9. Mangano et. al. JAMA 1992

1. Vascular Disease
(hazard ratio, 6.1; 95% confidence interval [CI], 2.5 to 15.0; P less than .0001)
2. History of congestive heart failure
(hazard ratio, 5.0; 95% CI, 2.0 to 12.0; P less than .0005)
3. Coronary artery disease
(hazard ratio, 3.7; 95% CI, 1.7 to 8.0; P less than .0007)
4. Myocardial infarction/unstable angina
(hazard ratio, 20; 95% CI, 7.5 to 53.0; P less than .0001)
5. Myocardial ischemia
(hazard ratio, 2.2; 95% CI, 1.1 to 4.3; P less than .03)

Mangano found five (really six) risk factors: Vascular disease, history of congestive heart failure, coronary artery disease, myocardial infarction, unstable angina, and myocardial ischemia. This study is important because myocardial ischemia is the first risk factor that is not fixed. It is something you might be able to change.

One more amazing fact about the Mangano study. If a patient survives their perioperative MI, they have a 28 fold increased risk of another cardiac event in the next six months and a 20% two year survival. Perioperative myocardial infarctions are lethal. Myocardial ischemia is a risk factor.

	Patients surviving a postoperative in-hospital myocardial infarction had a 28-fold increase in the rate of subsequent cardiac complications within 6 months following surgery, a 15-fold increase within 1 year, and a 14-fold increase within 2 years (95% CI, 5.8 to 32; P less than .00001).
	Seventy percent of all long-term adverse outcomes were preceded by in-hospital postoperative ischemia that occurred at least 30 days (median, 282 days) before the long-term event.
	CONCLUSIONS--Survivors of in-hospital perioperative ischemic events, specifically myocardial infarction, unstable angina, and postoperative ischemia, warrant more aggressive long-term follow-up and treatment than is currently practiced.

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