Reference: Ann Intern Med. 2022 Mar 22 early online
Surgery is a known generator of stress on the body. In some cases, that stress may result in myocardial infarction. Assessing this risk is the reason patients are evaluated prior to surgery. However, not all procedures are equally stressful to the body and traditionally ophthalmic surgery has been considered low risk. The European Society of Cardiology considers the cardiovascular risk of eye surgery to be < 1%. A 2019 Cochrane review found no benefit of routine preoperative testing before cataract surgery compared to selective or no testing. The American Academy of Ophthalmology recommends against routine preoperative testing before cataract surgery, but does suggest targeted evaluation such as an EKG in someone with known heart disease. To further investigate the short-term risk of eye surgery, researchers from Norway and Sweden used national patient registries to examine whether there was an increased risk of acute myocardial infarction (AMI) in the week following ophthalmic surgery.
The study protocol involved identifying AMI patients and then looking retrospectively to identify those who had had eye surgery either during days 0-7 prior to the AMI, or during an 8-day period 1 month earlier. There were 353,031 patients identified with a first AMI, and 806 of those identified had eye surgery during one of the 2 weeks of interest. Most of these individuals had no relevant comorbidities. There were 344 patients who had eye surgery in the week before the AMI, and 462 had eye surgery in the comparable period a month earlier. The risk of AMI was lower in the 8-day window following eye surgery than it was a month before the procedure (odds ratio 0.83, 95% CI 0.75-0.91). The results were consistent in analyses based on the type of eye surgery. In subgroup analyses that included length of surgery, type of anesthesia, and the presence of comorbidities, there was no group that had significantly increased risk in the 8 days following eye surgery.
These results support the categorization of eye surgery as low risk. There did not appear to be an increase in risk of AMI in the time-frame when risk would be anticipated to be increased due to surgery. However, this retrospective observational study has some limitations. First of all, as patients typically have routine preoperative evaluation (whether with testing or not), those who are most at risk for complications will likely have their surgeries delayed until their medical status has been optimized. Also, it is possible that in the month after surgery, there are factors which start to increase risk, such as reduced activity due to the need to recover from surgery. Finally, most patients did not have relevant cardiovascular, pulmonary, or renal comorbidities so it is uncertain whether similar results would be seen in a population with such comorbidities. Nonetheless, these findings are reassuring and support the current recommendations that suggest little to no preoperative testing for eye surgery is needed.
For more information, see the topic Perioperative Cardiac Management for Noncardiac Surgery in DynaMed.
DynaMed EBM Focus Editorial Team
This EBM Focus was written by Alan Ehrlich, MD, Executive Editor at DynaMed and Associate Professor in Family Medicine at the University of Massachusetts Medical School. Edited by Katharine DeGeorge, MD, MS, Deputy Editor at DynaMed and Associate Professor of Family Medicine at the University of Virginia; Dan Randall, MD, Deputy Editor at DynaMed; Carina Brown, MD, Assistant Professor at Cone Health Family Medicine Residency; Nicole Jensen, MD, Family Physician at WholeHealth Medical; Vincent Lemaitre, PhD, Senior Medical Writer at DynaMed; and Christine Fessenden, Editorial Operations Assistant at DynaMed.