Adverse cardiac events after surgery: assessing risk in a veteran population

Point of care transthoracic echocardiography for the prediction of post - spinal anesthesia hypotension in elderly patients with cardiac diseases and left ventricular dysfunction : Inferior vena cava and post-spinal anesthesia hypotension in elderly patients

In elderly patients with cardiac diseases, changes in cardiovascular physiology diminish cardiovascular reserve and predispose to hemodynamic instability after spinal anesthesia; hence, such patients could be at risk of postoperative complications. Additionally, transthoracic echocardiography (TTE) is used in clinical practice to evaluate cardiovascular hemodynamics. Therefore, we hypothesized that echocardiographic measurements could display significant diagnostic power in the prediction of post - spinal anesthesia hypotension in elderly patients with cardiac diseases and reduced left ventricular ejection fraction (LV-EF). Therefore, sixty-one elderly orthopedic-trauma patients were recruited. Prior to spinal anesthesia a TTE examination was performed. The LV-EF, the stroke volume index (SVI), the peripheral vascular resistance (PVR), the LV filling pressures (E/Em ratio), the right ventricular function [tricuspid annular plane systolic excursion (TAPSE), tricuspid annular systolic velocity (TASV) and fractional area change (FAC)], as well as inferior vena cava (IVC) measurements, such as IVCCI (collapsibility index of the IVC) and dIVCmax (maximum diameter of IVC)-to-IVCCI ratio were assessed. Twenty-six out of sixty-one patients manifested hypotension. Preoperative dIVCmax-to-IVCCI ratio demonstrated the greatest performance amongst echocardiographic indices in predicting post - spinal anesthesia hypotension. The dIVCmax-to-IVCCI ratio < 48 had significantly higher diagnostic power than IVCCI > 0.28, FAC > 42, E/Em ratio < 9 and SVI < 32 (receiver operator characteristic curve analysis). The gray zone for the dIVCmax-to-IVCCI ratio (40-49) showed the lowest number of inconclusive measurements among echocardiographic variables. The preoperative dIVCmax-to-IVCCI ratio could be a reliable echocardiographic index to predict post - spinal anesthesia hypotension in elderly patients with left ventricular dysfunction.

Body Mass Index (BMI) Related Morbidity with Thyroid Surgery

OBJECTIVES

The increase in incidence of thyroid cancer correlates with strict increases in body mass index (BMI) and obesity in the United States. Thyroid hormone dysregulation has been shown to precipitate circulatory volume, peripheral resistance, cardiac rhythm, and even cardiac muscle health. Theoretically, thyroid surgery could precipitate injury to the cardiopulmonary system.

METHODS

The American College of Surgery National Quality Improvement Program database was queried for thyroidectomy cases in the 2007-2020 Participant User files. Continuous and categorical associations between BMI and cardiopulmonary complications were investigated as reported in the database.

RESULTS

The query resulted 186,095 cases of thyroidectomy procedures in which the mean age was 51.3 years and sample was 79.3% female. No correlation was evident in univariate and multivariate analyses between BMI and the incidence of postoperative stroke or myocardial infarction. The incidence of complications was extremely low. However, risk of deep venous thrombosis correlated with BMI in the categorical, univariate, and multivariate (OR 1.036, CI 1.014-1.057, p < 0.01) regression analysis. Additionally, increased BMI was associated with increased risk of pulmonary embolism (PE) (OR 1.050 (1.030, 1.069), p < 0.01), re-intubation (OR 1.012 (1.002, 1.023), p = 0.02), and prolonged intubation (OR 1.031 (1.017, 1.045), p < 0.01).

CONCLUSION

Despite the rarity of cardiopulmonary complications during thyroid surgery, patients with very high BMI carry a significant risk of deep venous thrombosis, PE, and prolonged intubation.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:2823-2830, 2023.

Cardiovascular risk management in the peri-operative setting

Peri-operative cardiovascular events occur in up to 3% of patients undergoing non-cardiac surgery. Accurate cardiovascular risk assessment is important in the peri-operative setting, as it allows informed and shared decisions regarding the appropriateness of proceeding with surgery, guides surgical and anaesthetic approaches, and may influence the use of preventive medications and post-operative cardiac monitoring. Quantitative risk assessment may also inform a reconsideration of choosing a more limited lower risk type of surgery, or conservative management. Pre-operative cardiovascular risk assessment starts with clinical assessment and should include an estimate of functional capacity. Specialised cardiac investigations are rarely indicated specifically to assess pre-operative cardiovascular risk. The decision regarding cardiac investigations is influenced by the nature, extent and urgency of surgery. The strategy of performing pre-operative revascularisation to improve post-operative outcomes is not evidence-based and recent international guidelines recommend against this.

External Validation of the Revised Cardiac Risk Index and the Geriatric-Sensitive Perioperative Cardiac Risk Index in Oldest Old Patients Following Surgery Under Spinal Anaesthesia; a Retrospective Cross-Sectional Cohort Study

Background

The Revised Cardiac Risk Index (RCRI) and the Geriatric Sensitive Cardiac Risk Index (GSCRI) estimate the risk of postoperative major adverse cardiac events (MACE) regardless of the type of anesthesia and without specifying the oldest old patients. Since spinal anesthesia (SA) is a preferred technique in geriatrics, we aimed to test the external validity of these indices in patients ≥ 80 years old who underwent surgery under SA and tried to identify other potential risk factors for postoperative MACE.

Methods

The performance of both indices to estimate postoperative in-hospital MACE risk was tested through discrimination, calibration, and clinical utility. We also investigated the correlation between both indices and postoperative ICU admission and length of hospital stay (LOS).

Results

The MACE incidence was 7.5%. Both indices had limited discriminative (AUC for RCRI and GSCRI were 0.69 and 0.68, respectively) and predictive abilities. The regression analysis showed that patients with atrial fibrillation (AF) were 3.77 and those with trauma surgery were 2.03 times more likely to exhibit MACE, and the odds of MACE increased by 9% for each additional year above 80. Introducing these factors into both indices (multivariable models) increased the discriminative ability (AUC reached 0.798 and 0.777 for RCRI and GSCRI, respectively). Bootstrap analysis showed that the predictive ability of the multivariate GSCRI but not the multivariate RCRI improved. Decision curve analysis (DCA) showed that multivariate GSCRI had superior clinical utility when compared with multivariate RCRI. Both indices correlated poorly with postoperative ICU admission and LOS.

Conclusion

Both indices had limited predictive and discriminative ability to estimate postoperative in-hospital MACE risk and correlated poorly with postoperative ICU admission and LOS, following surgery under SA in the oldest-old patients. Updated versions by introducing age, AF, and trauma surgery improved the GSCRI performance but not the RCRI.

Predictive factors for major adverse cardiac and cerebrovascular events in octogenarians after elective endovascular aneurysm repair

OBJECTIVES

The aim of this study was to identify risk factors of major adverse cardiac and cerebrovascular events (MACCE) in octogenarians who received elective endovascular aneurysm repair (EVAR).

METHODS

Consecutive patients aged ≥ 80 years undergoing elective EVAR from 2009 to 2020 were retrospectively evaluated. The primary outcome was long-term MACCE. All independent risk factors for outcomes were determined by multivariate logistic analysis or Cox regression analysis.

RESULTS

A total of 163 patients were enrolled in this study. The median age was 81 (interquartile range, IQR, 80-84) years and 85.9% (140/163) of them were male. MACCE happened in 2.5% (4/163) patients within 30 days. With median follow-up of 28 (IQR, 15-46) months, the incidence of long-term MACCE was 26.4% (43/163). Arrythmia was significantly associated with long-term MACCE (hazard ratio, HR = 2.64, 95% confidence interval, CI, 1.16-6.03, P = .021). Carotid artery disease was found a significant association with 2-year MACCE (odd ratio, OR = 6.50, 95% CI, 1.07-39.51, P = .042). Besides, we found that arrythmia and congestive heart failure (CHF) were predictors for overall survival (arrythmia, HR = 2.56, 95% CI, 1.05-6.28, P = .039; CHF, HR = 8.96, 95% CI, 2.12-37.79, P = .003).

CONCLUSIONS

EVAR in octogenarians had acceptable perioperative risk and long-term outcome. Considering high risk of 2-year MACCE, intervention strategy should be more cautious for patients with carotid artery disease. Octogenarians with arrythmia and CHF should receive stricter postoperative management in case of MACCE.

The comparative and added prognostic value of biomarkers to the Revised Cardiac Risk Index for preoperative prediction of major adverse cardiac events and all-cause mortality in patients who undergo noncardiac surgery

BACKGROUND

The Revised Cardiac Risk Index (RCRI) is a widely acknowledged prognostic model to estimate preoperatively the probability of developing in-hospital major adverse cardiac events (MACE) in patients undergoing noncardiac surgery. However, the RCRI does not always make accurate predictions, so various studies have investigated whether biomarkers added to or compared with the RCRI could improve this.

OBJECTIVES

Primary: To investigate the added predictive value of biomarkers to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery. Secondary: To investigate the prognostic value of biomarkers compared to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery. Tertiary: To investigate the prognostic value of other prediction models compared to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery.

SEARCH METHODS

We searched MEDLINE and Embase from 1 January 1999 (the year that the RCRI was published) until 25 June 2020. We also searched ISI Web of Science and SCOPUS for articles referring to the original RCRI development study in that period.

SELECTION CRITERIA

We included studies among adults who underwent noncardiac surgery, reporting on (external) validation of the RCRI and: - the addition of biomarker(s) to the RCRI; or - the comparison of the predictive accuracy of biomarker(s) to the RCRI; or - the comparison of the predictive accuracy of the RCRI to other models. Besides MACE, all other adverse outcomes were considered for inclusion.

DATA COLLECTION AND ANALYSIS

We developed a data extraction form based on the CHARMS checklist. Independent pairs of authors screened references, extracted data and assessed risk of bias and concerns regarding applicability according to PROBAST. For biomarkers and prediction models that were added or compared to the RCRI in ≥ 3 different articles, we described study characteristics and findings in further detail. We did not apply GRADE as no guidance is available for prognostic model reviews.

MAIN RESULTS

We screened 3960 records and included 107 articles.   Over all objectives we rated risk of bias as high in ≥ 1 domain in 90% of included studies, particularly in the analysis domain. Statistical pooling or meta-analysis of reported results was impossible due to heterogeneity in various aspects: outcomes used, scale by which the biomarker was added/compared to the RCRI, prediction horizons and studied populations.  Added predictive value of biomarkers to the RCRI Fifty-one studies reported on the added value of biomarkers to the RCRI. Sixty-nine different predictors were identified derived from blood (29%), imaging (33%) or other sources (38%). Addition of NT-proBNP, troponin or their combination improved the RCRI for predicting MACE (median delta c-statistics: 0.08, 0.14 and 0.12 for NT-proBNP, troponin and their combination, respectively). The median total net reclassification index (NRI) was 0.16 and 0.74 after addition of troponin and NT-proBNP to the RCRI, respectively. Calibration was not reported. To predict myocardial infarction, the median delta c-statistic when NT-proBNP was added to the RCRI was 0.09, and 0.06 for prediction of all-cause mortality and MACE combined. For BNP and copeptin, data were not sufficient to provide results on their added predictive performance, for any of the outcomes. Comparison of the predictive value of biomarkers to the RCRI  Fifty-one studies assessed the predictive performance of biomarkers alone compared to the RCRI. We identified 60 unique predictors derived from blood (38%), imaging (30%) or other sources, such as the American Society of Anesthesiologists (ASA) classification (32%). Predictions were similar between the ASA classification and the RCRI for all studied outcomes. In studies different from those identified in objective 1, the median delta c-statistic was 0.15 and 0.12 in favour of  BNP and NT-proBNP alone, respectively, when compared to the RCRI, for the prediction of MACE. For C-reactive protein, the predictive performance was similar to the RCRI. For other biomarkers and outcomes, data were insufficient to provide summary results. One study reported on calibration and none on reclassification. Comparison of the predictive value of other prognostic models to the RCRI   Fifty-two articles compared the predictive ability of the RCRI to other prognostic models. Of these, 42% developed a new prediction model, 22% updated the RCRI, or another prediction model, and 37% validated an existing prediction model. None of the other prediction models showed better performance in predicting MACE than the RCRI. To predict myocardial infarction and cardiac arrest, ACS-NSQIP-MICA had a higher median delta c-statistic of 0.11 compared to the RCRI. To predict all-cause mortality, the median delta c-statistic was 0.15 higher in favour of ACS-NSQIP-SRS compared to the RCRI. Predictive performance was not better for CHADS₂, CHA₂DS₂-VASc, R₂CHADS₂, Goldman index, Detsky index or VSG-CRI compared to the RCRI for any of the outcomes. Calibration and reclassification were reported in only one and three studies, respectively.

AUTHORS' CONCLUSIONS

Studies included in this review suggest that the predictive performance of the RCRI in predicting MACE is improved when NT-proBNP, troponin or their combination are added. Other studies indicate that BNP and NT-proBNP, when used in isolation, may even have a higher discriminative performance than the RCRI. There was insufficient evidence of a difference between the predictive accuracy of the RCRI and other prediction models in predicting MACE. However, ACS-NSQIP-MICA and ACS-NSQIP-SRS outperformed the RCRI in predicting myocardial infarction and cardiac arrest combined, and all-cause mortality, respectively. Nevertheless, the results cannot be interpreted as conclusive due to high risks of bias in a majority of papers, and pooling was impossible due to heterogeneity in outcomes, prediction horizons, biomarkers and studied populations. Future research on the added prognostic value of biomarkers to existing prediction models should focus on biomarkers with good predictive accuracy in other settings (e.g. diagnosis of myocardial infarction) and identification of biomarkers from omics data. They should be compared to novel biomarkers with so far insufficient evidence compared to established ones, including NT-proBNP or troponins. Adherence to recent guidance for prediction model studies (e.g. TRIPOD; PROBAST) and use of standardised outcome definitions in primary studies is highly recommended to facilitate systematic review and meta-analyses in the future.

Early postoperative acute myocardial infarction in kidney transplant recipients: A nested case-control study

INTRODUCTION

The epidemiology of early acute myocardial infarctions after kidney transplantation has not been well characterized. This study sought to examine the incidence, risk factors, and clinical outcomes of early acute myocardial infarctions or EAMI in kidney transplant recipients.

METHODS

A total of 1976 patients who underwent kidney transplantation at our center from Jan 1, 2000, to Sept 30, 2016, were included. A nested case-control design was used to study EAMI risk factors using a conditional logistic regression model. A Cox proportional hazards model was used to assess the association of EAMI with death-censored graft failure, death with graft function, and total graft failure.

RESULTS

Seventy four patients had an EAMI within 3 months post-transplant. Based on univariable analyses, risk factors for EAMI included age and recipient history of diabetes mellitus or coronary artery disease. After adjustment, recipient history of coronary artery disease was the only independent predictor for EAMI (OR 3.76, p < .001). Patients who experienced EAMI were more likely to experience death-censored graft failure, death with graft function, and total graft failure.

CONCLUSION

While the incidence of EAMI in kidney transplant recipients is relatively low, these data show that EAMI has profound long-term effects on morbidity and mortality.

Examining Risk: A Systematic Review of Perioperative Cardiac Risk Prediction Indices

OBJECTIVE

To conduct a systematic review of published cardiac risk indices relevant to patients undergoing noncardiac surgery and to provide clinically meaningful recommendations to physicians regarding the use of these indices.

METHODS

A literature search of articles published from January 1, 1999, through December 28, 2018, was conducted in Ovid (MEDLINE), PubMed, Embase, CINAHL, and Web of Science. Publications describing models predicting risk of cardiac complications after noncardiac surgery were included and citation chaining was used to identify additional studies for inclusion.

RESULTS

Eleven risk indices involving 2,910,297 adult patients were included in this analysis. Studies varied in size, population, quality, risk of bias, outcome event definitions, risk factors identified, index outputs, accuracy, and clinical usefulness. Studies considered 6 to 83 variables to develop their models. Among the identified models, the factors with the highest predictiveness for adverse cardiac outcomes included congestive heart failure, type of surgery, creatinine, diabetes, history of stroke or transient ischemic attack, and emergency surgery. Substantial data from the large studies also supports advancing age, American Society of Anesthesiology physical status classification, functional status, and hypertension as additional risks.

CONCLUSION

The risk indices identified generally fell into two groups - those with higher accuracy for predicting a narrow range of cardiac outcomes and those with lower accuracy for predicting a broader range of cardiac outcomes. Using one index from each group may be the most clinically useful approach. Risk factors identified varied widely among studies. In addition to judicious use of predictive indices, reasoned clinical judgment remains indispensable in assessing perioperative cardiac risk.

Low-dose aspirin and burr-hole drainage of chronic subdural hematoma: study protocol for a randomized controlled study

BACKGROUND

Low-dose acetylsalicylic acid (ASA) in patients with chronic subdural hematoma (cSDH) represents a significant neurosurgical challenge. While continuation of ASA during the perioperative phase might increase recurrence and bleeding rates, discontinuation increases the risk of thromboembolic events. The aim of this study is to compare the postoperative recurrence and cardiovascular complication rates of patients undergoing burr-hole trepanation for cSDH with and without discontinuation of ASA.

METHODS

In this prospective randomized, placebo-controlled, double-blinded study we include all patients undergoing burr-hole drainage of cSDH who are under ASA treatment. The patients are randomized into two groups, one receiving ASA and the other placebo perioperatively. The study primarily seeks to compare the rate of recurrent events under ASA to that under placebo treatment. Secondary objectives are thromboembolic event rate, perioperative blood loss, postoperative anemia, intra- and postoperative blood transfusion rate, and clinical outcome.

DISCUSSION

To date, there is no evidence-based consensus on how to manage patients undergoing burr-hole drainage for cSDH who are under ASA treatment. Therefore, the decision to maintain or interrupt ASA treatment is based mostly on the surgeons' preference. A randomized placebo-controlled study for this frequent question is urgently needed in order to provide class I evidence for the best possible treatment of this large group of patients.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03120182 . Initial Release: 19.04.2017.

STUDY PROTOCOL

V2_23.02.2017.

Cardiac Biomarkers Predicting MACE in Patients Undergoing Noncardiac Surgery: A Meta-Analysis

Objective: The present meta-analysis was aimed to systematically evaluate the effectiveness and accuracy of brain natriuretic peptide (BNP), cardiac troponin (cTn), high sensitive C reactive protein (hs-CRP) and CRP for predicting postoperative major adverse cardiovascular events (MACE) in patients undergoing noncardiac surgery.

Methods: A total of 26 relevant studies with 7,877 participants were collected from five databases, namely PubMed, Embase, China National Knowledge Infrastructure (CNKI), CQVIP and the Wanfang Database until August 10, 2018. And the Review Manager Version 5.3 and Stata/SE 12 software were used for data syntheses in the meta-analysis.

Results: Strong relationships of BNP/NT-proBNP, cTnI/cTnT and hs-CRP with MACE were detected in patients undergoing noncardiac surgery, and the five biomarkers all increased the risk of MACE. Compared to normal levels, elevated BNP/NT-proBNP could increase the MACE risk by almost 4-fold [RR:3.92, 95%CI: 3.23–4.75, P < 0.001]; elevated BNP corresponded to a 4.5-fold risk [RR:4.57, 95%CI: 3.37–6.20, P < 0.001]; elevated NT-proBNP led to a 3-fold higher risk [RR:3.48, 95%CI: 2.71–4.46, P < 0.001]. Comparing with normal levels of cTnI/cTnT, increased cTnI/cTnT was associated with nearly 5-fold more higher risk of MACE [RR:5.52, 95%CI: 4.62–6.58, P < 0.001]; elevated cTnI faced a 5-fold risk [RR:5.21, 95%CI: 3.96–6.86, P < 0.001]; elevated cTnT resulted in nearly 6-fold higher risk [RR:5.73, 95%CI: 4.55–7.22, P < 0.001]. The elevation of hs-CRP was associated with nearly 4-fold higher risk of MACE in comparison with normal concentration [RR:3.73, 95%CI: 2.63–5.30, P < 0.001].

Conclusion: According to the results of our meta-analysis, the elevations of BNP/NT-proBNP, cTnI/cTnT, and hs-CRP, pre-operation or post-operation immediately, can predict much higher risk of postoperative MACE in patients undergoing noncardiac surgery.

Risk factors contributing to cardiac events following general and vascular surgery

Background

Cardiac events (CE) following surgery have been associated with morbidity and mortality. Defining risk factors that contribute to CE is essential to improve surgical outcomes.

Study design

This was a retrospective study at a large urban teaching hospital for surgery performed from 2013 to 2015. Adult patients (≥18 years) that underwent general and vascular surgery were analyzed. Patients were grouped into those who experienced postoperative CE and those who did not. Univariate and multivariate regression analyses were used to identify predictors of postoperative CE, and association of CE with adverse postoperative outcomes. Separate subgroup analyses were also conducted for general and vascular surgery patients to assess predictors of CE.

Results

Out of 8441 patients, 157 (1.9%) experienced CE after major general and vascular surgery. Underlying predictors for CE included age >65 years(OR 4.9, 95%CI 3.4–6.9,p < 0.01), ASA >3(OR 12.0, 95%CI 8.5–16.9,p < 0.01), emergency surgery(OR 3.7, 95%CI 2.7–5.1,p = 0.01), CHF(OR 11.2, 95%CI 6.4–16.7,p = 0.02), COPD(OR 3.9, 95%CI 2.4–6.4,p = 0.04), acute renal failure or dialysis(OR 8.0, 95%CI 5.2–12.1,p = 0.04), weight loss(OR 3.3, 95%CI 1.7–6.7,p < 0.01), preoperative creatinine >1.2 mg/dL(OR 5.1, 95%CI 3.7–7.1,p = 0.01), hematocrit <34%(OR 4.0, 95%CI 2.8–5.7,p < 0.01), and operative time >240 min(OR 2.0, 95%CI 1.3–3.3,p = 0.02). Following surgery, CE was associated with increased mortality(OR 3.5, 95%CI 1.2–6.5,p < 0.01), pulmonary complications(OR 5.0, 95%CI 3.1–8.9,p < 0.01), renal complications(OR 2.3, 95%CI 1.9–4.5,p < 0.01), neurologic complications(OR 2.5, 95%CI 1.4–5.2,p < 0.01), systemic sepsis(OR 2.2, 95%CI 1.7–4.0,p < 0.01), postoperative RBC transfusion(OR 4.4, 95%CI 2.7–6.5,p < 0.01), unplanned return to operating room(OR 4.0, 95%CI 2.3–6.9,p < 0.01), and prolonged hospitalization (OR 5.5, 95%CI 3.1–8.8,p = 0.03). There was no statistical difference in incidence of CE between general and vascular surgery patients (p = 0.44); however, predictors of CE differed between the two surgical groups.

Conclusion

Postoperative CE are associated with significant morbidity and mortality. Identified predictors of CE should allow for adequate risk stratification and optimization of perioperative surgical management.

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Cardiac events following general and vascular surgery were associated with a mortality rate of 55%.

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Underlying risk factors for cardiac events following general and vascular surgery include COPD, hypertension on medication, and renal failure.

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Return to the OR, deep wound infection, unplanned intubation and ventilator dependence are also associated with a post-op cardiac event.

Consensus Document ANMCO/ANCE/ARCA/GICR-IACPR/GISE/SICOA: Long-term Antiplatelet Therapy in Patients with Coronary Artery Disease

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the cornerstone of pharmacologic management of patients with acute coronary syndrome (ACS) and/or those receiving coronary stents. Long-term (>1 year) DAPT may further reduce the risk of stent thrombosis after a percutaneous coronary intervention (PCI) and may decrease the occurrence of non-stent-related ischaemic events in patients with ACS. Nevertheless, compared with aspirin alone, extended use of aspirin plus a P2Y12 receptor inhibitor may increase the risk of bleeding events that have been strongly linked to adverse outcomes including recurrent ischaemia, repeat hospitalisation and death. In the past years, multiple randomised trials have been published comparing the duration of DAPT after PCI and in ACS patients, investigating either a shorter or prolonged DAPT regimen. Although the current European Society of Cardiology guidelines provide a backup to individualised treatment, it appears to be difficult to identify the ideal patient profile which could safely reduce or prolong the DAPT duration in daily clinical practice. The aim of this consensus document is to review contemporary literature on optimal DAPT duration, and to guide clinicians in tailoring antiplatelet strategies in patients undergoing PCI or presenting with ACS.

Postoperative Adverse Cardiovascular Events Associated with Leptin and Adverse Age After Elective Major Non-Cardiac Surgery: An Asian Single-Center Study

BACKGROUND The postoperative adverse cardiovascular events (PACE) after surgery can result in prolonged length of stay and poorer prognosis. The purpose of this Asian single-center study was to investigate the potential predicative role of leptin for PACE in elderly patients undergoing major non-cardiac surgery. MATERIAL AND METHODS The patients in the study were prospectively recruited from a series of elderly patients (≥60 years) undergoing elective major non-cardiac surgery (≥2 hours) in our hospital from June 2013 to June, 2016. The demographic and clinical data and the preoperative serum biomarkers of each participant were recorded in details. Suspected PACE were assessed by the same experienced expert based on clinical, blood, and other accessory tests. The univariate and multiple logistic regression analyses were plotted to evaluate the potential independent predictive factors for PACE. RESULTS A total of 270 elderly patients (145 males and 125 females), undergoing major elective non-cardiac surgery, were finally enrolled in this study. Older age, higher revised cardiac risk index score, higher levels of systolic blood pressure, B-type natriuretic peptide and leptin, the preoperative medication of beta blocker and lipid-lowering agents were positive predictors of PACE by univariate analyses (p<0.05). Our results indicated that preoperative leptin level (OR 1.84, 95% CI 1.08-3.42; p=0.015) and advanced age (OR 0.24, 95% CI 0.09-0.94; p=0.041) were significantly associated with the occurrence of PACE by multiple logistic regression analyses. CONCLUSIONS Preoperative serum leptin level and advanced age were two independent risk factors for PACE among elderly patients undergoing elective major non-cardiac surgery.

Defining the Intrinsic Cardiac Risks of Operations to Improve Preoperative Cardiac Risk Assessments

Background

Current preoperative cardiac risk stratification practices group operations into broad categories, which might inadequately consider the intrinsic cardiac risks of individual operations. We sought to define the intrinsic cardiac risks of individual operations and to demonstrate how grouping operations might lead to imprecise estimates of perioperative cardiac risk.

Methods

Elective operations (based on Common Procedural Terminology codes) performed from January 1, 2010 to December 31, 2015 at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program were studied. A composite measure of perioperative adverse cardiac events was defined as either cardiac arrest requiring cardiopulmonary resuscitation or acute myocardial infarction. Operations’ intrinsic cardiac risks were derived from mixed-effects models while controlling for patient mix. Resultant risks were sorted into low-, intermediate-, and high-risk categories, and the most commonly performed operations within each category were identified. Intrinsic operative risks were also examined using a representative grouping of operations to portray within-group variation.

Results

Sixty-six low, 30 intermediate, and 106 high intrinsic cardiac risk operations were identified. Excisional breast biopsy had the lowest intrinsic cardiac risk (overall rate, 0.01%; odds ratio, 0.11; 95% CI, 0.02 to 0.25) relative to the average, whereas aorto-bifemoral bypass grafting had the highest (overall rate, 4.1%; odds ratio, 6.61; 95% CI, 5.54 to 7.90). There was wide variation in the intrinsic cardiac risks of operations within the representative grouping (median odds ratio, 1.40; interquartile range, 0.88 to 2.17).

Conclusions

A continuum of intrinsic cardiac risk exists among operations. Grouping operations into broad categories inadequately accounts for the intrinsic cardiac risk of individual operations.

Does Early Resumption of Low-Dose Aspirin After Evacuation of Chronic Subdural Hematoma With Burr-Hole Drainage Lead to Higher Recurrence Rates?

BACKGROUND

Antiplatelet therapy in patients with chronic subdural hematoma (cSDH) presents significant neurosurgical challenges. Given the lack of guidelines regarding perioperative management with antiplatelet therapy, it is difficult to balance the patient's increased cardiovascular risk and prevalence of cSDH.

OBJECTIVE

To better understand the risk and recurrence rates related to resuming low-dose acetylsalicylic acid (ASA) by evaluating our patients' resumption of low-dose ASA at various times after burr-hole drainage of the hematoma.

METHODS

In our retrospective study, 140 consecutive patients taking low-dose ASA undergoing surgical evacuation of cSDH were included. Data included baseline characteristics and rates of recurrence, morbidity, and mortality. A multivariate logistic regression model analyzed the association between ASA resumption time and recurrence rates.

RESULTS

No statistically significant association was observed between early postoperative resumption of low-dose ASA and recurrence of cSDH (odds ratio, 1.01; 95% confidence interval, 1.001-1.022; P = .06). Corresponding odds ratios and risk differences for restarting ASA treatment on postoperative days 1, 7, 14, 21, 28, 35, or 42 were estimated at 1.53 and 5.9%, 1.42 and 5.1%, 1.33 and 4.1%, 1.23 and 3.2%, 1.15 and 2.2%, 1.07 and 1.1%, and 1.01 and 0.2%, respectively (P > .05). Cardiovascular event rates, surgical morbidity, and mortality did not significantly differ between patients with or without ASA therapy.

CONCLUSION

Given the few published studies regarding ASA use in cranial neurosurgery, our findings elucidate one issue, showing comparable recurrence rates with early or late resumption of low-dose ASA after burr-hole evacuation of cSDH.

ABBREVIATIONS

ASA, acetylsalicylic acidCAD, coronary artery diseaseCI, confidence intervalcSDH, chronic subdural hematomaGCS, Glasgow Coma ScalemRS, modified Rankin ScaleOR, odds ratioRD, risk difference.

Development of a new risk nomogram of perioperative major adverse cardiac events for Chinese patients undergoing colorectal carcinoma surgery

PURPOSE

The purpose of this study is to create a new risk nomogram to predict perioperative major adverse cardiac events in patients undergoing colorectal carcinoma surgery.

METHODS

A total of 1899 patients who underwent colorectal carcinoma surgery at a tertiary teaching hospital in China between 2007 and 2012 were recruited. Logistic regression analysis was used to define risk factors for major adverse cardiac events. A nomogram-predicting model was built based on the logistic regression model and discrimination was tested by receiver operating characteristic curves.

RESULTS

Fifty-six (2.9%) among 1899 included patients developed at least one cardiac event. Eight risk factors were found in the multivariate logistic regression model, which included age ≥60 years, smoking, a history of chronic kidney disease, coronary artery disease, congestive heart failure, hypertension, preoperative albumin levels ≤35 g/L, blood transfusion ≥500 mL, and intraoperative blood pressure variability. P = 0.708 in the Hosmer-Lemeshow test indicated acceptable calibration power. Based on this multivariate model, we built a risk nomogram model for these cardiac events with an area under the curve (95% confidence interval) of 0.923 (0.889, 0.957), which demonstrated good discrimination of this model. When the probability cutoff was 1.9% (total score of 83), the nomogram model had the best sensitivity and specificity in predicting cardiac events.

CONCLUSIONS

A new nomogram model for predicting perioperative major adverse cardiac events in patients who had colorectal carcinoma surgery was established in this study. When the total score is >83, patients undergoing colorectal carcinoma surgery should be considered at high risk of perioperative major adverse cardiac events.

Preoperative serum potassium predicts the clinical outcome after non-cardiac surgery

BACKGROUND

Potassium disorders have been linked to adverse outcomes in various medical conditions. However, the association of preoperative serum potassium with postoperative outcome is not well established. We aimed to examine the association between preoperative potassium with a 30-day mortality and adverse cardiovascular event (MACE).

METHODS

We conducted a cohort study using a prospectively collected database of patients, undergoing surgical procedures from 1998 to 2013 in the VA Western New York Healthcare System, which are reported to the Veterans Affairs Surgical Quality Improvement Program (VASQIP). The patients were categorized into three groups based on their documented preoperative potassium concentrations. Hypokalemia was defined as serum potassium concentration <4 mmol/L and hyperkalemia was defined as serum potassium concentrations >5.5 mmol/L. The values within the range of 4.0-5.5 mmol/L were considered as normokalemia and used as the control group. Statistical analyses included Chi-square test, analysis of variance and multivariate logistic regression to estimate the risk of MACE within 30 days of surgery.

RESULTS

Study included 5959 veterans who underwent surgery between 1998 and 2013. The patients in the hyperkalemics group had lower kidney function compared to the other two groups. The frequency of MACE was 13.6% in hypokalemics and 21.9% in hyperkalemics that were both significantly higher than 4.9% in controls. In multivariate logistic regression the hazard risk (HR) ratios of MACE were (2.17, 95% CI 1.75-2.70) for hypokalemics and (3.23, 95% CI 2.10-4.95) for hyperkalemics when compared to normokalemic controls.

CONCLUSIONS

Preoperative hypokalemia and hyperkalemia are both independent predictors of MACE within 30 days.

Burr-Hole Drainage for Chronic Subdural Hematoma Under Low-Dose Acetylsalicylic Acid: A Comparative Risk Analysis Study

BACKGROUND

Chronic subdural hematoma (cSDH) is one of the most common neurosurgical diseases typically affecting older people. Many of these patients have coronary artery disease and receive antiplatelet therapy, usually acetylsalicylic acid (ASA). Despite growing clinical relevance, there is still a lack of data focusing on the perioperative management of such patients.

OBJECTIVE

The aim of this study is to compare the perioperative and postoperative bleeding and cardiovascular complication rates of patients undergoing burr-hole drainage for cSDH with and without discontinuation of low-dose ASA.

METHODS

Of 963 consecutive patients undergoing burr-hole drainage for cSDH, 198 (20.5%) patients were receiving low-dose ASA treatment. In 26 patients (13.1%), ASA was not discontinued (ASA group; ASA discontinuation ≤7 days); in the remaining patients (n = 172; 86.9%), ASA was discontinued at least for 7 days (control group). The primary outcome measure was recurrent cSDH that required revision surgery owing to clinical symptoms, whereas secondary outcome measures were postoperative cardiovascular and thromboembolic events, other complications, operation and hospitalization time, morbidity, and mortality.

RESULTS

No statistically significant difference was observed between the 2 groups regarding recurrence of cSDH (P = 1). Cardiovascular event rates, surgical morbidity, and mortality did not significantly differ between patients with and without discontinuation of low-dose ASA.

CONCLUSION

Given the lack of guidelines regarding perioperative management with antiplatelet therapy, our findings elucidate one issue, showing comparable recurrence rates with and without discontinuation of low-dose ASA in patients undergoing burr-hole drainage for cSDH.

Early cardiology assessment and intervention reduces mortality following myocardial injury after non-cardiac surgery (MINS)

BACKGROUND

Myocardial injury after non-cardiac surgery (MINS) is defined as troponin elevation of ≥0.03 ng/mL associated with 3.87-fold increase in early mortality. We sought to determine the impact of cardiology intervention on mortality in patients who developed MINS after general thoracic surgery.

METHODS

A retrospective review was performed in patients over 5 years. Troponin was routinely measured and levels ≥0.04 ng/mL classified as positive. Data acquisition and mortality status was obtained via medical records and NHS tracing systems. Thirty-day mortality was compared on MINS cohort using Fisher's exact square testing and logistic regression analysis.

RESULTS

Troponin levels were measured in 491 (96%) of 511 patients. Eighty (16%) patients fulfilled the MINS criteria. Sixty-one (76%) received early cardiology consult and "myocardial infarction" stated in four (5%) patients. Risk assessment (for AMI) was undertaken; 20 (25%) patients were commenced on aspirin, four (5%) on β-blockers and one (1%) underwent percutaneous coronary intervention. Forty-nine (61%) patients received primary risk factor modifications and 26 (33%) had outpatient follow-up. There were no significant differences in the proportion of patients who died within 30 days post-operatively in the MINS group of 2.6% compared to the non-MINS group of 1.6% (P=0.625). The odds ratio for 30-day mortality in the MINS group was 1.69 (95% CI: 0.34 to 8.57, P=0.522).

CONCLUSIONS

MINS is common after general thoracic surgery. Early cardiology intervention reduced the expected hazard ratio of early death from 3.87 to an odds ratio of 1.69 with no significant difference in 30-day mortality for patients who developed MINS.

Congestive Heart Failure and Noncardiac Operations: Risk of Serious Morbidity, Readmission, Reoperation, and Mortality

BACKGROUND

Congestive heart failure (CHF) predicts surgical morbidity and mortality. However, few studies evaluate CHF's impact on noncardiac operations. Because of CHFs serious threat to health and survival, surgeons must understand risks CHF poses to patients undergoing a diverse array of operations.

STUDY DESIGN

We used 2009 to 2013 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Files to estimate the risk of serious morbidity, reoperation, readmission, mortality, and other postoperative complications associated with preoperative diagnosis of CHF. Multivariable logistic regression analysis provided odds ratios (OR) and 95% confidence intervals (CI) for outcomes in 34 ACS NSQIP procedure groups, controlling for age, sex, race, emergency surgery status, American Society of Anesthesiologists Classification, body mass index, and selected laboratory values.

RESULTS

Unadjusted ORs indicate adverse effects of CHF on surgical outcomes for most procedures considered. When adjusted for age and other confounders, CHF persists with adverse effects on most outcomes, including serious morbidity (OR 1.52, 95% CI, 1.44 to 1.61; p < 0.001); reoperation (OR 1.29, 95% CI, 1.17 to 1.42; p < 0.001); readmission (OR 1.39, 95% CI, 1.29 to 1.50; p < 0.001); and 30-day mortality (OR 1.96, 95% CI 1.80 to 2.13; p < 0.001). The impact of CHF on morbidity and mortality substantially affected those undergoing carotid endarterectomy and lower extremity endovascular repair. Cardiac arrest, mortality, unplanned intubation, and ventilator > 48 hours were complications most affected by CHF.

CONCLUSIONS

Congestive heart failure strongly predicts serious morbidity, unplanned reoperation, readmission, and surgical mortality for noncardiac operations. Surgeons must pay particular attention to recognizing CHF and optimizing perioperative management when considering surgery.

A review of the peri-operative risk stratification assessment tools used for the prediction of cardiovascular complications in non-cardiac surgery

The development of atherosclerosis is a complex process that involves several inflammatory mechanisms. The evolution of a fatty streak to a mature occlusive atheromatous plaque occurs over several decades. However, during acute plaque rupture, to a varying degree, these same inflammatory systems are involved.Evidence exists that suggests a relationship between the activated inflammatory pathways; in the setting of lower respiratory tract or urinary tract infections and cardiac events such as unstable angina or myocardial infarctions.Peripheral vascular disease patients demonstrate atheromatous disease throughout their arterial tree, with coronary artery involvement in a significant proportion of individuals. The stress that a surgical intervention creates may be the catalyst for an acute coronary syndrome through the activation of these inflammatory pathways. Individual responses to the surgical insult are unpredictable and the extent to which the inflammatory mechanisms are stimulated is variable. The measurements of inflammatory biomarkers, such as C-reactive protein, have been associated with adverse short- and long-term mortality in patients who experience an acute coronary syndrome.This review article looks at the previous assessment tools that have been developed over time to try and predict the peri-operative risk of patients undergoing non-cardiac surgery, based on traditional patient parameters. We also explore the use of bio-markers in addition to these characteristics and how future work is being developed to look at the potential use of these to improve individual risk profiles.

The prediction of postoperative stroke or death in patients with preoperative atrial fibrillation undergoing non-cardiac surgery: a VISION sub-study

BACKGROUND

The optimal means of pre-operative risk stratification in patients with atrial fibrillation (AF) is uncertain.

OBJECTIVE

To examine the accuracy of AF thromboembolic risk models (the CHADS2, CHA2DS2-VASc, and R2CHADS2 scores) for predicting 30-day stroke and/or all-cause mortality after non-cardiac surgery in patients with preoperative AF, and to compare these risk scores with the Revised Cardiac Risk Index (RCRI).

PATIENTS/METHODS

A multicentre (8 countries, 2007-2011) prospective cohort study of patients ≥ 45 years of age undergoing inpatient non-cardiac surgery, who were followed until 30 days after surgery. We calculated c-statistics for each risk prediction model and net reclassification improvements (NRIs) compared with the RCRI.

RESULTS

The 961 patients with preoperative AF were at higher risk of any cardiovascular event in the 30 days postoperatively compared with the 13 001 patients without AF: 26.6% vs. 9.0%; adjusted odds ratio, 1.58; 95% confidence interval [CI], 1.33-1.88. All thromboembolic risk scores predicted postoperative death just as well as the RCRI (with c-indices between 0.67 and 0.72). Compared with the RCRI (which had a c-index of 0.64 for 30-day stroke/death), the CHADS2 (c-index, 0.67; NRI, 0.31; 95% CI, 0.02-0.61) significantly improved postoperative stroke/mortality risk prediction, largely due to improved discrimination of patients who did not subsequently have an event.

CONCLUSIONS

In AF patients, the three thromboembolic risk scores performed similarly to the RCRI in predicting death within 30 days and the CHADS2 score was the best predictor of postoperative stroke/death regardless of type of surgery.

Major adverse cardiac events in elderly patients with coronary artery disease undergoing noncardiac surgery: A multicenter prospective study in China

BACKGROUND

Major adverse cardiac events (MACEs) are important causes of perioperative morbidity and mortality for elderly patients undergoing non-cardiac surgery. Treatment and control rates for coronary artery disease (CAD) in Chinese patients are poorer than rates in western countries. However, no previous prospective study has focused on perioperative MACE in this population. Our aim was to ascertain the incidence and risk factors associated with MACEs in Chinese patients.

METHODS

Consecutive CAD patients, aged ≥60 years, who underwent non-cardiac surgery at five medical centers in China, were prospectively enrolled. Clinical variables, including electrocardiogram and troponin I levels, were evaluated to estimate MACEs. The main outcome was occurrence of at least one perioperative MACE from admittance to 30 days after surgery, defined as any of the following complications: cardiac death, nonfatal cardiac arrest, acute myocardial infarction (MI), congestive heart failure (CHF), and angina. MACE independent risk factors were based on the Andersen-Gill multiplicative intensity model.

RESULTS

Of the 1422 patients recruited, 129 (9.1%) developed at least one MACE, and cardiac death occurred in 11 patients (0.8%). The independent risk factors contributing to postoperative MACE included age ≥75 years, female gender, history of MI, history of hypertension, high-risk surgery, intraoperative hypotension, and intraoperative hypoxemia.

CONCLUSIONS

The incidence of MACE in Chinese elderly patients with CAD who underwent non-cardiac surgery was 9.1%. Seven independent risk factors for a perioperative MACE were identified. Preventing intraoperative hypoxemia and hypotension may reduce the occurrence of MACE in these high risk patients.

Worsening preoperative heart failure is associated with mortality and noncardiac complications, but not myocardial infarction after noncardiac surgery: a retrospective cohort study

BACKGROUND

Heart failure (HF) is an important risk factor for perioperative morbidity and mortality. While these patients are at high risk for cardiac adverse events, there are few current data describing the types of noncardiac complications that occur in this population.

METHODS

We performed a multicenter cohort study of patients undergoing noncardiac surgery from 2005 to 2010 as part of the American College of Surgeons National Surgical Quality Improvement Program. A HF cohort (HF that is new or worsening within 30 days of surgery) was compared with a control cohort that was matched regarding other surgical risk factors.

RESULTS

Five thousand ninety-four patients with worsening preoperative HF were compared with an otherwise similar cohort of patients without worsening preoperative HF. Worsening preoperative HF was associated with increased risk of 30-day all-cause mortality (relative risk [RR] 2.08; 95% confidence interval [CI], 1.75-2.46; P < 0.001) and increased risk of morbidity (any recorded postoperative complication) (RR 1.54; 95% CI, 1.40-1.69; P < 0.001). HF patients had increased risk of developing renal failure (RR 1.85; 95% CI, 1.37-2.49; P < 0.001), need for mechanical ventilation longer than 48 hours (RR 1.81; 95% CI, 1.52-2.15; P < 0.001), pneumonia (RR 1.73; 95% CI, 1.44-2.08; P < 0.001), cardiac arrest (RR 1.69; 95% CI, 1.29-2.21; P < 0.001), unplanned intubation (RR 1.68; 95% CI, 1.41-1.99; P < 0.001), renal insufficiency (RR 1.64; 95% CI, 1.10-2.44; P = 0.014), sepsis (RR 1.43, 95% CI, 1.24-1.64; P < 0.001), and urinary tract infection (RR 1.29; 95% CI, 1.06-1.58; P = 0.011). The incidence of myocardial infarction in the sample was similar between the 2 groups (RR 1.07; 95% CI, 0.75-1.52; P = 0.719).

CONCLUSIONS

Worsening preoperative HF is associated with a significant increase in postoperative morbidity and mortality when controlling for other comorbidities. Although these likely have a multifactorial etiology, patients are much more likely to suffer from respiratory, renal, and infectious complications than cardiac complications.

Which risk score best predicts perioperative outcomes in nonvalvular atrial fibrillation patients undergoing noncardiac surgery?

BACKGROUND

Patients with nonvalvular atrial fibrillation (NVAF) are at increased risk for adverse events after noncardiac surgery. The Revised Cardiac Index (RCI) is commonly used to predict perioperative events; however, the prognostic utility of NVAF risk scores (CHADS2, CHA2DS2-VASc, and R2CHADS2) has not been evaluated in patients undergoing noncardiac surgery.

METHODS

Using a population-based data set of NVAF patients (n = 32,160) who underwent major or minor noncardiac surgery between April 1, 1999, and November 30, 2009, in Alberta, Canada, we examined the incremental prognostic value of the CHADS2, CHA2DS2-VASc, and R2CHADS2 scores over the RCI using continuous net reclassification improvement (NRI). The primary composite outcome was 30-day mortality, stroke, transient ischemic attack, or systemic embolism.

RESULTS

The median age was 73 years, 55.1% were male, 6.6% had a previous thromboembolism, 17% of patients underwent major surgery, and the median risk scores were as follows: RCI = 1, CHADS2 = 1, CHA2DS2-VASc = 3, and R2CHADS2 = 2. The incidence of our 30-day composite was 4.2% (mortality 3.3%; stroke, transient ischemic attack, or systemic embolism 1.2%); and c indices were 0.65 for the RCI, 0.67 for the CHADS2 (NRI 14.3%, P < .001), 0.67 for CHA2DS2-VASc (NRI 10.7%, P < .001), and 0.68 for R2CHADS2 (NRI 11.4%, P < .001). The CHADS2, CHA2DS2-VASc, and R2CHADS2 scores were also all significantly better than the RCI for mortality risk prediction (NRI 12.3%, 8.4%, and 13.3%, respectively; all Ps < .01).

CONCLUSIONS

In NVAF patients undergoing noncardiac surgery, the CHADS2, CHA2DS2-VASc, and R2CHADS2 scores all improved the prediction of major perioperative events including mortality compared to the RCI.

Perioperative management of the patient with diabetes mellitus: update and overview

Perioperative management of diabetic patients involves optimizing glycemic control and negotiating comorbidities to help reduce complications and obtain results on par with nondiabetics. These goals are usually achievable in the elective surgical setting, but they can be more difficult to control in urgent or emergent situations. Understanding and recognizing the comorbidities associated with diabetes is imperative for optimizing outcomes. Regulating hyperglycemia can reduce morbidity, mortality, and postoperative infections. Understanding the effects of cardiac and renal disease is also important. Taking a team approach in managing these complex patients leads to improved outcomes and is now considered the standard of care.

Clinical use of ultrasensitive cardiac troponin I assay in intermediate- and high-risk surgery patients

Background. Cardiac troponin levels have been reported to add value in the detection of cardiovascular complications in noncardiac surgery. A sensitive cardiac troponin I (cTnI) assay could provide more accurate prognostic information. Methods. This study prospectively enrolled 142 patients with at least one Revised Cardiac Risk Index risk factor who underwent noncardiac surgery. cTnI levels were measured postoperatively. Short-term cardiac outcome predictors were evaluated. Results. cTnI elevation was observed in 47 patients, among whom 14 were diagnosed as having myocardial infarction (MI). After 30 days, 16 patients had major adverse cardiac events (MACE). Excluding patients with a final diagnosis of MI, predictors of cTnI elevation included dialysis, history of heart failure, transoperative major bleeding, and elevated levels of pre- and postoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP). Maximal cTnI values showed the highest sensitivity (94%), specificity (75%), and overall accuracy (AUC 0.89; 95% CI 0.80–0.98) for postoperative MACE. Postoperative cTnI peak level (OR 9.4; 95% CI 2.3–39.2) and a preoperative NT-proBNP level ≥917 pg/mL (OR 3.47; 95% CI 1.05–11.6) were independent risk factors for MACE. Conclusions. cTnI was shown to be an independent prognostic factor for cardiac outcomes and should be considered as a component of perioperative risk assessment.

Three-dimensional computed tomography angiography for the preoperative evaluation of coronary artery disease in lung cancer patients

BACKGROUND

The number of elderly patients undergoing surgery for lung cancer is increasing. In this study, we assessed the usefulness of three-dimensional computed tomographicangiography (3D-CTA) for the detection of coronary disease in the elderly before surgical intervention for lung cancer.

METHODS

One hundred twenty patients admitted to our institution for lung cancer resection were enrolled in the study. 3D-CTA was performed in all 120 patients.

RESULTS

Seventy-one patients had normal findings, and forty-nine patients showed coronary stenosis on 3D-CTA examination. Among the latter 49 patients, 24 with slight stenosis underwent lung tumor resection, 23 had coronary angiography for severe stenosis before lung surgery and 2 were not eligible for lung resection because of very severe coronary stenosis. The diagnostic value of 3D-CTA was better than conventional CT.

CONCLUSIONS

This study suggests the usefulness of 3D-CTA for the preoperative diagnosis of coronary ischemic disease in elderly lung cancer patients.

Impact of preoperative myocardial infarction on surgical outcomes in inpatient orthopaedic surgery

PURPOSE

The purpose of this study was to evaluate the impact of a preoperative myocardial infarction (MI) on outcomes of inpatient orthopaedic operations.

METHODS

The National Surgical Quality Improvement Program database was used to identify patients who underwent common orthopaedic operations from 2006 to 2010. Patient demographic data, comorbidities, complications, and lengths of stay were collected. Multivariate logistic regression and linear regression models were used to compare outcomes for patients with and without a history of MI in the six months prior to surgery.

RESULTS

Of the 32,462 patients identified, 86 had sustained an MI in the six months prior to surgery. The MI cohort had no cardiac complications but had increased incidences of superficial surgical site infection, unplanned re-intubation, ventilator-assisted respiration for more than 48 hours, pneumonia, sepsis or septic shock, and postoperative mortality within 30 days of surgery, as well as prolonged lengths of stay. Following logistic regression to adjust for baseline differences, a history of MI showed no association with cardiac complications and was significantly associated with superficial surgical site infection (OR 3.6, 95% CI 1.1-11.8), ventilator dependence for over 48 hours (OR 4.0, 95% CI 1.1-14.0), and extended length of stay (median with interquartile range 4 [4-4] vs. 5 [5-5] days).

CONCLUSIONS

A myocardial infarction within six months prior to orthopaedic surgery is not associated with a higher risk of 30-day perioperative cardiac complications; however, it is associated with increased rates of surgical site infection, prolonged ventilator dependence, and longer hospital stay.

Incidence and mortality of perioperative cardiac events in cervical spine surgery

STUDY DESIGN

Retrospective database analysis.

OBJECTIVE

To determine the national incidence, mortality, and risk factors for perioperative cardiac complications associated with cervical spine surgery in the United States.

SUMMARY OF BACKGROUND DATA

Perioperative myocardial infarctions and cardiac failure are leading causes of mortality in noncardiac surgery. The incidence of these complications has not been reported in cervical spine surgery.

METHODS

Data from the Nationwide Inpatient Sample was obtained from 2002-2009. Patients undergoing anterior or posterior cervical fusion and posterior cervical decompression without fusion for degenerative etiologies were identified. Only elective admissions were included. Incidences of cardiac complications were identified and patient demographics, hospital costs, length of stay, and mortality were compared for each group. Logistic regression was used to identify independent predictors of cardiac complications.

RESULTS

A total of 214,900 elective cervical spine procedures were identified in the United States from 2002-2009. Overall, there were 4.0 cardiac events per 1000 cases. For individual procedures, the incidence was 11.6 per 1000 posterior cervical fusions, 5.2 per 1000 posterior cervical decompressions, and 3.2 per 1000 anterior cervical fusions. Patients with cardiac events were statistically older with greater comorbidities (P < 0.0005). Across all cohorts, length of stay increased an additional 4.5 days, hospital costs increased $13,435, and mortality increased from 0.8 to 65.3 deaths per 1000 cases in the presence of a cardiac event (P < 0.0005). Logistic regression analysis demonstrated that independent predictors for cardiac events included age 65 years or more, multilevel fusions, acute blood-loss anemia, congestive heart failure, fluid/electrolyte disorders, and pulmonary circulation disorders.

CONCLUSION

Our results demonstrate an overall incidence of 4.0 cardiac events per 1000 cervical spine surgical procedures. Older patients with greater comorbid risk factors, particularly cardiovascular diseases, were at significantly increased risk for cardiac complications. Due to the large impact cardiac events have on health care utilization and mortality, we recommend thorough risk stratification for older patients undergoing elective cervical spine procedures.

LEVEL OF EVIDENCE

3.

Nanosensor electrical immunoassay for quantitative detection of NT-pro brain natriuretic peptide

AIM

To demonstrate a label-free electrical immunoassay for profiling vascular biomarker N-terminal pro-brain natriuretic peptide (NT-proBNP) associated with improved cardiac risk prediction.

MATERIALS & METHODS

A high-density nanowell-based electrical immunoassay has been designed by integrating nanoporous aluminum oxide onto printed circuit board chips for the detection of NT-proBNP. The concentration of the biomarker is quantitatively determined by measuring impedance changes to the electrical double layer within the nanowells using electrochemical impedance spectroscopy. Detection sensitivity in the fg/ml range was obtained due to spatial confinement of the target biomarkers in size-matched nanowells.

RESULTS & DISCUSSION

Electrical immunoassay performance was determined for the detection of NT-proBNP in phosphate-buffered saline (PBS) and human serum (HS). The lower limit of detection for the sensor was observed to be 10 fg/ml in PBS and 500 fg/ml in HS. The upper limit of detection was observed to be 500 fg/ml in PBS and 500 ng/ml in HS.

CONCLUSION

A label-free technique for detection of NT-proBNP at clinically relevant concentrations for evaluating cardiac risk is demonstrated. High sensitivity and specificity, robust detection and low volume (100 µl) per assay project the technology to be a successful competitor to traditional ELISA-based techniques.

Neither diabetes nor glucose-lowering drugs are associated with mortality after noncardiac surgery in patients with coronary artery disease or heart failure

BACKGROUND

It is unclear whether diabetes mellitus or use of particular glucose-lowering agents is associated with increased risk of mortality after noncardiac surgery in patients with known cardiac disease.

METHODS

We carried out a retrospective cohort study using 4 linked administrative databases in the province of Alberta, Canada from 1999-2006.

RESULTS

Of the 32,834 patients with known cardiac disease in our cohort, 9305 (28%) had diabetes. All-cause 30-day mortality after noncardiac surgery was 6.4% in patients with diabetes, and 6.1% in those without diabetes (multivariate adjusted odds ratio [aOR] 0.97, 95% confidence interval [CI], 0.87-1.08). In the 24,037 patients older than 65, mortality was 7.5% in individuals with diabetes and 7.5% in those without diabetes (5.7% in those taking insulin [aOR, 0.89; 95% CI, 0.70-1.13], 8.0% in those using oral agents only [aOR, 1.08; 95% CI, 0.95-1.22]). None of the glucose-lowering drug classes were associated with perioperative mortality in elderly cardiac patients (sulfonylureas aOR, 0.94; 95% CI, 0.76-1.16; metformin aOR, 0.92; 95% CI, 0.74-1.14; thiazolidinediones aOR, 0.64; 95% CI, 0.40-1.04; insulin aOR, 0.83; 95% CI, 0.65-1.08), but use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (aOR, 0.83; 95% CI, 0.75-0.93), β-blockers (aOR, 0.82; 95% CI, 0.72-0.93), or statins (aOR, 0.65; 95% CI, 0.55-0.78) in the 100 days before surgery were associated with lower 30-day mortality.

CONCLUSIONS

Neither diabetes nor exposure to common classes of glucose-lowering drugs preoperatively were associated with increased perioperative mortality in cardiac patients undergoing noncardiac surgery. However, cardiac patients not using angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, β-blockers, or statins preoperatively exhibited higher mortality rates, emphasizing the importance of optimizing evidence-based therapy before elective surgery in these patients.

Should more patients continue aspirin therapy perioperatively?: clinical impact of aspirin withdrawal syndrome

OBJECTIVE

To provide an evidence-based focused review of aspirin use in the perioperative period along with an in-depth discussion of the considerations and risks associated with its preoperative withdrawal.

BACKGROUND

For patients with established cardiovascular disease, taking aspirin is considered a critical therapy. The cessation of aspirin can cause a platelet rebound phenomenon and prothrombotic state leading to major adverse cardiovascular events. Despite the risks of aspirin withdrawal, which are exacerbated during the perioperative period, standard practice has been to stop aspirin before elective surgery for fear of excessive bleeding. Mounting evidence suggests that this practice should be abandoned.

METHODS

We performed a PubMed and Medline literature search using the keywords aspirin, withdrawal, and perioperative. We manually reviewed relevant citations for inclusion.

RESULTS/CONCLUSIONS

Clinicians should employ a patient-specific strategy for perioperative aspirin management that weighs the risks of stopping aspirin with those associated with its continuation. Most patients, especially those taking aspirin for secondary cardiovascular prevention, should have their aspirin continued throughout the perioperative period. When aspirin is held preoperatively, the aspirin withdrawal syndrome may significantly increase the risk of a major thromboembolic complication. For many operative procedures, the risk of perioperative bleeding while continuing aspirin is minimal, as compared with the concomitant thromboembolic risks associated with aspirin withdrawal. Those cases where aspirin should be stopped include patients undergoing intracranial, middle ear, posterior eye, intramedullary spine, and possibly transurethral prostatectomy surgery.

An international prospective cohort study evaluating major vascular complications among patients undergoing noncardiac surgery: the VISION Pilot Study

OBJECTIVES

among patients undergoing noncardiac surgery, our objectives were to: (1) determine the feasibility of undertaking a large international cohort study; (2) estimate the current incidence of major perioperative vascular events; (3) compare the observed event rates to the expected event rates according to the Revised Cardiac Risk Index (RCRI); and (4) provide an estimate of the proportion of myocardial infarctions without ischemic symptoms that may go undetected without perioperative troponin monitoring.

DESIGN

An international prospective cohort pilot study.

PARTICIPANTS

Patients undergoing noncardiac surgery who were >45 years of age, receiving a general or regional anesthetic, and requiring hospital admission.

MEASUREMENTS

Patients had a Roche fourth-generation Elecsys troponin T measurement collected 6 to 12 hours postoperatively and on the first, second, and third days after surgery. Our primary outcome was major vascular events (a composite of vascular death [i.e., death from vascular causes], nonfatal myocardial infarction, nonfatal cardiac arrest, and nonfatal stroke) at 30 days after surgery. Our definition for perioperative myocardial infarction included: (1) an elevated troponin T measurement with at least one of the following defining features: ischemic symptoms, development of pathologic Q waves, ischemic electrocardiogram changes, coronary artery intervention, or cardiac imaging evidence of myocardial infarction; or (2) autopsy findings of acute or healing myocardial infarction.

RESULTS

We recruited 432 patients across 5 hospitals in Canada, China, Italy, Colombia, and Brazil. During the first 30 days after surgery, 6.3% (99% confidence interval 3.9-10.0) of the patients suffered a major vascular event (10 vascular deaths, 16 nonfatal myocardial infarctions, and 1 nonfatal stroke). The observed event rate was increased 6-fold compared with the event rate expected from the RCRI. Of the 18 patients who suffered a myocardial infarction, 12 (66.7%) had no ischemic symptoms to suggest myocardial infarction.

CONCLUSIONS

This study suggests that major perioperative vascular events are common, that the RCRI underestimates risk, and that monitoring troponins after surgery can assist physicians to avoid missing myocardial infarction. These results underscore the need for a large international prospective cohort study.

A randomised controlled pilot trial to evaluate and optimize the use of anti-platelet agents in the perioperative management in patients undergoing general and abdominal surgery--the APAP trial (ISRCTN45810007)

PURPOSE

Surgeons are increasingly confronted by patients on long-term low-dose acetylsalicylic acid (ASA). However, owing to a lack of evidence-based data, a widely accepted consensus on the perioperative management of these patients in the setting of non-cardiac surgery has not yet been reached. Primary objective was to evaluate the safety of continuous versus discontinuous use of ASA in the perioperative period in elective general or abdominal surgery.

METHODS

Fifty-two patients undergoing elective cholecystectomy, inguinal hernia repair or colonic/colorectal surgery were recruited to this pilot study. According to cardiological evaluation, non-high-risk patients who were on long-term treatment with low-dose ASA were eligible for inclusion. Patients were allocated randomly to continuous use of ASA or discontinuation of ASA intake for 5 days before until 5 days after surgery. The primary outcome was the incidence of major haemorrhagic and thromboembolic complications within 30 days after surgery.

RESULTS

A total of 26 patients were allocated to each study group. One patient (3.8%) in the ASA continuation group required re-operation due to post-operative haemorrhage. In neither study group, further bleeding complications occurred. No clinically apparent thromboembolic events were reported in the ASA continuation and the ASA discontinuation group. Furthermore, there were no significant differences between both study groups in the secondary endpoints.

CONCLUSIONS

Perioperative intake of ASA does not seem to influence the incidence of severe bleeding in non-high-risk patients undergoing elective general or abdominal surgery. Further, adequately powered trials are required to confirm the findings of this study.

The Procedural Index for Mortality Risk (PIMR): an index calculated using administrative data to quantify the independent influence of procedures on risk of hospital death

BACKGROUND

Surgeries and other procedures can influence the risk of death in hospital. All published scales that predict post-operative death risk require clinical data and cannot be measured using administrative data alone. This study derived and internally validated an index that can be calculated using administrative data to quantify the independent risk of hospital death after a procedure.

METHODS

For all patients admitted to a single academic centre between 2004 and 2009, we estimated the risk of all-cause death using the Kaiser Permanente Inpatient Risk Adjustment Methodology (KP-IRAM). We determined whether each patient underwent one of 503 commonly performed therapeutic procedures using Canadian Classification of Interventions codes and whether each procedure was emergent or elective. Multivariate logistic regression modeling was used to measure the association of each procedure-urgency combination with death in hospital independent of the KP-IRAM risk of death. The final model was modified into a scoring system to quantify the independent influence each procedure had on the risk of death in hospital.

RESULTS

275 460 hospitalizations were included (137,730 derivation, 137,730 validation). In the derivation group, the median expected risk of death was 0.1% (IQR 0.01%-1.4%) with 4013 (2.9%) dying during the hospitalization. 56 distinct procedure-urgency combinations entered our final model resulting in a Procedural Index for Mortality Rating (PIMR) score values ranging from -7 to +11. In the validation group, the PIMR score significantly predicted the risk of death by itself (c-statistic 67.3%, 95% CI 66.6-68.0%) and when added to the KP-IRAM model (c-index improved significantly from 0.929 to 0.938).

CONCLUSIONS

We derived and internally validated an index that uses administrative data to quantify the independent association of a broad range of therapeutic procedures with risk of death in hospital. This scale will improve risk adjustment when administrative data are used for analyses.

Mortality and Readmission of Patients With Heart Failure, Atrial Fibrillation, or Coronary Artery Disease Undergoing Noncardiac Surgery

Background—

The postoperative risks for patients with coronary artery disease (CAD) undergoing noncardiac surgery are well described. However, the risks of noncardiac surgery in patients with heart failure (HF) and atrial fibrillation (AF) are less well known. The purpose of this study is to compare the postoperative mortality of patients with HF, AF, or CAD undergoing major and minor noncardiac surgery.

Methods and Results—

Population-based data were used to create 4 cohorts of consecutive patients with either nonischemic HF (NIHF; n=7700), ischemic HF (IHF; n=12 249), CAD (n=13 786), or AF (n=4312) who underwent noncardiac surgery between April 1, 1999, and September 31, 2006, in Alberta, Canada. The main outcome was 30-day postoperative mortality. The unadjusted 30-day postoperative mortality was 9.3% in NIHF, 9.2% in IHF, 2.9% in CAD, and 6.4% in AF (each versus CAD, P <0.0001). Among patients undergoing minor surgical procedures, the 30-day postoperative mortality was 8.5% in NIHF, 8.1% in IHF, 2.3% in CAD, and 5.7% in AF ( P <0.0001). After multivariable adjustment, postoperative mortality remained higher in NIHF, IHF, and AF patients than in those with CAD (NIHF versus CAD: odds ratio 2.92; 95% confidence interval 2.44 to 3.48; IHF versus CAD: odds ratio 1.98; 95% confidence interval 1.70 to 2.31; AF versus CAD: odds ratio 1.69; 95% confidence interval 1.34 to 2.14).

Conclusions—

Although current perioperative risk prediction models place greater emphasis on CAD than HF or AF, patients with HF or AF have a significantly higher risk of postoperative mortality than patients with CAD, and even minor procedures carry a risk higher than previously appreciated.

Perioperative myocardial ischemia and isolated systolic hypertension in non-cardiac surgery

PURPOSE

To determine whether patients with isolated systolic hypertension (ISH) undergoing non-cardiac surgery have a higher incidence of perioperative myocardial ischemia than normotensive patients and hence a greater risk for perioperative adverse events.

METHODS

After obtaining Research Ethics Board approval, patients were recruited to either an ISH group (systolic blood pressure [SBP] > 140 mmHg with diastolic blood pressure [DBP] < 90 mmHg) or a normotensive group (SBP < 140 mmHg and DBP < 90 mmHg), according to their resting preoperative blood pressure. The primary outcome was the overall incidence of perioperative myocardial ischemia (PMI) as determined by 48-hr ambulatory Holter monitoring. P values ≤ 0.05 were considered to be statistically significant.

RESULTS

A total of 312 (150 ISH and 162 normotensive) patients completed the study. Orthopedic surgery was the most frequent surgical procedure in both groups. The overall incidence of PMI was 19.7% in the ISH group compared with 18.8% in the normotensive group (difference 0.9%; 95% confidence interval [CI], -7.9% to 9.8%). The overall incidence of adverse events was 4.0% in the ISH group compared with 1.9% in the normotensive group (difference 2.2%; 95% CI, -1.6% to 5.9%).

CONCLUSION

In this study, we chose to examine ISH as potential cardiac risk factor for patients undergoing non-cardiac surgery. The incidence of myocardial ischemia, a surrogate outcome, was similar in the two groups. The relatively high incidence of myocardial ischemia (19.2%) was of particular interest in this relatively low cardiac risk surgical population. (ClinicalTrials.gov number, NCT01237652).

Quality of life and mortality assessment in patients with major cardiac events in the postoperative period

BACKGROUND AND OBJECTIVES

Cardiovascular complications in the postoperative period are associated with high mortality and morbidity. Few studies have assessed the degree of dependence in these patients and their perception of health. The objective of this study was to assess the mortality and the quality of life in patients who developed major cardiac events (MCE) in the postoperative period.

METHOD

Retrospective study carried out in a Surgical Intensive Care Unit (SICU), between March 2006 and March 2008. The patients were assessed regarding the occurrence of CE. Six months after the hospital discharge, the Short-Form-36 (SF-36) questionnaire was filled out and dependence was assessed in relation to activities of daily living (ADL). The comparisons between independent groups of patients were carried out using Student's t test. The comparison between each variable and the occurrence of CE was carried out by logistic regression and included all patients.

RESULTS

Of the 1,280 patients that met the inclusion criteria, 26 (2%) developed MCE. The univariate analysis identified as independent determinants for the development of major cardiac events: ASA physical status, hypertension, ischemic heart disease, congestive heart disease and score of the Revised Cardiac Risk Index (RCRI). The six-month mortality after the SICU discharge was 35%. Of the 17 surviving patients, 13 completed the questionnaires. Thirty-one percent of them reported that their general health was better on the day they answered the questionnaire, when compared to 12 months before. Sixty-nine percent of the patients were dependent in instrumental ADL e 15% in personal ADL.

CONCLUSIONS

The development of MCE has a significant impact on the duration of hospital stay and mortality rates. Six months after the discharge from the SICU, more than 50% of the patients were dependent in at least one instrumental ADL.