Ambulatory Cardiology or General Internal Medicine Assessment Prior to Scheduled Major Vascular Surgery is Associated with Improved Outcomes

Charles de Mestral; Husam M Abdel-Qadir; Peter C Austin; Alice S Chong; Finlay A McAlister; Thomas F Lindsay; Heather J Ross; George Oreopoulos; Duminda N Wijeysundera; Douglas S Lee

doi:10.1097/SLA.0000000000006321

Ambulatory Cardiology or General Internal Medicine Assessment Prior to Scheduled Major Vascular Surgery is Associated with Improved Outcomes

Ann Surg. 2024 May 6. doi: 10.1097/SLA.0000000000006321. Online ahead of print.

Authors

Charles de Mestral^{1

2

3}, Husam M Abdel-Qadir^{1

4

5

6}, Peter C Austin¹, Alice S Chong¹, Finlay A McAlister⁷, Thomas F Lindsay², Heather J Ross^{4

5}, George Oreopoulos², Duminda N Wijeysundera^{1

2

8}, Douglas S Lee^{2

4

5}

Affiliations

¹ ICES, Toronto, ON, Canada.
² Department of Surgery, Temerty Faculty of Medicine, University of Toronto, ON, Canada.
³ Division of Vascular Surgery, St. Michael's Hospital, Toronto, ON, Canada.
⁴ Department of Medicine, Temerty Faculty of Medicine, University of Toronto, ON, Canada.
⁵ Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON Canada.
⁶ Department of Medicine, Women's College Hospital, Toronto, ON, Canada.
⁷ Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, AB, Canada.
⁸ Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, ON, Canada.

PMID: 38709199
DOI: 10.1097/SLA.0000000000006321

Abstract

Objective: To characterize the association between ambulatory cardiology or general internal medicine (GIM) assessment prior to surgery and outcomes following scheduled major vascular surgery.

Background: Cardiovascular risk assessment and management prior to high-risk surgery remains an evolving area of care.

Methods: This is population-based retrospective cohort study of all adults who underwent scheduled major vascular surgery in Ontario, Canada, April 1, 2004-March 31, 2019. Patients who had an ambulatory cardiology and/or GIM assessment within 6 months prior to surgery were compared to those who did not. The primary outcome was 30-day mortality. Secondary outcomes included: composite of 30-day mortality, myocardial infarction or stroke; 30-day cardiovascular death; 1-year mortality; composite of 1-year mortality, myocardial infarction or stroke; and 1-year cardiovascular death. Cox proportional hazard regression using inverse probability of treatment weighting (IPTW) was used to mitigate confounding by indication.

Results: Among 50,228 patients, 20,484 (40.8%) underwent an ambulatory assessment prior to surgery: 11,074 (54.1%) with cardiology, 8,071 (39.4%) with GIM and 1,339 (6.5%) with both. Compared to patients who did not, those who underwent an assessment had a higher Revised Cardiac Risk Index (N with Index over 2= 4,989[24.4%] vs. 4,587[15.4%], P<0.001) and more frequent pre-operative cardiac testing (N=7,772[37.9%] vs. 6,113[20.6%], P<0.001) but, lower 30-day mortality (N=551[2.7%] vs. 970[3.3%], P<0.001). After application of IPTW, cardiology or GIM assessment prior to surgery remained associated with a lower 30-day mortality (weighted Hazard Ratio [95%CI] = 0.73 [0.65-0.82]) and a lower rate of all secondary outcomes.

Conclusions: Major vascular surgery patients assessed by a cardiology or GIM physician prior to surgery have better outcomes than those who are not. Further research is needed to better understand potential mechanisms of benefit.