study was MACE,and participants were divided into MACE group and non-MACE group according to whether the end point occured.Clinical variables and TTE parameters were adopted in the binary Logistic regression model to construct prediction models.Cut-off was set as P<0.05.Eligible variables and TTE variables were then combined as a clinical+TTE prediction model in the binary Logistic regression analysis.The ROC of the above prediction models and RCRI score were calculated to compare the the predictive values for perioperative MACE.Results:MACE occurred in 179 patients(8.5%)during the perioperative period.159(88.8%)patients experienced MACE within 3 days after surgery.Of the three predictive models,the clinical+TTE variables model showed the highest predictive value for perioperative MACE(AUC=0.697,95%CI:0.655?0.740,P<0.001),followed by the clinical variables model(AUC=0.686,95%CI:0.643?0.729,P<0.001).However,TTE variables model based solely on TTE parameters exhibited insufficient predictive value(AUC=0.625,95%CI:0.579?0.671,P<0.001).Specially,RCRI,as the most validated predictive model exhibited poor value in this study(AUC=0.526,95%CI:0.481?0.570,P=0.258).Conclusions:Elderly patients with CHD undergoing noncardiac surgery are at high risks for perioperative MACE.Among the three prediction models constructed in this study,the clinical+TTE variables model exhibited better than clinical variables model.The predictive value of clinical variables model was superior to TTE variables model based solely on TTE parameters.RCRI,as the most widely validated prediction model,it exhibited poorly in this study.The predictive value of TTE variables model exhibited inadequate in this study.We could hardly evaluate the cardiac function and accurately predict the occurrence of perioperative MACE by simply relying on it.Combined with the corresponding high-risk clinical factors,the predictive value was improved but still lacked of significant advantage.The preoperative TTE could be performed in elderly patients with CHD who were unable to assess their physical activity tolerance or lack of detailed medical history.