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The revised cardiac risk index (RCRI) holds a central role in preoperative cardiac risk stratification in noncardiac surgery. Its performance in unselected populations, including different age groups, has, however, not been systematically investigated. We assessed the relationship of RCRI with major adverse cardiovascular events in an unselected cohort of patients undergoing elective, noncardiac surgery overall and in different age groups.

IMPORTANCE: Clinical guidelines have been criticized for encouraging the use of β-blockers in noncardiac surgery despite weak evidence. Relevant clinical trials have been small and have not convincingly demonstrated an effect of β-blockers on hard end points (ie, perioperative myocardial infarction, ischemic stroke, cardiovascular death, and all-cause death). OBJECTIVE: To assess the association of β-blocker treatment with major cardiovascular adverse events (MACE) and all-cause mortality in patients with ischemic heart disease undergoing noncardiac surgery. DESIGN, SETTING, PARTICIPANTS, AND EXPOSURE: Individuals with ischemic heart disease with or without heart failure (HF) and with and without a history of myocardial infarction undergoing noncardiac surgery between October 24, 2004, and December 31, 2009, were identified from nationwide Danish registries. Adjusted Cox regression models were used to calculate the 30-day risks of MACE (ischemic stroke, myocardial infarction, or cardiovascular death) and all-cause mortality associated with β-blocker therapy. MAIN OUTCOMES AND MEASURES: Thirty-day risk of MACE and all-cause mortality. RESULTS: Of 28 263 patients with ischemic heart disease undergoing surgery, 7990 (28.3%) had HF and 20 273 (71.7%) did not. β-Blockers were used in 4262 (53.3%) with and 7419 (36.6%) without HF. Overall, use of β-blockers was associated with a hazard ratio (HR) of 0.91 (95% CI, 0.81-1.02) for MACE and 0.95 (0.85-1.06) for all-cause mortality. Among patients with HF, use of β-blockers was associated with a significantly lower risk of MACE (HR, 0.78; 95% CI, 0.67-0.90) and all-cause mortality (0.80; 0.70-0.92), whereas among patients without HF, there was no significant association of β-blocker use with MACE (1.11; 0.94-1.31) or mortality (1.15; 0.98-1.35) (P < .001 for interactions). Among patients without HF, β-blockers were also associated with a lowered risk among those with a recent myocardial infarction (<2 years), with HRs of 0.60 (95% CI, 0.42-0.86) for MACE and 0.80 (0.53-1.21) for all-cause mortality (P < .02 for interactions between β-blockers and time period after myocardial infarction), but with no significant association in the remaining patients. Results were similar in propensity score–matched analyses. CONCLUSIONS AND RELEVANCE: Among patients with ischemic heart disease undergoing noncardiac surgery, use of β-blockers was associated with lower risk of 30-day MACE and mortality only among those with HF or recent myocardial infarction.

Aims To investigate the relative importance of individual tissue Doppler imaging variables to predict adverse events in a high-risk population with diabetes, ischaemic heart disease, and/or systolic dysfunction. Methods and results Transthoracic echocardiograms were analysed in 388 diabetic patients without significant valve disease, bundle branch block, and atrial fibrillation who underwent coronary angiography. Multivariable Coxs regression analyses were used to establish the association between peak systolic (s′), early diastolic (e′), and late diastolic (a′) tissue velocities and outcomes (hospitalization for heart failure or death). The mean age and left ventricular ejection fraction (LVEF) was 66 ± 10 years and 45 ± 12%, respectively. During 2.3 (±1.0) years of follow-up, 91 patients (24%) met the combined endpoint. After adjustment for LVEF, coronary artery pathology, heart failure at baseline, age, and gender, each 1 cm/s decrease in s′, e′, and a′ was associated with a hazard ratio (HR) of 1.18 (0.89–1.57), 1.03 (0.86–1.22), and 1.20 (1.05–1.37), respectively. A significant interaction was found between s′ and a′, P < 0.01. In patients with lower than mean s′, 1 cm/s decrease in a′ was associated with HR 1.31 (1.10–1.55, P < 0.01), whereas a′ was without prognostic importance in patients with higher than mean s′ [HR 0.99 (0.78–1.25, P = 0.6)]. Patients having lower than mean values of both s′ and a′ had a poorer prognosis than patients having at least one of s′ and a′ high. Conclusion Peak systolic and late diastolic tissue velocities add prognostic information beyond LVEF in high-risk patients. Variables should be considered together as they interact on prognosis.

The risk of stroke after coronary artery bypass grafting (CABG) is known to increase dramatically with age. During recent years, the age of patients operated on has increased and concomitant therapy has changed. Therefore, we have re-evaluated the risk of stroke after CABG.