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Anemia as an Independent Predictor of Perioperative and Long-Term Cardiovascular Outcome in Patients Scheduled for Elective Vascular Surgery

https://doi.org/10.1016/j.amjcard.2007.11.072Get rights and content

Anemia is common in patients scheduled for vascular surgery and is a risk factor for adverse cardiac outcome. However, it is unclear whether this is an independent risk factor or an expression of underlying co-morbidities. In total, 1,211 patients (77% men, 68 ± 11 years of age) were enrolled. Anemia was defined as serum hemoglobin levels <13 g/dl for men and <12 g/dl for women and was divided into tertiles to compare mild (men 12.2 to 13.0, women 11.2 to 12.0), moderate (men 11.0 to 12.1, women 10.2 to 11.1), and severe (men 7.2 to 11.0, women 7.5 to 10.1) anemia with nonanemia. Outcome measurements were 30-day and 5-year major adverse cardiac events (MACEs; cardiac death or myocardial infarction). All risk factors were noted. Multivariable logistic and Cox regression analyses were used, adjusting for all cardiac risk factors, including heart failure and renal disease. Data are presented as hazard ratios with 95% confidence intervals. In total, 74 patients (6%) had 30-day MACEs and 199 (17%) had 5-year MACEs. Anemia was present in 399 patients (33%), 133 of whom had mild anemia, 133 had moderate anemia, and 133 had severe anemia. Presence of anemia was associated with renal dysfunction, diabetes, and heart failure. After adjustment for all clinical risk factors, 30-day hazard ratios for a MACE per anemia group were 1.8 for mild (0.8 to 4.1), 2.3 for moderate (1.1 to 5.4), and 4.7 for severe (2.6 to 10.9) anemia, and 5-year hazard ratios for MACE per anemia group were 2.4 for mild (1.5 to 4.2), 3.6 for moderate (2.4 to 5.6), and 6.1 for severe (4.1 to 9.1) anemia. In conclusion, the presence and severity of preoperative anemia in vascular patients are significant predictors of 30-day and 5-year cardiac events, regardless of underlying heart failure or renal disease.

Section snippets

Methods

In a retrospective study, a series of 1,363 patients scheduled for elective noncardiac open vascular surgery with known or suspected coronary artery disease who were referred for preoperative testing from February 1990 to August 2006 to the Erasmus Medical Centre, Rotterdam, The Netherlands, were analyzed. Preoperative testing included laboratory measurement, echocardiography, and assessment of baseline characteristics. A total of 152 patients were treated at another hospital and were excluded

Results

Of the 1,211 patients included in the study, 877 were men (77%) and mean age was 68 ± 11 years. At baseline, anemia was present in 399 patients (33%), of which tertiles were calculated, resulting in 133 patients with mild anemia, 133 with moderate anemia, and 133 with severe anemia. Mean hemoglobin levels were 14.5 ± 1.1 g/dl in nonanemic patients, 12.4 ± 0.5 g/dl in patients with mild anemia, 11.3 ± 0.5 g/dl in patients with moderate anemia, and 9.8 ± 0.8 g/dl in patients with severe anemia.

Discussion

This study showed that extent of preoperative anemia and worsening renal function were strong predictors of perioperative and long-term MACEs, even after adjusting for known confounders. The association was graded, with increasing severity of anemia and renal dysfunction correlating with an increasing risk for MACEs. At 30 days postoperatively, only moderate and severe anemias were significantly associated with increased risk of MACEs. However, this could be due to the power of the study

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    Dr. Dunkelgrun is supported by an unrestricted research grant (Grant 2003B143) from the Netherlands Heart Foundation, The Hague, The Netherlands. Dr. Schouten is supported by an unrestricted research grant from the Netherlands Organization of Health Research and Development (ZonMW), The Hague, The Netherlands. Dr. Hoeks and Dr. Vidakovic are supported by an unrestricted research grant from the Lijf & Leven Foundation, Rotterdam, The Netherlands.

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