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Krievins DK, Zellans E, Latkovskis G, Kumsars I, Krievina AK, Jegere S, Erglis A, Lacis A, Plopa E, Stradins P, Ivanova P, Zarins CK. Diagnosis and treatment of ischemia-producing coronary stenoses improves 5-year survival of patients undergoing major vascular surgery. J Vasc Surg 2024:S0741-5214(24)00500-7. [PMID: 38518962 DOI: 10.1016/j.jvs.2024.02.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/22/2024] [Accepted: 02/24/2024] [Indexed: 03/24/2024]
Abstract
OBJECTIVE Patients undergoing vascular surgery procedures have poor long-term survival due to coexisting coronary artery disease (CAD), which is often asymptomatic, undiagnosed, and undertreated. We sought to determine whether preoperative diagnosis of asymptomatic (silent) coronary ischemia using coronary computed tomography (CT)-derived fractional flow reserve (FFRCT) together with postoperative ischemia-targeted coronary revascularization can reduce adverse cardiac events and improve long-term survival following major vascular surgery METHODS: In this observational cohort study of 522 patients with no known CAD undergoing elective carotid, peripheral, or aneurysm surgery we compared two groups of patients. Group I included 288 patients enrolled in a prospective Institutional Review Board-approved study of preoperative coronary CT angiography (CTA) and FFRCT testing to detect silent coronary ischemia with selective postoperative coronary revascularization in addition to best medical therapy (BMT) (FFRCT guided), and Group II included 234 matched controls with standard preoperative cardiac evaluation and postoperative BMT alone with no elective coronary revascularization (Usual Care). In the FFRCT group, lesion-specific coronary ischemia was defined as FFRCT ≤0.80 distal to a coronary stenosis, with severe ischemia defined as FFRCT ≤0.75. Results were available for patient management decisions. Endpoints included all-cause death, cardiovascular death, myocardial infarction (MI), and major adverse cardiovascular events (MACE [death, MI, or stroke]) during 5-year follow-up. RESULTS The two groups were similar in age, gender, and comorbidities. In FFRCT, 65% of patients had asymptomatic lesion-specific coronary ischemia, with severe ischemia in 52%, multivessel ischemia in 36% and left main ischemia in 8%. The status of coronary ischemia was unknown in Usual Care. Vascular surgery was performed as planned in both cohorts with no difference in 30-day mortality. In FFRCT, elective ischemia-targeted coronary revascularization was performed in 103 patients 1 to 3 months following surgery. Usual Care had no elective postoperative coronary revascularizations. At 5 years, compared with Usual Care, FFRCT guided had fewer all-cause deaths (16% vs 36%; hazard ratio [HR], 0.37; 95% confidence interval [CI], 0.22-0.60; P < .001), fewer cardiovascular deaths (4% vs 21%; HR, 0.11; 95% CI, 0.04-0.33; P < .001), fewer MIs (4% vs 24%; HR, 0.13; 95% CI, 0.05-0.33; P < .001), and fewer MACE (20% vs 47%; HR, 0.36; 95% CI, 0.23-0.56; P < .001). Five-year survival was 84% in FFRCT compared with 64% in Usual Care (P < .001). CONCLUSIONS Diagnosis of silent coronary ischemia with ischemia-targeted coronary revascularization in addition to BMT following major vascular surgery was associated with fewer adverse cardiovascular events and improved 5-year survival compared with patients treated with BMT alone as per current guidelines.
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Affiliation(s)
- Dainis K Krievins
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia.
| | - Edgars Zellans
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Gustavs Latkovskis
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Indulis Kumsars
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia
| | | | - Sanda Jegere
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Andrejs Erglis
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Aigars Lacis
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | | | - Peteris Stradins
- Department of Vascular Surgery, Pauls Stradins Clinical University Hospital, Riga, Latvia; Riga Stradins University, Riga, Latvia
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Morgan H, Ezad SM, Rahman H, De Silva K, Partridge JSL, Perera D. Assessment and Management of Ischaemic Heart Disease in Non-Cardiac Surgery. Heart Int 2023; 17:19-26. [PMID: 38419719 PMCID: PMC10898586 DOI: 10.17925/hi.2023.17.2.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/18/2023] [Indexed: 03/02/2024] Open
Abstract
In the setting of non-cardiac surgery, cardiac complications contribute to over a third of perioperative deaths. With over 230 million major surgeries performed annually, and an increasing prevalence of cardiovascular risk factors and ischaemic heart disease, the incidence of perioperative myocardial infarction is also rising. The recent European Society of Cardiology guidelines on cardiovascular risk in noncardiac surgery elevated practices aiming to identify those at most risk, including biomarker monitoring and stress testing. However the current evidence base on if, and how, the risk of cardiac events can be modified is lacking. This review focuses on patient, surgical and cardiac risk assessment, as well as exploring the data on perioperative revascularization and other risk-reduction strategies.
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Affiliation(s)
- Holly Morgan
- British Heart Foundation Centre of Research Excellence at the School of Cardiovascular and Metabolic Medicine and Sciences, King's College, London, UK
| | - Saad M Ezad
- British Heart Foundation Centre of Research Excellence at the School of Cardiovascular and Metabolic Medicine and Sciences, King's College, London, UK
| | - Haseeb Rahman
- British Heart Foundation Centre of Research Excellence at the School of Cardiovascular and Metabolic Medicine and Sciences, King's College, London, UK
| | - Kalpa De Silva
- British Heart Foundation Centre of Research Excellence at the School of Cardiovascular and Metabolic Medicine and Sciences, King's College, London, UK
| | - Judith S L Partridge
- British Heart Foundation Centre of Research Excellence at the School of Cardiovascular and Metabolic Medicine and Sciences, King's College, London, UK
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Divaka Perera
- British Heart Foundation Centre of Research Excellence at the School of Cardiovascular and Metabolic Medicine and Sciences, King's College, London, UK
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
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Binu AJ, Kapoor N, Bhattacharya S, Kishor K, Kalra S. Sarcopenic Obesity as a Risk Factor for Cardiovascular Disease: An Underrecognized Clinical Entity. Heart Int 2023; 17:6-11. [PMID: 38419720 PMCID: PMC10897945 DOI: 10.17925/hi.2023.17.2.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/15/2023] [Indexed: 03/02/2024] Open
Abstract
Sarcopenic obesity (SO) is a chronic condition and an emerging health challenge, in view of the growing elderly population and the obesity epidemic. Due to a lack of awareness among treating doctors and the non-specific nauture of the associated symptoms, SO remains grossly underdiagnosed. There is no consensus yet on a standard definition or diagnostic criteria for SO, which limits the estimation of the global prevalence of this condition. It has been linked to numerous metabolic derangements, cardiovascular disease (CVD) and mortality. The treatment of SO is multimodal and requires expertise across multiple specialties. While dietary modifications and exercise regimens have shown a potential therapeutic benefit, there is currently no proven pharmacological management for SO. However, numerous drugs and the role of bariatric surgery are still under trial, and have great scope for further research. This article covers the available literature regarding the definition, diagnostic criteria, and prevalence of SO, with available evidence linking it to CVD, metabolic disease and mortality, and an overview of current directives on management.
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Affiliation(s)
- Aditya John Binu
- Department of Cardiology, Christian Medical College, Vellore, India
| | - Nitin Kapoor
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India
- Non-communicable Disease Unit, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | | | - Kamal Kishor
- Department of Cardiology, Rama Hospital, Karnal, India
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, India
- University Center for Research & Development, Chandigarh University, Mohali, India
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Zarins CK. Adding value to routine postoperative troponin testing of vascular surgery patients. J Vasc Surg 2023; 77:1224-1225. [PMID: 36948679 DOI: 10.1016/j.jvs.2022.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 03/24/2023]
Affiliation(s)
- Christopher K Zarins
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
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Mouselimis D, Hagstotz S, Lichtenberg M, Donas KP, Heinrich U, Avranas K, Dimitriadis Z, Blessing E, Langhoff R, Frey N, Katus HA, Korosoglou G. Cardiac Troponins for the Clinical Management of Patients with Claudication and without Cardiac Symptoms. J Clin Med 2022; 11:jcm11247287. [PMID: 36555902 PMCID: PMC9785062 DOI: 10.3390/jcm11247287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/01/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022] Open
Abstract
Many patients with peripheral arterial disease (PAD) exhibit undiagnosed obstructive coronary artery disease. We aim to identify the patients with lifestyle limiting claudication due to PAD and without cardiac symptoms, requiring coronary revascularization based on high-sensitive troponin T (hsTnT) values. We assessed hsTnT in consecutive patients referred for elective endovascular treatment due to claudication [Rutherford categories (RC) 2 & 3] between January 2018 and December 2021. Diagnostic work-up by non-invasive imaging and, if required, cardiac catheterization was performed according to clinical data, ECG findings and baseline hsTnT. The occurrence of cardiac death, myocardial infarction or urgent revascularization during follow-up was the primary endpoint. Of 346 patients, 14 (4.0%) exhibited elevated hsTnT ≥ 14 ng/L, including 7 (2.0%) with acute myocardial injury by serial hsTnT sampling. Coronary revascularization by percutaneous coronary intervention was necessary in 6 of 332 (1.5%) patients with normal versus nine of 14 (64.3%) patients with elevated hsTnT (p < 0.001). During 2.4 ± 1.4 years of follow-up, 20 of 286 (7.0%) patients with normal versus four of 13 (30.8%) with elevated hsTnT at baseline reached the composite primary endpoint (p = 0.03 by log-rank test). In conclusion, elevated troponins in cardiac asymptomatic patients with claudication modify subsequent cardiac management and may increase the need for closer surveillance and more aggressive conservative management in polyvascular disease.
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Affiliation(s)
- Dimitrios Mouselimis
- Cardiology, Vascular Medicine & Pneumology, GRN Hospital Weinheim, Roentgentrasse 1, 69469 Weinheim, Germany
| | - Saskia Hagstotz
- Cardiology, Vascular Medicine & Pneumology, GRN Hospital Weinheim, Roentgentrasse 1, 69469 Weinheim, Germany
| | | | - Konstantinos P. Donas
- Department of Vascular and Endovascular Surgery, Asclepios Clinic Langen, 63225 Langen, Germany
| | - Ulrike Heinrich
- Practice for Vascular Medicine and Gastroenterology, 69469 Weinheim, Germany
| | | | - Zisis Dimitriadis
- Department of Cardiology, University Hospital Frankfurt, 60590 Frankfurt, Germany
| | - Erwin Blessing
- SRH Hospital, Department of Internal Medicine, 76307 Karlsbad, Germany
| | - Ralf Langhoff
- Department of Angiology, Sankt-Gertrauden-Krankenhaus, 10713 Berlin, Germany
| | - Norbert Frey
- Cardiology, Angiology & Pneumology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Hugo A. Katus
- Cardiology, Angiology & Pneumology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Grigorios Korosoglou
- Cardiology, Vascular Medicine & Pneumology, GRN Hospital Weinheim, Roentgentrasse 1, 69469 Weinheim, Germany
- Correspondence: ; Tel.: +49-(0)-6201-89-2142
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Illuminati G, Tanzilli G, Miraldi F, Ricco JB. Concerning revascularization of patients with silent coronary ischemia following carotid endarterectomy. J Vasc Surg 2022; 76:1757. [DOI: 10.1016/j.jvs.2022.06.102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 06/27/2022] [Indexed: 11/19/2022]
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Kashiwazaki D, Tomita T, Hori E, Akioka N, Akai T, Kuroda S. Impact of system approach and personal performance on preventable morbidity and mortality events in neurosurgery patients. Acta Neurochir (Wien) 2022; 164:2811-8. [PMID: 36044084 DOI: 10.1007/s00701-022-05357-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/23/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE Adverse events in neurosurgery are a serious problem. The approach for seeking solutions for adverse events has shifted from a personal approach to a systemic approach. However, to some extent, preventable morbidity events could be related to personal performance. This study aimed to clarify the impact of personal performance and systematic failure on the occurrence of morbidity and mortality events in neurosurgery patients. METHODS All morbidity and mortality conference data stored within our department over a 9-year period were analyzed. There were 4580 admitted patients and 3262 surgical procedures performed. We performed a three-step classification of morbidity and mortality events based on the possibility of prevention, root of the event, and personal or systemic issues. RESULTS As a result of the first step, 214 preventable and 278 unpreventable events were identified. Of the preventable events, two mortality and 212 morbidity events were analyzed. In the second step, 155 (72.4%), 34 (15.9%), 13 (6.1%), and 12 (5.6%) events were categorized as technical complications, critical events, judgment errors, and human factors, respectively. There were 179 events (83.6%) classified as personal performance issues and 35 events (16.4%) as systemic issues. The ratio of personal performance to systemic issues varied widely, with significant differences among the four categories (P < 0.01). CONCLUSIONS Among neurosurgery patients who have preventable morbidity, issues related to personal performance were more frequent than systemic issues. Efforts to improve systems should be unwavering. However, the personal responsibility of neurosurgeons to avoid preventable complications should not be ignored.
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