What type of cardiac risk is an amputation?

From the Guidelines

Amputation is considered a high cardiac risk procedure due to the significant cardiovascular comorbidities and physiological stress associated with the surgery. According to the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline for the management of lower extremity peripheral artery disease 1, patients undergoing amputation typically have significant cardiovascular comorbidities, particularly peripheral arterial disease which often coexists with coronary artery disease. The physiological stress of amputation surgery triggers substantial hemodynamic changes, including blood loss, fluid shifts, and a marked inflammatory response that can strain the cardiovascular system.

Some of the key factors that contribute to the high cardiac risk associated with amputation include:

• Diabetes, which is associated with a higher risk of all-cause death and major adverse cardiovascular events (MACE) 1
• Chronic kidney disease (CKD), which is associated with higher rates of cardiovascular death, myocardial infarction, and ischemic stroke 1
• End-stage renal disease (ESKD), which is associated with a higher risk of lower extremity amputation and readmission after revascularization 1
• Polyvascular disease, which is associated with a higher risk of all-cause death and MACE 1
• Microvascular disease, which increases the risk of PAD 14-fold and is associated with a higher risk of amputation 1

The 2014 ESC/ESA guidelines on non-cardiac surgery 1 also emphasize the importance of preoperative cardiac evaluation and risk stratification for patients undergoing high-risk procedures like amputation. The guidelines recommend using risk indices such as the Lee index or the NSQIP MICA model to predict the risk of perioperative cardiac complications.

Therefore, thorough preoperative cardiac evaluation and careful perioperative management are essential to minimize cardiac complications in patients undergoing amputation. This may include stress testing or coronary angiography in high-risk patients, as well as careful hemodynamic monitoring, judicious fluid management, and continuation of cardiac medications like beta-blockers and statins throughout the perioperative period 1.

From the Research

Cardiac Risk Associated with Amputation

• Amputation is associated with an increased risk of cardiac complications, including myocardial infarction, heart failure, and atrial fibrillation 2.
• The risk of cardiac disease is higher in individuals with dysvascular amputation, with a prevalence of concomitant cardiovascular disease as high as 75% 3.
• Amputees have a greater burden of underlying atherosclerotic disease, as detected by coronary artery calcification scores (CACS), compared to control subjects matched by Framingham risk stratification 4.

Specific Cardiac Risks

• Myocardial infarction: amputees have a higher risk of myocardial infarction, with an adjusted hazard ratio (aHR) of 1.30 (95% CI, 1.14-1.47) 2.
• Heart failure: amputees have a higher risk of heart failure, with an aHR of 1.27 (95% CI, 1.17-1.38) 2.
• Atrial fibrillation: amputees have a higher risk of atrial fibrillation, with an aHR of 1.17 (95% CI, 1.03-1.33) 2.

Factors Influencing Cardiac Risk

• Amputation etiology: dysvascular amputation is associated with a higher risk of cardiac events, while traumatic amputation is not 5.
• Disability: the presence of disability further increases the risk of myocardial infarction and heart failure in amputees 2.
• Traditional cardiac risk factors: hypertension, chronic kidney disease, dyslipidemia, and insulin resistance are common in amputees and contribute to their increased cardiac risk 4.