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Sun N, Zhao J, Luo W, Luo X, Wu S, Wang Z, Li P, Li J, Zhou R, Ou S, Qin Z. B-type natriuretic peptide levels at admission predict the prognosis of patients with infective endocarditis undergoing cardiac surgery. Biomark Med 2024; 18:93-102. [PMID: 38358345 DOI: 10.2217/bmm-2023-0590] [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] [Indexed: 02/16/2024] Open
Abstract
Purpose: The objective of this study was to explore the relationship between elevated B-type natriuretic peptide (BNP) levels and the prognosis of patients with infective endocarditis (IE) undergoing cardiac surgery. Methods: In total, 162 IE patients with recorded BNP levels upon admission were included in the present study. The primary end point was all-cause mortality. Results: Multivariate Cox analysis revealed a significant association between log BNP and all-cause mortality. Kaplan-Meier analysis revealed a poorer prognosis for patients with BNP levels ≥ the 75th percentile. Furthermore, the linear trend test indicated a significant link between BNP quartiles and the primary end point within the models. Conclusion: Elevated BNP levels upon admission could predict all-cause mortality in IE patients undergoing cardiac surgery.
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Affiliation(s)
- Ning Sun
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Junyong Zhao
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Wenjian Luo
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Xiaolin Luo
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Shaofa Wu
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Zelan Wang
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Pengda Li
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Jia Li
- Department of Emergency, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Renjie Zhou
- Department of Emergency, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
| | - Shulin Ou
- Department of Cardiology, People's Hospital of Nanchuan District, Chongqing, 408400, China
| | - Zhexue Qin
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, China
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2
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Rao RA, Varghese SS, Ansari F, Rao A, Meng E, El-Diasty M. The Role of Natriuretic Peptides in Predicting Adverse Outcomes After Cardiac Surgery: An Updated Systematic Review. Am J Cardiol 2024; 210:16-36. [PMID: 37884264 DOI: 10.1016/j.amjcard.2023.09.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 09/12/2023] [Accepted: 09/25/2023] [Indexed: 10/28/2023]
Abstract
The increasing global burden of cardiovascular disease, particularly, in the aging population, has led to an increase in high-risk cardiac surgical procedures. The current preoperative risk stratification scores, such as the European System for Cardiac Operative Risk Evaluation and the Society for Thoracic Surgeons score, have limitations in their predictive accuracy and tend to underestimate the mortality risk in higher-risk populations. This systematic review aimed to evaluate the utility of natriuretic peptides, brain natriuretic peptide (BNP) and its precursor prohormone (N-terminal prohormone BNP), as predictive biomarkers for adverse outcomes after cardiac surgery. A comprehensive search strategy was performed, and 63 studies involving 40,667 patients who underwent major cardiac operations were included for data extraction. Preoperative levels of BNP and N-terminal prohormone BNP seemed to be associated with an increased risk of short- and long-term mortality, postoperative heart failure, kidney injury, and length of intensive care unit stay. However, their predictive value for postoperative arrhythmias and myocardial infarction was less established. Our findings suggest that natriuretic peptides may play an important role in risk prediction in patients who underwent cardiac surgery. The addition of these biomarkers to the existing clinical risk stratification strategies may enhance their predictive accuracy. However, this needs to be endorsed by data derived from wide-scale clinical trials.
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Affiliation(s)
- Reddi Ashwin Rao
- Queen's University School of Medicine, Kingston, Ontario, Canada
| | | | - Farzan Ansari
- Queen's University School of Medicine, Kingston, Ontario, Canada
| | - Aditya Rao
- Queen's University School of Medicine, Kingston, Ontario, Canada
| | - Eric Meng
- Queen's University School of Medicine, Kingston, Ontario, Canada
| | - Mohammad El-Diasty
- Harrington Heart and Vascular Institute, Cardiac Surgery Department, University Hospitals, Cleveland, Ohio.
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3
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Yacout AG, ELHoshy HS. Continuous femoral nerve block enhances outcome of spinal anaesthesia in preventing perioperative cardiac complications in patients with cardiac risk. EGYPTIAN JOURNAL OF ANAESTHESIA 2023. [DOI: 10.1080/11101849.2023.2175896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Affiliation(s)
- A G Yacout
- Lecturer of Anaesthesia and Surgical Intensive Care Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - H S ELHoshy
- Lecturer of Anaesthesia and Surgical Intensive Care Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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4
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Mahendran S, Thiagalingam A, Hillis G, Halliwell R, Pleass HC, Chow CK. Cardiovascular risk management in the peri-operative setting. Med J Aust 2023. [PMID: 37302136 DOI: 10.5694/mja2.51988] [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: 11/29/2022] [Revised: 03/17/2023] [Accepted: 03/27/2023] [Indexed: 06/13/2023]
Abstract
Peri-operative cardiovascular events occur in up to 3% of patients undergoing non-cardiac surgery. Accurate cardiovascular risk assessment is important in the peri-operative setting, as it allows informed and shared decisions regarding the appropriateness of proceeding with surgery, guides surgical and anaesthetic approaches, and may influence the use of preventive medications and post-operative cardiac monitoring. Quantitative risk assessment may also inform a reconsideration of choosing a more limited lower risk type of surgery, or conservative management. Pre-operative cardiovascular risk assessment starts with clinical assessment and should include an estimate of functional capacity. Specialised cardiac investigations are rarely indicated specifically to assess pre-operative cardiovascular risk. The decision regarding cardiac investigations is influenced by the nature, extent and urgency of surgery. The strategy of performing pre-operative revascularisation to improve post-operative outcomes is not evidence-based and recent international guidelines recommend against this.
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Affiliation(s)
| | | | | | | | - Henry Cc Pleass
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW
| | - Clara K Chow
- Westmead Hospital, Sydney, NSW
- University of Sydney, Sydney, NSW
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5
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Clerico A, Zaninotto M, Aimo A, Musetti V, Perrone M, Padoan A, Dittadi R, Sandri MT, Bernardini S, Sciacovelli L, Trenti T, Malloggi L, Moretti M, Burgio MA, Manno ML, Migliardi M, Fortunato A, Plebani M. Evaluation of the cardiovascular risk in patients undergoing major non-cardiac surgery: role of cardiac-specific biomarkers. A consensus document by the Inter-Society Study Group on Cardiac Biomarkers of the Italian Societies of Clinical Biochemistry: European Ligand Assay Society (ELAS), Italian section; Società Italiana di Biochimica Clinica e Biologia Molecolare Clinica (SIBioC); Società Italiana di Patologia Clinica e Medicina di Laboratorio (SIPMel). Clin Chem Lab Med 2022; 60:1525-1542. [PMID: 35858238 DOI: 10.1515/cclm-2022-0481] [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: 05/18/2022] [Accepted: 07/05/2022] [Indexed: 11/15/2022]
Abstract
Major adverse cardiovascular events are frequently observed in patients undergoing major non-cardiac surgery during the peri-operative period. At this time, the possibility to predict cardiovascular events remains limited, despite the introduction of several algorithms to calculate the risk of adverse events, mainly death and major adverse cardiovascular events (MACE) based on the clinical history, risk factors (sex, age, lipid profile, serum creatinine) and non-invasive cardiac exams (electrocardiogram, echocardiogram, stress tests). The cardiac-specific biomarkers natriuretic peptides (NPs) and cardiac troponins (cTn) have been proposed as additional tools for risk prediction in the peri-operative period, particularly for the identification of myocardial injury in patients undergoing major non-cardiac surgery. The prognostic information from the measurement of BNP/NT-proBNP and hs-cTn is independent and complementary to other important indicators of risk, also including ECG and imaging techniques. Elevated levels of cardiac-specific biomarkers before surgery are associated with a markedly higher risk of MACE during the peri-operative period. BNP/NT-proBNP and hs-cTn should be measured in all patients during the clinical evaluation before surgery, particularly during intermediate- or high-risk surgery, in patients aged >65 years and/or with comorbidities. Several questions remain to be assessed in dedicated clinical studies, such as how to optimize the management of patients with raised cardiac specific biomarkers before surgery, and whether a strategy based on biomarker measurement improves patient outcomes and is cost-effective.
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Affiliation(s)
- Aldo Clerico
- Scuola Superiore Sant'Anna e Fondazione CNR-Regione Toscana G. Monasterio, Pisa, Italy
| | - Martina Zaninotto
- Dipartimento di Medicina di Laboratorio, Università-Ospedale di Padova e Azienda Ospedaliera Universitaria di Padova, e Dipartimento di Medicina-Università di Padova, Padova, Italy
| | - Alberto Aimo
- Scuola Superiore Sant'Anna e Fondazione CNR-Regione Toscana G. Monasterio, Pisa, Italy
| | - Veronica Musetti
- Scuola Superiore Sant'Anna e Fondazione CNR-Regione Toscana G. Monasterio, Pisa, Italy
| | - Marco Perrone
- Dipartimento di Medicina Sperimentale, Università di Roma Tor Vergata, Roma, Italy
| | - Andrea Padoan
- Dipartimento di Medicina di Laboratorio, Università-Ospedale di Padova e Azienda Ospedaliera Universitaria di Padova, e Dipartimento di Medicina-Università di Padova, Padova, Italy
| | | | | | - Sergio Bernardini
- Dipartimento di Medicina Sperimentale, Università di Roma Tor Vergata, Roma, Italy
| | - Laura Sciacovelli
- Dipartimento di Medicina di Laboratorio, Università-Ospedale di Padova e Azienda Ospedaliera Universitaria di Padova, e Dipartimento di Medicina-Università di Padova, Padova, Italy
| | - Tommaso Trenti
- Dipartimento di Medicina di Laboratorio e Anatomia Patologica, Azienda Ospedaliera Universitaria e USL di Modena, Modena, Italy
| | - Lucia Malloggi
- Laboratorio Analisi, Azienda Ospedaliera-Universitaria di Pisa, Pisa, Italy
| | - Marco Moretti
- Medicina di Laboratorio, AOU Ospedali Riuniti Ancona, Ancona, Italy
| | | | | | - Marco Migliardi
- Laboratorio Analisi, Ospedale Ordine Mauriziano, Torino, Italy
| | | | - Mario Plebani
- Dipartimento di Medicina di Laboratorio-DIMED, Università di Padova, Padova, Italy
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Natriuretic Peptides and Troponins to Predict Cardiovascular Events in Patients Undergoing Major Non-Cardiac Surgery. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19095182. [PMID: 35564577 PMCID: PMC9103429 DOI: 10.3390/ijerph19095182] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/17/2022] [Accepted: 04/19/2022] [Indexed: 02/01/2023]
Abstract
Patients undergoing major surgery have a substantial risk of cardiovascular events during the perioperative period. Despite the introduction of several risk scores based on medical history, classical risk factors and non-invasive cardiac tests, the possibility of predicting cardiovascular events in patients undergoing non-cardiac surgery remains limited. The cardiac-specific biomarkers, natriuretic peptides (NPs) and cardiac troponins (cTn) have been proposed as additional tools for risk prediction in the perioperative period. This review paper aims to discuss the value of preoperative levels and perioperative changes in cardiac-specific biomarkers to predict adverse outcomes in patients undergoing major non-cardiac surgery. Based on several prospective observational studies and six meta-analyses, some guidelines recommended the measurement of NPs to refine perioperative cardiac risk estimation in patients undergoing non-cardiac surgery. More recently, several studies reported a higher mortality in surgical patients presenting an elevation in high-sensitivity cardiac troponin T and I, especially in elderly patients or those with comorbidities. This evidence should be considered in future international guidelines on the evaluation of perioperative risk in patients undergoing major non-cardiac surgery.
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7
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ASA Status, NPPA/NPPB Haplotype and Coronary Artery Disease Have an Impact on BNP/NT-proBNP Plasma Levels. Cells 2022; 11:cells11050766. [PMID: 35269388 PMCID: PMC8909668 DOI: 10.3390/cells11050766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/04/2022] [Accepted: 02/18/2022] [Indexed: 12/31/2022] Open
Abstract
Plasma concentrations of natriuretic peptides (NP) contribute to risk stratification and management of patients undergoing non-cardiac surgery. However, genetically determined variability in the levels of these biomarkers has been described previously. In the perioperative setting, genetic contribution to NP plasma level variability has not yet been determined. A cohort of 427 patients presenting for non-cardiac surgery was genotyped for single-nucleotide polymorphisms (SNPs) from the NPPA/NPPB locus. Haplotype population frequencies were estimated and adjusted haplotype trait associations for brain natriuretic peptide (BNP) and amino-terminal pro natriuretic peptide (NT-proBNP) were calculated. Five SNPs were included in the analysis. Compared to the reference haplotype TATAT (rs198358, rs5068, rs632793, rs198389, rs6676300), haplotype CACGC, with an estimated frequency of 4%, showed elevated BNP and NT-proBNP plasma concentrations by 44% and 94%, respectively. Haplotype CGCGC, with an estimated frequency of 9%, lowered NT-proBNP concentrations by 28%. ASA classification status III and IV, as well as coronary artery disease, were the strongest predictors of increased NP plasma levels. Inclusion of genetic information might improve perioperative risk stratification of patients based on adjusted thresholds of NP plasma levels.
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8
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The Influence of Perioperative Fluid Therapy on N-terminal-pro-brain Natriuretic Peptide and the Association With Heart and Lung Complications in Patients Undergoing Colorectal Surgery: Secondary Results of a Clinical Randomized Assessor-blinded Multicenter Trial. Ann Surg 2021; 272:941-949. [PMID: 31850996 DOI: 10.1097/sla.0000000000003724] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To investigate the influence of intravenous (iv) fluid volumes on the secretion of N-terminal-pro-brain natriuretic peptide (NT-Pro-BNP) in colorectal surgical patients and its association with cardiopulmonary complications (CPC). In addition, to examine if preoperative NT-Pro-BNP can predict the risk for postoperative CPC. METHODS Blood samples from patients enrolled in a previously published clinical randomized assessor-blinded multicenter trial were analyzed. Included were adult patients undergoing elective colorectal surgery with the American-Society-of-Anesthesiologists-scores of 1-3. Samples from 135 patients were available for analysis. Patients were allocated to either a restrictive (R-group) or a standard (S-group) iv-fluid regimen, commencing preoperatively and continuing until discharge. Blood was sampled every morning until the fourth postoperative day. The primary outcome for this study was NT-Pro-BNP changes and its association with fluid therapy and CPC. RESULTS The S-group received more iv-fluid than the R-group on the day-of-surgery [milliliter, median (range) 6485 (4401-10750) vs 3730 (2250-8510); P < 0.001] and on the first postoperative day. NT-Pro-BNP was elevated in the S-group compared with the R-group on all postoperative days [area under the curve: median (interquartile range) pg/mL: 3285 (1697-6179) vs 1290 (758-3719); P < 0.001 and in patients developing CPC vs no-CPC (area under the curve), median (interquartile range): 5196 (1823-9061) vs 1934 (831-5301); P = 0.005]. NT-pro-BNP increased with increasing fluid volumes all days (P < 0.003). Preoperative NT-Pro-BNP predicted CPC [odds ratio (confidence interval): 1.573 (0.973-2.541), P = 0.032; positive predictive value = 0.257, negative predictive value = 0.929]. CONCLUSIONS NT-pro-BNP increases with iv-fluid volumes given to colorectal surgical patients, and the level of NT-Pro-BNP is associated with CPC. Preoperative NT-Pro-BNP is predictive for CPC, but the diagnostic value is low.Clinicaltrials.gov NCT03537989.
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Patra V, Jha R, Anand V, Dhillan R, Mehra R, Reddy TS. Role of Cardio-biomarkers (NT-Pro BNP and Troponin I) in cardiac risk stratification of patients undergoing major vascular surgeries. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2021. [DOI: 10.4103/ijves.ijves_144_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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10
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Utility and limitations of natriuretic peptide screening in preoperative cardiac risk assessment. Int Anesthesiol Clin 2020; 59:30-35. [PMID: 33231942 DOI: 10.1097/aia.0000000000000308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Drapkina OM, Dzhioeva ON. Predictive value of brain natriuretic peptide for cardiovascular risk assessment in non-cardiac surgery. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2020. [DOI: 10.15829/1728-8800-2020-2558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- O. M. Drapkina
- National Medical Research Center for Therapy and Preventive Medicine
| | - O. N. Dzhioeva
- National Medical Research Center for Therapy and Preventive Medicine
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12
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Cao D, Chandiramani R, Capodanno D, Berger JS, Levin MA, Hawn MT, Angiolillo DJ, Mehran R. Non-cardiac surgery in patients with coronary artery disease: risk evaluation and periprocedural management. Nat Rev Cardiol 2020; 18:37-57. [PMID: 32759962 DOI: 10.1038/s41569-020-0410-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2020] [Indexed: 12/18/2022]
Abstract
Perioperative cardiovascular complications are important causes of morbidity and mortality associated with non-cardiac surgery, particularly in patients with coronary artery disease (CAD). Although preoperative cardiac risk assessment can facilitate the identification of vulnerable patients and implementation of adequate preventive measures, excessive evaluation might lead to undue resource utilization and surgical delay. Owing to conflicting data, there remains some uncertainty regarding the most beneficial perioperative strategy for patients with CAD. Antithrombotic agents are the cornerstone of secondary prevention of ischaemic events but substantially increase the risk of bleeding. Given that 5-25% of patients undergoing coronary stent implantation require non-cardiac surgery within 2 years, surgery is the most common reason for premature cessation of dual antiplatelet therapy. Perioperative management of antiplatelet therapy, which necessitates concomitant evaluation of the individual thrombotic and bleeding risks related to both clinical and procedural factors, poses a recurring dilemma in clinical practice. Current guidelines do not provide detailed recommendations on this topic, and the optimal approach in these patients is yet to be determined. This Review summarizes the current data guiding preoperative risk stratification as well as periprocedural management of patients with CAD undergoing non-cardiac surgery, including those treated with stents.
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Affiliation(s)
- Davide Cao
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rishi Chandiramani
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Davide Capodanno
- Division of Cardiology, C.A.S.T., P.O. "G. Rodolico", Azienda Ospedaliero-Universitaria "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Jeffrey S Berger
- Center for the Prevention of Cardiovascular Disease, New York University Langone Health, New York, NY, USA
| | - Matthew A Levin
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mary T Hawn
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Roxana Mehran
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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13
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Palamuthusingam D, Johnson DW, Hawley CM, Pascoe E, Sivalingam P, Fahim M. Perioperative outcomes and risk assessment in dialysis patients: current knowledge and future directions. Intern Med J 2020; 49:702-710. [PMID: 30485661 DOI: 10.1111/imj.14168] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 08/07/2018] [Accepted: 11/09/2018] [Indexed: 10/27/2022]
Abstract
Perioperative medicine is rapidly emerging as a key discipline to address the specific needs of high-risk surgical groups, such as those on chronic dialysis. Crude hospital separation rates for chronic dialysis patients are considerably higher than patients with normal renal function, with up to 15% of admission being related to surgical intervention. Dialysis dependency carries substantial mortality and morbidity risk compared to patients with normal renal function. This group of patients has a high comorbid burden and complex medical need, making accurate perioperative planning essential. Existing perioperative risk assessment tools are unvalidated in chronic dialysis patients. Furthermore, they fail to incorporate important dialysis treatment-related characteristics that could potentially influence perioperative outcomes. There is a dearth of information on perioperative outcomes of Australasian dialysis patients. Current perioperative outcome estimates stem predominantly from North American literature; however, the generalisability of these findings is limited, as the survival of North American dialysis patients is significantly inferior to their Australasian counterparts and potentially confounds reported perioperative outcomes; let alone regional variation in surgical indication and technique. We propose that data linkage between high-quality national registries will provide more complete data with more detailed patient and procedural information to allow for more informative analyses to develop and validate dialysis-specific risk assessment tools.
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Affiliation(s)
- Dharmenaan Palamuthusingam
- Department of Nephrology, Princess Alexandra Hospital, Metro South and Ipswich Nephrology and Transplant Services (MINTS), Queensland, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Metro South and Ipswich Nephrology and Transplant Services (MINTS), Queensland, Australia
| | - Carmel M Hawley
- Department of Nephrology, Princess Alexandra Hospital, Metro South and Ipswich Nephrology and Transplant Services (MINTS), Queensland, Australia
| | | | - Pal Sivalingam
- Department of Anaesthetics, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Magid Fahim
- Department of Nephrology, Princess Alexandra Hospital, Metro South and Ipswich Nephrology and Transplant Services (MINTS), Queensland, Australia
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14
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Ruzycki SM, Prystajecky M, Driedger MR, Kachra R. Peri-operative cardiac biomarker screening: a narrative review. Anaesthesia 2020; 75 Suppl 1:e165-e173. [PMID: 31903570 DOI: 10.1111/anae.14920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2019] [Indexed: 12/26/2022]
Abstract
Peri-operative risk estimation has traditionally focused on assessing the likelihood of postoperative morbidity and mortality using pre-operative functional assessment. Although this strategy is currently recommended by most major society guidelines, contemporary evidence suggests that cardiac biomarker measurement has important advantages over pre-operative functional assessment. These advantages include superior predictive discrimination and inclusion of the postoperative course in risk estimation. In this review, we provide an overview of the evidence supporting the peri-operative utilisation, compare risk estimation methods and discuss which patients may benefit most from cardiac biomarker screening. We also discuss protocols for biomarker screening and management of patients with abnormal results.
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Affiliation(s)
- S M Ruzycki
- Department of Medicine, Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Canada
| | - M Prystajecky
- Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - M R Driedger
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - R Kachra
- Division of General Internal Medicine, Department of Medicine, University of Calgary, AB, Canada
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15
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Chen S, Redfors B, O’Neill BP, Clavel MA, Pibarot P, Elmariah S, Nazif T, Crowley A, Ben-Yehuda O, Finn MT, Alu MC, Vahl TP, Kodali S, Leon MB, Lindman BR. Low and elevated B-type natriuretic peptide levels are associated with increased mortality in patients with preserved ejection fraction undergoing transcatheter aortic valve replacement: an analysis of the PARTNER II trial and registry. Eur Heart J 2019; 41:958-969. [DOI: 10.1093/eurheartj/ehz892] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 08/08/2019] [Accepted: 11/30/2019] [Indexed: 12/12/2022] Open
Abstract
Abstract
Aims
B-type natriuretic peptide (BNP) is a cardiac neurohormone that is secreted in response to ventricular volume expansion and pressure overload. There are conflicting data regarding the association between BNP levels and outcomes after transcatheter aortic valve replacement (TAVR). We therefore sought to assess the association between baseline BNP and adverse outcomes in patients with symptomatic, severe aortic stenosis (AS), and left ventricular ejection fraction (LVEF) ≥50%, undergoing TAVR in the PARTNER 2 Trial and Registry.
Methods and results
A total of 1782 patients were included in the analysis, and BNP was evaluated both as a continuous log-transformed value and by a priori categories: low (<50 pg/mL), normal (≥50 and <100 pg/mL), moderately elevated (≥100 and <400 pg/mL), or markedly elevated (≥400 pg/mL). Clinical outcomes from discharge to 2 years were compared between patients according to their baseline BNP level, using Kaplan–Meier event rates and multivariable Cox proportional hazards regression models. After adjustment, spline curves revealed a non-linear association between log-transformed BNP and all-cause and cardiovascular mortality in which both the lowest and highest values were associated with increased mortality. Two-year all-cause mortality rates for those with low (n = 86), normal (n = 202), moderately elevated (n = 885), and markedly elevated (n = 609) baseline BNP were 20.0%, 9.8%, 17.7%, and 26.1%, respectively. In adjusted models, compared to a normal baseline BNP, low [adjusted hazard ratio (HR) 2.6, 95% confidence interval (CI) 1.3–5.0, P-value 0.005], moderately elevated (adjusted HR 1.6, 95% CI 1.0–2.6, P-value 0.06), and markedly elevated (adjusted HR 2.1, 95% CI 1.3–3.5, P-value 0.003) BNP were associated with increased all-cause mortality, driven by cardiovascular mortality.
Conclusions
In a large cohort of patients with severe symptomatic AS and preserved LVEF undergoing TAVR, all-cause and cardiovascular mortality rates at 2 years were higher in patients with low and markedly elevated BNP levels.
Clinical Trial Registration
https://clinicaltrials.gov/ unique identifier #NCT01314313, #NCT02184442, #NCT03222128, and #NCT03222141.
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Affiliation(s)
- Shmuel Chen
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
- Structural Heart & Valve Center, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Bjorn Redfors
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
- Structural Heart & Valve Center, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Brian P O’Neill
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | | | - Philippe Pibarot
- Quebec Heart & Lung Institute, Laval University, Quebec, QC, Canada
| | - Sammy Elmariah
- Department of Medicine, Massachusetts General Hospital, Harvard University School of Medicine, Boston, MA, USA
| | - Tamim Nazif
- Structural Heart & Valve Center, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Aaron Crowley
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
| | - Ori Ben-Yehuda
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
| | - Matthew T Finn
- Structural Heart & Valve Center, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Maria C Alu
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
- Structural Heart & Valve Center, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Torsten P Vahl
- Structural Heart & Valve Center, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Susheel Kodali
- Structural Heart & Valve Center, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Martin B Leon
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
- Structural Heart & Valve Center, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Brian R Lindman
- Structural Heart and Valve Center, Vanderbilt University School of Medicine, 2525 West End Ave., Suite 300-A, Nashville, TN 37203, USA
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16
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Alphonsus CS, Govender P, Rodseth RN, Biccard BM. The role of cardiac rehabilitation using exercise to decrease natriuretic peptide levels in non-surgical patients: a systematic review. Perioper Med (Lond) 2019; 8:14. [PMID: 31832178 PMCID: PMC6859626 DOI: 10.1186/s13741-019-0124-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 10/09/2019] [Indexed: 12/29/2022] Open
Abstract
Exercise is recommended in patients with cardiac failure. In the perioperative patient, exercise is also gaining popularity as a form of prehabilitation. In this meta-analysis, we examine if exercise is able to reduce natriuretic peptide levels. Natriuretic peptide (NP) has strong prognostic ability in identifying patients who will develop adverse postoperative cardiovascular outcomes. The protocol was registered with PROSPERO (CRD42017051468). The database search included MEDLINE (PubMed), CINAHL (EBSCO host), EMBASE (EBSCO host), ProQuest, Web of Science, and Cochrane database. The primary outcomes were to determine whether exercise therapy was effective in reducing NP levels as compared to control group, the shortest time period required to reduce NP levels after exercise therapy, and whether reducing NP levels decreased morbidity and mortality. Full texts of 16 trials were retrieved for this review. Exercise therapy showed a significant reduction in natriuretic peptide levels between the intervention and control groups (SMD - 0.45, 95% CI - 0.88 to - 0.03) with significant heterogeneity between the included trials. This was also shown in the within a 12-week period.
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Affiliation(s)
- Christella S. Alphonsus
- University of Cape Town, Cape Town, Western Cape South Africa
- D23, Groote Schuur Hospital, Anzio Road, Observatory, Cape Town, Western Cape 7925 South Africa
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17
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Chahal D, Yau A, Casciato P, Marquez V. B-type peptides to predict post–liver transplant mortality: systematic review and meta-analysis. CANADIAN LIVER JOURNAL 2019; 2:4-18. [DOI: 10.3138/canlivj.2018-0014] [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] [Received: 05/11/2018] [Accepted: 06/14/2018] [Indexed: 11/20/2022]
Abstract
Background: Cirrhotic patients undergoing liver transplantation are at risk of cardiac complications. Brain natriuretic peptide (BNP) and amino terminal brain natriuretic peptide (NT-BNP) are used in cardiac risk stratification. Their significance in predicting mortality risk in cirrhotic patients during or after liver transplantation is unknown. We conducted a systematic review and meta-analysis to answer this question. Methods: An electronic search of EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews (2005–September 2016), Google Scholar, and study bibliographies was conducted. Study quality was determined, and demographic and outcome data were gathered. Random effects meta-analyses of mortality-based BNP and NT-BNP level or presence of post-transplant heart failure were conducted. Results: Seven studies including 2,010 patients were identified. Demographics were similar between patients with high or low BNP or NT-BNP levels. Hepatitis C was the most prevalent etiology of cirrhosis (38%). Meta-analysis revealed a pooled relative risk of 3.1 (95% CI 1.9% to 5.0%) for post-transplant mortality based on elevated BNP or NT-BNP level. Meta-analysis also revealed a pooled relative risk of 1.6 (95% CI 1.3% to 2.1%) for post-transplant mortality if patients had demonstrated post-transplant heart failure. Conclusions: Our analysis suggests that BNP or NT-BNP measurement may help in risk stratification and provides data on post-operative mortality in cirrhotic patients undergoing liver transplantation. Discriminatory thresholds are higher in cirrhotic patients relative to prior studies with non-cirrhotic patients. However, the number of analyzed studies is limited, and our findings should be validated further through larger, prospective studies.
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Affiliation(s)
- Daljeet Chahal
- Postgraduate Medicine Program, University of British Columbia, Vancouver, British Columbia
| | - Alan Yau
- Division of Gastroenterology, University of British Columbia, Vancouver, British Columbia
| | | | - Vladimir Marquez
- Division of Gastroenterology, University of British Columbia, Vancouver, British Columbia
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18
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Lee LKK, Tsai PNW, Ip KY, Irwin MG. Pre-operative cardiac optimisation: a directed review. Anaesthesia 2019; 74 Suppl 1:67-79. [PMID: 30604417 DOI: 10.1111/anae.14511] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2018] [Indexed: 12/30/2022]
Affiliation(s)
- L. K. K. Lee
- Department of Anaesthesia; Pamela Youde Nethersole Eastern Hospital; Hong Kong Special Administrative Region; Hong Kong China
| | - P. N. W. Tsai
- Department of Adult Intensive Care Unit; Queen Mary Hospital; Hong Kong Special Administrative Region; Hong Kong China
| | - K. Y. Ip
- Department of Anaesthesiology; Queen Mary Hospital; Hong Kong Special Administrative Region; Hong Kong China
| | - M. G. Irwin
- Department of Anaesthesiology; The University of Hong Kong; Hong Kong Special Administrative Region; Hong Kong China
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19
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Golubovic M, Peric V, Stanojevic D, Lazarevic M, Jovanovic N, Ilic N, Djordjevic M, Kostic T, Milic D. Potential New Approaches in Predicting Adverse Cardiac Events One Month after Major Vascular Surgery. Med Princ Pract 2019; 28:63-69. [PMID: 30391950 PMCID: PMC6558343 DOI: 10.1159/000495079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 11/04/2018] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE The aim of our study was to find the best model with sufficient power to improve the risk stratification in major vascular surgery patients during the first 30 days after this procedure. The discriminatory power of 4 biomarkers (troponin I [TnI], N-terminal prohormone of brain natriuretic peptide [NT-proBNP], creatine kinase-MB isoenzyme [CK-MB], high-sensitivity C-reactive protein [hs-CRP]) was tested as well as 2 risk assessment models and 13 different combinations of them. SUBJECTS AND METHODS The study included 122 patients (77% men, 23% women) with an average age of 67.03 ± 4.5 years. An aortobifemoral bypass was performed in 6.56% of the patients, a femoropopliteal bypass in 18.85%, and 49.18% received open surgical reconstruction of the carotid arteries. A total of 25.41% of the patients were given an aortobi-iliac bypass. RESULTS During the first 30 days, 13 patients (10.7%) had 17 cardiac complications. The most common complication was the new onset of atrial fibrillation (35.3%). During the first 10 days, 10 patients had 1 complication and 2 patients had 2 cardiac events, while 1 patient had 3 complications. By comparing combinations of scores and markers, it was shown that revised cardiac risk index (RCRI) + Vascular Portsmouth Physiological and Operative Severity Score (V-POSSUM) + hsTnI and RCRI + V-POSSUM + hsTnI + NT-proBNP with 100% sensitivity, > 80% specificity had the best discriminatory ability (AUC 0.924 and 0.933, respectively; p < 0.001 for both models) for cardiac complications during the 30 days after surgery. CONCLUSION Combinations of traditional preoperative risk factors and scores can enhance the assessment of major adverse cardiac events (MACE) in patients preparing for large vascular surgery. Using only one risk score in these patients seems to be underperforming in preoperative risk assessment.
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Affiliation(s)
- Mladjan Golubovic
- Clinic for Anesthesiology and Reanimatology, Clinical Center Nis, Nis, Serbia,
| | | | | | - Milan Lazarevic
- Clinic for Cardiovascular and Transplantation Surgery, Clinical Center Nis, Nis, Serbia
| | - Nenad Jovanovic
- Clinic for Anesthesiology and Reanimatology, Clinical Center Nis, Nis, Serbia
| | - Nenad Ilic
- Clinic for Cardiovascular and Transplantation Surgery, Clinical Center Nis, Nis, Serbia
| | | | - Tomslav Kostic
- Faculty of Medicine, University of Nis, Nis, Serbia
- Clinic for Cardiology, Clinical Center Nis, Nis, Serbia
| | - Dragan Milic
- Faculty of Medicine, University of Nis, Nis, Serbia
- Clinic for Cardiovascular and Transplantation Surgery, Clinical Center Nis, Nis, Serbia
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20
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Zheng H, Li L, Liang H, Qu J, Li J, Cui Y, Chen X. Normalization of N-Terminal Pro-B-Type Natriuretic Peptide After Cardiac Surgery Among Children With Tetralogy of Fallot. Am J Cardiol 2018; 122:2125-2130. [PMID: 30293655 DOI: 10.1016/j.amjcard.2018.08.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/21/2018] [Accepted: 08/24/2018] [Indexed: 12/01/2022]
Abstract
The aim of this study was to temporally measure N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels over a period of 18 months after corrective surgery among children with tetralogy of Fallot (TOF) and to explore how commonly used pharmaceuticals (i.e., spironolactone and digoxin) might affect the normalization pattern. This retrospective study included 136 children with a median age of 7 months who underwent cardiac surgery for TOF. NT-proBNP level was measured at 1, 3, 6, 12, and 18 months after the surgery. Normalization of NT-proBNP was defined as an NT-proBNP level ≤250 pg/ml. The commonly used pharmaceuticals spironolactone and digoxin after discharge were collected. The normalization pattern, normalization time, and potential influence of the pharmaceuticals were determined. The rate of normalization was 24.2% (95% confidence interval [CI] 8.58% to 68.4%) per 100 person-days. Kaplan-Meier survival analysis showed a median normalization time of 517 (95% CI 429.6 to 604.3) days. The children whose NT-proBNP level did not normalize had a significantly higher readmission rate than those whose NT-proBNP level normalized (19.0% vs 2.8%, p = 0.018). Multivariable logistic regression models confirmed that the regular users of spironolactone, alone (odds ratio = 1.45, 95% CI 1.15 to 1.83) or in combination with digoxin (odds ratio = 1.28, 95% CI 1.03 to 1.58), had markedly faster recovery trajectories for measures of NT-proBNP than the irregular users of both. In conclusion, NT-proBNP normalization after cardiac surgery for TOF is a lengthy process, and irregular use of spironolactone could lead to failure in recovery and hospital readmission.
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Affiliation(s)
- Haiqing Zheng
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Lijuan Li
- The Cardiac Intensive Care Unit, Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Huiying Liang
- Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jiangbo Qu
- The Cardiac Intensive Care Unit, Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jianbin Li
- The Cardiac Intensive Care Unit, Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yanqin Cui
- The Cardiac Intensive Care Unit, Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
| | - Xinxin Chen
- The Cardiac Intensive Care Unit, Heart Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China.
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21
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Redfors B, Chen S, Crowley A, Ben-Yehuda O, Gersh BJ, Lembo NJ, Brown WM, Banning AP, Taggart DP, Serruys PW, Kappetein AP, Sabik JF, Stone GW. B-Type Natriuretic Peptide Assessment in Patients Undergoing Revascularization for Left Main Coronary Artery Disease. Circulation 2018; 138:469-478. [DOI: 10.1161/circulationaha.118.033631] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Elevated B-type natriuretic peptide (BNP) is reflective of impaired cardiac function and is associated with worse prognosis among patients with coronary artery disease (CAD). We sought to assess the association between baseline BNP, adverse outcomes, and the relative efficacy of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with left main CAD.
Methods:
The EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) randomized patients with left main CAD and low or intermediate SYNTAX scores (Synergy Between PCI With TAXUS and Cardiac Surgery) to PCI with everolimus-eluting stents versus CABG. The primary end point was the composite of all-cause death, myocardial infarction, or stroke. We used multivariable Cox proportional hazards regression to assess the associations between normal versus elevated BNP (≥100 pg/mL), randomized treatment, and the 3-year risk of adverse events.
Results:
BNP at baseline was elevated in 410 of 1037 (39.5%) patients enrolled in EXCEL. Patients with elevated BNP levels were older and more frequently had additional cardiovascular risk factors and lower left ventricular ejection fraction than those with normal BNP, but had similar SYNTAX scores. Patients with elevated BNP had significantly higher 3-year rates of the primary end point (18.6% versus 11.7%; adjusted hazard ratio [HR], 1.62; 95% confidence interval [CI], 1.16–2.28;
P
=0.005) and higher mortality (11.5% versus 3.9%; adjusted HR, 2.49; 95% CI, 1.48–4.19;
P
=0.0006), both from cardiovascular and noncardiovascular causes. In contrast, there were no significant differences in the risks of myocardial infarction, stroke, ischemia-driven revascularization, stent thrombosis, graft occlusion, or major bleeding. A significant interaction (
P
interaction
=0.03) was present between elevated versus normal BNP and treatment with PCI versus CABG for the adjusted risk of the primary composite end point at 3 years among patients with elevated BNP (adjusted HR for PCI versus CABG, 1.54; 95% CI, 0.96–2.47) versus normal BNP (adjusted HR, 0.74; 95% CI, 0.46–1.20). This interaction was stronger when log(BNP) was modeled as a continuous variable (
P
interaction
=0.002).
Conclusions:
In the EXCEL trial, elevated baseline BNP levels in patients with left main CAD undergoing revascularization were independently associated with long-term mortality but not nonfatal adverse ischemic or bleeding events. The relative long-term outcomes after PCI versus CABG for revascularization of left main CAD may be conditioned by the baseline BNP level.
Clinical Trial Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT01205776.
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Affiliation(s)
- Björn Redfors
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., S.C., A.C., O.B.-Y., G.W.S.)
| | - Shmuel Chen
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., S.C., A.C., O.B.-Y., G.W.S.)
| | - Aaron Crowley
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., S.C., A.C., O.B.-Y., G.W.S.)
| | - Ori Ben-Yehuda
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., S.C., A.C., O.B.-Y., G.W.S.)
- New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY (O.B.-Y., N.J.L., G.W.S)
| | - Bernard J. Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN (B.J.G.)
| | - Nicholas J. Lembo
- New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY (O.B.-Y., N.J.L., G.W.S)
| | | | | | - David P. Taggart
- John Radcliffe Hospital, Oxford, United Kingdom (A.P.B., D.P.T.)
| | - Patrick W. Serruys
- Imperial College of Science, Technology and Medicine, London, United Kingdom (P.W.S.)
| | | | - Joseph F. Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, OH (J.F.S.)
| | - Gregg W. Stone
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., S.C., A.C., O.B.-Y., G.W.S.)
- New York-Presbyterian Hospital/Columbia University Medical Center, New York, NY (O.B.-Y., N.J.L., G.W.S)
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22
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McGillion MH, Duceppe E, Allan K, Marcucci M, Yang S, Johnson AP, Ross-Howe S, Peter E, Scott T, Ouellette C, Henry S, Le Manach Y, Paré G, Downey B, Carroll SL, Mills J, Turner A, Clyne W, Dvirnik N, Mierdel S, Poole L, Nelson M, Harvey V, Good A, Pettit S, Sanchez K, Harsha P, Mohajer D, Ponnambalam S, Bhavnani S, Lamy A, Whitlock R, Devereaux PJ. Postoperative Remote Automated Monitoring: Need for and State of the Science. Can J Cardiol 2018; 34:850-862. [PMID: 29960614 DOI: 10.1016/j.cjca.2018.04.021] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 04/18/2018] [Accepted: 04/18/2018] [Indexed: 01/12/2023] Open
Abstract
Worldwide, more than 230 million adults have major noncardiac surgery each year. Although surgery can improve quality and duration of life, it can also precipitate major complications. Moreover, a substantial proportion of deaths occur after discharge. Current systems for monitoring patients postoperatively, on surgical wards and after transition to home, are inadequate. On the surgical ward, vital signs evaluation usually occurs only every 4-8 hours. Reduced in-hospital ward monitoring, followed by no vital signs monitoring at home, leads to thousands of cases of undetected/delayed detection of hemodynamic compromise. In this article we review work to date on postoperative remote automated monitoring on surgical wards and strategy for advancing this field. Key considerations for overcoming current barriers to implementing remote automated monitoring in Canada are also presented.
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Affiliation(s)
- Michael H McGillion
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.
| | - Emmanuelle Duceppe
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada; Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Katherine Allan
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Maura Marcucci
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Stephen Yang
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | | | | | - Ted Scott
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Carley Ouellette
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Shaunattonie Henry
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Yannick Le Manach
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Guillaume Paré
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Bernice Downey
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Sandra L Carroll
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Joseph Mills
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | | | - Wendy Clyne
- Hope for the Community, Community Interest Company, Coventry, United Kingdom
| | - Nazari Dvirnik
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | - Laurie Poole
- Ontario Telemedicine Network, Toronto, Ontario, Canada
| | | | - Valerie Harvey
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Amber Good
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Shirley Pettit
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Karla Sanchez
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Prathiba Harsha
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | | | - Sanjeev Bhavnani
- Scripps Clinic and Research Institute, La Jolla, California, USA
| | - Andre Lamy
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Richard Whitlock
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - P J Devereaux
- McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
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23
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Golubović M, Janković R, Sokolović D, Ćosić V, Maravić-Stojkovic V, Kostić T, Perišić Z, Lađević N. Preoperative Midregional Pro-Adrenomedullin and High-Sensitivity Troponin T Predict Perioperative Cardiovascular Events in Noncardiac Surgery. Med Princ Pract 2018; 27. [PMID: 29514145 PMCID: PMC6062667 DOI: 10.1159/000488197] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE We evaluated the utility of preoperative midregional (MR) pro-adrenomedullin (proADM) and cardiac troponin T (TnT) for improved detection of patients at high risk for perioperative cardiac events and mortality after major noncardiac surgery. SUBJECTS AND METHODS This prospective, single-center, observational study enrolled 79 patients undergoing major noncardiac surgery. After initial clinical assessment (clinical history, physical examination, echocardiogram, blood tests, and chest X-ray), MR-proADM and high-sensitivity TnT (hsTnT) were measured within 48 h prior to surgery by immunoluminometric and electrochemiluminescence immunoassay. Patients were followed by the consulting physician until discharge or up to 14 days in the hospital after surgery. Perioperative cardiac events included myocardial infarction and development or aggravation of congestive heart failure. Data were compared between patients who developed target events and event-free patients. RESULTS Within 14 days of monitoring, 14 patients (17.72%) developed target events: 9 (11.39%) died and 5 (6.33%) developed cardiovascular events. The average age of the patients was 71.29 ± 6.62 years (range: 55-87). Sex, age, and hsTnT did not significantly differ between groups. MR- proADM concentration was higher in deceased patients (p = 0.01). The upper quartile of MR-proADM was associated with a fatal outcome (66.7 vs. 20.0%, p < 0.01) and with cardiovascular events (64.3 vs. 16.9%, p < 0.01). MR-proADM above the cutoff value (≥0.85) was associated with a fatal outcome (88.9 vs. 20.0%, p < 0.01) and cardiovascular events (71.4 vs. 28.6%, p < 0.01); this association was not observed for hsTnT. CONCLUSION Preoperative measurement of MR-proADM provides useful information for perioperative cardiac events in high-risk patients scheduled for noncardiac surgery.
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Affiliation(s)
- Mlađjan Golubović
- Center for Anesthesiology and Reanimatology, Clinical Center Nis, Niš, Serbia
- *Mlađan Golubović, Center for Anesthesiology and Reanimatology, Clinical Center Nis, Grčka 17, RS–18000 Niš (Serbia), E-Mail
| | - Radmilo Janković
- Center for Anesthesiology and Reanimatology, Clinical Center Nis, Niš, Serbia
- Faculty of Medicine, University of Nis, Niš, Serbia
| | | | - Vladan Ćosić
- Center for Biochemistry, Clinical Center Nis, Niš, Serbia
| | | | - Tomislav Kostić
- Faculty of Medicine, University of Nis, Niš, Serbia
- Clinic for Cardiovascular Diseases, Clinical Center Nis, Niš, Serbia
| | - Zoran Perišić
- Faculty of Medicine, University of Nis, Niš, Serbia
- Clinic for Cardiovascular Diseases, Clinical Center Nis, Niš, Serbia
| | - Nebojša Lađević
- Center for Anesthesiology and Reanimatology, Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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24
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Lacey J, Khan N, Oliver CM. Perioperative risk. Br J Hosp Med (Lond) 2017; 78:616-621. [PMID: 29111800 DOI: 10.12968/hmed.2017.78.11.616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The high-risk surgical patient is a growing challenge to modern health care. This cohort, although comprising only 10-15% of surgical procedures, accounts for approximately 80% of postoperative deaths and suffers a high rate of postoperative morbidity. Developing robust systems to help identify and better manage this patient group should be a priority. Risk stratification has become a valuable clinical tool for shared decision-making and the development of individualized care plans. Methods for stratifying individual risk include assessment tools, measures of functional capacity and plasma biomarker assays. Routine evaluation of perioperative risk is central to the delivery of high quality, appropriate surgical care.
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Affiliation(s)
- Jrn Lacey
- Fellow in Perioperative Medicine and Anaesthesia, University College London Hospitals NHS Trust, London
| | - N Khan
- Post-CCT Fellow in Perioperative Medicine and Anaesthesia, University College London Hospitals NHS Trust, London
| | - C M Oliver
- NIHR Clinical Lecturer in Anaesthesia, Division of Surgery and Interventional Science, University College London, London WC1E 6AU
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25
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Lyons MM, Bhatt NY, Kneeland-Szanto E, Keenan BT, Pechar J, Stearns B, Elkassabany NM, Memtsoudis SG, Pack AI, Gurubhagavatula I. Sleep apnea in total joint arthroplasty patients and the role for cardiac biomarkers for risk stratification: an exploration of feasibility. Biomark Med 2016; 10:265-300. [PMID: 26925513 DOI: 10.2217/bmm.16.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Obstructive sleep apnea (OSA) is highly prevalent in patients undergoing total joint arthroplasty (TJA) and is a major risk factor for postoperative cardiovascular complications and death. Recognizing this, the American Society of Anesthesiologists urges clinicians to implement special considerations in the perioperative care of OSA patients. However, as the volume of patients presenting for TJA increases, resources to implement these recommendations are limited. This necessitates mechanisms to efficiently risk stratify patients having OSA who may be susceptible to post-TJA cardiovascular complications. We explore the role of perioperative measurement of cardiac troponins (cTns) and brain natriuretic peptides (BNPs) in helping determine which OSA patients are at increased risk for post-TJA cardiovascular-related morbidity.
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Affiliation(s)
- M Melanie Lyons
- Division of Sleep Medicine, Center for Sleep & Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Biobehavioral Research, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Nitin Y Bhatt
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, The Ohio State University, Columbus, OH, USA
| | - Elizabeth Kneeland-Szanto
- Division of Sleep Medicine, Center for Sleep & Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brendan T Keenan
- Division of Sleep Medicine, Center for Sleep & Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joanne Pechar
- Department of Penn Orthopaedics, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Branden Stearns
- Division of Sleep Medicine, Center for Sleep & Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nabil M Elkassabany
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology & Public Health, Weill Cornell Medical College & Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA
| | - Allan I Pack
- Division of Sleep Medicine, Center for Sleep & Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Indira Gurubhagavatula
- Division of Sleep Medicine, Center for Sleep & Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Sleep Medicine, CMC VA Medical Center, Philadelphia, PA, USA
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Duceppe E, Parlow J, MacDonald P, Lyons K, McMullen M, Srinathan S, Graham M, Tandon V, Styles K, Bessissow A, Sessler DI, Bryson G, Devereaux PJ. Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery. Can J Cardiol 2016; 33:17-32. [PMID: 27865641 DOI: 10.1016/j.cjca.2016.09.008] [Citation(s) in RCA: 420] [Impact Index Per Article: 52.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 09/20/2016] [Accepted: 09/21/2016] [Indexed: 02/06/2023] Open
Abstract
The Canadian Cardiovascular Society Guidelines Committee and key Canadian opinion leaders believed there was a need for up to date guidelines that used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of evidence assessment for patients who undergo noncardiac surgery. Strong recommendations included: 1) measuring brain natriuretic peptide (BNP) or N-terminal fragment of proBNP (NT-proBNP) before surgery to enhance perioperative cardiac risk estimation in patients who are 65 years of age or older, are 45-64 years of age with significant cardiovascular disease, or have a Revised Cardiac Risk Index score ≥ 1; 2) against performing preoperative resting echocardiography, coronary computed tomography angiography, exercise or cardiopulmonary exercise testing, or pharmacological stress echocardiography or radionuclide imaging to enhance perioperative cardiac risk estimation; 3) against the initiation or continuation of acetylsalicylic acid for the prevention of perioperative cardiac events, except in patients with a recent coronary artery stent or who will undergo carotid endarterectomy; 4) against α2 agonist or β-blocker initiation within 24 hours before surgery; 5) withholding angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker starting 24 hours before surgery; 6) facilitating smoking cessation before surgery; 7) measuring daily troponin for 48 to 72 hours after surgery in patients with an elevated NT-proBNP/BNP measurement before surgery or if there is no NT-proBNP/BNP measurement before surgery, in those who have a Revised Cardiac Risk Index score ≥1, age 45-64 years with significant cardiovascular disease, or age 65 years or older; and 8) initiating of long-term acetylsalicylic acid and statin therapy in patients who suffer myocardial injury/infarction after surgery.
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Affiliation(s)
- Emmanuelle Duceppe
- Department of Medicine, University of Montreal, Montreal, Quebec, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Joel Parlow
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada.
| | - Paul MacDonald
- Cape Breton Regional Hospital, Cape Breton, Nova Scotia, Canada
| | - Kristin Lyons
- Division of Cardiology, University of Calgary, Calgary, Alberta, Canada
| | - Michael McMullen
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Sadeesh Srinathan
- Department of Surgery, Section of Thoracic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Michelle Graham
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Vikas Tandon
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kim Styles
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Amal Bessissow
- Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gregory Bryson
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - P J Devereaux
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Postoperative complications in cardiac patients undergoing noncardiac surgery. Curr Opin Crit Care 2016; 22:357-64. [DOI: 10.1097/mcc.0000000000000315] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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28
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Malhotra AK, Ramakrishna H. N-terminal pro B type natriuretic peptide in high cardiovascular-risk patients for noncardiac surgery: What is the current prognostic evidence? Ann Card Anaesth 2016; 19:314-20. [PMID: 27052075 PMCID: PMC4900342 DOI: 10.4103/0971-9784.179636] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
As millions of surgical procedures are performed worldwide on an aging population with multiple comorbidities, accurate and simple perioperative risk stratification is critical. The cardiac biomarker, brain natriuretic peptide (BNP), has generated considerable interest as it is easy to obtain and appears to have powerful predictive and prognostic capabilities. BNP is currently being used to guide medical therapy for heart failure and has been added to several algorithms for perioperative risk stratification. This review examines the current evidence for the use of BNP in the perioperative period in patients who are at high-cardiovascular risk for noncardiac surgery. In addition, we examined the use of BNP in patients with pulmonary embolism and left ventricular assist devices. The available data strongly suggest that the addition of BNP to perioperative risk calculators is beneficial; however, whether this determination of risk will impact outcomes, remains to be seen.
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Affiliation(s)
- Anita K Malhotra
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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29
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Prognostic Value of Preoperative Brain Natriuretic Peptide Serum Levels in Liver Transplantation. Transplantation 2016; 100:819-24. [DOI: 10.1097/tp.0000000000001077] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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30
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Vanniyasingam T, Rodseth RN, Lurati Buse GA, Bolliger D, Burkhart CS, Cuthbertson BH, Gibson SC, Mahla E, Leibowitz DW, Biccard BM, Thabane L. Predicting the occurrence of major adverse cardiac events within 30 days of a vascular surgery: an empirical comparison of the minimum p value method and ROC curve approach using individual patient data meta-analysis. SPRINGERPLUS 2016; 5:304. [PMID: 27066338 PMCID: PMC4783313 DOI: 10.1186/s40064-016-1936-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 02/25/2016] [Indexed: 12/16/2022]
Abstract
We aimed to compare the minimum p value method and the area under the receiver operating characteristics (ROC) curve approach to categorize continuous biomarkers for the prediction of postoperative 30-day major adverse cardiac events in noncardiac vascular surgery patients. Individual-patient data from six cohorts reporting B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NTproBNP) were obtained. These biomarkers were dichotomized using the minimum p value method and compared with previously reported ROC curve-derived thresholds using logistic regression analysis. A final prediction model was developed, internally validated, and assessed for its sensitivity to clustering effects. Finally, a preoperative risk score system was proposed. Thresholds identified by the minimum p value method and ROC curve approach were 115.57 pg/ml (p < 0.001) and 116 pg/ml for BNP, and 241.7 pg/ml (p = 0.001) and 277.5 pg/ml for NTproBNP, respectively. The minimum p value thresholds were slightly stronger predictors based on our logistic regression analysis. The final model included a composite predictor of the minimum p value method’s BNP and NTproBNP thresholds [odds ratio (OR) = 8.5, p < 0.001], surgery type (OR = 2.5, p = 0.002), and diabetes (OR = 2.1, p = 0.015). Preoperative risks using the scoring system ranged from 2 to 49 %. The minimum p value method and ROC curve approach identify similar optimal thresholds. We propose to replace the revised cardiac risk index with our risk score system for individual-specific preoperative risk stratification after noncardiac nonvascular surgery.
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Affiliation(s)
- Thuva Vanniyasingam
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Health Sciences Centre, Room 2C7, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada
| | - Reitze N Rodseth
- Perioperative Research Unit, Department of Anaesthetics, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Pietermaritzburg, South Africa ; Department of Anaesthetics, Grey's Hospital, Pietermaritzburg, South Africa
| | - Giovanna A Lurati Buse
- Department of Anaesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Daniel Bolliger
- Department of Anaesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | | | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON Canada
| | | | - Elisabeth Mahla
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - David W Leibowitz
- Division of Cardiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Bruce M Biccard
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Health Sciences Centre, Room 2C7, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada ; Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON Canada ; Biostatistics Unit, St Joseph's Healthcare, Hamilton, ON Canada ; Departments of Paediatrics and Anaesthesia, McMaster University, Hamilton, ON Canada ; Centre for Evaluation of Medicine, St Joseph's Healthcare, Hamilton, ON Canada
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31
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Lahoz C, Gracia CE, García LR, Montoya SB, Hernando ÁB, Heredero ÁF, Tembra MS, Velasco MB, Guijarro C, Ruiz EB, Pintó X, de Ceniga MV, Moñux Ducajú G. [Not Available]. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2016; 28 Suppl 1:1-49. [PMID: 27107212 DOI: 10.1016/s0214-9168(16)30026-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Carlos Lahoz
- Unidad de Lípidos y Riesgo Vascular, Servicio de Medicina Interna, Hospital Carlos III, Madrid, España.
| | - Carlos Esteban Gracia
- Servicio de Angiología y Cirugía Vascular, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España
| | | | - Sergi Bellmunt Montoya
- Servicio de Angiología y Cirugía Vascular, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Ángel Brea Hernando
- Unidad de Lípidos, Servicio de Medicina Interna, Hospital San Pedro, Logroño, España
| | | | - Manuel Suárez Tembra
- Unidad de Lípidos y Riesgo Cardiovascular, Servicio de Medicina Interna, Hospital San Rafael, A Coruña, España
| | - Marta Botas Velasco
- Servicio de Angiología y Cirugía Vascular, Hospital de Cabueñes, Gijón, España
| | - Carlos Guijarro
- Consulta de Riesgo Vascular, Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - Esther Bravo Ruiz
- Servicio de Angiología y Cirugía Vascular, Hospital Universitario de Basurto, Bilbao, España
| | - Xavier Pintó
- Unidad de Riesgo Vascular, Servicio de Medicina Interna, Hospital Universitario de Bellvitge, L' Hospitalet de Llobregat, Barcelona, España
| | - Melina Vega de Ceniga
- Servicio de Angiología y Cirugía Vascular, Hospital de Galdakao-Usansolo, Vizcaya, España
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Abstract
Routine preoperative testing is not cost-effective, because it is unlikely to identify significant abnormalities. Abnormal findings from routine testing are more likely to be false positive, are costly to pursue, introduce a new risk, increase the patient's anxiety, and are inconvenient to the patient. Abnormal findings rarely alter the surgical or anesthetic plan, and there is usually no association between perioperative complications and abnormal laboratory results. Incidental findings and false positive results may lead to increased hospital visits and admissions. Preoperative testing needs to be done based on a targeted history and physical examination and the type of surgery.
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Affiliation(s)
- Matthias Bock
- Department of Anesthesia and Intensive Care Medicine, Central Hospital, Via Lorenz Boehler 5, Bolzano 39100, Italy; Department of Anesthesiology, Perioperative Medicine and Intensive Care, Paracelsus Medical University, Muellner Hauptrstrasse 48, Salzburg 5020, Austria
| | - Gerhard Fritsch
- Department of Anesthesiology, Perioperative Medicine and Intensive Care, Paracelsus Medical University, Muellner Hauptrstrasse 48, Salzburg 5020, Austria; Department of Anesthesiology and Intensive Care, UKH Lorenz Boehler, Donaueschingerstrasse 3, Vienna 1220, Austria
| | - David L Hepner
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02459, USA.
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34
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Fraser K, Raju I. Anaesthesia for lower limb revascularization surgery. BJA Educ 2015. [DOI: 10.1093/bjaed/mku042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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N-terminal pro-B-type Natriuretic Peptides’ Prognostic Utility Is Overestimated in Meta-analyses Using Study-specific Optimal Diagnostic Thresholds. Anesthesiology 2015. [DOI: 10.1097/aln.0000000000000728] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Abstract
Background:
N-terminal fragment B-type natriuretic peptide (NT-proBNP) prognostic utility is commonly determined post hoc by identifying a single optimal discrimination threshold tailored to the individual study population. The authors aimed to determine how using these study-specific post hoc thresholds impacts meta-analysis results.
Methods:
The authors conducted a systematic review of studies reporting the ability of preoperative NT-proBNP measurements to predict the composite outcome of all-cause mortality and nonfatal myocardial infarction at 30 days after noncardiac surgery. Individual patient-level data NT-proBNP thresholds were determined using two different methodologies. First, a single combined NT-proBNP threshold was determined for the entire cohort of patients, and a meta-analysis conducted using this single threshold. Second, study-specific thresholds were determined for each individual study, with meta-analysis being conducted using these study-specific thresholds.
Results:
The authors obtained individual patient data from 14 studies (n = 2,196). Using a single NT-proBNP cohort threshold, the odds ratio (OR) associated with an increased NT-proBNP measurement was 3.43 (95% CI, 2.08 to 5.64). Using individual study-specific thresholds, the OR associated with an increased NT-proBNP measurement was 6.45 (95% CI, 3.98 to 10.46). In smaller studies (<100 patients) a single cohort threshold was associated with an OR of 5.4 (95% CI, 2.27 to 12.84) as compared with an OR of 14.38 (95% CI, 6.08 to 34.01) for study-specific thresholds.
Conclusions:
Post hoc identification of study-specific prognostic biomarker thresholds artificially maximizes biomarker predictive power, resulting in an amplification or overestimation during meta-analysis of these results. This effect is accentuated in small studies.
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Mirkheshti A, Heidari Farzan M, Nasiri Y, Mottaghi K, Dabbagh A. The effect of anesthesia method on serum level of pro-brain natriuretic Peptide in patients undergoing orthopedic surgery. Anesth Pain Med 2015; 5:e19707. [PMID: 25893184 PMCID: PMC4389104 DOI: 10.5812/aapm.19707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 08/08/2014] [Accepted: 08/16/2014] [Indexed: 11/24/2022] Open
Abstract
Background: Surgical stress response is among the most severe stress tolerated by the patient, which needs suppression by anesthesia. Objectives: We assessed the effect of three methods of anesthesia on postoperative levels of pro-brain natriuretic peptide (pro-BNP) to determine the most effective one in preventing surgical stress response. Patients and Methods: In a randomized clinical trial, 120 patients who were 18 to 65 years old and met inclusion and exclusion criteria were selected and randomly allocated to three groups of 40:Group A, general anesthesia plus epidural catheter; Group B, general anesthesia and intravenous patient-controlled analgesia; and Group C, spinal anesthesia plus intravenous patient-controlled analgesia. Results: There was no difference between three groups for basic characteristics and variables and baseline pro-BNP levels; however, postoperative pro-BNP levels in Groups A, B, and C were respectively63.8 ± 10.1, 83.2 ± 12.3, and 51.5 ± 8.5 ng/L (ANOVA, P = 0.01). Conclusions: The results of the current study suggested that spinal anesthesia plus intravenous patient-controlled analgesia have the most favorable cardiac effects regarding postoperative levels of pro-BNP.
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Affiliation(s)
- Alireza Mirkheshti
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoume Heidari Farzan
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Yashar Nasiri
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Kamran Mottaghi
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Dabbagh
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Corresponding author: Ali Dabbagh, Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Tel: +98-9121972368, Fax: +98-2122074101, E-mail:
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Ma J, Xin Q, Wang X, Gao M, Wang Y, Liu J. Prediction of perioperative cardiac events through preoperative NT-pro-BNP and cTnI after emergent non-cardiac surgery in elderly patients. PLoS One 2015; 10:e0121306. [PMID: 25799524 PMCID: PMC4370461 DOI: 10.1371/journal.pone.0121306] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 01/29/2015] [Indexed: 01/26/2023] Open
Abstract
Objectives Clinical risk stratification has an important function in preoperative evaluation of patients at risk for cardiac events prior to non-cardiac surgery. The aim of this study was to determine whether the combined measurement of pre-operative N-terminal pro-brain natriuretic peptide (NT-pro-BNP) and cardiac troponin I (cTnI) could provide useful prognostic information about postoperative major adverse cardiac events (MACE) within 30 days in patients aged over 60 years undergoing emergent non-cardiac surgery. Methods The study group comprised 2519 patients aged over 60 years that were undergoing emergent non-cardiac surgery between December 2007 and December 2013. NT-pro-BNP and cTnI were measured during hospital admission. The patients were monitored for MACE (cardiac death, non-fatal myocardial infarction, or cardiac arrest) during the 30-day postoperative follow-up period. Results MACE occurred in 251 patients (10.0%). Preoperative NT-pro-BNP and cTNI level were significantly higher in the individuals that experienced MACE than in those who did not (P < 0.001). The confounding factors of age, sex, co-morbidities and preoperative medications were adjusted in a multivariate logistic regression analysis. This analysis showed that preoperative NT-proBNP level > 917 pg/mL (OR 4.81, 95% CI 3.446–6.722, P < 0.001) and cTnI ≥ 0.07 ng/mL (OR 8.74, 95% CI 5.881–12.987, P < 0.001) remained significantly and independently associated with MACE after the adjustment of the confounding factors. Kaplan-Meier event-free survival curves demonstrated that patients with preoperative simultaneous NT-proBNP level > 917 pg/mL and cTnT ≥0.07 ng/mL had worse event-free survival than individual assessments of either biomarker. Conclusion Preoperative plasma NT-proBNP and cTnI are both independently associated with an increased risk of MACE in elderly patients after emergent non-cardiac surgery. The combination of these biomarkers provides better prognostic information than using either biomarker separately.
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Affiliation(s)
- Jinling Ma
- Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China
- * E-mail:
| | - Qian Xin
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Xiujie Wang
- Department of Radiology, Zhaoyuan People's Hospital, Shandong, China
| | - Meng Gao
- Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Yutang Wang
- Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Jie Liu
- Emergency Department, Chinese PLA General Hospital, Beijing, China
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38
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Wayne Causey M, Singh N. Clinical implications of B-type natriuretic peptide and N-terminal pro−B-type natriuretic peptide in the care of the vascular surgery patient. Semin Vasc Surg 2014; 27:143-7. [DOI: 10.1053/j.semvascsurg.2015.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Grupo de Trabajo Conjunto sobre cirugía no cardiaca: Evaluación y manejo cardiovascular de la Sociedad Europea de Cardiología (ESC) y la European Society of Anesthesiology (ESA). Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2014.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Kristensen SD, Knuuti J, Saraste A, Anker S, Bøtker HE, De Hert S, Ford I, Juanatey JRG, Gorenek B, Heyndrickx GR, Hoeft A, Huber K, Iung B, Kjeldsen KP, Longrois D, Luescher TF, Pierard L, Pocock S, Price S, Roffi M, Sirnes PA, Uva MS, Voudris V, Funck-Brentano C. 2014 ESC/ESA Guidelines on non-cardiac surgery. Eur J Anaesthesiol 2014; 31:517-73. [DOI: 10.1097/eja.0000000000000150] [Citation(s) in RCA: 286] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Shang C. B-type natriuretic peptide-guided therapy for perioperative medicine? Open Heart 2014; 1:e000105. [PMID: 25332815 PMCID: PMC4189229 DOI: 10.1136/openhrt-2014-000105] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 05/22/2014] [Accepted: 07/15/2014] [Indexed: 12/27/2022] Open
Abstract
The recent guideline from the European Society of Cardiology and European Society of Anesthesiology recommended the use of B-type natriuretic peptide (BNP) as preoperative testing for high-risk cardiac patients undergoing non-cardiac surgery. In this article, the potential benefits, risks and details for implementing BNP testing in perioperative medicine are discussed. Review of four related lines of research including the use of BNP test for preoperative prognosis, BNP test for screening asymptomatic heart failure, BNP as prognostic test in asymptomatic, non-heart failure patients and using BNP for detecting silent myocardial ischaemia showed converging cut-off levels of BNP for risk stratification. BNP has better OR and relative risk in comparison with Revised Cardiac Risk Index (RCRI) in predicting perioperative cardiac risk. BNP-guided therapy can be low risk based on current evidence on non-surgical patients, including treating asymptomatic patients without heart failure to prevent cardiovascular complications. At present, there is lack of direct evidence supporting perioperative BNP testing. Further research with randomised controlled trials is needed to confirm the benefit of BNP-guided management. Preoperative BNP testing may be considered in patients with RCRI above 0 undergoing intermediate or high-risk surgery. BNP-guided therapy is likely a beneficial addition to perioperative medicine. Its combination with β-blocker titration, RCRI and perioperative cardiovascular monitoring can be a major advance in reducing cardiac risk resulting in a dynamic, individualised optimisation process.
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Affiliation(s)
- Charles Shang
- Department of Medicine , Baylor College of Medicine , Houston, Texas , USA
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42
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Kristensen SD, Knuuti J, Saraste A, Anker S, Bøtker HE, Hert SD, Ford I, Gonzalez-Juanatey JR, Gorenek B, Heyndrickx GR, Hoeft A, Huber K, Iung B, Kjeldsen KP, Longrois D, Lüscher TF, Pierard L, Pocock S, Price S, Roffi M, Sirnes PA, Sousa-Uva M, Voudris V, Funck-Brentano C. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J 2014; 35:2383-431. [PMID: 25086026 DOI: 10.1093/eurheartj/ehu282] [Citation(s) in RCA: 803] [Impact Index Per Article: 80.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Biccard BM, Devereaux PJ, Rodseth RN. Cardiac biomarkers in the prediction of risk in the non-cardiac surgery setting. Anaesthesia 2014; 69:484-93. [PMID: 24738805 DOI: 10.1111/anae.12635] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2014] [Indexed: 12/24/2022]
Abstract
B-Type natriuretic peptides and troponin measurements have potential in predicting risk in patients undergoing non-cardiac surgery. Using the American Heart Association framework for the evaluation of novel biomarkers, we review the current evidence supporting the peri-operative use of these two biomarkers. In patients having major non-cardiac surgery who are risk stratified using clinical risk scores, the measurement of natriuretic peptides and troponin, both before and after surgery, significantly improves risk stratification. However, only pre- and postoperative natriuretic peptide measurement and postoperative troponin measurement have shown clinical utility. It is now important for trials to be conducted to determine whether integrating pre- and postoperative natriuretic peptide and postoperative troponin measurement into clinical practice is able to improve clinical outcomes in patients undergoing non-cardiac surgery.
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Affiliation(s)
- B M Biccard
- Perioperative Research Group, Department of Anaesthetics, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
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Young YR, Sheu BF, Li WC, Hsieh TM, Hung CW, Chang SS, Lee CC. Predictive value of plasma brain natriuretic peptide for postoperative cardiac complications--a systemic review and meta-analysis. J Crit Care 2014; 29:696.e1-10. [PMID: 24793659 DOI: 10.1016/j.jcrc.2014.03.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 03/02/2014] [Accepted: 03/25/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND We aimed to undertake a systematic review and meta-analysis of studies addressing perioperative natriuretic peptide (NP) levels to predict postoperative major adverse cardiac events (MACE) after major surgery. METHODS We searched MEDLINE and Embase with no language restrictions up to May 2013. The end points were major cardiac complications. We summarized test performance characteristics with the use of forest plots, hierarchical summary receiver operating characteristic curves, and bivariate random effects models. RESULTS Of the 662 retrieved articles, 24 studies satisfied the predefined eligibility criteria, including 5438 patients along with 712 (13.1%) events. After major surgery, the diagnostic odds ratio (DOR) of NP in predicting postoperative MACE was 14.3 (95% confidence interval [CI], 9.87-20.7) for overall population, 13.9 (8.43-22.8) for patients undergoing cardiac surgery, and 15.0 (8.84-25.5) for patients undergoing noncardiac surgery. The pooled sensitivity was 0.84 (95% CI, 0.79-0.88) and specificity was 0.76 (95% CI, 0.71-0.81). Postoperative measurement (DOR, 18.9; 7.68-46.3) was associated with higher predictive value than preoperative measurement (DOR, 13.6; 7.68-46.3). Results were similar for a subgroup with the composite outcome including mortality (DOR, 16.4; 10.6-25.5). B-type natriuretic peptide was associated with higher predictive accuracy (area under the summary receiver operating characteristic, 0.84; 0.81-0.87) than N-terminal pro-b-type natriuretic peptide (area under the summary receiver operating characteristic, 0.90; 0.87-0.92). CONCLUSIONS The existing literature suggests that perioperative NP testing have reasonable accuracy and can be useful in perioperative risk stratification. Natriuretic peptide testing has high rule-out value and low rule-in value for predicting postoperative MACE. Medical decisions should be made in the context of these characteristics.
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Affiliation(s)
- Yui-Rwei Young
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi Branch, Puzih City, Chiayi County, 613, Taiwan; Chang Gung University College of Medicine, Gueishan Township, Taoyuan County, 333, Taiwan
| | - Bor-Fuh Sheu
- Chang Gung University College of Medicine, Gueishan Township, Taoyuan County, 333, Taiwan; Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou Branch, Gueishan Township, Taoyuan County, 333, Taiwan
| | - Wen-Cheng Li
- Chang Gung University College of Medicine, Gueishan Township, Taoyuan County, 333, Taiwan; Department of Occupation Medicine, Chang-Gung Memorial Hospital, Chiayi Branch, Puzih City, Chiayi County, 613, Taiwan
| | - Ting-Min Hsieh
- Chang Gung University College of Medicine, Gueishan Township, Taoyuan County, 333, Taiwan; Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Kaohsiung Branch, Kaohsiung County, 833, Taiwan
| | - Chi-Wei Hung
- Chang Gung University College of Medicine, Gueishan Township, Taoyuan County, 333, Taiwan; Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung County, 833, Taiwan
| | - Shy-Shin Chang
- Chang Gung University College of Medicine, Gueishan Township, Taoyuan County, 333, Taiwan; Department of Family Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Chien-Chang Lee
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA; Department of Emergency Medicine, National Taiwan University Hospital, Douliou, Yunlin Branch, Taiwan and Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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Comparison of the prognostic accuracy of scoring systems, cardiopulmonary exercise testing, and plasma biomarkers: a single-centre observational pilot study. Br J Anaesth 2014; 112:491-7. [DOI: 10.1093/bja/aet346] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Cai GL, Chen J, Hu CB, Yan ML, Xu QH, Yan J. Value of plasma brain natriuretic peptide levels for predicting postoperative atrial fibrillation: a systemic review and meta-analysis. World J Surg 2014; 38:51-9. [PMID: 24129801 DOI: 10.1007/s00268-013-2284-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Blood natriuretic peptide (NP) levels have been reported to be useful for predicting postoperative atrial fibrillation (AF). We aimed to quantitatively synthesize the current evidence of the accuracy of using NP levels in predicting postoperative AF. METHODS AND RESULTS Medline, Embase, and reference lists were searched. Studies were included if either brain natriuretic peptide (BNP) or N-terminal pro-b type natriuretic peptide (NT-proBNP) had been evaluated perioperatively to predict postoperative AF. Data were analyzed to obtain summary accuracy estimates. Data from 1,844 patients in 10 studies were analyzed. Summary estimates for the sensitivity and specificity of using NP levels for predicting postoperative AF were 75 % [95 % confidence interval (CI) 67-79 %] and 80 % (95 % CI 62-91 %), respectively. The overall diagnostic odds ratio was 3.28 (95 % CI 2.23-4.84). Subgroup analysis showed that elevated NP levels in the perioperative period were a strong independent predictor of postoperative AF. NT-proBNP appeared to have better predictive value than BNP, as did postoperative assessment over preoperative assessment. BNP had a better correlation with postoperative AF in patients undergoing thoracic surgery than in patients undergoing cardiac surgery. CONCLUSIONS Perioperative assessment of the natriuretic peptide level in patients undergoing major cardiothoracic surgery could be a valuable diagnostic aid for identifying patients at high risk of developing postoperative AF, and for providing critical clinical information to guide prophylactic antiarrhythmic therapy in the perioperative period.
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Affiliation(s)
- Guo-Long Cai
- Intensive Care Unit of ZheJiang Hospital, No. 12, LingYin Road, Xihu District, Hangzhou City, 310013, Zhejiang, China
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Brain natriuretic Peptide predicting outcome after congenital heart surgery … are we there yet? Pediatr Crit Care Med 2013; 14:550-1. [PMID: 23867437 DOI: 10.1097/pcc.0b013e31828d93f3] [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: 11/26/2022]
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Causey MW, McVay DP, Oguntoye M, Andersen C, Singh N. Application of preoperative brain natriuretic peptide levels in clinical practice. Vascular 2013; 21:225-31. [DOI: 10.1177/1708538113478761] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of the study was to determine the clinical utility and practical application of preoperative brain natriuretic peptide (BNP) levels. This is a retrospective review of operating room procedures from November 2006 to March 2009. Preoperative history and physical were reviewed and BNP laboratory levels obtained prior to all procedures and the postoperative course reviewed for incidence of 30-day cardiac complications. A receiver operator curve analysis demonstrated that a preoperative BNP threshold ≥95.5 pg/mL correctly identified 75% of patients with cardiac complications and values ≤18.5 pg/mL identified 100% of patients without adverse postoperative cardiac complications. Multivariable analysis also revealed a history of peripheral arterial disease as the most significant preoperative predictor of cardiac complications followed by BNP above the threshold (odds ratio = 3.7), hypothyroidism, coronary artery disease and prior myocardial infarction. In conclusion, preoperative BNP levels are a useful adjunct in clinical practice to help identify those patients with a high postoperative risk and those with a minimal postoperative risk.
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Affiliation(s)
- Marlin Wayne Causey
- Department of Vascular Surgery, Madigan Healthcare System, Tacoma, WA 98431, USA
| | - Derek P McVay
- Department of Vascular Surgery, Madigan Healthcare System, Tacoma, WA 98431, USA
| | | | - Charles Andersen
- Department of Vascular Surgery, Madigan Healthcare System, Tacoma, WA 98431, USA
| | - Niten Singh
- Department of Vascular Surgery, Madigan Healthcare System, Tacoma, WA 98431, USA
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Farzi S, Stojakovic T, Marko T, Sankin C, Rehak P, Gumpert R, Baumann A, Höfler B, Metzler H, Mahla E. Role of N-terminal pro B-type natriuretic peptide in identifying patients at high risk for adverse outcome after emergent non-cardiac surgery. Br J Anaesth 2013; 110:554-60. [DOI: 10.1093/bja/aes454] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Chopra V, Froehlich JB. Assessing and Managing Cardiovascular Risk. Perioper Med (Lond) 2012. [DOI: 10.1002/9781118375372.ch9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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