Key result
Adding the Surgical Apgar Score to the Revised Cardiac Risk Index improved the c-index for predicting postoperative acute myocardial injury from 0.68 to 0.75 (95% CI 0.73-0.77).
Why the study?
The incremental prognostic value of the Surgical Apgar Score when combined with standard preoperative risk indices to predict perioperative cardiac risk was unclear.
Does the addition of the Surgical Apgar Score to the Revised Cardiac Risk Index improve the prediction of postoperative acute myocardial injury in adults undergoing elective noncardiac surgery?
Cohort (n=16,835)
No
Does the addition of the Surgical Apgar Score to the Revised Cardiac Risk Index improve the prediction of postoperative acute myocardial injury in adults undergoing elective noncardiac surgery?
Answers are grounded in this paper and cite their sources.
The addition of the intraoperative Surgical Apgar Score to the preoperative Revised Cardiac Risk Index significantly improves the prediction of postoperative acute myocardial injury in patients undergoing noncardiac surgery.
OBJECTIVE: To assess whether the Surgical Apgar Score (SAS) improves re-estimation of perioperative cardiac risk. BACKGROUND: The SAS is a novel risk index that integrates three relevant and easily measurable intraoperative parameters (blood loss, heart rate, mean arterial pressure) to predict outcomes. The incremental prognostic value of the SAS when used in combination with standard preoperative risk indices is unclear. METHODS: We conducted a retrospective cohort study of adults (18 years and older) who underwent elective noncardiac surgery at a quaternary care hospital in Canada (2009-2014). The primary outcome was postoperative acute myocardial injury. The SAS (range 0-10) was calculated based on intraoperative estimated blood loss, lowest mean arterial pressure, and lowest heart rate documented in electronic medical records. Incremental prognostic value of the SAS when combined with the Revised Cardiac Risk Index was assessed based on discrimination (c-statistic), reclassification (integrated discrimination improvement, net reclassification index), and clinical utility (decision curve analysis). RESULTS: The cohort included 16,835 patients, of whom 607 (3.6%) patients had acute postoperative myocardial injury. Addition of the SAS to the Revised Cardiac Risk Index improved risk estimation based on the integrated discrimination improvement [2.0%; 95% confidence interval (CI): 1.5%-2.4%], continuous net reclassification index (54%; 95% CI: 46%-62%), and c-index, which increased from 0.68 (95% CI: 0.65-0.70) to 0.75 (95% CI: 0.73-0.77). On decision curve analysis, addition of the SAS to the Revised Cardiac Risk Index resulted in a higher net benefit at all decision thresholds. CONCLUSIONS: When combined with a validated preoperative risk index, the SAS improved the accuracy of cardiac risk assessment for noncardiac surgery. Further research is needed to delineate how intraoperative data can better guide postoperative decision-making.
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Daza et al. (2022) conducted a cohort in elective noncardiac surgery (n=16,835). Surgical Apgar Score (SAS) vs. Revised Cardiac Risk Index alone was evaluated on postoperative acute myocardial injury (c-index 0.75, 95% CI 0.73-0.77). Adding the Surgical Apgar Score to the Revised Cardiac Risk Index improved the c-index for predicting postoperative acute myocardial injury from 0.68 to 0.75 (95% CI 0.73-0.77).
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