Surveillance and prevention of major perioperative ischemic cardiac events in patients undergoing noncardiac surgery: a review

Clopidogrel Management in Abdominal Surgery: A Comparison of Perioperative Bleeding Risks with Low-Molecular-Weight Heparin Bridging, No-Bridging and Clopidogrel Continuation Strategies

Clopidogrel is usually discontinued 5-7 days before elective surgery to reduce the risk of bleeding. However, the perioperative safety of patients receiving low-molecular-weight heparin (LMWH) bridging therapy or continuing clopidogrel therapy remains unknown. We identified patients who received clopidogrel for cardiovascular diseases and underwent elective surgery at a large central hospital in China between June 2022 and January 2024. The primary endpoints were perioperative blood transfusion events and bleeding-related reoperations. A total of 62 patients who received clopidogrel and underwent abdominal surgery were included in this study. Based on the preoperative clopidogrel therapy strategy, patients were categorised into three groups: the LMWH bridging group (clopidogrel withdrawal followed by LMWH bridging therapy for 5-7 days; n = 22), the no-bridging group (clopidogrel withdrawal for 5-7 days; n = 26), and the continued group (clopidogrel therapy maintained; n = 24). Perioperative blood transfusion rates were higher in the LMWH bridging and continued groups. However, there was not a significant distinction (P = .197). Additionally, hospital stay length, bleeding-related reoperation, and 3-month mortality were similar across the groups (P > .05). No patients experienced myocardial infarction or stroke within 3 months post-procedure. Patients who received preoperative LMWH bridging therapy or continued clopidogrel therapy had a slightly higher risk of perioperative bleeding. These findings need to be confirmed by further randomised controlled trials.

Wireless continuous single-lead ST-segment monitoring to detect new-onset myocardial injury at the general ward-An exploratory subanalysis

Patients admitted for acute medical conditions and major noncardiac surgery are at risk of myocardial injury. This is frequently asymptomatic, especially in the context of concomitant pain and analgesics, and detection thus relies on cardiac biomarkers. Continuous single-lead ST-segment monitoring from wireless electrocardiogram (ECG) may enable more timely intervention, but criteria for alerts need to be defined to reduce false alerts. This study aimed to determine optimal ST-deviation thresholds from wireless single-lead ECG for detection of myocardial injury following major abdominal cancer surgery and during acute exacerbation of chronic obstructive pulmonary disease. Patients were monitored with a wireless single-lead ECG patch for up to 4 days and had daily troponin measurements. Single-lead ST-segment deviations of <0.255 mV and/or >0.245 mV (based on previous study comparison with 0.1 mV 12-lead ECG and variation in single-lead ECG) were analyzed for relation to myocardial injury defined as hsTnT elevation of 20-64 ng/L with an absolute change of ≥5 ng/L, or a hsTnT level ≥ 65 ng/L. In total, 528 patients were included for analysis, of which 15.5% had myocardial injury. For corrected ST-thresholds lasting ≥10 and ≥ 20 min, we found specificities of 91% and 94% and sensitivities of 17% and 13% with odds ratios of 2.0 (95% CI: 1.1; 3.9) and 2.4 (95% CI: 1.1; 5.1) for myocardial injury. In conclusion, wireless single-lead ECG monitoring with corrected ST thresholds detected patients developing myocardial injury with specificities >90% and sensitivities <20%, suggesting increased focus on sensitivity improvement.

Intraoperative Variables Enhance the Predictive Performance of Myocardial Injury in Patients with High Cardiovascular Risk After Thoracic Surgery When Added to Baseline Prediction Model

Purpose

Myocardial injury after non-cardiac surgery is closely related to major adverse cardiac and cerebrovascular event and is difficult to identify. This study aims to investigate how to predict the myocardial injury of thoracic surgery and whether intraoperative variables contribute to the prediction of myocardial injury.

Methods

The prospective study included adult patients with high cardiovascular risk who underwent elective thoracic surgery from May 2022 to October 2022. Multivariate logistic regression was used to establish a model with baseline variables and a model with baseline and intraoperative variables. We compare the predictive performance of two models for postoperative myocardial injury.

Results

In general, 31.5% (94 of 298) occurred myocardial injury. Age ≥65 years old, obesity, smoking, preoperative hsTnT, and one-lung ventilation time were independent predictors of myocardial injury. Compared with baseline model, the intraoperative variables improved model fit, modestly improved the reclassification (continuous net reclassification improvement 0.409, 95% CI, 0.169 to 0.648, P<0.001, improved integrated discrimination 0.036, 95% CI, 0.011 to 0.062, P<0.01) of myocardial injury cases, and achieved higher net benefit in decision curve analysis.

Conclusion

The risk stratification and anesthesia management of high-risk patients are essential. The addition of intraoperative variables to the baseline predictive model improved the performance of the overall model of myocardial injury and helped anesthesiologists screen out the patients at the greatest risk for myocardial injury and adjust anesthesia strategies.

Cardiovascular imaging following perioperative myocardial infarction/injury

Patients developing perioperative myocardial infarction/injury (PMI) have a high mortality. PMI work-up and therapy remain poorly defined. This prospective multicenter study included high-risk patients undergoing major non-cardiac surgery within a systematic PMI screening and clinical response program. The frequency of cardiovascular imaging during PMI work-up and its yield for possible type 1 myocardial infarction (T1MI) was assessed. Automated PMI detection triggered evaluation by the treating physician/cardiologist, who determined selection/timing of cardiovascular imaging. T1M1 was considered with the presence of a new wall motion abnormality within 30 days in transthoracic echocardiography (TTE), a new scar or ischemia within 90 days in myocardial perfusion imaging (MPI), and Ambrose-Type II or complex lesions within 7 days of PMI in coronary angiography (CA). In patients with PMI, 21% (268/1269) underwent at least one cardiac imaging modality. TTE was used in 13% (163/1269), MPI in 3% (37/1269), and CA in 5% (68/1269). Cardiology consultation was associated with higher use of cardiovascular imaging (27% versus 13%). Signs indicative of T1MI were found in 8% of TTE, 46% of MPI, and 63% of CA. Most patients with PMI did not undergo any cardiovascular imaging within their PMI work-up. If performed, MPI and CA showed high yield for signs indicative of T1MI.Trial registration: https://clinicaltrials.gov/ct2/show/NCT02573532 .

Continuously monitored vital signs for detection of myocardial injury in high-risk patients - An observational study

Background

Patients are at risk of myocardial injury after major non‐cardiac surgery and during acute illness. Myocardial injury is associated with mortality, but often asymptomatic and currently detected through intermittent cardiac biomarker screening. This delays diagnosis, where vital signs deviations may serve as a proxy for early signs of myocardial injury. This study aimed to assess the association between continuous monitored vital sign deviations and subsequent myocardial injury following major abdominal cancer surgery and during acute exacerbation of chronic obstructive pulmonary disease.

Methods

Patients undergoing major abdominal cancer surgery or admitted with acute exacerbation of chronic obstructive pulmonary disease had daily troponin measurements. Continuous wireless monitoring of several vital signs was performed for up to 96 h after admission or surgery. The primary exposure was cumulative duration of peripheral oxygen saturation (SpO₂) below 85% in the 24 h before the primary outcome of myocardial injury, defined as a new onset ischaemic troponin elevation assessed daily. If no myocardial injury occurred, the primary exposure was based on the first 24 h of measurement.

Results

A total of 662 patients were continuously monitored and 113 (17%) had a myocardial injury. Cumulative duration of SpO₂ < 85% was significantly associated with myocardial injury (mean difference 14.2 min [95% confidence interval −4.7 to 33.1 min]; p = .005). Durations of hypoxaemia (SpO₂ < 88% and SpO₂ < 80%), tachycardia (HR > 110 bpm and HR > 130 bpm) and tachypnoea (RR > 24 min⁻¹ and RR > 30 min⁻¹) were also significantly associated with myocardial injury (p < .04, for all).

Conclusion

Duration of severely low SpO₂ detected by continuous wireless monitoring is significantly associated with myocardial injury in high‐risk patients admitted to hospital wards. The effect of early detection and interventions should be assessed next.

Intraoperative Hypotension and Myocardial Infarction Development Among High-Risk Patients Undergoing Noncardiac Surgery: A Nested Case-Control Study

BACKGROUND

Hemodynamic instability during anesthesia and surgery is common and associated with cardiac morbidity and mortality. Information is needed regarding optimal blood pressure (BP) threshold in the perioperative period. Therefore, the effect of intraoperative hypotension (IOH) on risk of perioperative myocardial infarction (MI) was explored.

METHODS

A nested case-control study with patients developing MI <30 days postsurgery matched with non-MI patients, sampled from a large surgery cohort. Study participants were adults undergoing noncardiac surgery at 3 university hospitals in Sweden, 2007-2014. Matching criteria were age, sex, American Society of Anesthesiologists (ASA) physical status, cardiovascular disease, hospital, year-, type-, and extent of surgery. Medical records were reviewed to validate MI diagnoses and retrieve information on comorbid history, baseline BP, laboratory and intraoperative data. Main exposure was IOH, defined as a decrease in systolic blood pressure (SBP), in mm Hg, from preoperative individual resting baseline lasting at least 5 minutes. Outcomes were acute MI, fulfilling the universal criteria, subclassified as type 1 and 2, occurring within 30 days and mortality beyond 30 days among case and control patients. Conditional logistic regression assessed the association between IOH, decrease in SBP from individual baseline, and perioperative MI. Mortality rates were estimated using Cox proportional hazards. Relative risk estimates are reported as are the corresponding absolute risks derived from the well-characterized source population.

RESULTS

A total of 326 cases met the inclusion criteria and were successfully matched with 326 controls. The distribution of MI type was 59 (18%) type 1 and 267 (82%) type 2. Median time to MI diagnosis was 2 days; 75% were detected within a week of surgery. Multivariable analysis acknowledged IOH as an independent risk factor of perioperative MI. IOH, with reduction of 41-50 mm Hg, from individual baseline SBP, was associated with a more than tripled increased odds, odds ratio (OR) = 3.42 (95% confidence interval [CI], 1.13-10.3), and a hypotensive event >50 mm Hg with considerably increased odds in respect to MI risk, OR = 22.6, (95% CI, 7.69-66.2). In patients with a very high-risk burden, the absolute risk of an MI diagnosis increased from 3.6 to 68 per 1000 surgeries.

CONCLUSIONS

In patients undergoing noncardiac surgery, IOH is a possible contributor to clinically significant perioperative MI. The high absolute MI risk associated with IOH, among a growing population of patients with a high-risk burden, suggests that increased vigilance of BP control in these patients may be beneficial.

Incidence of major adverse cardiac events following non-cardiac surgery

AIMS

Major adverse cardiac events (MACE) triggered by non-cardiac surgery are prognostically important perioperative complications. However, due to often asymptomatic presentation, the incidence and timing of postoperative MACE are incompletely understood.

METHODS AND RESULTS

We conducted a prospective observational study implementing a perioperative screening for postoperative MACE [cardiovascular death (CVD), acute heart failure (AHF), haemodynamically relevant arrhythmias, spontaneous myocardial infarction (MI), and perioperative myocardial infarction/injury (PMI)] in patients at increased cardiovascular risk (≥65 years OR ≥45 years with history of cardiovascular disease) undergoing non-cardiac surgery at a tertiary hospital. All patients received serial measurements of cardiac troponin to detect asymptomatic MACE. Among 2265 patients (mean age 73 years, 43.4% women), the incidence of MACE was 15.2% within 30 days, and 20.6% within 365 days. CVD occurred in 1.2% [95% confidence interval (CI) 0.9-1.8] and in 3.7% (95% CI 3.0-4.5), haemodynamically relevant arrhythmias in 1.2% (95% CI 0.9-1.8) and in 2.1% (95% CI 1.6-2.8), AHF in 1.6% (95% CI 1.2-2.2) and in 4.2% (95% CI 3.4-5.1), spontaneous MI in 0.5% (95% CI 0.3-0.9) and in 1.6% (95% CI 1.2-2.2), and PMI in 13.2% (95% CI 11.9-14.7) and in 14.8% (95% CI 13.4-16.4) within 30 days and within 365 days, respectively. The MACE-incidence was increased above presumed baseline rate until Day 135 (95% CI 104-163), indicating a vulnerable period of 3-5 months.

CONCLUSION

One out of five high-risk patients undergoing non-cardiac surgery will develop one or more MACE within 365 days. The risk for MACE remains increased for about 5 months after non-cardiac surgery.

TRIAL REGISTRATION

https://www.clinicaltrials.gov. Unique identifier: NCT02573532.

Perioperative mortality of head and neck cancers

Background

Head and neck cancers are aggressive cancers, most clinical studies focused on the prognosis of patients with head and neck cancer. However, perioperative mortality was rarely mentioned.

Methods

A retrospective analysis was performed using all head and neck cancer patients admitting in the Department of Oral and Maxillofacial Surgery of the Second Xiangya Hospital, Central South University from January 2010 to December 2019. The analysis of overall survival and progression-free survival were performed using the Kaplan–Meier method, and cross tabulation with chi-squared testing was applied to analyze the difference in parameters between groups.

Results

From January 2010 to December 2019, a total of 6576 patients with head and neck cancers were admitted to our department and 7 died in the hospital, all of whom were middle-aged and elderly patients including 6 males and 1 female. The perioperative mortality rate (POMR) was about 1‰. The causes of death included acute heart failure, rupture of large blood vessels in the neck, hypoxic ischemic encephalopathy due to asphyxia, respiratory failure and cardiopulmonary arrest.

Conclusion

Preoperative radiotherapy, previous chemotherapy, hypertension, diabetes, advanced clinical stage and postoperative infection are risk factors for perioperative mortality of head and neck cancer.

The Effects of Oral Anticoagulant Exposure on the Surgical Outcomes of Patients Undergoing Surgery for High-Risk Abdominal Emergencies

BACKGROUND

In chronic anticoagulant users undergoing surgery, bleeding and thromboembolism are common and serious complications. Many studies on mainly elective or minor emergency surgical procedures with low associated risks have focused on these outcomes. In comparison, patients undergoing high-risk emergency abdominal surgical procedures have not received sufficient attention. This study aimed to compare outcomes between oral anticoagulant users and nonusers who required emergency laparotomy for high-risk abdominal emergencies.

METHODS

Patients who underwent surgery for abdominal emergencies at our institution between January 2012 and July 2019 were retrospectively reviewed.

RESULTS

There were 875 patients, including 370 anticoagulant users and 505 nonusers. Of the 370 anticoagulant users, 189 (51.3), 77 (20.8%), 45 (12.2%), and 59 (15.9%) were prescribed antiplatelets, a vitamin k antagonist, a direct oral anticoagulant, and a combination drug regimen, respectively. The most common high-risk emergencies requiring surgery in both groups were perforated viscus (25.7% vs 40.9%), mesenteric ischemia with enteric necrosis (27% vs 12.8%), and bowel obstruction (17.6% vs 28.1%). The overall bleeding rate was higher (29.2% vs 22%, p = 0.015) in anticoagulant users than in nonusers, but the major bleeding rate was similar (17.8% vs 14.1%, p = 0.129) between the two groups. The rates of thromboembolic events and mortality were significantly higher in anticoagulant users than in nonusers (25.7% vs 9.7%, p < 0.0001 and 39.7% vs 31.1%, p = 0.01, respectively). Liver cirrhosis, peripheral arterial diseases, reoperation, and blood product transfusion were independent predictors of the overall risk of bleeding or TEEs, according to the multivariate analysis. In this model, liver cirrhosis had the largest overall effect on mortality, followed by pneumonia, thromboembolism, peripheral arterial disease, blood product transfusion, and atrial fibrillation. The use of oral anticoagulants was not an independent predictor of either bleeding or in-hospital mortality. The use of oral anticoagulants was associated with a decreased risk of all-cause in-hospital mortality.

CONCLUSION

Based on our results, the continued use of oral anticoagulants is more protective than harmful considering the overall outcomes in this subset of patients.

Strategies to Modulate MicroRNA Functions for the Treatment of Cancer or Organ Injury

Cancer and organ injury-such as that occurring in the perioperative period, including acute lung injury, myocardial infarction, and acute gut injury-are among the leading causes of death in the United States and impose a significant impact on quality of life. MicroRNAs (miRNAs) have been studied extensively during the last two decades for their role as regulators of gene expression, their translational application as diagnostic markers, and their potential as therapeutic targets for disease treatment. Despite promising preclinical outcomes implicating miRNA targets in disease treatment, only a few miRNAs have reached clinical trials. This likely relates to difficulties in the delivery of miRNA drugs to their targets to achieve efficient inhibition or overexpression. Therefore, understanding how to efficiently deliver miRNAs into diseased tissues and specific cell types in patients is critical. This review summarizes current knowledge on various approaches to deliver therapeutic miRNAs or miRNA inhibitors and highlights current progress in miRNA-based disease therapy that has reached clinical trials. Based on ongoing advances in miRNA delivery, we believe that additional therapeutic approaches to modulate miRNA function will soon enter routine medical treatment of human disease, particularly for cancer or perioperative organ injury. SIGNIFICANCE STATEMENT: MicroRNAs have been studied extensively during the last two decades in cancer and organ injury, including acute lung injury, myocardial infarction, and acute gut injury, for their regulation of gene expression, application as diagnostic markers, and therapeutic potentials. In this review, we specifically emphasize the pros and cons of different delivery approaches to modulate microRNAs, as well as the most recent exciting progress in the field of therapeutic targeting of microRNAs for disease treatment in patients.

Troponin in critical care patients and outcomes

Myocardial infarction is common in the critically unwell population with pre-existing cardiovascular disease and is associated with a greater overall mortality. This article explores guidelines for diagnosing myocardial infarction, and research into the use of troponin as both a diagnostic and prognostic tool. Currently, the majority of patients in the intensive care unit with acute myocardial infarction go unrecognised. The underlying cause is predominantly oxygen supply-demand imbalance, therefore identifying those at risk is important as there is the potential to modify elements of their care and reduce their overall mortality.

The association of endothelial injury and systemic inflammation with perioperative myocardial infarction

Background

Major surgery predisposes to endothelial glycocalyx injury. Endothelial glycocalyx injury associates with cardiac morbidity, including spontaneous myocardial infarction. However, the relation between endothelial glycocalyx injury and the development of perioperative myocardial infarction remains unknown.

Methods

Fifteen perioperative myocardial infarction patients and 60 propensity-matched controls were investigated in this prospective study. The diagnosis of perioperative myocardial infarction was based on repeated cardiac troponin T measurements, electrocardiographs and recordings of ischaemic signs and symptoms. We measured endothelial glycocalyx markers – soluble thrombomodulin, syndecan-1 and vascular adhesion protein 1 – and an inflammatory marker, namely interleukin-6, preoperatively and 6 h and 24 h postoperatively. We calculated the areas under the receiver operating characteristics curves (AUCs) to compare the performances of the different markers in predicting perioperative myocardial infarction. The highest value of each marker was used in the analysis.

Results

The interleukin-6 concentrations of perioperative myocardial infarction patients were significantly higher preoperatively and 6 and 24 h postoperatively ( P =  0.002, P =  0.002 and P =  0.001, respectively). The AUCs (95% confidence intervals) for the detection of perioperative myocardial infarction were 0.51 (0.34–0.69) for soluble thrombomodulin, 0.63 (0.47–0.79) for syndecan-1, 0.54 (0.37–0.70) for vascular adhesion protein 1 and 0.69 (0.54–0.85) for interleukin-6.

Conclusions

Systemic inflammation, reflected by interleukin-6, associates with cardiac troponin T release and perioperative myocardial infarction. Circulating interleukin-6 demonstrated some potential to predict perioperative myocardial infarction, whereas endothelial glycocalyx markers did not.

Postoperative Management in Patients with Pheochromocytoma and Paraganglioma

Pheochromocytomas and paragangliomas (PPGLs) are rare catecholamine-secreting neuroendocrine tumors of the adrenal medulla and sympathetic/parasympathetic ganglion cells, respectively. Excessive release of catecholamines leads to episodic symptoms and signs of PPGL, which include hypertension, headache, palpitations, and diaphoresis. Intraoperatively, large amounts of catecholamines are released into the bloodstream through handling and manipulation of the tumor(s). In contrast, there could also be an abrupt decline in catecholamine levels after tumor resection. Because of such binary manifestations of PPGL, patients may develop perplexing and substantially devastating cardiovascular complications during the perioperative period. These complications include hypertension, hypotension, arrhythmias, myocardial infarction, heart failure, and cerebrovascular accident. Other complications seen in the postoperative period include fever, hypoglycemia, cortisol deficiency, urinary retention, etc. In the interest of safe patient care, such emergencies require precise diagnosis and treatment. Surgeons, anesthesiologists, and intensivists must be aware of the clinical manifestations and complications associated with a sudden increase or decrease in catecholamine levels and should work closely together to be able to provide appropriate management to minimize morbidity and mortality associated with PPGLs.

Efficacy and safety of intravenous esmolol for cardiac protection in non-cardiac surgery. A systematic review and meta-analysis

Haemodynamic instability predisposes patients to cardiac complications in non-cardiac surgery. Esmolol, a short-acting cardioselective beta-adrenergic blocker might be efficient in perioperative cardiac protection, but could affect other vital organs, such as the kidneys, and post-discharge survival. We performed a systematic review on the use of esmolol for perioperative cardiac protection. We searched PubMed, Ovid Medline and Cochrane Central Register for Controlled trials. Eligible randomized controlled studies (RCTs) reported a perioperative esmolol intervention with at least one of the primary (major cardiac or renal complications during the first 30 postoperative days) or secondary (postoperative adverse effects and all-cause mortality) outcomes. We included 196 adult patients from three RCTs. Esmolol significantly reduced postoperative myocardial ischaemia, RR =0.43 [95% confidence interval, CI: 0.21-0.88], p = .02. No association with clinically significant bradycardia and hypotension compared to patients receiving control treatment could be confirmed (RR =7.4 [95% CI: 0.29-139.81], p = .18 and RR =2.21 [95% CI: 0.34-14.36], p = .41, respectively). No differences regarding other outcomes were observed. No study reported postoperative renal outcomes. Esmolol seems promising for the prevention of perioperative myocardial ischaemia. However, the association with bradycardia and hypotension remains unclear. Randomized trials investigating the effect of β1-selective blockade on clinically relevant outcomes and non-cardiac vital organs are warranted. Key messages Short-acting cardioselective esmolol seems efficient in the prevention of perioperative myocardial ischaemia. The possibly increased risk of bradycardia and hypotension with short-acting intravenous beta blockade could not be confirmed or refuted by available data. Future adequately powered trials investigating the effect of β1-selective blockade on clinically relevant outcomes and non-cardiac vital organs are warranted.

A Risk Stratification Model for Cardiovascular Complications during the 3-Month Period after Major Elective Vascular Surgery

Introduction

The Revised Cardiac Risk Index (RCRI) is an extensively used simple risk stratification tool advocated by the European Society of Cardiology and European Society of Anesthesiology (ESC/ESA).

Purpose

The aim of this study was to find the best model for predicting 3-month cardiovascular complications in elective major vascular surgical patients using preoperative clinical assessment, calculation of the RCRI and Vascular Physiological and Operative Severity Score for the enumeration of mortality and morbidity (V-POSSUM) scores, and the preoperative levels of N-terminal brain natriuretic peptide (NT pro-BNP), high-sensitivity troponin I (hs TnI), and high-sensitivity C-reactive protein (hs CRP).

Materials and Methods

We included 122 participants in a prospective, single-center, observational study. The levels of NT pro-BNP, hs CRP, and hs TnI were measured 48 hours prior to surgery. During the perioperative period and 90 days after surgery the following adverse cardiac events were recorded: myocardial infarction, arrhythmias, pulmonary edema, acute decompensated heart failure, and cardiac arrest.

Results

During the first 3 months after surgery 29 participants (23.8%) had 50 cardiac complications. There was a statistically significant difference in the RCRI score between participants with and without cardiac complications. ROC analysis showed that a combination of RCRI with hs TnI has good discriminatory power (AUC 0.909, p<0,001). By adding NT pro-BNP concentrations to the RCRI+hs TnI+V-POSSSUM combination we obtained the model with the best predictive power for 3-month cardiac complications (AUC 0.963, p<0,001).

Conclusion

We need to improve preoperative risk assessment in participants scheduled for major vascular surgery by combining their clinical scores with biomarkers. Therefore, it is possible to identify patients at risk of cardiovascular complications who need adequate preoperative diagnosis and treatment.

Prophylaxis and Treatment of Complications After Tracheal Resection

Tracheal resections are major surgical procedures with a complication rate as high as 44%. Early detection of complications followed by a structured and expedited course of action is critical for achieving a successful outcome. The prevention of complications after tracheal resection starts with a correct indication for resection. A thorough preoperative evaluation, meticulous surgical technique, and good postoperative care in a center that performs airway surgery routinely are important factors for achieving good results.

Myocardial injury after non-cardiac surgery: a perioperative affair?

Myocardial injury after non-cardiac surgery (MINS) is a rather new nosological entity and an unfortunately common perioperative complication. The diagnostic criteria for MINS, also indicated as isolated myocardial injury (IMI), are an elevated postoperative high sensitivity troponin T (hsTnT level ranging between 20 and 65 ng/L with an absolute change of at least 5 ng/L or hsTnT level >65 ng/L), in absence of symptoms and/or EKG findings suggestive of ischemia and without a non-ischemic etiology causing troponin elevation. MINS does not fulfill the universal definition of myocardial infarction even if it is related to ischemic causes and it is independently associated with 30-day postoperative mortality and complications. Nevertheless, mortality at 30 days in MINS patients has been calculated up to 10% and it increases exponentially as a function of peak postoperative troponin concentration. Physician and researchers should discriminate MINS from perioperative myocardial infarction and from not ischemic troponin increases. In the postoperative period, the possibility of missing the diagnosis of an acute coronary syndrome for the paucity of clinical symptoms or because physician failed to evaluate a postoperative EKG recording should always be considered. Physiopathology of MINS is not yet well defined: current hypotheses are surrogated from perioperative myocardial infarction studies. Up to now there are not specific treatments for MINS, even if antithrombotic therapy is under evaluation. Treatment decisions should be tailored to the individual case; potential benefits of troponin screening include a cardiology consultation and consequently, improved patients' information to promote lifestyle changes and enhanced therapy.

Targeting Hypoxia Signaling for Perioperative Organ Injury

Perioperative organ injury has a significant impact on surgical outcomes and presents a leading cause of death in the United States. Recent research has pointed out an important role of hypoxia signaling in the protection from organ injury, including for example myocardial infarction, acute respiratory distress syndrome, acute kidney, or gut injury. Hypoxia induces the stabilization of hypoxia-inducible factors (HIFs), thereby leading to the induction of HIF target genes, which facilitates adaptive responses to low oxygen. In this review, we focus on current therapeutic strategies targeting hypoxia signaling in various organ injury models and emphasize potential clinical approaches to integrate these findings into the care of surgical patients. Conceptually, there are 2 options to target the HIF pathway for organ protection. First, drugs became recently available that promote the stabilization of HIFs, most prominently via inhibition of prolyl hydroxylase. These compounds are currently trialed in patients, for example, for anemia treatment or prevention of ischemia and reperfusion injury. Second, HIF target genes (such as adenosine receptors) could be activated directly. We hope that some of these approaches may lead to novel pharmacologic strategies to prevent or treat organ injury in surgical patients.

The Clinical Impact of Cardiology Consultation Prior to Major Vascular Surgery

OBJECTIVE

To understand statewide variation in preoperative cardiology consultation prior to major vascular surgery and to determine whether consultation was associated with differences in perioperative myocardial infarction (poMI).

SUMMARY BACKGROUND DATA

Medical consultation prior to major vascular surgery is obtained to reduce perioperative risk. Despite perceived benefit of preoperative consultation, evidence is lacking specifically for major vascular surgery on the effect of preoperative cardiac consultation.

METHODS

Patient and clinical data were obtained from a statewide vascular surgery registry between January 2012 and December 2014. Patients were risk stratified by revised cardiac risk index category and compared poMI between patients who did or did not receive a preoperative cardiology consultation. We then used logistic regression analysis to compare the rate of poMI across hospitals grouped into quartiles by rate of preoperative cardiology consultation.

RESULTS

Our study population comprised 5191 patients undergoing open peripheral arterial bypass (n = 3037), open abdominal aortic aneurysm repair (n = 332), or endovascular aneurysm repair (n = 1822) at 29 hospitals. At the patient level, after risk-stratification by revised cardiac risk index category, there was no association between cardiac consultation and poMI. At the hospital level, preoperative cardiac consultation varied substantially between hospitals (6.9%-87.5%, P <0.001). High preoperative consulting hospitals (rate >66%) had a reduction in poMI (OR, 0.52; confidence interval: 0.28-0.98; P <0.05) compared with all other hospitals. These hospitals also had a statistically greater consultation rate with a variety of medical specialties.

CONCLUSIONS

Preoperative cardiology consultation for vascular surgery varies greatly between institutions, and does not appear to impact poMI at the patient level. However, reduction of poMI was noted at the hospitals with the highest rate of preoperative cardiology consultation as well as a variety of medical services, suggesting that other hospital culture effects play a role.

Postoperative troponin measurement as a screening tool for adverse cardiac events in adult patients undergoing moderate or major non-cardiac surgery

Elevated troponin levels within three days of surgery are strongly linked to major adverse cardiac events (MACE). However, the value of screening with troponin measurements is controversial. The extent to which this is done in routine practice is uncertain. We examined the medical records of all patients ≥45 years of age undergoing moderate or major non-cardiac surgery in our tertiary referral hospital over a six-month period. We determined how many patients had a troponin (TnT) measurement recorded in the first three days postoperatively, how many of these were abnormal, and the occurrence of MACE within 30 days. Two thousand and two hundred patients underwent 2,577 operations that met the study criteria. A postoperative TnT was measured after 4.5% of operations. Thirty-eight percent of patients with a recorded TnT measurement, and 44% of those with an abnormal measurement, experienced a MACE within 30 days. The sensitivity of an abnormal TnT to detect MACE was 86%. The specificity was low at 32% with a false positive rate of 56%. Patients with an abnormal TnT result had an increased risk of MACE (23%). The 'number needed to measure' to detect one patient with MACE was 4.4. In our institution, postoperative TnT levels were rarely measured and were used as a diagnostic rather than as a screening tool. The high false positive rate for MACE prediction limits its potential value as a screening tool. The test could be considered useful if it leads to further investigation, and may be best considered as one component of a multivariate approach to cardiac risk evaluation and diagnosis.

Identification of Periprocedural Myocardial Infarction Using a High-Sensitivity Troponin I Assay in Patients Who Underwent Transcatheter Aortic Valve Implantation

Periprocedural myocardial infarction (MI), a rare complication after transcatheter aortic valve implantation (TAVI), is associated with worse outcome. According to the Valve Academic Research Consortium (VARC-2), MI is defined by an increase in cardiac troponin (cTn) and creatine kinase MB (CK-MB) levels; however, many patients show periprocedurally elevated cTn without clinical evidence of MI. The aims of this study were to establish reference values of cardiac troponin I measured with a high-sensitivity assay (hs-cTnI) and to assess the periprocedural diagnostic value of this biomarker in patients who underwent TAVI. Hs-cTnI and CK-MB levels were assessed before and up to 3 days after transfemoral (TF) or transapical (TA) TAVI in 515 patients. A high proportion (61.2%) of patients had elevated hs-cTnI at baseline. According to VARC-2 criteria, almost all TA-patients (99.5%) showed an MI based on hs-cTnI compared with 4.2% based on CK-MB. In TF-patients, 81.1% had an MI based on hs-cTnI compared with 9.0% based on CK-MB. Only 10 patients (2%), however, had a type 1 MI. The ninety-ninth percentile for hs-cTnI was 285 ng/L in the TAVI cohort. After applying a TAVI-specific cutoff the frequency of MI was lower and more realistic (TF: 5% vs 81.1%; p <0.001; TA: 22.2% vs 99.5%; p <0.001). In conclusion, the VARC-2 definition leads to an overestimation of periprocedural MI. Our new TAVI-specific reference values yield a more realistic estimation of the myocardial ischemic risk. hs-cTnI, however, does not seem to be the biomarker of choice for MI detection in this setting.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Isolated cardiac troponin rise does not modify the prognosis in elderly patients with hip fracture

Perioperative myocardial infarction remains a life-threatening complication in noncardiac surgery and even an isolated troponin rise (ITR) is associated with significant mortality. Our aim was to assess the prognostic value of ITR in elderly patients with hip fracture.In this cohort study, all patients admitted between 2009 and 2013 in our dedicated geriatric postoperative unit after hip fracture surgery with a cardiac troponin I determination were included and divided into Control, ITR, and acute coronary syndrome (ACS) groups. The primary end point was a composite criteria defined as 6-month mortality and/or re-hospitalization. Secondary end points included 30-day mortality, 6-month mortality, and 6-month functional outcome.Three hundred twelve patients were (age 85 ± 7 years) divided into Control (n = 217), ITR (n = 50), and ACS (n = 45) groups. There was no significant difference for any postoperative complications between ITR and Control groups. In contrast, atrial fibrillation, acute heart failure, hemorrhage, and ICU admission were significantly more frequent in the ACS group. Compared to the Control group, 6-month mortality and/or rehospitalization was not significantly modified in the ITR group (26% vs. 28%, P = 0.84, 95% confidence interval [CI] of the difference -13%-14%), whereas it was increased in the ACS group (44% vs. 28%, P = 0.02, 95% CI of the difference 2%-32%). ITR was not associated with a higher risk of new institutionalization or impaired walking ability at 6 months, in contrast to ACS group.In elderly patients with hip fracture, ITR was not associated with a significant increase in death and/or rehospitalization within 6 months.

Deaths Following Cholecystectomy and Herniotomy: An Analysis of Nationwide German Hospital Discharge Data From 2009 to 2013

BACKGROUND

In 2010, 158 000 cholecystectomies and 207 000 herniotomies (without bowel surgery) were performed in Germany as inpatient procedures, generally on a routine, elective basis. Deaths following such operations are rare events. We studied the potential association of death after cholecystectomy or herniotomy with risk factors that could have been detected beforehand, and we examined the types of complications that were documented in these cases.

METHODS

Using nationwide hospital discharge data (DRG statistics) for the years 2009-2013, we analyzed the characteristics of patients who died in the hospital after undergoing a cholecystectomy for cholelithiasis or the repair of an inguinal, femoral, umbilical, or abdominal wall hernia. We compared these data with those of patients who survived and studied the impact of the coded comorbidities on the risk of death.

RESULTS

In Germany, in the years 2009-2013, there were 2957 deaths after a total of 731 000 cholecystectomies (in-hospital mortality, 0.4%) and 1316 deaths after a total of 1 023 000 herniotomies without bowel surgery (0.13%). The patients who died were markedly older than those who did not, and they more commonly had comorbidities. Factors associated with a higher risk of death were age over 65 years, and comorbidities such as congestive heart failure, chronic pulmonary or hepatic disease, or poor nutritional status. Complications were coded much more often for the patients who died than for those who did not.

CONCLUSION

These findings suggest that there is potential for improvement in preoperative risk identification, complication avoidance, and the early recognition and treatment of complications, as well as in safe surgical technique. Measures to lower the mortality associated with herniotomy and cholecystectomy would lessen patients' individual risk and thereby improve patient safety.

Perioperative Myocardial Infarction in Non-Cardiac Surgery Patients: A Prospective Observational Study

Background and Aims:

Perioperative myocardial infarction is an underdiagnosed complication causing morbidity, mortality, and considerable costs. However, evidence of preventive and therapeutic options is scarce. We investigated the incidence and outcome of perioperative myocardial infarction in non-cardiac surgery patients in order to define a target population for future interventional trials.

Material and Methods:

We conducted a prospective single-center study on non-cardiac surgery patients aged 50 years or older. High-sensitivity troponin T and electrocardiograph were obtained five times perioperatively. Perioperative myocardial infarction diagnosis required a significant troponin T release and an ischemic sign or symptom. Perioperative risk calculator was used for risk assessment.

Results:

Of 385 patients with systematic ischemia screening, 27 patients (7.0%) had perioperative myocardial infarction. The incidence was highest in vascular surgery—19 of 172 patients (11.0%). The 90-day mortality was 29.6% in patients with perioperative myocardial infarction and 5.6% in non–perioperative myocardial infarction patients ( p <  0.001). Perioperative risk calculator predicted perioperative myocardial infarction with an area under curve of 0.73 (95% confidence interval: 0.64–0.81).

Conclusion:

Perioperative myocardial infarction is a common complication associated with a 90-day mortality of 30%. The ability of the perioperative risk calculator to predict perioperative myocardial infarction was fair supporting its routine use.

Prospective controlled cohort study of Troponin I levels in patients undergoing elective spine surgery for degenerative conditions: Prone versus supine position

Prior studies have suggested that elevated serum Troponin-I (TnI) levels immediately after non-cardiac surgical procedures (8-40%) represent subclinical cardiac stress which independently predicts increased 30-day mortality. Routine post-operative TnI monitoring has therefore been suggested as a standard of care. However, no prior studies have focussed on elective degenerative spine surgery, whilst few have measured pre-op TnI. Further, prolonged prone positioning could represent an additional, independent, cardiac stress. We planned a prospective controlled cohort study of consecutive TnI levels in routine elective spine surgery for degenerative spine conditions, incorporating 3 groups: 'prone<2h', 'prone>2h' and 'supine' positioning. TnI levels (>0.04μg/L) were recorded immediately pre-/post-surgery, and by 24h of surgery. N=120 patients were recruited. Complete results were obtained in 92 (39 supine, 53 prone). No significant between-groups differences were observed in demographic or cardiovascular risk factors. Validated TnI-elevation by 24h was not observed in any group. Spurious elevations were recorded in one 'prone<2h' and one 'prone>2h'. One non-ST segment myocardial infarction (STEMI) occurred on day 7 without TnI elevation by 24h (prone>2h). There was no 30-day mortality.

CONCLUSIONS

Despite a lower cut-off, no validated TnI elevation was observed in any group by 24h after surgery. One non-STEMI had not been associated with TnI-elevation by 24h. Immediately peri-operative cardiac stress therefore appeared comparatively rare in patients undergoing routine elective spine surgery. Further, prone positioning did not represent an additional, independent, risk. Routine immediately post-operative TnI monitoring in elective spine surgery therefore appears unjustified. Our study highlighted several caveats regarding consecutive TnI testing.

Perioperative Statin Treatment: Can it Decrease Postsurgical Cardiac Event Risk in Noncardiac Surgery?

Cardiac events are an important cause of postsurgical morbidity and mortality. Statin drugs have been studied as potentially risk-modifying agents in perioperative medicine. They have been shown to confer a protective benefit in cardiac surgery, but the evidence available in noncardiac surgery patient populations remains less conclusive. We hypothesized that perioperative statin treatment would be associated with lower incidence of postsurgical cardiac events (PSCEs) after major noncardiac surgery. A retrospective cohort study included 21,637 major noncardiac surgeries. Statin treatment was the exposure of interest and PSCE was the primary outcome measure. Data collection included patient age, body mass index, smoking status, diabetic status, cardiac event history, statin treatment history, and PSCE diagnoses. Perioperative statin treatment occurred in 4176 cases (19.3%). PSCEs occurred in 50 cases (0.23%), 29 in the untreated control group (0.17%) and 21 in the statin treatment group (0.50%). Relative risk in the untreated group was 0.3303 (95% confidence interval = 0.1886, 0.5786). This implied that statin-treated patients had higher risk than the untreated group. However, a logistic regression model that accounted for observed cardiac disease risk factors showed statin treatment not to be a significant predictor of PSCE in this sample. Analysis repeated in high-risk subsets of the cohort yielded similar results. A propensity score matching method that minimized differences between study groups also failed to demonstrate a significant association between statin treatment and PSCE risk. Our study did not demonstrate a significant association between perioperative statin treatment and PSCEs after major noncardiac surgery.

Minor Postoperative Increases of Creatinine Are Associated with Higher Mortality and Longer Hospital Length of Stay in Surgical Patients

BACKGROUND

Surgical patients frequently experience postoperative increases in creatinine levels. The authors hypothesized that even small increases in postoperative creatinine levels are associated with adverse outcomes.

METHODS

The authors examined the association of postoperative changes from preoperative baseline creatinine with all-cause in-hospital mortality and hospital length of stay (HLOS) in a retrospective analysis of surgical patients at a single tertiary care center between January 2006 and June 2012.

RESULTS

The data of 39,369 surgical patients (noncardiac surgery n = 37,345; cardiac surgery n = 2,024) were analyzed. Acute kidney injury (AKI)-by definition of the Kidney Disease: Improving Global Outcome group-was associated with a five-fold higher mortality (odds ratio [OR], 4.8; 95% CI, 4.1 to 5.7; P < 0.001) and a longer HLOS of 5 days (P < 0.001) after adjusting for age, sex, comorbidities, congestive heart failure, preoperative hemoglobin, preoperative creatinine, exposure to radiocontrast agent, type of surgery, and surgical AKI risk factors. Importantly, even minor creatinine increases (Δcreatinine 25 to 49% above baseline but < 0.3 mg/dl) not meeting AKI criteria were associated with a two-fold increased risk of death (OR, 1.7; 95% CI, 1.3 to 2.4; P < 0.001) and 2 days longer HLOS (P < 0.001). This was more pronounced in noncardiac surgery patients. Patients with minor creatinine increases had a five-fold risk of death (OR, 5.4; 95% CI, 1.5 to 20.3; P < 0.05) and a 3-day longer HLOS (P < 0.01) when undergoing noncardiac surgery.

CONCLUSIONS

Even minor postoperative increases in creatinine levels are associated with adverse outcomes. These results emphasize the importance to find effective therapeutic approaches to prevent or treat even mild forms of postoperative kidney dysfunction to improve surgical outcomes.

Myocardial injury associated with transcatheter aortic valve implantation (TAVI)

Transcatheter aortic valve implantation (TAVI) has emerged as an important treatment option for elderly patients with symptomatic aortic stenosis whose risk is too high or prohibitive for conventional surgery. Despite notable progress during the past decade, continuous efforts directed at further improvement of procedural safety and performance are required, especially considering expanding indications for interventional treatment options among lower-risk populations. One issue that needs to be addressed is myocardial damage, which can frequently be observed after TAVI and has been linked to worse prognosis. Yet, knowledge concerning the underlying mechanisms and clinical impact remains scarce, and further investigation in this field is warranted. In this review, we provide a contemporary summary of the types of myocardial injury associated with TAVI, including access-related injury, mechanical trauma and ischemia, the role of myocardial biomarkers, and the impact on left ventricular function, with emphasis on potential mechanisms and clinical implications.

Preexisting Diabetes and Risks of Morbidity and Mortality After Gastrectomy for Gastric Cancer: A Nationwide Database Study

The purpose of this study was to determine the risk of surgical mortality and morbidity in patients with diabetes mellitus (DM) undergoing a gastrectomy for gastric cancer (GC). Using the Taiwan National Health Insurance Research Database, we identified 6284 patients who underwent gastrectomy for GC from 1999 to 2010. In addition, we created a non-DM control cohort consisting of 6268 patients who received gastrectomy during the same period. Compared with the non-DM cohort, the DM cohort exhibited a higher prevalence of preoperative coexisting medical conditions, namely hypertension, hyperlipidemia, coronary artery disease, chronic kidney disease, chronic pulmonary disease, stroke, and cirrhosis. The odds ratio (OR) of 30-day postoperative mortality after gastrectomy in the DM cohort was 1.04 (95% confidence interval 0.78-1.40) after we adjusted for covariates. The DM cohort did not exhibit a significantly higher risk of 30-day postoperative morbidities. Further analysis revealed that only patients with a history of a DM-related coma exhibited a higher risk of 30-day postoperative mortality (adjusted OR 2.46, 95% confidence interval 1.10 - 5.54). Moreover, the risk of 90-day postoperative mortality was significantly higher in patients with DM-related eye involvement, coma, peripheral circulatory disease, and renal manifestations, in comparison with the non-DM cohort. The risk of 90-day mortality after gastrectomy for GC is higher in patients with DM-related manifestations than those without DM.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Diabetic patients have increased perioperative cardiac risk in heart-type fatty acid-binding protein-based assessment

OBJECTIVE

To test the potential role of heart-type fatty acid-binding protein (H-FABP) in detecting increased perioperative cardiac risk in comparison with cardiac troponin I (cTnI) in the early postoperative period.

SUBJECTS AND METHODS

Sixty-seven patients who had clinical risk factors and underwent elective intermediate - or high-risk noncardiac surgery were included in this study. Serum specimens were analyzed for H-FABP and cTnI levels before and at 8 h after surgery. None of the patients had chest pain; 27 had a history of ischemic heart disease, 3 of heart failure, 5 of cerebrovascular diseases, 40 of diabetes and 46 of hypertension.

RESULTS

The mean duration of the operations was 2.33 ± 1.27 h (range 1-6). In the postoperative period, 27 (40.3%) patients had increased H-FABP levels (≥7.5 ng/ml); the median preoperative serum H-FABP level was 0.13 ng/ml (<0.1-5.9) and the median postoperative H-FABP level was 6.86 ng/ml (<0.1-13.7). Only 1 (1.5%) patient had cTnI >0.1 µg/l during the postoperative period. Correlation analysis revealed that the presence of diabetes was associated with an increased H-FABP level (r = 0.30, p = 0.01). Of the 27 patients with H-FABP ≥7.5 ng/ml, 21 (87%) had diabetes. There was no significant correlation with other clinical risk factors, type or duration of surgery.

CONCLUSION

The H-FABP levels significantly increased in the postoperative period. Most patients with increased postoperative H-FABP levels were diabetic. High H-FABP levels could alert clinicians to increased perioperative cardiovascular risk and could prevent underdiagnosis, especially in diabetic patients.