Joseph Jaeger, MPH, Daniel Shine, MD. Long Branch, New Jersey, Livingston, New Jersey. Background: There is limited information concerning the risks for, ...
Cardiovascular complications after GI endoscopy: occurrence and risks in a large hospital system Sumana Gangi, MD, Firas Saidi, MD, Kapil Patel, MD, Barbara Johnstone, RN, Joseph Jaeger, MPH, Daniel Shine, MD Long Branch, New Jersey, Livingston, New Jersey
Background: There is limited information concerning the risks for, and occurrence of, cardiovascular complications because of GI endoscopy. Published data are based on questionnaire surveys, which have a potential for bias. Moreover, available studies pertain exclusively to out-patients. Methods: In-patients and day-stay patients who incurred charges for endoscopy with endoscopic procedure coding from 1999 through 2001 were identiﬁed from a ﬁnancial database for all 9 hospitals in a large health care system. From these patients, those considered ‘‘at risk’’ for cardiovascular complications were selected based on charges for cardioactive medications, cardiac enzyme determinations, or intensive care services on the day of or the day after endoscopy. Medical records were reviewed for 25% of these patients, selected at random, noting demographics, history, and a modiﬁed Goldman score in patients with cardiovascular complications (deﬁned as arrhythmia, chest pain or anginal equivalent, hypotension or myocardial infarction occurring within 24 hours after endoscopy). Identical information was obtained from a random sample of 0.5% of the chart records for all patients undergoing endoscopy. Results: Patients who underwent endoscopy were not reliably identiﬁed for one hospital. This hospital was omitted from the calculation of the extrapolated rate of complication occurrence, but patients identiﬁed through chart review as having or not having a complication after endoscopy were included in the risk analysis. The extrapolated rate of occurrence of cardiovascular complications was 308: 95% CI [197, 457] per 100,000 procedures. Independent risk factors were: male gender, modiﬁed Goldman score, and use of propofol. Conclusions: In this study of patients undergoing hospital-based GI endoscopy, the risk of procedure-related cardiovascular complications was 2 to 70 times higher than previously reported. This ﬁnding may be ascribed to differences in the populations sampled and to a case-ﬁnding method that minimized reporting and ascertainment biases. (Gastrointest Endosc 2004;60:679-85.)
The clinical features of cardiovascular complications caused by upper- and lower-GI endoscopy are well described.1-4 There is less certainty, however, as to the frequency of these adverse outcomes.5-9 Questionnaire-based studies that rely on selfreporting of complications estimate the risk for out-patients at 0.005% to 0.5%.5-8 No information is Received December 17, 2003. For revision April 28, 2004. Accepted June 16, 2004. Current affiliations: Department of Medicine, Monmouth Medical Center, Long Branch, New Jersey, Department of Decision Support, Saint Barnabas Healthcare System, Livingston, New Jersey, Department of Medical Education, Monmouth Medical Center, Long Branch, New Jersey. Presented in part at the annual meeting of the National Association for Healthcare Quality, September 8, 2003, Phoenix, Arizona. Reprint requests: Daniel Shine, MD, Department of Medicine, Monmouth Medical Center, 300 Second Ave., Long Branch, NJ 07740. Copyright Ó 2004 by the American Society for Gastrointestinal Endoscopy 0016-5107/$30.00 PII: S0016-5107(04)02016-4 VOLUME 60, NO. 5, 2004
available on the occurrence of complications among patients who undergo endoscopic procedures in the hospital; nor has there been an attempt to identify risk factors in detail for any cohort. Despite limited data, concern for possible cardiovascular complications has led to recommendations for continuous patient monitoring from the American Society for Gastrointestinal Endoscopy (ASGE), the Joint Commission for the Accreditation of Health Care Organizations (JCAHO), and other groups.6,10,11 The ASGE recommends, and the JCAHO requires, that all patients undergoing conscious sedation be monitored for oxygen saturation, and the ASGE suggests cardiac monitoring for high-risk patients and those who have long procedures.6,10 By contrast, the American Society of Anesthesiologists (ASA) Task Force on Sedation and Analgesia by Non-Anesthesiologists recommends stratification of patients according to risk and to depth of sedation. This group advises that pulse oximetry be used, that vital signs be monitored frequently for patients undergoing moderate sedation, and that continuous GASTROINTESTINAL ENDOSCOPY
S Gangi, F Saidi, K Patel, et al.
Cardiovascular complications after GI endoscopy
Table 1. Modiﬁed Goldman criteria Criterion
Ventricular gallop or jugular venous distension Myocardial infarction within 6 mo Rhythm other than sinus >5 premature ventricular contractions per min on any recording Age >70 Emergency procedure Partial pressure of oxygen 50 mm Hg* Serum potassium 3.0y Elevated hepatic enzymes or signs of liver disease or bedridden from a noncardiac causey Intraperitoneal, intrathoracic, or aortic operationy
11 10 7 7
Total possible score, Goldman criteria Total possible score, modified Goldman criteria
5 5 3 3 3 3 3
*Modified to arterial oxygen saturation