Myocardial injury after noncardiac surgery - an update

Standards of anaesthesia for total knee and hip arthroplasty procedures. A survey-based study. Part II: Anaesthetic management

BACKGROUND

Total knee arthroplasty (TKA) and total hip arthroplasty (THA) procedures are being performed more and more frequently. Since these procedures carry an indirect risk of perioperative complications, practice standards are warranted to minimise the incidence of adverse events. A survey-based study was carried out to identify the patterns of anaesthesiology practice in Polish hospitals.

METHODS

A survey was conducted among anaesthetists nationwide using the LimeSurvey application. The questions concerned the intraoperative and postoperative periods and focused mainly on the determination of anaesthetic methods for total joint replacement (TJR) procedures and postoperative pain management. Questionnaires included both single and multiple-choice questions.

RESULTS

A total of 258 responses from anaesthetists from 112 Polish healthcare institutions were included in the analysis. The subarachnoid block is performed by 86.0% of anaesthetists for TKA and 88.0% for THA. For TKA procedures, 30.6% of respondents state that they do not perform any additional peripheral block, and for THA this percentage is 44.6%. The most commonly performed peripheral nerve block for TKA is the femoral nerve block (46.5%) and for THA it is the fascia iliaca compartment block (42.6%). More than 90% of anaesthetists report routine use of systemic analgesics in TJR, with opioid use exceeding 80%.

CONCLUSIONS

The study showed that anaesthetic perioperative care in Poland requires several modifications to better adhere to clinical standards. The most important issues include increasing the number of regional blocks, decreasing the use of opioid analgesics for post-operative pain management and introducing perioperative troponin screening.

Comprehensive review of myocardial injury after noncardiac surgery: prevention, intervention, and long-term management strategies

Myocardial Injury after Noncardiac Surgery (MINS) is an increasingly recognized complication that significantly impacts postoperative morbidity and mortality. Characterized by elevated cardiac troponin levels without overt ischemic symptoms, MINS presents a challenge in perioperative care. This review article explores the epidemiology, etiology, and management of MINS, with a particular focus on prevention and the latest management strategies. We discuss the role of aspirin, statins, anticoagulation, and Dual Antiplatelet Therapy (DAPT) within the context of MINS, drawing on evidence from notable clinical trials as well as observational studies. Despite advancements in understanding and managing MINS, the condition continues to be associated with high mortality and major adverse cardiovascular events (MACE), underscoring the need for ongoing research and development of more effective management protocols.

Hederagenin protects against myocardial ischemia-reperfusion injury via attenuating ALOX5-mediated ferroptosis

Hederagenin (HDG), a medical herb, is known for its beneficial activities against diverse diseases. The cardioprotective effect of HDG has been preliminarily disclosed, but the efficacy and underlying mechanism by which HDG protects against myocardial ischemia-reperfusion (MI/R) injury have not been elucidated yet. To simulate MI/R injury, the left anterior descending artery was occluded for 30 min and then reperfusion for 120 min in a rat model, and the cellular model of hypoxia-reoxygenation (H/R) injury was constructed in H9c2 cardiomyocytes. Hematoxylin-eosin, Prussian blue, and 2,3,5-triphenyl-2H-tetrazolium chloride (TTC) staining were conducted to assess the histological injury, iron deposition, and myocardial infarction. Myocardial enzymes and oxidative stress-related factors were detected using their commercial kits. Lipid peroxidation was measured using BODIPY581/591 probe, and iron content was detected. Cell counting kit (CCK)-8, terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL), and flow cytometry assays were performed to assess cell viability and apoptosis. Protein levels were investigated by western blot. The interaction between HDG and 5-lipoxygenase (ALOX5) was verified using molecular docking. Our findings indicated that HDG significantly attenuated myocardial dysfunction by reducing infarction and myocardial injury. HDG significantly attenuated myocardial apoptosis in vitro and in vivo, as well as alleviating oxidative stress via reducing reactive oxygen species (ROS) and maintaining the balance between antioxidant and oxidant enzymes. Meanwhile, HDG inhibited I/R-induced ferroptosis in myocardium and cardiomyocytes, including reducing lipid peroxidation and iron level. Moreover, the binding relationship between HDG and ALOX5 was verified, and HDG could concentration dependently downregulate ALOX5. Furthermore, ALOX5 overexpression eliminated the inhibition of HDG on H/R-induced apoptosis, oxidative stress, and ferroptosis in H9c2 cardiomyocytes. HDG ameliorated myocardial dysfunction and cardiomyocyte injury by reducing apoptosis, oxidative stress, and ferroptosis through inhibiting ALOX5, providing a new perspective on the prevention and treatment of MI/R injury.

Anaesthetic peripheral nerve blocks for a total knee replacement revision due to infection in a patient with symptomatic chronic coronary syndrome: A case report

This report aims to describe the perioperative management of a high-risk cardiovascular patient proposed for urgent total knee replacement revision. We discuss the use of peripheral nerve blocks and its impact on haemodynamic stability and clinical outcomes, including major cardiovascular adverse events and myocardial injury after non-cardiac surgery.

Implementing screening for myocardial injury in non-cardiac surgery: perspectives of an ad-hoc interdisciplinary expert group

Objectives. Perioperative myocardial injury (PMI) is increasingly recognised as an important complication of non-cardiac surgery, with often clinically silent presentation, but detrimental prognosis. Active screening for PMI, involving the detection of dynamic and elevated levels of cardiac troponin, has recently been advocated by an increasing number of guidelines; however, active PMI screening has not been reflected in clinical practice. Design. As consensus on a common screening and management pathway is lacking, we synthesise the current evidence to provide suggestions on the selection of patients for screening, organisation of a screening program, and a potential management pathway, building upon a recently published perioperative screening algorithm. Results. Screening should be performed using high-sensitivity assays both preoperatively and postoperatively (postoperative Days 1 and 2) in patients at high-risk of experiencing perioperative complications. Conclusion. This expert opinion piece by an interdisciplinary group of predominantly Norwegian clinicians aims to assist healthcare professionals planning to implement guideline-recommended PMI screening at a local level in order to improve patient outcomes following non-cardiac surgery.

Troponin elevation as a marker of short deterioration and one-year death in a high-risk surgical patient cohort in a low and middle income country setting: a postoperative approach to increase surveillance

PURPOSE

Myocardial injury after noncardiac surgery is common and mostly asymptomatic. The ideal target population that will benefit from routine troponin measurements in low and middle income countries (LMICs) is unclear. This study aims to evaluate the clinical outcomes of a cohort of high-risk surgical patients according to high-sensitivity troponin T (hsTnT) in an LMIC setting.

METHODS

We conducted a prospective cohort study of 442 high-risk patients undergoing noncardiac surgery at a Brazilian hospital between February 2019 and March 2020. High-sensitivity troponin T levels were measured preoperatively, 24 hr, and 48 hr after surgery and stratified into three groups: normal (< 20 ng·L-1); minor elevation (20-65 ng·L-1); and major elevation (> 65 ng·L-1). We performed survival analysis to determine the association between myocardial injury and one-year mortality. We described medical interventions and evaluated unplanned intensive care unit (ICU) admission and complications using multivariable models.

RESULTS

Postoperative myocardial injury occurred in 45% of patients. Overall, 30-day mortality was 8%. Thirty-day and one-year mortality were higher in patients with hsTnT ≥ 20 ng·L-1. One-year mortality was 18% in the unaltered troponin group vs 31% and 41% for minor and major elevation groups, respectively. Multivariable analysis of one-year survival showed a hazard ratio (HR) of 1.94 (95% confidence interval [CI], 1.22 to 3.09) for the minor elevation group and a HR of 2.73 (95% CI, 1.67 to 4.45) for the troponin > 65 ng·L-1 group. Patients with altered troponin had more unplanned ICU admissions (13% vs 5%) and more complications (78% vs 48%).

CONCLUSION

This study supports evidence that hsTnT is an important prognostic marker and a strong predictor of all-cause mortality after surgery. Troponin measurement in high-risk surgical patients could potentially be used as tool to scale-up care in LMIC settings.

STUDY REGISTRATION

ClinicalTrials.gov (NCT04187664); first submitted 5 December 2019.

Effect of Dexamethasone on Myocardial Injury After Total Knee Arthroplasty: A Substudy of the Randomized Clinical DEX-2-TKA Trial

BACKGROUND

Myocardial injury after noncardiac surgery (MINS) carries a high postoperative mortality. In this preplanned, subgroup analysis of the randomized DEX-2-TKA Trial, we investigated the effect of dexamethasone versus placebo on the concentration of cardiac troponin I and T (TnI and TnT) on the first postoperative morning after total knee arthroplasty. In addition, frequency of MINS, myocardial infarction, and major adverse cardiovascular events where evaluated.

METHODS

We included 290 patients who received either 24 mg of dexamethasone intravenously (given perioperatively) or placebo. Blood samples were analyzed as either TnI or T depending on trial site.

RESULTS

A total of 236 samples were eligible for analysis of TnI and 38 samples for TnT on the first postoperative morning. The median (IQR) TnI concentration was 4.6 ng/L (0-7.2 ng/L) in the dexamethasone group and 4.5ng/l (0-7.0 ng/L) in the placebo group (P = .96) on the first postoperative morning. The median TnT was 9 ng/L (6-11 ng/L) in the dexamethasone group and 8 ng/L (5-10 ng/L) in the placebo group (P = .68). The frequencies of MINS, myocardial infarction, and major adverse cardiovascular events were similar in the compared groups, but these analyses were underpowered.

CONCLUSION

We found no effect of dexamethasone on postoperative concentration of troponin I or T on the first postoperative morning after total knee arthroplasty.