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Heart rate variables in the Vascular Quality Initiative are not reliable predictors of adverse cardiac outcomes or mortality after major elective vascular.

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Presentation on theme: "Heart rate variables in the Vascular Quality Initiative are not reliable predictors of adverse cardiac outcomes or mortality after major elective vascular."— Presentation transcript:

1 Heart rate variables in the Vascular Quality Initiative are not reliable predictors of adverse cardiac outcomes or mortality after major elective vascular surgery  Salvatore Scali, MD, Daniel Bertges, MD, Daniel Neal, MS, Virendra Patel, MD, MPH, Jens Eldrup-Jorgensen, MD, Jack Cronenwett, MD, Adam Beck, MD  Journal of Vascular Surgery  Volume 62, Issue 3, Pages e9 (September 2015) DOI: /j.jvs Copyright © 2015 Society for Vascular Surgery Terms and Conditions

2 Fig 1 This bar graph demonstrates the nonrisk-adjusted major adverse cardiac event (MACE) rates as a function of arrival heart rate (AHR) group comparisons. Patients undergoing lower extremity bypass (LEB, A), aortofemoral bypass (AFB, B), or open abdominal aortic aneurysm (AAA) repair (C) are represented. “Controlled” (operating room AHR ≤75 beats/min) and uncontrolled heart rate (HR) cohorts were compared within each of the three index procedures. No significant differences in the rates of the composite MACE outcome are noted. Acute (meaning 0 to 30 days preoperatively) and chronic (>30 days preoperatively) beta-blocker exposure was also analyzed, and no significant intergroup differences were observed. Journal of Vascular Surgery  , e9DOI: ( /j.jvs ) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

3 Fig 2 The highest intraoperative heart rate (HR) minus the operating room arrival heart rate (AHR) was taken as a surrogate for HR variability. In analyzing major adverse cardiac event (MACE) rates among lower extremity bypass (LEB) patients (A), those exposed to beta-blockers or the low, medium, and high cardiac risk groups had no significant pattern of association with the MACE or 30-day outcomes. For aortofemoral bypass (AFB) patients (B), no discernible pattern of association is observed. The parabolic relationship in the highest cardiac risk group is explained by low numbers of patients (which is why octiles of HR variability were used instead of decile) and an unexpectedly low event rate in the lowest two octiles of HR variability. Similar to the infrainguinal bypass patients, the open abdominal aortic aneurysm (AAA) subjects (C) had no reliable correlation of MACE rate to cardiac risk or beta-blocker exposure status. This same analysis was repeated for 30-day mortality (data not shown), and no correlation to outcome was observed. Journal of Vascular Surgery  , e9DOI: ( /j.jvs ) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

4 Fig 3 This forest plot demonstrates the odds for development of a postoperative major adverse cardiac event (MACE) or 30-day mortality as a function of arrival heart rate (AHR) and beta-blocker exposure history or cardiac risk for lower extremity bypass (LEB) patients. Note that all confidence intervals (CIs) span 1, indicating no significant association with the observed outcome. HR, Heart rate. Journal of Vascular Surgery  , e9DOI: ( /j.jvs ) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

5 Fig 4 Patients undergoing aortofemoral bypass (AFB) have no discernible pattern of risk association to a major adverse cardiac event (MACE) or 30-day mortality when they are substratified by arrival heart rate (AHR), beta-blocker exposure, and cardiac risk status. The large confidence intervals (CIs) reflect the small sample sizes within each of the subgroups. HR, Heart rate. Journal of Vascular Surgery  , e9DOI: ( /j.jvs ) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

6 Fig 5 This graphic depicts the major adverse cardiac event (MACE) and 30-day mortality risk rates among the open abdominal aortic aneurysm (AAA) patients with or without “good” heart rate (HR) control, depending on preoperative beta-blocker exposure and cardiac risk history. Similar to the lower extremity bypass (LEB) and aortofemoral bypass (AFB) patients, no significant association with outcome is noted. The value of 75 beats/min was arbitrary, and the same lack of association was found in examining the 70 or 80 beats/min cutoff. CI, Confidence interval. Journal of Vascular Surgery  , e9DOI: ( /j.jvs ) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

7 Fig 6 The lower extremity bypass (LEB) major adverse cardiac event (MACE) prediction model receiver operating curve with and without addition of the arrival heart rate (AHR) variable is examined (A). AHR (and highest intraoperative HR) was not associated with MACE or 30-day mortality in univariate analysis. However, even if the variable was forced into the model to see if there was any predictive value (eg, improve the area under the curve [AUC]), no significant impact on prediction is noted. In fact, AHR has the same impact on the predictive model as when a dummy variable (eg, Patient ID) that has no possible way of affecting the outcome is entered into the model (B). This was repeated for the aortofemoral bypass (AFB) and open abdominal aortic aneurysm (AAA) models with similar negative findings. Journal of Vascular Surgery  , e9DOI: ( /j.jvs ) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

8 Supplementary Fig 1 (online only)
This image represents the forest plot for comparing the relative risk of lower extremity bypass (LEB) patients (A) with operating room arrival heart rate (AHR) >75 or <75 beats/ min and development of a postoperative major adverse cardiac event (MACE) or 30-day death. All odds ratios span 1, indicating no significant association with either group. This same lack of association is seen for aortofemoral bypass (AFB) patients (B). Notably, the seemingly “significant” association for the congestive heart failure (CHF) outcome in patients with AHR <75 beats/min does not meet the study criteria for significance (Bonferroni correction for significance, P < .004; observed P value in graphic = .02). Finally, in the open abdominal aortic aneurysm (AAA) cohort (C), no significant association is seen with any of the study end points as a function of AHR. Iterative analyses for cutoffs of 70 and 80 beats/min did not result in any significant association to outcomes. CI, Confidence interval; HR, heart rate; POMI, postoperative myocardial infarction. Journal of Vascular Surgery  , e9DOI: ( /j.jvs ) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

9 Supplementary Fig 2 (online only)
Subanalysis into whether extremes of intraoperative heart rate (HR) portend higher risk for development of postoperative adverse cardiac events (postoperative myocardial infarction [POMI] is depicted; however, the composite major adverse cardiac event [MACE] rate and individual MACE and 30-day mortality events were also analyzed; data not shown) did not reveal any evidence of association in lower extremity bypass (LEB) patients (A) and aortofemoral bypass (AFB) patients (B). Journal of Vascular Surgery  , e9DOI: ( /j.jvs ) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

10 Supplementary Fig 3 (online only)
There appears to be an elevated rate of postoperative myocardial infarction (POMI) in the highest intraoperative heart rate (HR) group for open abdominal aortic aneurysm (AAA) patients; however, this observation is based on only 17 patients, and the P value = .03 does not meet significance based on the Bonferroni correction that was used in this analysis. Journal of Vascular Surgery  , e9DOI: ( /j.jvs ) Copyright © 2015 Society for Vascular Surgery Terms and Conditions

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