Article Information

Dr. Muhammad Mobarock Hossain¹, Prof. Jannatul Ferdous^2*, Prof. Dr. Chaudhury Meshkat Ahmed³, Dr. Moniruzzaman Khan⁴, Prof. Md. Manir Hossain Khan⁵, Dr. Monowara Begum⁶, Dr. Mehidi Masud⁷, Dr. Jakanta Faika⁸

¹Assistant Professor, Department of Cardiology, Uttara Adhunik Medical College Hospital, Dhaka, Bangladesh

²Professor, Department of Gynecological Oncology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh

³Professor and Chairman, Department of Cardiology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh          

⁴Professor, Department of Physical Medicine and Rehabilitation, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh

⁵Professor, Department of Surgery, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh

⁶Consultant, Department of Gynecological Oncology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh

⁷Consultant, Department of Anaesthesia, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh

⁸Medical Officer, Department of Gynecological Oncology, Mugda Medical College Hospital, Dhaka, Bangladesh

*Corresponding author: Prof. Jannatul Ferdous, Department of Gynecological Oncology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh.

Received: 18 September 2024; Accepted: 24 September 2024; Published: 10 October 2024

Citation: Muhammad Mobarock Hossain, Jannatul Ferdous, Chaudhury Meshkat Ahmed, Moniruzzaman Khan, Manir Hossain Khan, Monowara Begum, Mehidi Masud, Jakanta Faika. Assessment of Cardiac Risk Index in Gynecological Oncology Surgical Patients. Cardiology and Cardiovascular Medicine. 8 (2024): 428-432.

Abstract

Keywords

Cardiac risk index; Gynecological oncology; Cardiac center

Article Details

1. Introduction

The cost of perioperative complications to the health care system is substantial [1]. Whether justified or not, the frequency of perioperative morbidity and mortality has been proposed as an indicator of surgical and hospital performance [2]. With the passage of the Affordable Care Act and a connection between physician performance and payment, there has been a renewed emphasis on lowering the frequency of surgical complications [3]. In 2016, the United States of America was estimated to have 105.000 new cases of gynecologic malignancies, of which two-thirds will require surgery [4]. Typically, the goal is complete tumor resection. Depending on the patient's condition and diagnosis, these surgeries may be expanded to include upper abdominal procedures like diaphragmatic peritoneal resection, splenectomy, and segmental liver resection [5].

The correlation between a high number of surgical operations and postoperative morbidity and mortality makes it imperative to assess the effectiveness and safety of these treatments [6]. In addition, these difficulties may delay the start of postoperative chemotherapy. For instance, approximately 50% of patients who undergo extensive debulking ovarian cancer surgery to remove any gross residual tumor may experience significant complications [7]. These complications are particularly likely to affect older patients, who face higher risks of death and morbidity [8]. Systems for assessing surgical risk exist; however, their predictive value for patients with gynecologic cancer has not been established in most cases [9,10].

In order to forecast significant complications in ovarian cancer patients who had laparoscopic procedures prior to primary debulking surgery, a risk score model study was conducted. Observed risk and anticipated risk were 17.8% and 16.7%, respectively, in the validation population. This study's primary contribution was the preoperative tool it offered for outcome prediction [3]. A perfect risk assessment model would be straightforward, repeatable, accurate and legitimate, impartial, and available to all patients. It would also be especially capable of performing customized evaluations of patients based on patient-specific attributes [3,6]. It should also be feasible to execute at the bedside and inexpensive [6].

Therefore, as medical professionals, it is our goal to carry out a straightforward and useful risk assessment in order to avert difficulties, guarantee a reduction in perioperative healthcare expenses, and lower postoperative morbidity and mortality. Notably, conservative treatment or neoadjuvant chemotherapy can be administered in lieu of upfront surgery in comparison to other alternatives [7,11]. Numerous studies have demonstrated that the use of perioperative beta-blockers, with metoprolol being the most appropriate medication, lowers mortality in both low- and high-risk cardiac surgeries [12,15]. The purpose of this study was to evaluate the surgical risk for patients with gynecological oncologic conditions, to provide a simple risk assessment model that could be used at the patient's bedside, and to lower the risk of complications following surgery by utilizing the information we collected.

2. Methodology

This prospective observational study was conducted at Uttara Crescent Hospital and Lab Aid Cancer and Super Specialty Center from August 2022 to December 2023, involving 154 gynecological oncology patients scheduled for surgery. Preoperative assessments included a detailed medical history, physical examination, and calculation of the Revised Cardiac Risk Index (RCRI) for each patient. Based on their RCRI scores, patients were categorized into low-to-moderate risk (RCRI score 0-2) and high-risk (RCRI score 3 or more) groups. Standard intraoperative monitoring and tailored anesthesia management were provided, with postoperative cardiac complications such as arrhythmias, myocardial infarction, and congestive heart failure closely monitored. Data on patient demographics, comorbidities, surgical details, and postoperative outcomes were systematically collected. Statistical analysis was performed using SPSS software, with comparisons made between the risk groups to identify significant predictors of postoperative cardiac complications, and a p-value <0.05 was considered statistically significant.

3. Results

Table 1 shows that the study population presents a mean age of 49 years, indicating a middle-aged group, with a standard deviation of 12.3 years. The mean height of the participants is 60.2 inches with a relatively low standard deviation of 1.9 inches. The mean weight is 177 pounds, but with a high standard deviation of 59.7 pounds. The mean Body Mass Index (BMI) is 30 kg/m². The average hospital stay is 2.9 days, with a wide standard deviation of 5.6 days, the mean blood loss during surgery was 170 mL, with a large standard deviation of 370 ml.

Table 1: Patient demographic characteristics.

Table 2 shows that data provides Hypertension is the most common condition, affecting 42.20% of the participants, highlighting it as a significant comorbidity within this group. Chronic Obstructive Pulmonary Disease (COPD) is present in 11.68% of the population. Ascites, which affects 8.44% of the participants, and disseminated cancer, present in 6.49% of the cases. Diabetes is also common, with 5.85% of the patients managing their condition with oral medications and 5.19% requiring insulin.

Table 2: Medical history of the patients.

Less common conditions include prior cardiac events (7.79%), steroid use (3.24%), and dyspnea (3.24%). A small percentage of patients are dependent on ventilators (0.64%) or have sepsis (0.64%) or acute renal failure (0.64%). The low percentage of emergency surgeries (1.29%). Overall, the data highlights a population with significant cardiovascular, respiratory, and metabolic comorbidities.

Table 3 shows that the distribution of prior abdominal surgeries among 154 patients. A little over half of the patients (54.55%) have had no prior abdominal surgery, indicating that the majority of patients did not have a surgical history that could potentially complicate further procedures. Among those who had previous surgeries, 9.74% had undergone laparoscopic procedures, which are typically less invasive. Minor open abdominal surgeries were performed on 19.48% of the patients, while 16.23% had undergone major open abdominal surgeries (Figure 1).

Table 3: Prior abdominal surgery of the patient.

Figure 1: The Brier score approaches the threshold for death in cancer patients, pneumonia in all patients, cardiac complications in noncancer patients, UTI in cancer patients, VTE in all patients and renal failure in noncancer patients.

Table 4 shows that Uterine cancer is the most prevalent, affecting 54.55% of the patients, indicating it as the most common cancer in this group, Ovarian cancer is the second most common, present in 27.27% of the patients, Cervical cancer accounts for 10.39%, followed by less common cancers such as vulvar (4.54%) and vaginal cancer (0.64%), a small proportion of patients (2.59%) had non-gynecologic cancers. In cancer stage (FIGO) the majority of cancer cases (72.72%) are in stage I, suggesting early detection in a substantial portion of the patients, Stage III cancers account for 20.78% of the cases, representing more advanced disease, while stage II is less common, with 6.49% of the cases.

Table 4: Cancer type and stage of the patients.

4. Discussion

Similar to previous studies, the most common type of gynecologic cancer was uterine cancer, followed by ovarian and cervical cancer in this study [3]. In gynecologic cancers, prediction of postoperative complications is important because the incidence of these diseases is progressively increasing [6,8]. As a consequence, postoperative morbidity, mortality, and healthcare costs can be reduced through the prevention of postoperative complications. Previous studies have depicted that several parameters such as age, advanced stage, poor performance, ascites ≥1000, hypoalbuminemia, extended surgical time, and extensive surgery were associated with a higher risk of postoperative complications [6-8,16-20].

There are several studies about surgical risk assessment. Although some studies have been evaluated for gynecological cancers [4], generally they are non-specific in terms of gynecologic cancers or validated only for ovarian cancer [18-21]. On the other hand, several studies have shown that peri-operative beta-blockers use (metoprolol being more suitable and beneficial) was associated with reduced mortality among patients with high and low cardiac risk [12-15].

In our study, we evaluated the effect of metoprolol use on postoperative mortality and morbidity and it was significantly correlated with the prediction of complications (p<0.0001). Some studies investigated the role of extended surgery on postoperative mortality and morbidity. Patankar et al. [19] reported that extended cytoreductive procedures were the strongest risk factor for complications in ovarian cancers. Conversely, Phillips et al. [20] found that the number of surgical procedures was significantly correlated with an increased risk of major morbidity, and was a better predictor of major postoperative morbidity than the high-risk performance alone.

Also, in the prediction of major complications, they found that ultra-radical surgery was less useful than any solitary gastrointestinal resection. They identified standard surgery as “total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, pelvic and/ or para-aortic lymphadenectomy, and bowel surgery outside the definition of ‘ultra-radical’ (localized colonic resection, non-multiple bowel resection)” and ultra-radical surgery as “diaphragmatic stripping, extensive peritoneal stripping, multiple resections of the bowel (excluding localized colonic resection), liver resection, partial gastrectomy, cholecystectomy, splenectomy” [20].

In this study, upper abdominal surgery was found as a risk factor for postoperative complications. Other parameters that showed significance in our scoring system were the stage, ECOG, ascites, major pelvic surgery, total surgical time, and diabetes. Preoperative albumin levels, CA-125 levels, COPD, and heart and renal disease were parameters that were assessed in prior studies [6,8,9]. These parameters have been found to be correlated significantly with postoperative complictions. According to a study designed by Ataseven et al. [17] preoperative hypoalbuminemia had been found as an independent predictive parameter for severe postoperative complications in epithelial ovarian cancer. Conversely, in our study, no significant correlation was found between hypoalbuminemia and postoperative complications in gynecologic cancers.

CA 125 levels had no significant correlation with postoperative complications, which was probably influenced by our study design with the inclusion of all gynecologic cancers. Also, there were not many patients with COPD, renal disease, and heart disease in the study population, and thus these parameters were not found eligible for predicting complications. In our study, after estimating the risk assessment with ROC analysis, we found the AUC as 0.60 for the presence of complications and 0.70 for the number of complications, respectively. We have arranged a simple, practical and convenient model for preoperative risk assessment in patients with gynecological cancer.

5. Limitations of the study

The present study was conducted in a very short period due to time constraints and funding limitations. The small sample size was also a limitation of the present study.

6. Conclusion

Patients identified as high-risk based on the Revised Cardiac Risk Index (RCRI) exhibited a significantly higher incidence of postoperative complications, particularly cardiovascular events. These results suggest that careful evaluation and management of cardiac risk factors are essential to improving surgical outcomes in this population. Enhanced perioperative monitoring and tailored interventions should be considered for patients at increased cardiac risk to minimize adverse outcomes.

7. Recommendation

To improve surgical outcomes in gynecological oncology patients, it is recommended to implement comprehensive preoperative cardiac risk assessments using the Revised Cardiac Risk Index (RCRI) for all patients. High-risk patients should receive tailored perioperative management, including multidisciplinary involvement, enhanced monitoring, and cardioprotective strategies. Educating patients about managing pre-existing cardiac conditions and ensuring robust postoperative follow-up are crucial for minimizing complications. Additionally, ongoing research should be encouraged to refine risk assessment tools and develop targeted interventions for this population.

Acknowledgements

We would like to express our sincere gratitude to the entire medical and support staff at Uttara Crescent Hospital and Lab Aid Cancer Hospital & Super Specialty Center for their invaluable assistance during this study. Our deepest thanks go to the Department of Gynecological Oncology for their continuous support and collaboration. We are also immensely grateful to the patients who participated in this study, whose cooperation made this research possible. Lastly, we extend our appreciation to our colleagues and mentors for their guidance and encouragement throughout this research project.

References

1. Dimick JB, Chen SL, Taheri PA, et al. Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program. J Am Coll Surg 199 (2004): 531Y1.
2. Internal Revenue Service (IRS), Treasury. Computation of, and rules relating to, medical loss ratio. Final regulations. Fed Regist 79 (2014): 755Y758.
3. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA Cancer J Clin 66 (2016): 7-30.
4. Uppal S, Igwe E, Rice LW, et al. Frailty index predicts severe complications in gynecologic oncology patients. Gynecol Oncol 137 (2015): 98-101.
5. Benedetti Panici P, Di Donato V, Fischetti M, et al. Predictors of postoperative morbidity after cytoreduction for advanced ovarian cancer: Analysis and management of complications in upper abdominal surgery. Gynecol Oncol 137 (2015): 406-11.
6. Vizzielli G, Costantini B, Tortorella L, et al. A laparoscopic risk-adjusted model to predict major complications after primary debulking surgery in ovarian cancer: A single-institution assessment. Gynecol Oncol 142 (2016): 19-24.
7. Barber EL, Rutstein S, Miller WC, et al. A preoperative personalized risk assessment calculator for elderly ovarian cancer patients undergoing primary cytoreductive surgery. Gynecol Oncol 139 (2015): 401-6.
8. Szender JB, Frederick PJ, Eng KH, et al. Evaluation of the National Quality Improvement Program Universal Surgical Risk Calculator for a gynecologic oncology service. Int J Gynecol Cancer 25 (2015): 512-20.
9. Uppal S, Al-Niaimi A, Rice LW, et al. Preoperative hypoalbuminemia is an independent predictor of poor perioperative outcomes in women undergoing open surgery for gynecologic malignancies. Gynecol Oncol 131 2013: 416-22.
10. Barnett S, Moonesinghe SR. Clinical risk scores to guide perioperative management. Postgrad Med J 87 (2011): 535-41.
11. Chand M, Armstrong T, Britton G, et al. How and why do we measure surgical risk? J R Soc Med 100 (2007): 508-12.
12. Wiesbauer F, Schlager O, Domanovits H, et al. Perioperative beta-blockers for preventing surgery-related mortality and morbidity: a systematic review and meta-analysis. Anesth Analg 104 (2007): 27-41.
13. Angeli F, Verdecchia P, Karthikeyan G, et al. ß-Blockers reduce mortality in patients undergoing high risk non-cardiac surgery. Am J Cardiovasc Drugs 10 (2010): 247-59.
14. POISE Study Group, Devereaux PJ, Yang H, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet 371 (2008): 1839-47.
15. Devereaux PJ, Beattie WS, Choi PT, et al. How strong is the evidence for the use of perioperative beta blockers in non-cardiac surgery? Systematic review and meta analysis of randomised controlled trials. BMJ 331 (2005): 313-21.
16. Clark RM, Lee MS, Alejandro Rauh-Hain J, et al. Surgical Apgar Score and prediction of morbidity in women undergoing hysterectomy for malignancy. Gynecol Oncol 136 (2015): 516-20.
17. Ataseven B, du Bois A, Reinthaller A, et al. Pre-operative serum albumin is associated with post-operative complication rate and overall survival in patients with epithelial ovarian cancer undergoing cytoreductive surgery. Gynecol Oncol 138 (2015): 560-5.
18. Zighelboim I, Kizer N, Taylor NP, et al. “Surgical Apgar Score” predicts postoperative complications after cytoreduction for advanced ovarian cancer. Gynecol Oncol 116 (2010): 370-3.
19. Patankar S, Burke WM, Hou JY, et al. Risk stratification and outcomes of women undergoing surgery for ovarian cancer. Gynecol Oncol 138 (2015): 62-9.
20. Phillips A, Sundar S, Singh K, et al. The NICE classification for ‘Ultra-radical (extensive) surgery for advanced ovarian cancer’ guidance does not meaningfully predict postoperative complications: a cohort study. BJOG 126 (2019): 96-104.
21. Jering MZ, Marolen KN, Shotwell MS, et al. Combining the ASA Physical Classification System and Continuous Intraoperative Surgical Apgar Score Measurement in Predicting Postoperative Risk. J Med Syst 39 (2015): 147.