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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