The main reasons why people die after non-cardiac surgery are revealed in a study of more than 40,000 patients from six continents presented in a late breaking science session at ESC Congress 2018. Myocardial injury, major bleeding, and sepsis contributed to nearly three-quarters of all deaths.

“There’s a false assumption among patients that once you’ve undergone surgery, you’ve ‘made it’,” said study author Dr Jessica Spence, of the Population Health Research Institute (PHRI), a joint institute of Hamilton Health Sciences (HHS) and McMaster University, Hamilton, Canada. “Unfortunately, that’s not always the case, and now we have a much better sense of when and why people die after non-cardiac surgery. Most deaths are linked to cardiovascular causes.”

The VISION study included 40,004 patients aged 45 years or older undergoing non-cardiac surgery and remaining in hospital for at least one night. Patients were recruited from 27 centers in 14 countries in North and South America, Asia, Europe, Africa, and Australia, and monitored for complications until 30 days after their surgery.

The researchers found that 715 (1.8%) patients died within 30 days after non-cardiac surgery. Of those, 505 (71%) died in hospital (including four [0.6%] in the operating room), and 210 (29%) died after discharge from hospital. Dr. Spence said: “One in 56 patients died within 30 days of non-cardiac surgery and nearly all deaths occurred after leaving the operating room, with more than a quarter occurring after hospital discharge.”

Eight perioperative complications – including five cardiovascular – were associated with death within 30 days postoperatively. The top three complications, which contributed to nearly three-quarters of all deaths, were myocardial injury after non-cardiac surgery (MINS; 29%), major bleeding (25%), and sepsis (20%).

“We’re letting patients down in postoperative management,” said principal investigator Professor Philip J. Devereaux, director of cardiology at McMaster University. “The study suggests that most deaths after non-cardiac surgery are due to cardiovascular causes, so cardiologists have a major role to play to improve patient safety. This includes conducting blood and imaging tests to identify patients at risk then giving preventive treatment, including medications that prevent abnormal heart rhythms, lower blood pressure and cholesterol, and prevent blood clots.”

Earlier findings from the VISION study showed that a simple blood test can identify MINS, enabling clinicians to intervene early and prevent further complications. (3) The blood test measures a protein called high-sensitivity troponin T which is released into the bloodstream when injury to the heart occurs.

Regarding cardiovascular complications, MINS occurred in 5,191 (13%) patients and independently increased the risk of 30-day mortality by 2.6-fold; major bleeding occurred in 6,238 (16%) patients and increased risk by 2.4-fold; 372 (0.9%) patients had congestive heart failure, which raised risk by 1.6-fold; 152 (0.4%) patients had deep venous thrombosis which raised risk by 2.1-fold; and 132 (0.3%) patients had a stroke, which increased risk by a factor of 1.6.

Regarding non-cardiovascular complications associated with 30-day mortality, sepsis occurred in 1,783 (4.5%) patients and independently increased risk by 5.7-fold; infection occurred in 2,171 (5.4%) patients and raised risk by 1.9-fold; and 118 patients (0.3%) had acute kidney injury resulting in new dialysis, which increased risk by 4.7-fold.

“Combined, these discoveries tell us that we need to become more involved in care and monitoring after surgery to ensure that patients at risk have the best chance for a good recovery,” said Dr Spence, who is also an anesthesiologist at HHS and a PhD candidate at McMaster University.

SOURCES OF FUNDING: 

Roche Diagnostics provided the troponin T assays as well as financial support for the VISION Study. Funding for this study came from more than 60 grants for VISION and its sub studies.

Australia: National Health and Medical Research Council Program.

Brazil: Projeto Hospitais de Excelencia a Servico do SUS (PROADI-SUS) grant from the Brazilian Ministry of Health in partnership with Hcor (Cardiac Hospital Sao Paulo-SP); National Council for Scientific and Technological Development (CNPQ) grant from the Brazilian Ministry of Science and Technology. China: Public Policy Research Fund (grant CUHK-4002-PPR-3), Research Grant Council, Hong Kong SAR; General Research Fund (grant 461412). Research Grant Council, Hong Kong SAR: Australian and New Zealand College of Anaesthetists (grant 13/008).

Canada: Canadian Institutes of Health Research (7 grants); Heart and Stroke Foundation of Ontario (2 grants); Academic Health Science Centers Alternative Funding Plan Innovation Fund Ontario; Population Health Research Institute; CLARITY Research Group; McMaster University Department of Surgery Surgical Associates; Hamilton Health Science New Investigator Fund; Hamilton Health Sciences; Ontario Ministry of Resources and innovation; Stryker Canada; McMaster University, Department of Anesthesiology (2 grants); St. Joseph’s Healthcare, Department of Medicine (2 grants); Father Sean O’Sullivan Research Centre (2 grants); McMaster University Department of Medicine (2 grants); Roche Diagnostics Global Office (5 grants); Hamilton Health Sciences Summer Studentships (6 grants); McMaster University Department of Clinical Epidemiology and Biostatistics; McMaster University, Division of Cardiology; Canadian Network and Centre for Trials Internationally: Winnipeg Health Sciences Foundation; University of Manitoba Department of Surgery (2 grants); Diagnostic Services of Manitoba Research; Manitoba Medical Services Foundation; Manitoba Health Research Council; University of Manitoba Faculty of Dentistry Operational Fund; University of Manitoba Department of Anesthesia; University Medical Group, Department of Surgery, University of Manitoba, Start-up Fund.

Colombia: School of Nursing, Universida Industrial de Santander; Grupo de Cardiologia Preventiva, Universidad Autonoma de Bucaramanga: Fundacion Cardioinfantil-Instituto de Cardiologia; Alianza Diagnostica SA.

France: Universite Pierre et Marie Curie. Department d’anesthsie Reanimation, Pitie-Salpetriere, Assistance Publique-Hopitaux de Paris.

India: St. John’s Medical College and Research Institute: Division of Clinical Research and Training.

Malaysia: University of Malaya (grant RG302-14AFR); University of Malaya, Penyelidikan Jangka Pendek.

Poland: Polish Ministry of Science and Higher Education (grant NN402083939).

South Africa: University of KwaZulu-Natal.

Spain: Instituto de Salud Carlos III; Fundacio La Marato de TV3. United States: America Heart Association; Covidien.

United Kingdom: National Institute for Health Research.