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Sigl M, Baumann S, Könemann AS, Keese M, Schwenke K, Gerken ALH, Dürschmied D, Rosenkaimer S. Prognostic value of extended cardiac risk assessment before elective open abdominal aortic surgery. Herz 2024; 49:210-218. [PMID: 37789149 DOI: 10.1007/s00059-023-05209-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/10/2023] [Accepted: 09/01/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Major vascular surgery is associated with a high perioperative risk and significant mortality. Despite advances in risk stratification, monitoring, and management of perioperative complications, cardiac complications are still common. Stress echocardiography is well established in coronary artery disease diagnostics; however, its prognostic value before high-risk aortic surgery is unknown. This prospective, single-center study compared the outcome of patients undergoing extended cardiac risk assessment before open abdominal aortic surgery with the outcome of patients who had received standard preoperative assessment. METHODS The study included patients undergoing elective open abdominal aortic surgery. Patients who underwent standard preoperative assessment before the start of a dedicated protocol were compared with patients who had extended cardiac risk assessment, including dobutamine stress echocardiography, as part of a stepwise interdisciplinary cardiovascular team approach. The combined primary endpoint was cardiovascular death, myocardial infarction, emergency coronary revascularization, and life-threatening arrhythmia within 30 days. The secondary endpoint was acute renal failure and severe bleeding. RESULTS In total, 77 patients (mean age 68.1 ± 8.1 years, 70% male) were included: 39 underwent standard and 38 underwent cardiac risk assessment. The combined primary endpoint was reached significantly more often in patients before than after implementation of the extended cardiac stratification procedure (15% vs. 0%, p = 0.025). The combined secondary endpoint did not differ between the groups. CONCLUSIONS Patients with extended cardiac risk assessment undergoing elective open abdominal aortic surgery had better 30-day outcomes than did those who had standard preoperative assessment.
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Affiliation(s)
- Martin Sigl
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Stefan Baumann
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Ann-Sophie Könemann
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Michael Keese
- Division of Vascular Surgery, Department of Surgery, University Medical Center Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Kay Schwenke
- Division of Vascular Surgery, Department of Surgery, University Medical Center Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Andreas L H Gerken
- Division of Vascular Surgery, Department of Surgery, University Medical Center Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Daniel Dürschmied
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Stephanie Rosenkaimer
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Huang D, Yang X, Ruan H, Zhuo Y, Yuan K, Ruan B, Li F. Enhancing Prediction of Myocardial Recovery After Coronary Revascularization: Integrating Radiomics from Myocardial Contrast Echocardiography with Machine Learning. Int J Gen Med 2024; 17:2539-2555. [PMID: 38841127 PMCID: PMC11151281 DOI: 10.2147/ijgm.s465023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/23/2024] [Indexed: 06/07/2024] Open
Abstract
Introduction Chronic coronary artery disease (CAD) management often relies on myocardial contrast echocardiography (MCE), yet its effectiveness is limited by subjective interpretations and difficulty in distinguishing hibernating from necrotic myocardium. This study explores the integration of machine learning (ML) with radiomics to predict functional recovery in dyskinetic myocardial segments in CAD patients undergoing revascularization, aiming to overcome these limitations. Methods This prospective study enrolled 55 chronic CAD patients, dividing into training (39 patients, 205 segments) and testing sets (16 patients, 68 segments). Dysfunctional myocardial segments were identified by initial wall motion scores (WMS) of ≥2 (hypokinesis or higher). Functional recovery was defined as a decrease of ≥1 grade in WMS during follow-up echocardiography. Radiomics features were extracted from dyssynergic segments in end-systolic phase MCE images across five cardiac cycles post- "flash" impulse and processed through a five-step feature selection. Four ML classifiers were trained and compared using these features and MCE parameters, to identify the optimal model for myocardial recovery prediction. Results Functional improvement was noted in 139 out of 273 dyskinetic segments (50.9%) following revascularization. Receiver Operating Characteristic (ROC) analysis determined that myocardial blood flow (MBF) was the most precise clinical predictor of recovery, with an area under the curve (AUC) of 0.770. Approximately 1.34 million radiomics features were extracted, with nine features identified as key predictors of myocardial recovery. The random forest (RF) model, integrating MBF values and radiomics features, demonstrated superior predictive accuracy over other ML classifiers. Validation of the RF model on the testing dataset demonstrated its effectiveness, evidenced by an AUC of 0.821, along with consistent calibration and clinical utility. Conclusion The integration of ML with radiomics from MCE effectively predicts myocardial recovery in CAD. The RF model, combining radiomics and MBF values, presents a non-invasive, precise approach, significantly enhancing CAD management.
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Affiliation(s)
- Deyi Huang
- Department of Ultrasound, The People’s Hospital of Yuhuan, Yuhuan City, Zhejiang Province, People’s Republic of China
| | - Xingan Yang
- Department of Ultrasound, Taizhou Hospital of Zhejiang Province, Linhai City, Zhejiang Province, People’s Republic of China
| | - Hongbiao Ruan
- Department of Cardiology, The People’s Hospital of Yuhuan, Yuhuan City, Zhejiang Province, People’s Republic of China
| | - Yushui Zhuo
- Department of Ultrasound, The People’s Hospital of Yuhuan, Yuhuan City, Zhejiang Province, People’s Republic of China
| | - Kai Yuan
- Department of Clinical Laboratory, The People’s Hospital of Yuhuan, Yuhuan City, Zhejiang Province, People’s Republic of China
| | - Bowen Ruan
- Department of Ultrasound, The People’s Hospital of Yuhuan, Yuhuan City, Zhejiang Province, People’s Republic of China
| | - Fang Li
- Department of Ultrasound, The People’s Hospital of Yuhuan, Yuhuan City, Zhejiang Province, People’s Republic of China
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Smeltz AM, Newton EJ, Kumar PA, Isaak RS, Doyal A, Fernando RJ, Vanneman MW, Augoustides JGT. 2023 Update on Vascular Anesthesia. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00321-5. [PMID: 38862283 DOI: 10.1053/j.jvca.2024.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 05/11/2024] [Indexed: 06/13/2024]
Abstract
The authors thank thank the editors for this opportunity to review the recent literature on vascular surgery and anesthesia and provide this clinical update. The last in a series of updates on this topic was published in 2019.1 This review explores evolving discussions and current trends related to vascular surgery and anesthesia that have been published since then. The focus is on the major points discussed in the recent literature in the following areas: carotid artery surgery, infrarenal aortic surgery, peripheral vascular surgery, and the preoperative evaluation of vascular surgical patients.
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Affiliation(s)
- Alan M Smeltz
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Emily J Newton
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Priya A Kumar
- Department of Anesthesiology, University of Mississippi Medical Center, Jackson, MS; Outcomes Research Consortium, Cleveland, OH
| | - Robert S Isaak
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Alexander Doyal
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Rohesh J Fernando
- Department of Anesthesiology, Wake Forest University, Winston-Salem, NC
| | - Matthew W Vanneman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA
| | - John G T Augoustides
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
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Latkovskis G, Krievins D, Zellans E, Kumsars I, Krievina A, Angena A, Jegere S, Erglis A, Lacis A, Zarins C. Ischemia-Guided Coronary Revascularization Following Lower-Extremity Revascularization Improves 5-Year Survival of Patients With Chronic Limb-Threatening Ischemia. J Endovasc Ther 2024:15266028241245909. [PMID: 38616613 DOI: 10.1177/15266028241245909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
PURPOSE To determine whether diagnosis of asymptomatic (silent) coronary ischemia using coronary computed tomography (CT)-derived fractional flow reserve (FFRCT) together with targeted coronary revascularization of ischemia-producing coronary lesions following lower-extremity revascularization can reduce adverse cardiac events and improve long-term survival of patients with chronic limb-threatening ischemia (CLTI). MATERIALS AND METHODS Prospective cohort study of CLTI patients with no cardiac history or symptoms undergoing elective lower-extremity revascularization. Patients with pre-operative coronary computed tomography angiography (CTA) and FFRCT evaluation with selective post-operative coronary revascularization (FFRCT group) were compared with patients with standard pre-operative evaluation and no post-operative coronary revascularization (control group). Lesion-specific coronary ischemia was defined as FFRCT≤0.80 distal to a coronary stenosis with FFRCT≤0.75 indicating severe ischemia. Endpoints included all-cause death, cardiac death, myocardial infarction (MI) and major adverse cardiovascular (CV) events (MACE=CV death, MI, stroke, or unplanned coronary revascularization) during 5 year follow-up. RESULTS In the FFRCT group (n=111), FFRCT analysis revealed asymptomatic (silent) coronary ischemia (FFRCT≤0.80) in 69% of patients, with severe ischemia (FFRCT≤0.75) in 58%, left main ischemia in 8%, and multivessel ischemia in 40% of patients. The status of coronary ischemia in the control group (n=120) was unknown. Following lower-extremity revascularization, 42% of patients in FFRCT had elective coronary revascularization with no elective revascularization in controls. Both groups received guideline-directed medical therapy. During 5 year follow-up, compared with control, the FFRCT group had fewer all-cause deaths (24% vs 47%, hazard ratio [HR]=0.43 [95% confidence interval [CI]=0.27-0.69], p<0.001), fewer cardiac deaths (5% vs 26%, HR=0.18 [95% CI=0.07-0.45], p<0.001), fewer MIs (7% vs 28%, HR=0.21 [95% CI=0.10-0.47], p<0.001), and fewer MACE events (14% vs 39%, HR=0.28 [95% CI=0.15-0.51], p<0.001). CONCLUSIONS Ischemia-guided coronary revascularization of CLTI patients with asymptomatic (silent) coronary ischemia following lower-extremity revascularization resulted in more than 2-fold reduction in all-cause death, cardiac death, MI, and MACE with improved 5 year survival compared with patients with standard cardiac evaluation and care (76% vs 53%, p<0.001). CLINICAL IMPACT Silent coronary ischemia in patients with chronic limb-threatening ischemia (CLTI) is common even in the absence of cardiac history or symptoms. FFRCT is a convenient tool to diagnose silent coronary ischemia perioperatively. Our data suggest that post-surgery elective FFRCT-guided coronary revascularization reduces adverse cardiac events and improves long-term survival in this very-high risk patient group. Randomized study is warranted to finally test this concept.
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Affiliation(s)
- Gustavs Latkovskis
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | - Dainis Krievins
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | - Edgars Zellans
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | - Indulis Kumsars
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | | | | | - Sanda Jegere
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | - Andrejs Erglis
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | - Aigars Lacis
- Pauls Stradins Clinical University Hospital, Riga, Latvia
- Riga Stradins University, Riga, Latvia
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Bollen Pinto B, Ackland GL. Pathophysiological mechanisms underlying increased circulating cardiac troponin in noncardiac surgery: a narrative review. Br J Anaesth 2024; 132:653-666. [PMID: 38262855 DOI: 10.1016/j.bja.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 11/23/2023] [Accepted: 12/15/2023] [Indexed: 01/25/2024] Open
Abstract
Assay-specific increases in circulating cardiac troponin are observed in 20-40% of patients after noncardiac surgery, depending on patient age, type of surgery, and comorbidities. Increased cardiac troponin is consistently associated with excess morbidity and mortality after noncardiac surgery. Despite these findings, the underlying mechanisms are unclear. The majority of interventional trials have been designed on the premise that ischaemic cardiac disease drives elevated perioperative cardiac troponin concentrations. We consider data showing that elevated circulating cardiac troponin after surgery could be a nonspecific marker of cardiomyocyte stress. Elevated concentrations of circulating cardiac troponin could reflect coordinated pathological processes underpinning organ injury that are not necessarily caused by ischaemia. Laboratory studies suggest that matching of coronary artery autoregulation and myocardial perfusion-contraction coupling limit the impact of systemic haemodynamic changes in the myocardium, and that type 2 ischaemia might not be the likeliest explanation for cardiac troponin elevation in noncardiac surgery. The perioperative period triggers multiple pathological mechanisms that might cause cardiac troponin to cross the sarcolemma. A two-hit model involving two or more triggers including systemic inflammation, haemodynamic strain, adrenergic stress, and autonomic dysfunction might exacerbate or initiate acute myocardial injury directly in the absence of cell death. Consideration of these diverse mechanisms is pivotal for the design and interpretation of interventional perioperative trials.
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Affiliation(s)
- Bernardo Bollen Pinto
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.
| | - Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
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Stanley GA, Scherer MD, Hajostek MM, Yammine H, Briggs CS, CrespoSoto HO, Nussbaum T, Arko FR. Utilization of coronary computed tomography angiography and computed tomography-derived fractional flow reserve in a critical limb-threatening ischemia cohort. J Vasc Surg Cases Innov Tech 2024; 10:101272. [PMID: 38435790 PMCID: PMC10907840 DOI: 10.1016/j.jvscit.2023.101272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/23/2023] [Indexed: 03/05/2024] Open
Abstract
Objective Patients with peripheral arterial disease (PAD) have a significant risk of myocardial infarction and death secondary to concomitant coronary artery disease (CAD). This is particularly true in patients with critical limb-threatening ischemia (CLTI) who exceed a 20% mortality rate at 6 months despite standard treatment with risk factor modification. Although systematic preoperative coronary testing is not recommended for patients with PAD without cardiac symptoms, the clinical manifestations of CAD are often muted in patients with CLTI due to poor mobility and activity intolerance. Thus, the true incidence and impact of "silent" CAD in a CLTI cohort is unknown. This study aims to determine the prevalence of ischemia-producing coronary artery stenosis in a CLTI cohort using coronary computed tomography angiography (cCTA) and computed tomography (CT)-derived fractional flow reserve (FFRCT), a noninvasive imaging modality that has shown significant correlation to cardiac catheterization in the detection of clinically relevant coronary ischemia. Methods Patients presenting with newly diagnosed CLTI at our institution from May 2020 to April 2021 were screened for underlying CAD. Included subjects had no known history of CAD, no cardiac symptoms, and no anginal equivalent complaints at presentation. Patients underwent cCTA and FFRCT evaluation and were classified by the anatomic location and severity of CAD. Significant coronary ischemia was defined as FFRCT ≤0.80 distal to a >30% coronary stenosis, and severe coronary ischemia was documented at FFRCT ≤0.75, consistent with established guidelines. Results A total of 170 patients with CLTI were screened; 65 patients (38.2%) had no coronary symptoms and met all inclusion/exclusion criteria. Twenty-four patients (31.2%) completed cCTA and FFRCT evaluation. Forty-one patients have yet to complete testing secondary to socioeconomic factors (insurance denial, transportation inaccessibility, testing availability, etc). The mean age of included subjects was 65.4 ± 7.0 years, and 15 (62.5%) were male. Patients presented with ischemic rest pain (n = 7; 29.1%), minor tissue loss (n = 14; 58.3%) or major tissue loss (n = 3; 12.5%). Significant (≥50%) coronary artery stenosis was noted on cCTA in 19 of 24 patients (79%). Significant left main coronary artery stenosis was identified in two patients (10%). When analyzed with FFRCT, 17 patients (71%) had hemodynamically significant coronary ischemia (FFRCT ≤0.8), and 54% (n = 13) had lesion-specific severe coronary ischemia (FFRCT ≤0.75). The mean FFRCT in patients with coronary ischemia was 0.70 ± 0.07. Multi-vessel disease pattern was present in 53% (n = 9) of patients with significant coronary stenosis. Conclusions The use of cCTA-derived fractional flow reserve demonstrates a significant percentage of patients with CLTI have silent (asymptomatic) coronary ischemia. More than one-half of these patients have lesion-specific severe ischemia, which may be associated with increased mortality when treated solely with risk factor modification. cCTA and FFRCT diagnosis of significant coronary ischemia has the potential to improve cardiac care, perioperative morbidity, and long-term survival curves of patients with CLTI. Systemic improvements in access to care will be needed to allow for broad application of these imaging assessments should they prove universally valuable. Additional study is required to determine the benefit of selective coronary revascularization in patients with CLTI.
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Affiliation(s)
| | | | | | - Halim Yammine
- Sanger Heart & Vascular Institute, Atrium Health, Charlotte, NC
| | | | | | - Tzvi Nussbaum
- Sanger Heart & Vascular Institute, Atrium Health, Charlotte, NC
| | - Frank R. Arko
- Sanger Heart & Vascular Institute, Atrium Health, Charlotte, NC
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Krievins DK, Zellans E, Latkovskis G, Kumsars I, Krievina AK, Jegere S, Erglis A, Lacis A, Plopa E, Stradins P, Ivanova P, Zarins CK. Diagnosis and treatment of ischemia-producing coronary stenoses improves 5-year survival of patients undergoing major vascular surgery. J Vasc Surg 2024:S0741-5214(24)00500-7. [PMID: 38518962 DOI: 10.1016/j.jvs.2024.02.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/22/2024] [Accepted: 02/24/2024] [Indexed: 03/24/2024]
Abstract
OBJECTIVE Patients undergoing vascular surgery procedures have poor long-term survival due to coexisting coronary artery disease (CAD), which is often asymptomatic, undiagnosed, and undertreated. We sought to determine whether preoperative diagnosis of asymptomatic (silent) coronary ischemia using coronary computed tomography (CT)-derived fractional flow reserve (FFRCT) together with postoperative ischemia-targeted coronary revascularization can reduce adverse cardiac events and improve long-term survival following major vascular surgery METHODS: In this observational cohort study of 522 patients with no known CAD undergoing elective carotid, peripheral, or aneurysm surgery we compared two groups of patients. Group I included 288 patients enrolled in a prospective Institutional Review Board-approved study of preoperative coronary CT angiography (CTA) and FFRCT testing to detect silent coronary ischemia with selective postoperative coronary revascularization in addition to best medical therapy (BMT) (FFRCT guided), and Group II included 234 matched controls with standard preoperative cardiac evaluation and postoperative BMT alone with no elective coronary revascularization (Usual Care). In the FFRCT group, lesion-specific coronary ischemia was defined as FFRCT ≤0.80 distal to a coronary stenosis, with severe ischemia defined as FFRCT ≤0.75. Results were available for patient management decisions. Endpoints included all-cause death, cardiovascular death, myocardial infarction (MI), and major adverse cardiovascular events (MACE [death, MI, or stroke]) during 5-year follow-up. RESULTS The two groups were similar in age, gender, and comorbidities. In FFRCT, 65% of patients had asymptomatic lesion-specific coronary ischemia, with severe ischemia in 52%, multivessel ischemia in 36% and left main ischemia in 8%. The status of coronary ischemia was unknown in Usual Care. Vascular surgery was performed as planned in both cohorts with no difference in 30-day mortality. In FFRCT, elective ischemia-targeted coronary revascularization was performed in 103 patients 1 to 3 months following surgery. Usual Care had no elective postoperative coronary revascularizations. At 5 years, compared with Usual Care, FFRCT guided had fewer all-cause deaths (16% vs 36%; hazard ratio [HR], 0.37; 95% confidence interval [CI], 0.22-0.60; P < .001), fewer cardiovascular deaths (4% vs 21%; HR, 0.11; 95% CI, 0.04-0.33; P < .001), fewer MIs (4% vs 24%; HR, 0.13; 95% CI, 0.05-0.33; P < .001), and fewer MACE (20% vs 47%; HR, 0.36; 95% CI, 0.23-0.56; P < .001). Five-year survival was 84% in FFRCT compared with 64% in Usual Care (P < .001). CONCLUSIONS Diagnosis of silent coronary ischemia with ischemia-targeted coronary revascularization in addition to BMT following major vascular surgery was associated with fewer adverse cardiovascular events and improved 5-year survival compared with patients treated with BMT alone as per current guidelines.
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Affiliation(s)
- Dainis K Krievins
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia.
| | - Edgars Zellans
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Gustavs Latkovskis
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Indulis Kumsars
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia
| | | | - Sanda Jegere
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Andrejs Erglis
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Aigars Lacis
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | | | - Peteris Stradins
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Riga Stradins University, Riga, Latvia
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Elias M, Tateosian VS, Richman DC. What's New in Preoperative Cardiac Testing. Anesthesiol Clin 2024; 42:9-25. [PMID: 38278596 DOI: 10.1016/j.anclin.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
More than 300 million surgeries are performed annually worldwide. Patients are progressively aging and often have multiple comorbidities that put them at increased cardiovascular risk in the perioperative period. The United States published latest guidelines regarding preoperative cardiac evaluation and risk stratification for patients undergoing non-cardiac surgery in 2014. There are multiple risk stratification tools available that can help guide management. Furthermore, newer laboratory tests, such as preoperative NT-proBNP and high-sensitivity troponin assays, may aid in preventing and diagnosing perioperative myocardial injury.
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Affiliation(s)
- Murad Elias
- Department of Anesthesiology, Renaissance School of Medicine at Stony Brook University, Health Sciences Center, Level 4, 101 Nicolls Road, Stony Brook, NY 11794-8480, USA.
| | - Vahé S Tateosian
- Department of Anesthesiology, Renaissance School of Medicine at Stony Brook University, Health Sciences Center, Level 4, 101 Nicolls Road, Stony Brook, NY 11794-8480, USA
| | - Deborah C Richman
- Department of Anesthesiology, Renaissance School of Medicine at Stony Brook University, Health Sciences Center, Level 4, 101 Nicolls Road, Stony Brook, NY 11794-8480, USA
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Lin TL, Chen IL, Lai WH, Chen YJ, Chang PH, Wu KH, Wang YC, Li WF, Liu YW, Wang CC, Lee IK. Prognostic factors for critically ill surgical patients with unplanned intensive care unit readmission: Developing a novel predictive scoring model for predicting readmission. Surgery 2024; 175:543-551. [PMID: 38008606 DOI: 10.1016/j.surg.2023.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 09/15/2023] [Accepted: 10/24/2023] [Indexed: 11/28/2023]
Abstract
BACKGROUND Unplanned readmission to the surgical intensive care unit has been demonstrated to worsen patient outcomes. Our objective was to identify risk factors and outcomes associated with unplanned surgical intensive care unit readmission and to develop a predictive scoring model to identify patients at high risk of readmission. METHODS We retrospectively analyzed patients admitted to the surgical intensive care unit (2020-2021) and categorized them as either with or without unplanned readmission. RESULTS Of 1,112 patients in the derivation cohort, 76 (6.8%) experienced unplanned surgical intensive care unit readmission, with sepsis being the leading cause of readmission (35.5%). Patients who were readmitted had significantly higher in-hospital mortality rates than those who were not. Multivariate analysis identified congestive heart failure, high Sequential Organ Failure Assessment-Hepatic score, use of carbapenem during surgical intensive care unit stay, as well as factors before surgical intensive care unit discharge such as inadequate glycemic control, positive fluid balance, low partial pressure of oxygen in arterial blood/fraction of inspired oxygen ratio, and receipt of total parenteral nutrition as independent predictors for unplanned readmission. The scoring model developed using these predictors exhibited good discrimination between readmitted and non-readmitted patients, with an area under the curve of 0.74. The observed rates of unplanned readmission for scores of <4 points and ≥4 points were 4% and 20.2% (P < .001), respectively. The model also demonstrated good performance in the validation cohort, with an area under the curve of 0.74 and 19% observed unplanned readmission rate for scores ≥4 points. CONCLUSION Besides congestive heart failure, clinicians should meticulously re-evaluate critical variables such as the Sequential Organ Failure Assessment-Hepatic score, partial pressure of oxygen in arterial blood/fraction of inspired oxygen ratio, glycemic control, and fluid status before releasing the patient from the surgical intensive care unit. It is crucial to determine the reasons for using carbapenems during surgical intensive care unit stay and the causes for the inability to discontinue total parenteral nutrition before discharging the patient from the surgical intensive care unit.
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Affiliation(s)
- Ting-Lung Lin
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Taiwan; Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - I-Ling Chen
- Chang Gung University College of Medicine, Kaohsiung, Taiwan; Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Taiwan; School of Pharmacy, Kaohsiung Medical University, Taiwan
| | - Wei-Hung Lai
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Taiwan; Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ying-Ju Chen
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Taiwan; Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Po-Hsun Chang
- Chang Gung University College of Medicine, Kaohsiung, Taiwan; Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - Kuan-Han Wu
- Chang Gung University College of Medicine, Kaohsiung, Taiwan; Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - Yu-Chen Wang
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Taiwan; Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wei-Feng Li
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Taiwan; Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yueh-Wei Liu
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Taiwan; Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Chi Wang
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Taiwan; Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ing-Kit Lee
- Chang Gung University College of Medicine, Kaohsiung, Taiwan; Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Taiwan.
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10
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Smilowitz NR. The impact of preoperative stress testing on cardiovascular and surgical care - Does it actually improve outcomes? J Clin Anesth 2024; 92:111267. [PMID: 37758564 DOI: 10.1016/j.jclinane.2023.111267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 09/17/2023] [Indexed: 09/29/2023]
Affiliation(s)
- Nathaniel R Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA; Cardiology Section, Department of Medicine, VA New York Harbor Healthcare System, New York, NY, USA.
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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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12
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Huck DM, Weber B, Schreiber B, Pandav J, Parks S, Hainer J, Brown JM, Divakaran S, Blankstein R, Dorbala S, Trinquart L, Chandraker A, Di Carli MF. Comparative Effectiveness of PET and SPECT MPI for Predicting Cardiovascular Events After Kidney Transplant. Circ Cardiovasc Imaging 2024; 17:e015858. [PMID: 38227694 PMCID: PMC10794031 DOI: 10.1161/circimaging.123.015858] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 12/08/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND Advanced chronic kidney disease is associated with high cardiovascular risk, even after kidney transplant. Pretransplant cardiac testing may identify patients who require additional assessment before transplant or would benefit from risk optimization. The objective of the current study was to determine the relative prognostic utility of pretransplant positron emission tomography (PET) and single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) for posttransplant major adverse cardiovascular events (MACEs). METHODS We retrospectively followed patients who underwent MPI before kidney transplant for the occurrence of MACE after transplant including myocardial infarction, stroke, heart failure, and cardiac death. An abnormal MPI result was defined as a total perfusion deficit >5% of the myocardium. To determine associations of MPI results with MACE, we utilized Cox hazard regression with propensity weighting for PET versus SPECT with model factors, including demographics and cardiovascular risk factors. RESULTS A total of 393 patients underwent MPI (208 PET and 185 SPECT) and were followed for a median of 5.9 years post-transplant. Most were male (58%), median age was 58 years, and there was a high burden of hypertension (88%) and diabetes (33%). A minority had abnormal MPI (n=58, 15%). In propensity-weighted hazard regression, abnormal PET result was associated with posttransplant MACE (hazard ratio, 3.02 [95% CI, 1.78-5.11]; P<0.001), while there was insufficient evidence of an association of abnormal SPECT result with MACE (1.39 [95% CI, 0.72-2.66]; P=0.33). The explained relative risk of the PET result was higher than the SPECT result (R2 0.086 versus 0.007). Normal PET was associated with the lowest risk of MACE (2.2%/year versus 3.6%/year for normal SPECT; P<0.001). CONCLUSIONS Kidney transplant recipients are at high cardiovascular risk, despite a minority having obstructive coronary artery disease on MPI. PET MPI findings predict posttransplant MACE. Normal PET may better discriminate lower risk patients compared with normal SPECT, which should be confirmed in a larger prospective study.
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Affiliation(s)
- Daniel M Huck
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Brittany Weber
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Brittany Schreiber
- Division of Nephrology (B.S., J.P., A.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jay Pandav
- Division of Nephrology (B.S., J.P., A.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sean Parks
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Division of Nuclear Medicine and Molecular Imaging (S.P., J.H., S. Divakaran, S. Dorbala, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jon Hainer
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Division of Nuclear Medicine and Molecular Imaging (S.P., J.H., S. Divakaran, S. Dorbala, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jenifer M Brown
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sanjay Divakaran
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Division of Nuclear Medicine and Molecular Imaging (S.P., J.H., S. Divakaran, S. Dorbala, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ron Blankstein
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sharmila Dorbala
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Division of Nuclear Medicine and Molecular Imaging (S.P., J.H., S. Divakaran, S. Dorbala, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ludovic Trinquart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA (L.T.)
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA (L.T.)
| | - Anil Chandraker
- Division of Nephrology (B.S., J.P., A.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Marcelo F Di Carli
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Division (D.M.H., B.W., J.M.B., S. Divakaran, R.B., S. Dorbala, M.F.D.C.), Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- CV Imaging Program (D.M.H., B.W., S.P., J.H., J.M.B., S. Divakaran, R.B., S. Dorbalat, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Division of Nuclear Medicine and Molecular Imaging (S.P., J.H., S. Divakaran, S. Dorbala, M.F.D.C.), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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M'Pembele R, Roth S, Lurati Buse G. [The role of cardiac biomarkers in perioperative risk evaluation of noncardiac surgery patients-A summary of the ESAIC guidelines 2023]. DIE ANAESTHESIOLOGIE 2024; 73:44-50. [PMID: 38063866 PMCID: PMC10791894 DOI: 10.1007/s00101-023-01363-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/23/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND The recently published ESAIC guidelines highlight the clinical value of cardiac troponins (cTn) and B‑type natriuretic peptides (BNP) for risk assessment in patients undergoing noncardiac surgery. OBJECTIVE Summary of the ESAIC guideline recommendations. MATERIAL AND METHODS The evidence for the recommendations was extracted from studies that investigated the perioperative role of cTn and BNP as prognostic factors, for risk prediction and for therapeutic guidance. To collate this evidence 12 relevant endpoints as well as risk benefit analyses of systematic screening were considered to issue the strength of the recommendations. RESULTS The body of evidence for these guidelines was based on 115 studies. The evidence varied significantly across the 12 predefined endpoints. Additionally, there was a gradient in evidence for the use of cTn and BNP as prognostic factors, for risk prediction and for therapeutic guidance. The guidelines issue a weak recommendation for the use of preoperative, postoperative and combined measurement of cTn as well as for preoperative BNP measurement to assess the prognosis. For risk prediction a weak recommendation was formulated for combined and postoperative cTn and preoperative BNP measurements. No recommendation could be given for the evidence on biomarkers as data were very limited. CONCLUSION Both cTn and BNP can be used as prognostic factors or to predict the risk for selected endpoints. Therapeutic interventions should not be guided by cardiac biomarker levels.
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Affiliation(s)
- René M'Pembele
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Moorenstr. 5, 40225, Düsseldorf, Deutschland.
- CARID (Cardiovascular Research Institute Düsseldorf), Universitätsklinikum Düsseldorf, Heinrich Heine Universität, Düsseldorf, Deutschland.
| | - Sebastian Roth
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Moorenstr. 5, 40225, Düsseldorf, Deutschland
- CARID (Cardiovascular Research Institute Düsseldorf), Universitätsklinikum Düsseldorf, Heinrich Heine Universität, Düsseldorf, Deutschland
| | - Giovanna Lurati Buse
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Moorenstr. 5, 40225, Düsseldorf, Deutschland
- CARID (Cardiovascular Research Institute Düsseldorf), Universitätsklinikum Düsseldorf, Heinrich Heine Universität, Düsseldorf, Deutschland
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Serrao G, Vinayak M, Nicolas J, Subramaniam V, Lai AC, Laskey D, Kini A, Seethamraju H, Scheinin S. The Evaluation and Management of Coronary Artery Disease in the Lung Transplant Patient. J Clin Med 2023; 12:7644. [PMID: 38137713 PMCID: PMC10743826 DOI: 10.3390/jcm12247644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/13/2023] [Accepted: 11/22/2023] [Indexed: 12/24/2023] Open
Abstract
Lung transplantation can greatly improve quality of life and extend survival in those with end-stage lung disease. In order to derive the maximal benefit from such a procedure, patients must be carefully selected and be otherwise healthy enough to survive a high-risk surgery and sometimes prolonged immunosuppressive therapy following surgery. Patients therefore must be critically assessed prior to being listed for transplantation with close attention paid towards assessment of cardiovascular health and operative risk. One of the biggest dictators of this is coronary artery disease. In this review article, we discuss the assessment and management of coronary artery disease in the potential lung transplant candidate.
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Affiliation(s)
- Gregory Serrao
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (M.V.); (J.N.); (V.S.); (A.C.L.); (D.L.); (A.K.); (H.S.); (S.S.)
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15
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Morgan H, Ezad SM, Rahman H, De Silva K, Partridge JSL, Perera D. Assessment and Management of Ischaemic Heart Disease in Non-Cardiac Surgery. Heart Int 2023; 17:19-26. [PMID: 38419719 PMCID: PMC10898586 DOI: 10.17925/hi.2023.17.2.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/18/2023] [Indexed: 03/02/2024] Open
Abstract
In the setting of non-cardiac surgery, cardiac complications contribute to over a third of perioperative deaths. With over 230 million major surgeries performed annually, and an increasing prevalence of cardiovascular risk factors and ischaemic heart disease, the incidence of perioperative myocardial infarction is also rising. The recent European Society of Cardiology guidelines on cardiovascular risk in noncardiac surgery elevated practices aiming to identify those at most risk, including biomarker monitoring and stress testing. However the current evidence base on if, and how, the risk of cardiac events can be modified is lacking. This review focuses on patient, surgical and cardiac risk assessment, as well as exploring the data on perioperative revascularization and other risk-reduction strategies.
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Affiliation(s)
- Holly Morgan
- British Heart Foundation Centre of Research Excellence at the School of Cardiovascular and Metabolic Medicine and Sciences, King's College, London, UK
| | - Saad M Ezad
- British Heart Foundation Centre of Research Excellence at the School of Cardiovascular and Metabolic Medicine and Sciences, King's College, London, UK
| | - Haseeb Rahman
- British Heart Foundation Centre of Research Excellence at the School of Cardiovascular and Metabolic Medicine and Sciences, King's College, London, UK
| | - Kalpa De Silva
- British Heart Foundation Centre of Research Excellence at the School of Cardiovascular and Metabolic Medicine and Sciences, King's College, London, UK
| | - Judith S L Partridge
- British Heart Foundation Centre of Research Excellence at the School of Cardiovascular and Metabolic Medicine and Sciences, King's College, London, UK
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Divaka Perera
- British Heart Foundation Centre of Research Excellence at the School of Cardiovascular and Metabolic Medicine and Sciences, King's College, London, UK
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
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16
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Binu AJ, Kapoor N, Bhattacharya S, Kishor K, Kalra S. Sarcopenic Obesity as a Risk Factor for Cardiovascular Disease: An Underrecognized Clinical Entity. Heart Int 2023; 17:6-11. [PMID: 38419720 PMCID: PMC10897945 DOI: 10.17925/hi.2023.17.2.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/15/2023] [Indexed: 03/02/2024] Open
Abstract
Sarcopenic obesity (SO) is a chronic condition and an emerging health challenge, in view of the growing elderly population and the obesity epidemic. Due to a lack of awareness among treating doctors and the non-specific nauture of the associated symptoms, SO remains grossly underdiagnosed. There is no consensus yet on a standard definition or diagnostic criteria for SO, which limits the estimation of the global prevalence of this condition. It has been linked to numerous metabolic derangements, cardiovascular disease (CVD) and mortality. The treatment of SO is multimodal and requires expertise across multiple specialties. While dietary modifications and exercise regimens have shown a potential therapeutic benefit, there is currently no proven pharmacological management for SO. However, numerous drugs and the role of bariatric surgery are still under trial, and have great scope for further research. This article covers the available literature regarding the definition, diagnostic criteria, and prevalence of SO, with available evidence linking it to CVD, metabolic disease and mortality, and an overview of current directives on management.
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Affiliation(s)
- Aditya John Binu
- Department of Cardiology, Christian Medical College, Vellore, India
| | - Nitin Kapoor
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India
- Non-communicable Disease Unit, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | | | - Kamal Kishor
- Department of Cardiology, Rama Hospital, Karnal, India
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, India
- University Center for Research & Development, Chandigarh University, Mohali, India
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Moody JB, Poitrasson-Rivière A, Renaud JM, Hagio T, Al-Mallah MH, Weinberg RL, Ficaro EP, Murthy VL. Integrated myocardial flow reserve (iMFR) assessment: diffuse atherosclerosis and microvascular dysfunction are more strongly associated with mortality than focally impaired perfusion. Eur J Nucl Med Mol Imaging 2023; 51:123-135. [PMID: 37787848 DOI: 10.1007/s00259-023-06448-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 09/17/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND AND AIMS Although treatment of ischemia-causing epicardial stenoses may improve symptoms of ischemia, current evidence does not suggest that revascularization improves survival. Conventional myocardial ischemia imaging does not uniquely identify diffuse atherosclerosis, microvascular dysfunction, or nonobstructive epicardial stenoses. We sought to evaluate the prognostic value of integrated myocardial flow reserve (iMFR), a novel noninvasive approach to distinguish the perfusion impact of focal atherosclerosis from diffuse coronary disease. METHODS This study analyzed a large single-center registry of consecutive patients clinically referred for rest-stress myocardial perfusion positron emission tomography. Cox proportional hazards modeling was used to assess the association of two previously reported and two novel perfusion measures with mortality risk: global stress myocardial blood flow (MBF); global myocardial flow reserve (MFR); and two metrics derived from iMFR analysis: the extents of focal and diffusely impaired perfusion. RESULTS In total, 6867 patients were included with a median follow-up of 3.4 years [1st-3rd quartiles, 1.9-5.0] and 1444 deaths (21%). Although all evaluated perfusion measures were independently associated with death, diffusely impaired perfusion extent (hazard ratio 2.65, 95%C.I. [2.37-2.97]) and global MFR (HR 2.29, 95%C.I. [2.08-2.52]) were consistently stronger predictors than stress MBF (HR 1.62, 95%C.I. [1.46-1.79]). Focally impaired perfusion extent (HR 1.09, 95%C.I. [1.03-1.16]) was only moderately related to mortality. Diffusely impaired perfusion extent remained a significant independent predictor of death when combined with global MFR (p < 0.0001), providing improved risk stratification (overall net reclassification improvement 0.246, 95%C.I. [0.183-0.310]). CONCLUSIONS The extent of diffusely impaired perfusion is a strong independent and additive marker of mortality risk beyond traditional risk factors, standard perfusion imaging, and global MFR, while focally impaired perfusion is only moderately related to mortality.
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Affiliation(s)
| | | | | | | | - Mouaz H Al-Mallah
- Houston Methodist DeBakey Heart and Vascular Center, Houston, TX, USA
| | - Richard L Weinberg
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Edward P Ficaro
- INVIA, LLC, Ann Arbor, MI, USA
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Venkatesh L Murthy
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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Djokic I, Milicic B, Matic P, Ilijevski N, Milojevic M, Jovic M. Enhancing predictive accuracy of the cardiac risk score in open abdominal aortic surgery: the role of left ventricular wall motion abnormalities. Front Cardiovasc Med 2023; 10:1239153. [PMID: 38107265 PMCID: PMC10722257 DOI: 10.3389/fcvm.2023.1239153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 11/20/2023] [Indexed: 12/19/2023] Open
Abstract
Background Open abdominal aortic surgery carries many potential complications, with cardiac adverse events being the most significant concern. The Vascular Study Group Cardiac Risk Index (VSG-CRI) is a commonly used tool for predicting severe cardiac complications and guiding clinical decision-making. However, despite the potential prognostic significance of left ventricular wall motion abnormalities (LVWMAs) and reduced LV ejection fraction (LVEF) for adverse outcomes, the VSG-CRI model has not accounted for them. Hence, the main objective of this study was to analyze the added value of LV wall motion on the discriminatory power of the modified VSG-CRI in predicting major postoperative cardiac complications. Methods A prospective study was conducted involving 271 patients who underwent elective abdominal aortic surgery between 2019 and 2021. VSG-CRI scores were calculated, and preoperative transthoracic echocardiography was conducted for all patients. Subsequently, a modified version of the VSG-CRI, accounting for reduced LVEF and LVWMAs, was developed and incorporated into the dataset. The postoperative incidence of the composite endpoint of major adverse cardiac events (MACEs), including myocardial infarction, clinically relevant arrhythmias treated with medicaments or by cardioversion, or congestive heart failure, was assessed at discharge from the index hospitalization, with adjudicators blinded to events. The predictive accuracy of both the original and modified VSG-CRI was assessed using C-Statistics. Results In total, 61 patients (22.5%) experienced MACEs. Among these patients, a significantly higher proportion had preoperative LVWMAs compared to those without (62.3% vs. 32.9%, p < 0.001). Multivariable regression analysis revealed the VSG-CRI [odds ratio (OR) 1.46, 95% confidence interval (CI) 1.21-1.77; p < 0.001] and LVWMA (OR 2.76; 95% CI 1.46-5.23; p = 0.002) as independent predictors of MACEs. Additionally, the modified VSG-CRI model demonstrated superior predictability compared to the baseline VSG-CRI model, suggesting an improved predictive performance for anticipating MACEs following abdominal aortic surgery [area under the curve (AUC) 0.74; 95% CI 0.68-0.81 vs. AUC 0.70; 95% CI 0.63-0.77; respectively]. Conclusion The findings of this study suggest that incorporating preoperative echocardiography can enhance the predictive accuracy of the VSG-CRI for predicting MACEs after open abdominal aortic surgery. Before its implementation in clinical settings, external validation is necessary to confirm the generalizability of this newly developed predictive model across different populations.
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Affiliation(s)
- Ivana Djokic
- Clinic for Anesthesia and Intensive Care, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Biljana Milicic
- Department of Medical Statistics and Informatics, Faculty of Dental Medicine, University of Belgrade, Belgrade, Serbia
| | - Predrag Matic
- Clinic for Vascular Surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia
- School of Medicine, Belgrade University, Belgrade, Serbia
| | - Nenad Ilijevski
- Clinic for Vascular Surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia
- School of Medicine, Belgrade University, Belgrade, Serbia
| | - Milan Milojevic
- Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Miomir Jovic
- Clinic for Anesthesia and Intensive Care, Dedinje Cardiovascular Institute, Belgrade, Serbia
- School of Medicine, Belgrade University, Belgrade, Serbia
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19
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Fang Q, Bai Y, Hu S, Ding J, Liu L, Dai M, Qiu J, Wu L, Rao X, Wang Y. Unleashing the Potential of Nrf2: A Novel Therapeutic Target for Pulmonary Vascular Remodeling. Antioxidants (Basel) 2023; 12:1978. [PMID: 38001831 PMCID: PMC10669195 DOI: 10.3390/antiox12111978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 10/22/2023] [Accepted: 11/05/2023] [Indexed: 11/26/2023] Open
Abstract
Pulmonary vascular remodeling, characterized by the thickening of all three layers of the blood vessel wall, plays a central role in the pathogenesis of pulmonary hypertension (PH). Despite the approval of several drugs for PH treatment, their long-term therapeutic effect remains unsatisfactory, as they mainly focus on vasodilation rather than addressing vascular remodeling. Therefore, there is an urgent need for novel therapeutic targets in the treatment of PH. Nuclear factor erythroid 2-related factor 2 (Nrf2) is a vital transcription factor that regulates endogenous antioxidant defense and emerges as a novel regulator of pulmonary vascular remodeling. Growing evidence has suggested an involvement of Nrf2 and its downstream transcriptional target in the process of pulmonary vascular remodeling. Pharmacologically targeting Nrf2 has demonstrated beneficial effects in various diseases, and several Nrf2 inducers are currently undergoing clinical trials. However, the exact potential and mechanism of Nrf2 as a therapeutic target in PH remain unknown. Thus, this review article aims to comprehensively explore the role and mechanism of Nrf2 in pulmonary vascular remodeling associated with PH. Additionally, we provide a summary of Nrf2 inducers that have shown therapeutic potential in addressing the underlying vascular remodeling processes in PH. Although Nrf2-related therapies hold great promise, further research is necessary before their clinical implementation can be fully realized.
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Affiliation(s)
- Qin Fang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (Q.F.); (Y.B.); (S.H.); (J.D.); (L.L.); (M.D.); (J.Q.); (L.W.)
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Yang Bai
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (Q.F.); (Y.B.); (S.H.); (J.D.); (L.L.); (M.D.); (J.Q.); (L.W.)
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Shuiqing Hu
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (Q.F.); (Y.B.); (S.H.); (J.D.); (L.L.); (M.D.); (J.Q.); (L.W.)
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Jie Ding
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (Q.F.); (Y.B.); (S.H.); (J.D.); (L.L.); (M.D.); (J.Q.); (L.W.)
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Lei Liu
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (Q.F.); (Y.B.); (S.H.); (J.D.); (L.L.); (M.D.); (J.Q.); (L.W.)
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Meiyan Dai
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (Q.F.); (Y.B.); (S.H.); (J.D.); (L.L.); (M.D.); (J.Q.); (L.W.)
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Jie Qiu
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (Q.F.); (Y.B.); (S.H.); (J.D.); (L.L.); (M.D.); (J.Q.); (L.W.)
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Lujin Wu
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (Q.F.); (Y.B.); (S.H.); (J.D.); (L.L.); (M.D.); (J.Q.); (L.W.)
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Xiaoquan Rao
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (Q.F.); (Y.B.); (S.H.); (J.D.); (L.L.); (M.D.); (J.Q.); (L.W.)
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Yan Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (Q.F.); (Y.B.); (S.H.); (J.D.); (L.L.); (M.D.); (J.Q.); (L.W.)
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Huazhong University of Science and Technology, Wuhan 430030, China
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20
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Pappas MA, Auerbach AD, Kattan MW, Blackstone EH, Rothberg MB, Sessler DI. Consequences of preoperative cardiac stress testing-A cohort study. J Clin Anesth 2023; 90:111158. [PMID: 37418830 PMCID: PMC10530324 DOI: 10.1016/j.jclinane.2023.111158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 07/09/2023]
Abstract
OBJECTIVE To understand the consequences of functional cardiac stress testing among patients considering noncardiac nonophthalmologic surgery. DESIGN A retrospective cohort study of 118,552 patients who made 159,795 visits to a dedicated preoperative risk assessment and optimization clinic between 2008 and 2018. SETTING A large integrated health system. PATIENTS Patients who visited a dedicated preoperative risk assessment and optimization clinic before noncardiac nonophthalmologic surgery. MEASUREMENTS To assess changes to care delivered, we measured the probability of completing additional cardiac testing, cardiac surgery, or noncardiac surgery. To assess outcomes, we measured time-to-mortality and total one-year mortality. MAIN RESULTS In causal inference models, preoperative stress testing was associated with increased likelihood of coronary angiography (relative risk: 8.6, 95% CI 6.1-12.1), increased likelihood of percutaneous coronary intervention (RR: 4.1, 95% CI: 1.8-9.2), increased likelihood of cardiac surgery (RR: 6.8, 95% CI 4.9-9.4), decreased likelihood of noncardiac surgery (RR: 0.77, 95% CI 0.75-0.79), and delayed noncardiac surgery for patients completing noncardiac surgery (mean 28.3 days, 95% CI: 23.1-33.6). The base rate of downstream cardiac testing was low, and absolute risk increases were small. Stress testing was associated with higher mortality in unadjusted analysis but was not associated with mortality in causal inference analyses. CONCLUSIONS Preoperative cardiac stress testing likely induces coronary angiography and cardiac interventions while decreasing use of noncardiac surgery and delaying surgery for patients who ultimately proceed to noncardiac surgery. Despite changes to processes of care, our results do not support a causal relationship between stress testing and postoperative mortality. Analyses of care cascades should consider care that is avoided or substituted in addition to care that is induced.
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Affiliation(s)
- Matthew A Pappas
- Center for Value-based Care Research, Cleveland Clinic, Cleveland, OH, United States of America; Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, United States of America; Outcomes Research Consortium, Cleveland, OH, United States of America.
| | - Andrew D Auerbach
- Department of Hospital Medicine, University of California, San Francisco, CA, United States of America
| | - Michael W Kattan
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Eugene H Blackstone
- Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Michael B Rothberg
- Center for Value-based Care Research, Cleveland Clinic, Cleveland, OH, United States of America
| | - Daniel I Sessler
- Outcomes Research Consortium, Cleveland, OH, United States of America; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
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21
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Nagy FT, Olajos D, Vattay B, Borzsák S, Boussoussou M, Deák M, Vecsey-Nagy M, Sipos B, Jermendy ÁL, Tóth GG, Nemes B, Merkely B, Szili-Török T, Ruzsa Z, Szilveszter B. Dynamic Perfusion Computed Tomography for the Assessment of Concomitant Coronary Artery Disease in Patients with a History of Percutaneous Transluminal Angioplasty for Chronic Limb-Threatening Ischemia-A Pilot Study. J Cardiovasc Dev Dis 2023; 10:443. [PMID: 37998501 PMCID: PMC10671941 DOI: 10.3390/jcdd10110443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Chronic limb-threatening ischemia (CLTI) is associated with high rates of long-term cardiovascular mortality. Exercise stress testing to detect obstructive coronary artery disease (CAD) can be difficult in this subset of patients due to inability to undergo exercise testing, presence of balanced ischemia and severe coronary artery calcification (CAC). AIM To test the feasibility of regadenoson stress dynamic perfusion computed tomography (DPCT) in CLTI patients. METHODS Between 2018 and 2023, coronary computed tomography angiography (CTA) and, in the case of a calcium score higher than 400, DPCT, were performed in 25 CLTI patients with a history of endovascular revascularization. RESULTS Of the 25 patients, 19 had a calcium score higher than 400, requiring DPCT image acquisition. Obstructive CAD could be ruled out in 10 of the 25 patients. Of the 15 CTA/DPCT+ patients, 13 proceeded to coronary angiography (CAG). Revascularization was necessary in all 13 patients. In these 13 patients, vessel-based sensitivity and specificity of coronary CTA/DPCT as compared to invasive evaluation was 75%, respectively. At follow-up (27 ± 21 months) there was no statistically significant difference in all-cause mortality between CTA/DPCT- positive and -negative patients (p = 0.065). CONCLUSIONS Despite a high prevalence of severe CAC, coronary CTA complemented by DPCT may be a feasible method to detect obstructive and functionally significant CAD in CLTI patients.
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Affiliation(s)
- Ferenc T. Nagy
- Division of Invasive Cardiology, Department of Internal Medicine, University of Szeged, 6725 Szeged, Hungary; (F.T.N.); (D.O.)
| | - Dorottya Olajos
- Division of Invasive Cardiology, Department of Internal Medicine, University of Szeged, 6725 Szeged, Hungary; (F.T.N.); (D.O.)
| | - Borbála Vattay
- Heart and Vascular Center, Semmelweis University, Határőr Str. 18, 1122 Budapest, Hungary
| | - Sarolta Borzsák
- Heart and Vascular Center, Semmelweis University, Határőr Str. 18, 1122 Budapest, Hungary
| | - Melinda Boussoussou
- Heart and Vascular Center, Semmelweis University, Határőr Str. 18, 1122 Budapest, Hungary
| | - Mónika Deák
- Bács-Kiskun County Hospital, 6725 Kecskemét, Hungary
| | - Milán Vecsey-Nagy
- Heart and Vascular Center, Semmelweis University, Határőr Str. 18, 1122 Budapest, Hungary
| | - Barbara Sipos
- Heart and Vascular Center, Semmelweis University, Határőr Str. 18, 1122 Budapest, Hungary
| | - Ádám L. Jermendy
- Heart and Vascular Center, Semmelweis University, Határőr Str. 18, 1122 Budapest, Hungary
| | - Gábor G. Tóth
- Graz University Heart Center Graz, Medical University of Graz, 8036 Graz, Austria
| | - Balázs Nemes
- Heart and Vascular Center, Semmelweis University, Határőr Str. 18, 1122 Budapest, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Határőr Str. 18, 1122 Budapest, Hungary
| | - Tamás Szili-Török
- Division of Invasive Cardiology, Department of Internal Medicine, University of Szeged, 6725 Szeged, Hungary; (F.T.N.); (D.O.)
| | - Zoltán Ruzsa
- Division of Invasive Cardiology, Department of Internal Medicine, University of Szeged, 6725 Szeged, Hungary; (F.T.N.); (D.O.)
| | - Bálint Szilveszter
- Heart and Vascular Center, Semmelweis University, Határőr Str. 18, 1122 Budapest, Hungary
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22
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Li Y, Feng L, Xie D, Luo Y, Lin M, Gao J, Zhang Y, He Z, Zhu YZ, Gong Q. Icariside II mitigates myocardial infarction by balancing mitochondrial dynamics and reducing oxidative stress through the activation of Nrf2/SIRT3 signaling pathway. Eur J Pharmacol 2023; 956:175987. [PMID: 37572941 DOI: 10.1016/j.ejphar.2023.175987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 08/14/2023]
Abstract
Nuclear factor erythroid 2-related factor 2 (Nrf2)/silent mating type information regulation 2 homolog 3 (SIRT3) signaling pathway plays a pivotal role in regulating mitochondrial dynamics and oxidative stress, which are considered to be the principal pathogenesis of myocardial infarction (MI). Our previous study proved that pretreatment with icariside II (ICS II), a major active ingredient of Herbal Epimedii, exerts cardioprotective effect on MI, however, whether post-treatment with ICS II can alleviate MI and its underlying mechanism are still uncertain. Therefore, the present study was designed to investigate the therapeutic effect and the possible mechanism of ICS II on MI both in vivo and in vitro. The results revealed that post-treatment with ICS II markedly ameliorated myocardial injury in MI-induced mice and mitigated oxygen and glucose deprivation (OGD)-elicited cardiomyocyte injury. Further researches showed that ICS II promoted mitochondrial fusion, and suppressed mitochondrial fission and oxidative stress, which were achieved by facilitating the nuclear translocation of Nrf2 and activation of SIRT3. In summary, our findings indicate that ICS II mitigates MI-induced mitochondrial dynamics disorder and oxidative stress via activating the Nrf2/SIRT3 signaling pathway.
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Affiliation(s)
- Yeli Li
- School of Pharmacy, Faculty of Medicine, Macau University of Science and Technology, Macau SAR, China; Key Laboratory of Basic Pharmacology of Ministry of Education and Joint International Research Laboratory of Ethnomedicine of Ministry of Education, Zunyi Medical University, Zunyi, China
| | - Linying Feng
- School of Pharmacy, Faculty of Medicine, Macau University of Science and Technology, Macau SAR, China
| | - Dianyou Xie
- School of Pharmacy, Faculty of Medicine, Macau University of Science and Technology, Macau SAR, China
| | - Yunmei Luo
- School of Pharmacy, Faculty of Medicine, Macau University of Science and Technology, Macau SAR, China; Key Laboratory of Basic Pharmacology of Ministry of Education and Joint International Research Laboratory of Ethnomedicine of Ministry of Education, Zunyi Medical University, Zunyi, China
| | - Mu Lin
- School of Pharmacy, Faculty of Medicine, Macau University of Science and Technology, Macau SAR, China
| | - Jianmei Gao
- School of Pharmacy, Faculty of Medicine, Macau University of Science and Technology, Macau SAR, China; Key Laboratory of Basic Pharmacology of Ministry of Education and Joint International Research Laboratory of Ethnomedicine of Ministry of Education, Zunyi Medical University, Zunyi, China; Department of Clinical Pharmacotherapeutics, School of Pharmacy, Zunyi Medical University, Zunyi, China
| | - Yuandong Zhang
- Department of Clinical Pharmacotherapeutics, School of Pharmacy, Zunyi Medical University, Zunyi, China
| | - Zhixu He
- The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine, Zunyi Medical University, Zunyi, China
| | - Yi Zhun Zhu
- School of Pharmacy, Faculty of Medicine, Macau University of Science and Technology, Macau SAR, China.
| | - Qihai Gong
- School of Pharmacy, Faculty of Medicine, Macau University of Science and Technology, Macau SAR, China; Key Laboratory of Basic Pharmacology of Ministry of Education and Joint International Research Laboratory of Ethnomedicine of Ministry of Education, Zunyi Medical University, Zunyi, China.
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23
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Columbo JA, Scali ST, Neal D, Powell RJ, Sarosi G, Crippen C, Huber TS, Soybel D, Wong SL, Goodney PP, Upchurch GR, Stone DH. Increased Preoperative Stress Test Utilization is Not Associated With Reduced Adverse Cardiac Events in Current US Surgical Practice. Ann Surg 2023; 278:621-629. [PMID: 37317868 DOI: 10.1097/sla.0000000000005945] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To measure the frequency of preoperative stress testing and its association with perioperative cardiac events. BACKGROUND There is persistent variation in preoperative stress testing across the United States. It remains unclear whether more testing is associated with reduced perioperative cardiac events. METHODS We used the Vizient Clinical Data Base to study patients who underwent 1 of 8 elective major surgical procedures (general, vascular, or oncologic) from 2015 to 2019. We grouped centers into quintiles by frequency of stress test use. We computed a modified revised cardiac risk index (mRCRI) score for included patients. Outcomes included in-hospital major adverse cardiac events (MACEs), myocardial infarction (MI), and cost, which we compared across quintiles of stress test use. RESULTS We identified 185,612 patients from 133 centers. The mean age was 61.7 (±14.2) years, 47.5% were female, and 79.4% were White. Stress testing was performed in 9.2% of patients undergoing surgery, and varied from 1.7% at lowest quintile centers, to 22.5% at highest quintile centers, despite similar mRCRI comorbidity scores (mRCRI>1: 15.0% vs 15.8%; P =0.068). In-hospital MACE was less frequent among lowest versus highest quintile centers (8.2% vs 9.4%; P <0.001) despite a 13-fold difference in stress test use. Event rates were similar for MI (0.5% vs 0.5%; P =0.737). Mean added cost for stress testing per 1000 patients who underwent surgery was $26,996 at lowest quintile centers versus $357,300 at highest quintile centers. CONCLUSIONS There is substantial variation in preoperative stress testing across the United States despite similar patient risk profiles. Increased testing was not associated with reduced perioperative MACE or MI. These data suggest that more selective stress testing may be an opportunity for cost savings through a reduction of unnecessary tests.
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Affiliation(s)
- Jesse A Columbo
- Geisel School of Medicine at Dartmouth, Hanover, NH
- Dartmouth-Hitchcock Medical Center, Lebanon, NH
- Veteran's Affairs Medical Center, White River Junction, VA
| | - Salvatore T Scali
- University of Florida, School of Medicine, Gainesville, FL
- Department of Surgery, University of Florida, Gainesville, FL
- Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Dan Neal
- University of Florida, School of Medicine, Gainesville, FL
- Department of Surgery, University of Florida, Gainesville, FL
- Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Richard J Powell
- Geisel School of Medicine at Dartmouth, Hanover, NH
- Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - George Sarosi
- University of Florida, School of Medicine, Gainesville, FL
- Department of Surgery, University of Florida, Gainesville, FL
| | - Cristina Crippen
- University of Florida, School of Medicine, Gainesville, FL
- Department of Surgery, University of Florida, Gainesville, FL
| | - Thomas S Huber
- University of Florida, School of Medicine, Gainesville, FL
- Department of Surgery, University of Florida, Gainesville, FL
| | - David Soybel
- Geisel School of Medicine at Dartmouth, Hanover, NH
- Veteran's Affairs Medical Center, White River Junction, VA
| | - Sandra L Wong
- Geisel School of Medicine at Dartmouth, Hanover, NH
- Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Philip P Goodney
- Geisel School of Medicine at Dartmouth, Hanover, NH
- Dartmouth-Hitchcock Medical Center, Lebanon, NH
- Veteran's Affairs Medical Center, White River Junction, VA
| | - Gilbert R Upchurch
- University of Florida, School of Medicine, Gainesville, FL
- Department of Surgery, University of Florida, Gainesville, FL
| | - David H Stone
- Geisel School of Medicine at Dartmouth, Hanover, NH
- Dartmouth-Hitchcock Medical Center, Lebanon, NH
- Veteran's Affairs Medical Center, White River Junction, VA
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24
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Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
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25
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Dabic P, Petrovic J, Vucurevic B, Bucic A, Bajcetic D, Ilijevski N, Sevkovic M. Caught Between Heart and Limbs: Navigating the Treatment of Patients With CAD and PAD in an Overwhelmed Healthcare System. Angiology 2023:33197231204087. [PMID: 37747707 DOI: 10.1177/00033197231204087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Peripheral arterial disease (PAD) and coronary artery disease (CAD) are manifestations of atherosclerosis, affecting a substantial proportion of the population. Despite their interrelation, the prevalence of CAD in severe PAD varies, prompting the need to understand their complex relationship. This study retrospectively analyzes prospectively collected data from a high-volume vascular center to assess CAD prevalence, risk factors, and implications for patients undergoing vascular surgery. Among 667 arterial disease patients, 19.5% underwent coronary angiography, with CAD detected in 61.5% of cases. CAD varied across vascular beds. Decision-making around preoperative coronary angiography and revascularization remains complex, with benefits for high-risk patients still being debated. In accordance with current guidelines, the routine practice of coronary revascularization preceding vascular surgery is generally discouraged. This study underscores the need for risk stratification to identify patients who might benefit from coronary revascularization prior to vascular surgery while adhering to cost-effectiveness and avoiding unnecessary and time-consuming diagnostics in the majority of patients. Patient demographics, risk factors, and clinical presentation were analyzed alongside hospital stay, mortality, and complications. The study highlights the challenges in managing patients with concurrent CAD and PAD and calls for improved protocols for treating this high-risk group.
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Affiliation(s)
- Petar Dabic
- Vascular Surgery Clinic, Institute for Cardiovascular Disease "Dedinje", Belgrade, Serbia
| | - Jovan Petrovic
- Vascular Surgery Clinic, Institute for Cardiovascular Disease "Dedinje", Belgrade, Serbia
| | - Bojan Vucurevic
- Vascular Surgery Clinic, Institute for Cardiovascular Disease "Dedinje", Belgrade, Serbia
| | - Andriana Bucic
- Vascular Surgery Clinic, Institute for Cardiovascular Disease "Dedinje", Belgrade, Serbia
| | - Danica Bajcetic
- Vascular Surgery Clinic, Institute for Cardiovascular Disease "Dedinje", Belgrade, Serbia
| | - Nenad Ilijevski
- Vascular Surgery Clinic, Institute for Cardiovascular Disease "Dedinje", Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Milorad Sevkovic
- Vascular Surgery Clinic, Institute for Cardiovascular Disease "Dedinje", Belgrade, Serbia
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26
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Patail H, Bali A, Sharma T, Frishman WH, Aronow WS. Review and Key Takeaways of the 2021 Percutaneous Coronary Intervention Guidelines. Cardiol Rev 2023:00045415-990000000-00151. [PMID: 37729589 DOI: 10.1097/crd.0000000000000608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
The 2021 Percutaneous Coronary Intervention guidelines completed by American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions provide a set of guidelines regarding revascularization strategies. With emphasis on equity of care, multidisciplinary heart team use, revascularization for acute coronary syndrome, and stable ischemic heart disease, the guidelines create a thorough framework with recommendations regarding therapeutic strategies. In this comprehensive review, our aim is to summarize the 2021 revascularization guidelines and analyze key points regarding each recommendation.
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Affiliation(s)
- Haris Patail
- From the Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, CT
| | - Atul Bali
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Tanya Sharma
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - William H Frishman
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York
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27
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Hiraoka E, Tanabe K, Izuta S, Kubota T, Kohsaka S, Kozuki A, Satomi K, Shiomi H, Shinke T, Nagai T, Manabe S, Mochizuki Y, Inohara T, Ota M, Kawaji T, Kondo Y, Shimada Y, Sotomi Y, Takaya T, Tada A, Taniguchi T, Nagao K, Nakazono K, Nakano Y, Nakayama K, Matsuo Y, Miyamoto T, Yazaki Y, Yahagi K, Yoshida T, Wakabayashi K, Ishii H, Ono M, Kishida A, Kimura T, Sakai T, Morino Y. JCS 2022 Guideline on Perioperative Cardiovascular Assessment and Management for Non-Cardiac Surgery. Circ J 2023; 87:1253-1337. [PMID: 37558469 DOI: 10.1253/circj.cj-22-0609] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Affiliation(s)
- Eiji Hiraoka
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital
| | | | - Tadao Kubota
- Department of General Surgery, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Amane Kozuki
- Division of Cardiology, Osaka Saiseikai Nakatsu Hospital
| | | | | | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Susumu Manabe
- Department of Cardiovascular Surgery, International University of Health and Welfare Narita Hospital
| | - Yasuhide Mochizuki
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Taku Inohara
- Department of Cardiovascular Medicine, Keio University Graduate School of Medicine
| | - Mitsuhiko Ota
- Department of Cardiovascular Center, Toranomon Hospital
| | | | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital
| | - Yumiko Shimada
- JADECOM Academy NP·NDC Training Center, Japan Association for Development of Community Medicine
| | - Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Tomofumi Takaya
- Department of Cardiovascular Medicine, Hyogo Prefectural Himeji Cardiovascular Center
| | - Atsushi Tada
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Kazuya Nagao
- Department of Cardiology, Osaka Red Cross Hospital
| | - Kenichi Nakazono
- Department of Pharmacy, St. Marianna University Yokohama Seibu Hospital
| | | | | | - Yuichiro Matsuo
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | | | | | | | | | | | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
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28
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Gashler KR, Ritchie AK, Hood R, Ibekwe SO. Anesthetic Management of Renal Cell Carcinoma With Level 3 Inferior Vena Cava Extension in a Patient With Severe Coronary Artery Disease. Cureus 2023; 15:e44180. [PMID: 37641726 PMCID: PMC10460294 DOI: 10.7759/cureus.44180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2023] [Indexed: 08/31/2023] Open
Abstract
A 49-year-old male with untreated type 2 diabetes and a family history of coronary artery disease (CAD) presented with right flank pain and profound progressive dyspnea on exertion to the emergency department of Ben Taub Hospital, a tertiary county hospital. Workup revealed right renal cell carcinoma with metastatic extension into the inferior vena cava (IVC). In addition, the patient had significant CAD with 95% occlusion of the proximal left anterior descending coronary artery amenable to percutaneous coronary intervention (PCI). After multidisciplinary discussions involving cardiovascular anesthesiology, cardiology, urology, and cardiothoracic surgery, it was estimated that the mortality benefit of immediate tumor resection outweighed the patient's need for PCI and further cardiac optimization. The patient underwent curative resection and thrombectomy under transesophageal echocardiography (TEE) guidance without complication, made an expedient recovery, and was discharged home on postoperative day seven.
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Affiliation(s)
- Kyle R Gashler
- Anesthesiology, Baylor College of Medicine, Houston, USA
| | - Alan K Ritchie
- Anesthesiology, Baylor College of Medicine, Houston, USA
| | - Ryan Hood
- Anesthesiology, Baylor College of Medicine, Houston, USA
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29
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Akingba AG, Chow WB, Rowe VL. Lower Extremity Bypass. Surg Clin North Am 2023; 103:767-778. [PMID: 37455036 DOI: 10.1016/j.suc.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
The original description of the lower extremity bypass (LEB) provided surgeons with a reliable method of limb revascularization. The tenets of the operation have formed the foundation for the advances of surgical care. A careful evaluation of the chronic limb-threatening ischemia patient due to the numerous comorbid conditions is paramount to obtain the best possible outcomes. Use of all adjuncts including judicious target vessels control, completion imaging, and vein harvesting techniques to ensure optimal outcomes because a functioning LEB remains a key to successful limb salvage.
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Affiliation(s)
- Ajibola George Akingba
- DC VAMC, Uniformed Services University of Health Sciences, 50 Irving Street, Washington, DC 20422, USA
| | - Warren Bryan Chow
- Division of Vascular Surgery and Endovascular Therapy, David Geffen School of Medicine at UCLA, 200 Peter Morton Medical Building, Suite 526, Los Angeles, CA 90095, USA
| | - Vincent Lopez Rowe
- Division of Vascular Surgery and Endovascular Therapy, David Geffen School of Medicine at UCLA, 200 Peter Morton Medical Building, Suite 526, Los Angeles, CA 90095, USA.
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30
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Beaulieu RJ. Preoperative Assessment of Patients with Vascular Disease. Surg Clin North Am 2023; 103:577-594. [PMID: 37455026 DOI: 10.1016/j.suc.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Patients with vascular disease represent a particularly high-risk surgical population. Many of the comorbidities that contribute to their vascular presentation impact a number of vascular beds or other organ systems. As a result, these patients have the highest rates of cardiac and pulmonary complications among patients with noncardiac surgery. The vascular surgeon is in a unique position to help evaluate and treat many of these conditions to not only reduce the perioperative risk but also to improve the patient's overall health. This article presents a comprehensive review of the common preoperative evaluations that have a high impact on patients with vascular disease.
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Affiliation(s)
- Robert J Beaulieu
- Department of Surgery, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, USA.
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Abstract
This review aims to provide a conceptual framework for preoperative evaluation and to highlight the clinical evidence available to support perioperative decision-making.
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Affiliation(s)
- Jeanna D Blitz
- Duke University School of Medicine, Durham, North Carolina
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32
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Cheng XS. Preoperative Evaluations Before Transplantation-Essential Tools, Not Obstacles-Reply. JAMA Intern Med 2023; 183:745-746. [PMID: 37184870 DOI: 10.1001/jamainternmed.2023.1242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Affiliation(s)
- Xingxing S Cheng
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
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33
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McGinigle KL, Spangler EL, Ayyash K, Arya S, Settembrini AM, Thomas MM, Dell KE, Swiderski IJ, Davies MG, Setacci C, Urman RD, Howell SJ, Garg J, Ljungvist O, de Boer HD. A framework for perioperative care for lower extremity vascular bypasses: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery. J Vasc Surg 2023; 77:1295-1315. [PMID: 36931611 DOI: 10.1016/j.jvs.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/30/2022] [Accepted: 01/03/2023] [Indexed: 03/17/2023]
Abstract
The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based suggestions for coordinated perioperative care for patients undergoing infrainguinal bypass surgery for peripheral artery disease. Structured around the ERAS core elements, 26 suggestions were made and organized into preadmission, preoperative, intraoperative, and postoperative sections.
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Affiliation(s)
- Katharine L McGinigle
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Emily L Spangler
- Department of Surgery, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Katie Ayyash
- Department of Perioperative Medicine (Merit), York and Scarborough Teaching Hospitals NHS Foundation Trust, York, United Kingdom
| | - Shipra Arya
- Department of Surgery, School of Medicine, Stanford University, Palo Alto, CA
| | | | - Merin M Thomas
- Lenox Hill Hospital, Northwell Health, New Hyde Park, NY
| | | | | | - Mark G Davies
- Department of Surgery, Joe R. & Teresa Lozano Long School of Medicine, University of Texas Health Sciences Center, San Antonio, TX
| | - Carlo Setacci
- Department of Surgery Surgery, University of Siena, Siena, Italy
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Simon J Howell
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom
| | - Joy Garg
- Department of Vascular Surgery, Kaiser Permanente San Leandro, San Leandro, CA
| | - Olle Ljungvist
- Department of Surgery, Orebro University, Orebro, Sweden
| | - Hans D de Boer
- Department of Anesthesiology, Pain Medicine, and Procedure Sedation and Analgesia, Martini General Hospital Groningen, Groningen, the Netherlands
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34
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Kassab K, Saltiel F. Current management of coronary artery disease prior to vascular surgery: A clinical dilemma. J Perioper Pract 2023; 33:148-152. [PMID: 36285610 PMCID: PMC10160823 DOI: 10.1177/17504589221123285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Here we present a case of an elderly man who underwent cardiac stress testing as a preoperative evaluation prior to femoral-popliteal bypass surgery. He subsequently underwent a preoperative coronary angiogram after a high-risk stress test with the latter demonstrating obstructive three-vessel coronary artery disease. We discuss the clinical challenges that such a common clinical scenario presents particularly when it comes to preoperative coronary revascularisation prior to vascular surgery. We examine the case within the framework of the latest revascularisation guidelines and discuss the available evidence for preoperative revascularisation and its limitations.
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Affiliation(s)
- Kameel Kassab
- Division of Cardiology, Borgess Heart Institute, Kalamazoo, MI, USA
- Michigan State University, East Lansing, MI, USA
| | - Frank Saltiel
- Division of Cardiology, Borgess Heart Institute, Kalamazoo, MI, USA
- Michigan State University, East Lansing, MI, USA
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35
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Zarins CK. Adding value to routine postoperative troponin testing of vascular surgery patients. J Vasc Surg 2023; 77:1224-1225. [PMID: 36948679 DOI: 10.1016/j.jvs.2022.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 03/24/2023]
Affiliation(s)
- Christopher K Zarins
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
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36
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The impact of angiotensin-converting-enzyme inhibitors versus angiotensin receptor blockers on 3-year clinical outcomes in elderly (≥ 65) patients with acute myocardial infarction without hypertension. Heart Vessels 2023; 38:898-908. [PMID: 36795168 DOI: 10.1007/s00380-023-02244-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 01/26/2023] [Indexed: 02/17/2023]
Abstract
OBJECTIVE This study aimed to investigate the impact of angiotensin-converting-enzyme inhibitors (ACEI) and angiotensin II type 1 receptor blockers (ARB) on 3-year clinical outcomes in elderly (≥ 65) acute myocardial infarction (AMI) patients without a history of hypertension who underwent successful percutaneous coronary intervention (PCI) with drug-eluting stents (DES). METHODS A total of 13,104 AMI patients who were registered in the Korea AMI registry (KAMIR)-National Institutes of Health (NIH) were included in the study. The primary endpoint was 3-year major adverse cardiac events (MACE), which was defined as the composite of all-cause death, recurrent myocardial infarction (MI), and any repeat revascularization. To adjust baseline potential confounders, an inverse probability weighting (IPTW) analysis was performed. RESULTS The patients were divided into two groups: the ACEI group, n = 872 patients and the ARB group, n = 508 patients. After IPTW matching, baseline characteristics were balanced. During the 3-year clinical follow-up, the incidence of MACE was not different between the two groups. However, incidence of stroke (hazard ratio [HR], 0.375; 95% confidence interval [CI], 0.166-0.846; p = 0.018) and re-hospitalization due to heart failure (HF) (HR, 0.528; 95% CI, 0.289-0.965; p = 0.038) in the ACEI group were significantly lower than in the ARB group. CONCLUSION In elderly AMI patients who underwent PCI with DES without a history of hypertension, the use of ACEI was significantly associated with reduced incidences of stroke, and re-hospitalization due to HF than those with the use of ARB.
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37
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Cheng XS, Liu S, Han J, Stedman MR, Baiocchi M, Tan JC, Chertow GM, Fearon WF. Association of Pretransplant Coronary Heart Disease Testing With Early Kidney Transplant Outcomes. JAMA Intern Med 2023; 183:134-141. [PMID: 36595271 PMCID: PMC9857067 DOI: 10.1001/jamainternmed.2022.6069] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 11/07/2022] [Indexed: 01/04/2023]
Abstract
Importance Testing for coronary heart disease (CHD) in asymptomatic kidney transplant candidates before transplant is widespread and endorsed by various professional societies, but its association with perioperative outcomes is unclear. Objective To estimate the association of pretransplant CHD testing with rates of death and myocardial infarction (MI). Design, Setting, and Participants This retrospective cohort study included all adult, first-time kidney transplant recipients from January 2000 through December 2014 in the US Renal Data System with at least 1 year of Medicare enrollment before and after transplant. An instrumental variable (IV) analysis was used, with the program-level CHD testing rate in the year of the transplant as the IV. Analyses were stratified by study period, as the rate of CHD testing varied over time. A combination of US Renal Data System variables and Medicare claims was used to ascertain exposure, IV, covariates, and outcomes. Exposures Receipt of nonurgent invasive or noninvasive CHD testing during the 12 months preceding kidney transplant. Main Outcomes and Measures The primary outcome was a composite of death or acute MI within 30 days of after kidney transplant. Results The cohort comprised 79 334 adult, first-time kidney transplant recipients (30 147 women [38%]; 25 387 [21%] Black and 48 394 [61%] White individuals; mean [SD] age of 56 [14] years during 2012 to 2014). The primary outcome occurred in 4604 patients (244 [5.3%]; 120 [2.6%] death, 134 [2.9%] acute MI). During the most recent study period (2012-2014), the CHD testing rate was 56% in patients in the most test-intensive transplant programs (fifth IV quintile) and 24% in patients at the least test-intensive transplant program (first IV quintile, P < .001); this pattern was similar across other study periods. In the main IV analysis, compared with no testing, CHD testing was not associated with a change in the rate of primary outcome (rate difference, 1.9%; 95% CI, 0%-3.5%). The results were similar across study periods, except for 2000 to 2003, during which CHD testing was associated with a higher event rate (rate difference, 6.8%; 95% CI, 1.8%-12.0%). Conclusions and Relevance The results of this cohort study suggest that pretransplant CHD testing was not associated with a reduction in early posttransplant death or acute MI. The study findings potentially challenge the ubiquity of CHD testing before kidney transplant and should be confirmed in interventional studies.
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Affiliation(s)
- Xingxing S. Cheng
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Sai Liu
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jialin Han
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Margaret R. Stedman
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Michael Baiocchi
- Department of Statistics, Stanford University, Stanford, California
| | - Jane C. Tan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Glenn M. Chertow
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - William F. Fearon
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
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38
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Liang F, Liu S, Liu G, Liu H, Wang Q, Song B, Yao L. Remote ischaemic preconditioning versus no remote ischaemic preconditioning for vascular and endovascular surgical procedures. Cochrane Database Syst Rev 2023; 1:CD008472. [PMID: 36645250 PMCID: PMC9841888 DOI: 10.1002/14651858.cd008472.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Despite advances in perioperative care, elective major vascular surgical procedures still carry a significant risk of morbidity and mortality. Remote ischaemic preconditioning (RIPC) is the temporary blocking of blood flow to vascular beds remote from those targeted by surgery. It has the potential to provide local tissue protection from further prolonged periods of ischaemia. However, the efficacy and safety of RIPC in people undergoing major vascular surgery remain unknown. This is an update of a review published in 2011. OBJECTIVES: To assess the benefits and harms of RIPC versus no RIPC in people undergoing elective major vascular and endovascular surgery. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov to 1 April 2022. SELECTION CRITERIA We included all randomised controlled trials that evaluated the role of RIPC in reducing perioperative mortality and morbidities in people undergoing elective major vascular or endovascular surgery. DATA COLLECTION AND ANALYSIS We collected data on the characteristics of the trial, methodological quality, and the remote ischaemic preconditioning stimulus used. Our primary outcome was perioperative mortality, and secondary outcomes included myocardial infarction, renal impairment, stroke, hospital stay, limb loss, and operating time or total anaesthetic time. We analysed the data using random-effects models. For each outcome, we calculated the risk ratio (RR) or mean difference (MD) with a 95% confidence interval (CI) based on an intention-to-treat analysis. In addition, we used GRADE to assess the certainty of the evidence for each outcome. MAIN RESULTS We included 14 trials which randomised a total of 1295 participants (age range: 64.5 to 76 years; 84% male; study periods ranged from 2003 to 2019). In general, the included studies were at low to unclear risk of bias for most risk of bias domains. The certainty of evidence of main outcomes was moderate due to imprecision of results, moderate heterogeneity, or possible publication bias. We found that RIPC made no clear difference in perioperative mortality compared with no RIPC (RR 1.41, 95% CI 0.59 to 3.40; I2 = 0%; 10 studies, 965 participants; moderate-certainty evidence). Similarly, we found no clear difference between the two groups for myocardial infarction (RR 0.82, 95% CI 0.49 to 1.40; I2 = 7%; 11 studies, 1001 participants; moderate-certainty evidence), renal impairment (RR 1.07, 95% CI 0.62 to 1.86; I2 = 40%; 12 studies, 1054 participants; moderate-certainty evidence), stroke (RR 0.33, 95% CI 0.04 to 3.15; I2 = 0%; 4 studies, 392 participants; moderate-certainty evidence), limb loss (RR 0.74, 95% CI 0.05 to 10.61; I2 = 32%; 3 studies, 322 participants; low-certainty evidence), hospital stay (MD -0.94 day, 95% CI -1.95 to 0.07; I2 = 17%; 7 studies, 569 participants; moderate-certainty evidence), and operating time or total anaesthetic time (MD 5.76 minutes, 95% CI -3.25 to 14.76; I2 = 44%; 10 studies, 803 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS: Overall, compared with no RIPC, RIPC probably leads to little or no difference in perioperative mortality, myocardial infarction, renal impairment, stroke, hospital stay, and operating time, and may lead to little or no difference in limb loss in people undergoing elective major vascular and endovascular surgery. Adequately powered and designed randomised studies are needed, focusing in particular on the clinical endpoints and patient-centred outcomes.
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Affiliation(s)
- Fuxiang Liang
- Department of Cardiovascular Surgery, The First Hospital of Lanzhou University, Lanzhou, China
- Department of Thoracic Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shidong Liu
- Department of Cardiovascular Surgery, The First Hospital of Lanzhou University, Lanzhou, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Guangzu Liu
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Hongxu Liu
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Qi Wang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Bing Song
- Department of Cardiovascular Surgery, The First Hospital of Lanzhou University, Lanzhou, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
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Bagateliya ZA, Grekov DN, Komarova AG, Kulushev VM, Sokolov NY, Kuts IN, Lebedko MS. [Integral scales in assessing the risk of postoperative morbidity and mortality]. Khirurgiia (Mosk) 2023:25-33. [PMID: 38010015 DOI: 10.17116/hirurgia202311125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
Annual number of surgeries exceeds 10 million In Russia, and this number is increasing every year. Searching for a scale or index determining the risk of postoperative complications and mortality is an important issue all over the world. The authors analyzed all available risk assessment scales for postoperative morbidity and mortality. The most significant ones in historical aspect and modern perspective grading systems were highlighted. We compared these indices with clinical recommendations and necessary preoperative preparation. Thus, these scales are valuable for surgeons and anesthesiologists to assess the risk, volume of surgical intervention and methods of preoperative management. However, they are not perfect and require improvement. Therefore, development of such scales is a priority objective of medicine in the foreseeable future.
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Affiliation(s)
| | - D N Grekov
- Botkin Clinical Hospital, Moscow, Russia
| | | | | | | | - I N Kuts
- Botkin Clinical Hospital, Moscow, Russia
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40
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Cormican DS, Khalif A, McHugh S, Dalia AA, Drennen Z, Nuñez-Gil IJ, Ramakrishna H. Analysis of the Updated ACC/AHA Coronary Revascularization Guidelines With Implications for Cardiovascular Anesthesiologists and Intensivists. J Cardiothorac Vasc Anesth 2023; 37:135-148. [PMID: 36347728 DOI: 10.1053/j.jvca.2022.09.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Daniel S Cormican
- Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Anesthesiology Institute, Allegheny Health Network, Pittsburgh, PA
| | - Adnan Khalif
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, PA
| | - Stephen McHugh
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Adam A Dalia
- Division of Cardiac Anesthesiology, Department of Critical Care, Anesthesia, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Zachary Drennen
- Anesthesiology Institute, Allegheny Health Network, Pittsburgh, PA
| | - Ivan J Nuñez-Gil
- Cardiovascular Institute, Hospital Clinico San Carlos, Madrid, Spain
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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41
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Abstract
Patients that require major vascular surgery suffer from widespread atherosclerosis and have multiple comorbidities that place them at increased risk for postoperative complications and require admission to the intensive care unit (ICU). Postoperative critical care of these patients is focused on hemodynamic optimization, and early identification and management of complications to improve outcomes.
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Affiliation(s)
- Milad Sharifpour
- Department of Anesthesiology, Cedars Sinai Medical Center, 8700 Beverly Boulevard #8211, Los Angeles, CA 90048, USA.
| | - Edward A Bittner
- Critical Care-Anesthesiology Fellowship, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, Boston MA 02114, USA
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42
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Kiefer J, Mazzeffi M. Complications of Vascular Disease. Anesthesiol Clin 2022; 40:587-604. [PMID: 36328617 DOI: 10.1016/j.anclin.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Vascular diseases and their sequelae increase perioperative risk for noncardiac surgical patients. In this review, the authors discuss vascular diseases, their epidemiology and pathophysiology, risk stratification, and management strategies to reduce adverse perioperative outcomes.
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Affiliation(s)
- Jesse Kiefer
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania - Perelman School of Medicine, 3400 Spruce Street, Suite 680 Dulles Philadelphia, PA 19104, USA
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Virginia Health, PO Box 800710, Charlottesville, VA, USA.
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43
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Illuminati G, Tanzilli G, Miraldi F, Ricco JB. Concerning revascularization of patients with silent coronary ischemia following carotid endarterectomy. J Vasc Surg 2022; 76:1757. [DOI: 10.1016/j.jvs.2022.06.102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 06/27/2022] [Indexed: 11/19/2022]
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44
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Ibrahim H, Williams MR. When Fixing Hinders, Why We Should Sometimes Fight the Urge to Fix. Circ Cardiovasc Interv 2022; 15:e012654. [PMID: 36538581 DOI: 10.1161/circinterventions.122.012654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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45
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Cheng XS, VanWagner LB, Costa SP, Axelrod DA, Bangalore S, Norman SP, Herzog C, Lentine KL. Emerging Evidence on Coronary Heart Disease Screening in Kidney and Liver Transplantation Candidates: A Scientific Statement From the American Heart Association: Endorsed by the American Society of Transplantation. Circulation 2022; 146:e299-e324. [PMID: 36252095 PMCID: PMC10124159 DOI: 10.1161/cir.0000000000001104] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Coronary heart disease is an important source of mortality and morbidity among kidney transplantation and liver transplantation candidates and recipients and is driven by traditional and nontraditional risk factors related to end-stage organ disease. In this scientific statement, we review evidence from the past decade related to coronary heart disease screening and management for kidney and liver transplantation candidates. Coronary heart disease screening in asymptomatic kidney and liver transplantation candidates has not been demonstrated to improve outcomes but is common in practice. Risk stratification algorithms based on the presence or absence of clinical risk factors and physical performance have been proposed, but a high proportion of candidates still meet criteria for screening tests. We suggest new approaches to pretransplantation evaluation grounded on the presence or absence of known coronary heart disease and cardiac symptoms and emphasize multidisciplinary engagement, including involvement of a dedicated cardiologist. Noninvasive functional screening methods such as stress echocardiography and myocardial perfusion scintigraphy have limited accuracy, and newer noninvasive modalities, especially cardiac computed tomography-based tests, are promising alternatives. Emerging evidence such as results of the 2020 International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease trial emphasizes the vital importance of guideline-directed medical therapy in managing diagnosed coronary heart disease and further questions the value of revascularization among asymptomatic kidney transplantation candidates. Optimizing strategies to disseminate and implement best practices for medical management in the broader end-stage organ disease population should be prioritized to improve cardiovascular outcomes in these populations.
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Affiliation(s)
| | | | | | | | | | | | - Charles Herzog
- Hennepin Healthcare/University of Minnesota, Minneapolis, MN
| | - Krista L. Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO
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46
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Sumin AN. Assessment and Correction of the Cardiac Complications Risk in Non-cardiac Operations – What's New? RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2022-10-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Cardiovascular complications after non-cardiac surgery are the leading cause of 30-day mortality. The need for surgical interventions is approximately 5,000 procedures per 100,000 population, according to experts, the risks of non-cardiac surgical interventions are markedly higher in the elderly. It should be borne in mind that the aging of the population and the increased possibilities of medicine inevitably lead to an increase in surgical interventions in older people. Recent years have been characterized by the appearance of national and international guidelines with various algorithms for assessing and correcting cardiac risk, as well as publications on the validation of these algorithms. The purpose of this review was to provide new information about the assessment and correction of the risk of cardiac complications in non-cardiac operations. Despite the proposed new risk assessment scales, the RCRI scale remains the most commonly used, although for certain categories of patients (with oncopathology, in older age groups) the possibility of using specific questionnaires has been shown. In assessing the functional state, it is proposed to use not only a subjective assessment, but also the DASI questionnaire, 6-minute walking test and cardiopulmonary exercise test). At the next stage, it is proposed to evaluate biomarkers, primarily BNP or NT-proBNP, with a normal level – surgery, with an increased level – either an additional examination by a cardiologist or perioperative troponin screening. Currently, the prevailing opinion is that there is no need to examine patients to detect hidden lesions of the coronary arteries (non-invasive tests, coronary angiography), since this leads to excessive examination of patients, delaying the implementation of non-cardiac surgery. The extent to which this approach has an advantage over the previously used one remains to be studied.
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Affiliation(s)
- A. N. Sumin
- Research Institute for Complex Issues of Cardiovascular Diseases
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47
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Modha K, Whinney C. Preoperative Evaluation for Noncardiac Surgery. Ann Intern Med 2022; 175:ITC161-ITC176. [PMID: 36343344 DOI: 10.7326/aitc202211150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The previous In the Clinic that addressed preoperative evaluation for noncardiac surgery was published in December 2016. This update reaffirms much of the information in the previous version and provides new information that has accumulated since then. The goal of preoperative assessment is to identify the risk for postoperative complications so health care teams can more fully understand how to implement strategies to mitigate risks before and after the operation.
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Affiliation(s)
- Kunjam Modha
- Cleveland Clinic Foundation, Cleveland, Ohio (K.M.)
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48
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Halvorsen S, Mehilli J, Cassese S, Hall TS, Abdelhamid M, Barbato E, De Hert S, de Laval I, Geisler T, Hinterbuchner L, Ibanez B, Lenarczyk R, Mansmann UR, McGreavy P, Mueller C, Muneretto C, Niessner A, Potpara TS, Ristić A, Sade LE, Schirmer H, Schüpke S, Sillesen H, Skulstad H, Torracca L, Tutarel O, Van Der Meer P, Wojakowski W, Zacharowski K. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J 2022; 43:3826-3924. [PMID: 36017553 DOI: 10.1093/eurheartj/ehac270] [Citation(s) in RCA: 231] [Impact Index Per Article: 115.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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49
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Lee C, Columbo JA, Stone DH, Creager MA, Henkin S. Preoperative evaluation and perioperative management of patients undergoing major vascular surgery. Vasc Med 2022; 27:496-512. [PMID: 36214163 PMCID: PMC9551317 DOI: 10.1177/1358863x221122552] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients undergoing major vascular surgery have an increased risk of perioperative major adverse cardiovascular events (MACE). Accordingly, in this population, it is of particular importance to appropriately risk stratify patients' risk for these complications and optimize risk factors prior to surgical intervention. Comorbidities that portend a higher risk of perioperative MACE include coronary artery disease, heart failure, left-sided valvular heart disease, and significant arrhythmic burden. In this review, we provide a current approach to risk stratification prior to major vascular surgery and describe the strengths and weaknesses of different cardiac risk indices; discuss the role of noninvasive and invasive cardiac testing; and review perioperative pharmacotherapies.
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Affiliation(s)
| | | | | | | | - Stanislav Henkin
- Stanislav Henkin, Heart and Vascular
Center, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at
Dartmouth, Lebanon, NH 03756, USA.
Twitter: @stanhenkin
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50
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Alekyan BG, Karapetyan NG, Chupin AV, Zotikov AE, Varava AB, Knish JB, Sedgaryan MA. Long-Term Results of the Treatment of Patients With Chronic Ischemia of the Lower Limbs in Combination With Ischemic Heart Disease. KARDIOLOGIIA 2022; 62:37-43. [DOI: 10.18087/cardio.2022.9.n1941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/04/2022] [Indexed: 11/07/2022]
Abstract
Aim To compare long-term outcomes of x-ray endovascular (percutaneous coronary intervention, PCI, and lower limb angioplasty with stent placement, LLA; group 1) and combination treatments (PCI and open LLA surgery; group 2) in patients with chronic lower limb ischemia (CLLI) associated with ischemic heart disease (IHD).Material and methods This retrospective study has been conducted in the Vishnevsky National Medical Research Center of Surgery since 2019. The study includes 92 patients with stage 2B CLLI associated with IHD who were managed from January 1, 2017 through December 31, 2020. Long-term outcomes were evaluated in 76 (82.6 %) patients. The endpoint was severe cardiovascular complications (CVC), including death, myocardial infarction, and acute cerebrovascular disease (ACVD).Results In group 1 during the long-term period, 1 (2.7%) fatal outcome due to pneumonia was observed. In group 2, 4 (10 %) patients died: 1 (2.5 %) patient due to ACVD, 1 (2.5 %) patient due to progression of oncological process, and 2 2 (5 %) patients due to COVID-19. Also, 2 (5.5 %) and 1 (2.5 %) cases of acute coronary syndrome (ACS) were observed in groups 1 and 2, respectively (p=0.61).Conclusion In the x-ray endovascular (group1) and the combination (group 2) intervention groups, lethal outcomes due to myocardial infarction were absent. This fact confirms the importance of PCI in patients with CLLI for prevention of possible ACS in the long-term. Both therapeutic tactics in managing CLLI patients with IHD demonstrated high safety and clinical efficacy during the hospital and long-term periods and can be extensively used in routine clinical practice.
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Affiliation(s)
- B. G. Alekyan
- Vishnevsky National Medical Research Center of Surgery, Moscow
| | | | - A. V. Chupin
- Vishnevsky National Medical Research Center of Surgery, Moscow
| | - A. E. Zotikov
- Vishnevsky National Medical Research Center of Surgery, Moscow
| | - A. B. Varava
- Vishnevsky National Medical Research Center of Surgery, Moscow
| | - Ju. B. Knish
- Vishnevsky National Medical Research Center of Surgery, Moscow
| | - M. A. Sedgaryan
- Vishnevsky National Medical Research Center of Surgery, Moscow
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