Self-Reported Exercise Tolerance and Perioperative Morbidity in Pulmonary Hypertension
May 3rd, 2015Western Anesthesia Residents Conference
Aalap C. Shah, MD CA3Department of Anesthesiology & Pain Medicine
University of Washington Medical Center
Pulmonary Hypertension (PHTN)◦Progressive increase in mean pulmonary
arterial pressure (PAP) > 25 mmHg at rest; ◦30mmHg during exercise
PAP > 30/15 Estimated PASP > 0.5 SBP
◦Symptoms Dyspnea Dizziness / Fatigue Arrhythmias Edema
Background
Background
Pathogenesis◦Vasodilator/
vasoconstrictorimbalance
Background
Pathogenesis
Background
Demographics:◦ Prevalence: 15-50 cases/1 million 1
◦ Incidence: 2.4 5-15 cases/1 million/year 1
◦ Average age: 53 +/- 14 yrs 1
◦ Overall survival: ~2.8 yrs (no treatment) 2
1 yr: 68%; 2 yr: 48%; 3 yr 34%
◦ Postoperative Mortality : 3.5-18%3-6
BackgroundPre-Anesthesia Clinic (PAC) evaluation
◦ Increasing chronic disease / comorbidity in PHTN patients
◦ Increasing # of treatments / survival◦Expensive diagnostic and monitoring workup
(+TTE)◦No consensus on severity assessment
Current risk stratification studies are underpowered (<100 patients)
ObjectiveDoes self-reported functional status (FS)
identify PHTN patients at risk for complications and increased hospital resource use?“Can you climb 1 flight of stairs without
getting short of breath?”
BackgroundFunctional status: 1 metabolic equivalent = 3.5 ml O2/kg/min
Climbing 1 flight of stairs
Study DesignRetrospective chart review of all PHTN
patients receiving elective procedures at UWMC (April 2007 – September 2013)
Inclusion Criteria:◦PHTN Diagnosis◦Recent TTE +/- cath within 1 year of procedure◦Non-obstetric / non-cardiac surgery
Exclusion criteria: All but most recent case***
Study Design
Group 1 (normal exercise tolerance) FS ≥ 4 METs N = 236 cases (all)
143 procedures (recent)
Group 2 (impaired exercise tolerance) FS < 4 METs N = 256 cases (all)
151 procedures (recent)
Primary Outcome MeasuresLOS LOS (< or ≥ 7 days)Mortality/Morbidity
◦before discharge◦Within 30d
Hospital ReadmissionsUnplanned ICU Stay
Primary OutcomesMajor Complications by dischargeMajor Complications by 30d post-
discharge◦ MI Reintubation PNA◦ Cardiac Arrest Stroke/TIA Sepsis◦ CHF Hypotension UTI◦ Arrhythmia Hemorrhage (Reop)
Hemorrhage (Tx)◦ Wound Debridement/Revision Tracheostomy◦ ARDS Delirium AKI◦ Other
CovariatesDemographics:
◦Age, Gender, BMIComorbidities:
◦CV: sHTN, CAD, previous MI, angina, CHF, arrhythmias
◦Pulm Tobacco use, asthma, OSA +/- CPAP use, COPD,
Home O2 use
◦Other: DM, Insulin Use, Renal Failure, h/o VTE, # of pHTN Rx
Covariates◦Vitals: SBP/DBP, HR, SpO2◦Labs: pH, pCO2, pO2, HCO3, K, Cr, Hgb, WBC,
Albumin◦Echo Findings:
PASP, RASP, LV/RV size, LV/RV thickness, LVF/RVF, valvular stenosis, AR, MR
◦Procedure Characteristics Anes approach, Surg approach (open vs lap),
procedure length (>2 hours)
StatisticsSPSS
◦Χ2 statistic◦T-tests vs. Mann-Whitney U (ranked sums)◦Bivariate logistic regression (ENTER) -> OR,
95% CI LOS Morbidity/Mortality by discharge Morbidity/Mortality by 30d
RESULTS
ResultsI. Demographics
Variable Group N n % pGender(M:F)
1:2:
143151
78 : 6569 : 82
.161
Age (years) Age (> 50)
1:2:1:2:
143151143151
60.7 +/- 14.261.8 +/- 13.7114125
(79.7%)(82.8%)
.491 .551
ASA (>= 3) 1:2:
142151
125145
(88.0%)(96.0%)
.015
BMI 1:2:
143151
29.4 +/- 10.334.6 +/- 16.1
.001
# of medications 1:2:
143151
3.2 +/- 1.93.0 +/- 2.0
.936
Anesthesia Approach (General) 1:2:
143151
118118
(82.5%)(78.1%)
.348
Surgical Approach (Open)
1:2:
143149
9192
(63.6%)(61.7%)
.809
Procedure Length (> 2 hours)
1:2:
143151
5855
(40.6%)(36.4%)
.475
ResultsVariable Group N n % pCurrent Tobacco Use 1:
2:139145
811
(5.8%)(7.6%)
.637
Systemic Hypertension 1:2:
143151
10186
(70.6%)(57.0%)
.016
CAD 1:2:
143151
4057
(28.0%)(37.7%)
.083
Previous MI 1:2:
143151
1722
(11.9%)(14.6%)
.606
Angina 1:2:
143151
518
(3.5%)(11.9%)
.008
CHF 1:2:
143151
3960
(27.3%)(39.7%)
.027
Any Arrhythmia 1:2:
143150
5574
(38.5%)(49.3%)
.077
AFib 1:2:
143151
3745
(25.9%)(29.8%)
.516
Atrial Flutter 1:2:
143151
39
(2.1%)(6.0%)
.140
VF 1:2:
143151
410
(2.8%)(6.6%)
.171
VT 1:2:
143151
321
(2.1%)(13.9%)
<.001
Bradycardia 1:2:
143151
73
(4.9%)(2.0%)
.208
Heart Block
1:2:
143151
74
(4.9%)(2.6%)
.368
OSA 1:2:
143150
2650
(18.2%)(33.3%)
.003
CPAP use 1:2:
2650
715
(24.9%)(30.0%)
.787
Asthma 1:2:
143151
1427
(9.8%)(17.9%)
.063
COPD 1:2:
142150
1619
(11.3%)(12.7%)
.723
DM 1:2:
143151
3460
(23.8%)(39.7%)
.004
Insulin Use 1:2:
143151
1536
(10.5%)(23.8%)
.003
Renal Failure 1:2:
143151
4143
(28.7%)(28.5%)
1.000
VTE 1:2:
143151
1215
(8.4%)(9.9%)
.690
Home O2 use 1:2:
141150
518
(3.5%)(12.0%)
.009
II. Comorbidities
% of patients
Results
Variable Group N Mean+/-St. Dev pSystolic BP (mmHg) 1:
2:125135
126.6 +/- 21.8120.7 +/- 20.9
.027
Diastolic BP (mmHg)
1:2:
124135
71.3 +/- 13.267.6 +/- 13.5
.024
HR (bpm) 1:2:
128138
74.0 +/- 15.778.7 +/- 17.6
.022
SaO2 (%) 1:2:
115124
97.6 +/- 2.096.3 +/- 3.9
.002
pH 1:2:
1119
7.40 +/- 0.067.37 +/- 0.11
.405
pCO2 1:2:
2830
32.5 +/- 8.437.7 +/- 9.6
.032
pO2 1:2:
1118
109.1 +/- 43.7114.1 +/- 54.9
.801
K 1:2:
107120
4.20 +/- 0.554.12 +/- 0.47
.217
Creatinine 1:2:
107118
1.73 +/- 2.101.25 +/- .85
.601
Hgb 1:2:
108124
12.15 +/- 2.5712.00 +/- 3.67
.724
WBC 1:2:
107122
7.39 +/- 3.159.26 +/- 7.18
.009
Albumin 1:2:
7886
3.41 +/- 0.753.28 +/- 0.78
.268
III. Vitals/Labs
Results
Variable Group N n p
Severe PHTN(PASP > 59mmHg)
1:2:
127135
8 (6.3%)19 (14.1%)
.039
PASP 1:2:
127135
43.34 +/- 12.9145.07 +/- 14.18
.302
RASP 1:2:
110104
7.42 +/- 3.779.42 +/- 5.30
.002
IV. Transthoracic Echocardiogram (TTE)
PHTN Findings
Results
Variable Group N n p
LVF(Decreased)
1:2:
133132
25 (20.8%)45 (32.4%)
.055
LV Size(Moderate to severely increased)
1:2:
131139
17 (13.0%)30 (21.6%)
.077
RVF(Decreased)
1:2:
133132
29 (21.8%)35 (26.5%)
.238
RV Size(Moderate to severely increased)
1:2:
136140
14 (10.3%)22 (15.7%)
.212
RV Thickness(Increased)
1:2:
7154
15 (21.1%)9 (16.7%)
.648
TTE LV vs RV
IV. Transthoracic Echocardiogram (TTE)
Results
Variable Group N n pValvular Stenosis (Any) 1:
2:143151
48 (33.6%)47 (31.1%)
.709
Mitral 1:2:
143151
5 (3.5%)7 (4.6%)
.771
Aortic 1:2:
143151
16 (11.2%)14 9.3%)
.701
Tricuspid 1:2:
143151
3 (2.1%)1 (0.7%)
.359
Pulmonary 1:2:
143151
1 (0.7%)1 (0.7%)
1.000
Aortic Regurgitation 1:2:
143151
25 (17.5%)13 (8.7%)
.036
Mitral Regurgitation 1:2:
143151
44 (30.8%)37 (24.5%)
.242
TTE Valve Assessment
IV. Transthoracic Echocardiogram (TTE)
ResultsV. LOS
Variable Group N n pLength of Stay (days) 1:
2:142151
4.75 +/- 9.91 days7.21 +/- 13.20 days
.047
Length of Stay > 7 days
1:2:
142151
24 (22.6%)40 (34.0%)
.023
FS >4 FS =<40
1
2
3
4
5
6
7
8
LOS
Axis Title
LOS
ResultsVI. Unplanned ICU, Readmissions, and Mortality
Variable Group N n p
Unplanned ICU stay 1:2:
143151
5 (7.25%)8 (4.86%)
.573
Hospital readmission (<30 days)
1:2:
143151
18 (14.93%)16 (20.92%)
.589
Death (<30 days) 1:2:
143151
0 (0%)3 (4.67%)
---
Results
VI. Univariate Analysis – LOSVariable pFS <4 METs (Group 2)
.047
ASA >=3 .021Surgical Approach (Open)
.002
Systemic HTN (None)
.053
SBP .007DBP .001HR .004pCO2 <.001Hgb <.001Albumin <.001RVF (decreased)
.008
RASP .006
V. Bivariate Logistic Regression - LOS
Results
Variable Odds Ratio (95% CI) pFS < 4 METs 2.09 (1.02-4.26) .044Surgical Approach (Open)
2.39 (1.56-3.66) .005
- Group 2 (poor FS) patients -trended towards a higher complication rate at discharge (14.6% vs. 7.0%, p=.041)
-had a higher cumulative number of complications at discharge (33 vs 13, p=.035)
- No association with poor FS and complications at 30d after surgery (p=.122)
ResultsVII. Complications
Most common: arrhythmias (2.0%) and delirium (2.7%)
Overall mortality for all PHTN patients at 30 days post-surgery was 2.0% (6 deaths).
ResultsVII. Complications (cont’d)
- Patient-reported functional status demonstrates associations with multiple cardiopulmonary comorbidities and independently predictive of a longer duration of hospital stay.
- RASP is strongly associated with severe PHTN and poor functional status.
- Complications were minimal prior to discharge, without any difference at 30d.
- Further data collection can help highlight the predictive role of FS and RASP on LOS elucidate their association with post-operative complications.- ~70% of all potential patient charts reviewed (March 2015)
Discussion
Acknowledgements
• Gail Van Norman, MD – Professor and Director of Compliance
• G. Alec Rooke, MD, PhD – Professor
• Kevin Ma, BA – Clinical Research Coordinator
• Jessica Wang Olivia Wang Se Won An• Edmond Lai Jacob DeBerry Daniel Masin• Tammy Tarhini Shilpa Santhosh Ruby Chen • Asha Melootu Jonathon Dang Zoe Ferguson-Steele
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