Patients without comorbidities, including common illnesses such as diabetes, congestive heart failure, and renal failure, had an average 2.6 % risk of dying. Those with one comorbidity had a 10.3% risk, and patients with more than one comorbidity had a mortality risk of 21.4%. Multivariate analysis revealed that the odds ratios for inpatient mortality were 3.94 for lung disease, 3.26 for cerebrovascular disease, 3.16 for renal disease, 2.89 for liver disease, 1.94 for pulmonary embolism, and 1.58 for heart disease.
The study also showed that patients hospitalized for longer than 10 days (comprising 35% of all patients) accounted for the majority of overall deaths (65%), overall cost (78%), and overall days spent in the hospital (74%).
Conclusions: The study provided an estimate of inpatient mortality associated with neutropenic fever in cancer patients and highlighted those subgroups as being at heightened risk for death. Important limitations include the retrospective nature of the study, the use of administrative data sets as the primary data source, and a failure to analyze for the duration of neutropenia prior to treatment. The authors’ conclusion that the identified factors may be useful in determining which patients warrant “more aggressive supportive care measures” is plausible, but does not find enough support in the study to warrant general implementation.
Long-Term Value of Electrocardiogram Before Noncardiac Surgery
Jeger RV, Probst C, Arsenic R, et al. Long-term prognostic value of the preoperative 12-lead electrocardiogram before major noncardiac surgery in coronary artery disease. Am Heart J. 2006 Feb;151(2):508-513.
Background: The 12-lead electrocardiogram is commonly utilized as part of the cardiovascular preoperative risk stratification. Certain ECG abnormalities, such as left bundle branch block, Q waves, ST-T abnormalities, arrhythmias, and left ventricular hypertrophy (LVH), have been associated with elevated risk in the perioperative period.1,2 This article prospectively evaluated whether an exhaustive analysis of preoperative ECGs in this population would have long-term predictive validity.
Methods: The study utilized a “predefined” analysis applied retrospectively on data obtained for another study.3,4
The study analyzed 172 patients, all of whom had documented coronary artery disease (CAD) as defined by previous myocardial infarction (MI), prior revascularization, significant stenoses on prior catheterization, ischemia (by dobutamine stress echocardiogram or adenosine thallium imaging), or who were high risk for CAD. High risk required at least two of the following: age over 70, hypertension, diabetes mellitus, prior stroke, exercise intolerance, or a “pathological resting ECG.” These patients were to undergo noncardiac surgery. The primary endpoint was all-cause mortality after two years, and the secondary endpoint was major adverse cardiac events (MACE) after two years. The MACE were defined as nonfatal MI, coronary revascularization, re-hospitalization due to recurrent ischemia, and/or cardiac death.
The ECGs were obtained one day prior to surgery and analyzed using the Minnesota classification. Telephone interviews were done at six, 12, and 24 months to evaluate outcome, and the Swiss Mortality Registry was used to determine cause of death. Analyzed data were adjusted for current beta-blocker use and perioperative ischemia using a sensitivity analysis-like correction that is described briefly in the report.
Results: ST depression (odds ratio [OR] 4.5) and faster heart rate (OR 1.6) were independent predictors of all-cause mortality. Faster heart rate (OR 1.7) was also an independent predictor of MACE.
Commentary: The results of this relatively small study raise awareness of resting tachycardia and ST depression as possible markers for poor perioperative and two-year postoperative outcomes. The latter is already included in risk stratification guidelines5, and the former is of uncertain validity due to possible confounding variables such as anxiety or pain, beta blocker dosing differences, and lack of intra- and postoperative beta blocker usage data which may affect postoperative cardiac morbidity and mortality long after the drugs are stopped.