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Bae MI, Kim TH, Yoon HJ, Song SW, Min N, Lee J, Ham SY. Myocardial Injury after Non-Cardiac Surgery in Patients Who Underwent Open Repair for Abdominal Aortic Aneurysm: A Retrospective Study. J Clin Med 2024; 13:959. [PMID: 38398272 PMCID: PMC10888606 DOI: 10.3390/jcm13040959] [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: 01/12/2024] [Revised: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Myocardial injury after non-cardiac surgery (MINS) has been known to be associated with mortality in various surgical patients; however, its prognostic role in abdominal aortic aneurysm (AAA) open repair remains underexplored. This study aimed to investigate the role of MINS as a predictor of mortality in patients who underwent AAA open repair. METHODS This retrospective study investigated 352 patients who underwent open repair for non-ruptured AAA. The predictors of 30-day and 1-year mortalities were investigated using logistic regression analysis. RESULTS MINS was diagnosed in 41% of the patients after AAA open repair in this study. MINS was an independent risk factor of 30-day mortality (odds ratio [OR]: 10.440, 95% confidence interval [CI]: 1.278-85.274, p = 0.029) and 1-year mortality (OR: 5.189, 95% CI: 1.357-19.844, p = 0.016). Kaplan-Meier survival curves demonstrated significantly lower overall survival rates in patients with MINS compared to those without MINS (p = 0.003). CONCLUSION This study revealed that MINS is a common complication after AAA open repair and is an independent risk factor of 30-day and 1-year mortalities. Patients with MINS have lower overall survival rates than those without MINS.
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Affiliation(s)
- Myung Il Bae
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (M.I.B.); (H.J.Y.); (N.M.); (J.L.)
| | - Tae-Hoon Kim
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul 03722, Republic of Korea;
| | - Hei Jin Yoon
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (M.I.B.); (H.J.Y.); (N.M.); (J.L.)
| | - Suk-Won Song
- Department of Cardiovascular Surgery, Ewha Womans University Aorta and Vascular Hospital, Seoul 07804, Republic of Korea
| | - Narhyun Min
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (M.I.B.); (H.J.Y.); (N.M.); (J.L.)
| | - Jongyun Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (M.I.B.); (H.J.Y.); (N.M.); (J.L.)
| | - Sung Yeon Ham
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (M.I.B.); (H.J.Y.); (N.M.); (J.L.)
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
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Mases A, Beltrán de Heredia S, Gallart L, Román L, Bosch L, Núñez M, Rueda M, Recasens L, Sabaté S. Prediction of Acute Myocardial Injury in Noncardiac Surgery in Patients at Risk for Major Adverse Cardiovascular and Cerebrovascular Events: A Multivariable Risk Model. Anesth Analg 2023; 137:1116-1126. [PMID: 37043386 DOI: 10.1213/ane.0000000000006469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
BACKGROUND The best use of perioperative cardiac biomarkers assessment is still under discussion. Massive postoperative troponin surveillance can result in untenably high workloads and costs for health care systems and potentially harmful interventions for patients. In a cohort of patients at risk for major adverse cardiovascular and cerebrovascular events (MACCEs), we aimed to (1) determine whether preoperative biomarkers can identify patients at major risk for acute myocardial injury in noncardiac surgery, (2) develop a risk model for acute myocardial injury prediction, and (3) propose an algorithm to optimize postoperative troponin surveillance. METHODS Prospective, single-center cohort study enrolling consecutive adult patients (≥45 years) at risk for MACCE scheduled for intermediate-to-high-risk noncardiac surgery. Baseline high-sensitivity troponin T (hsTnT) and N-terminal fragment of pro-B-type natriuretic peptide (NT-proBNP), as well as hsTnT on the first 3 postoperative days were obtained. The main outcome was the occurrence of acute myocardial injury. Candidate predictors of acute myocardial injury were baseline concentrations of hsTnT ≥14 ng/L and NT-proBNP ≥300 pg/mL and preoperative and intraoperative variables. A multivariable risk model and a decision curve were constructed. RESULTS Of 732 patients, 42.1% had elevated hsTnT and 37.3% had elevated NT-proBNP levels at baseline. Acute myocardial injury occurred in 161 patients (22%). Elevated baseline hsTnT, found in 84% of patients with acute myocardial injury, was strongly associated with this outcome: odds ratio (OR), 12.08 (95% confidence interval [CI], 7.78-19.42). Logistic regression identified 6 other independent predictors for acute myocardial injury: age, sex, estimated glomerular filtration rate (eGFR) <45 mL·min -1 ·1.73 m -2 , functional capacity <4 METs or unknown, NT-proBNP ≥300 pg/mL, and estimated intraoperative blood loss. The c -statistic for the risk model was 77% (95% CI, 0.73-0.81). The net benefit of the model began at a risk threshold of 7%. CONCLUSIONS Baseline determination of cardiac biomarkers in patients at risk for MACCE shortly before intermediate- or high-risk noncardiac surgery helps identify those with the highest risk for acute myocardial injury. A baseline hsTnT ≥14 ng/L indicates the need for postoperative troponin surveillance. In patients with baseline hsTnT <14 ng/L, our 6-predictor model will identify additional patients at risk for acute myocardial injury who may also benefit from postoperative surveillance.
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Affiliation(s)
- Anna Mases
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Sandra Beltrán de Heredia
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Lluís Gallart
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Bellaterra, Barcelona, Spain
| | - Lorena Román
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
| | - Laia Bosch
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
| | - Maria Núñez
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
| | - Mireia Rueda
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
| | - Lluís Recasens
- Department of Cardiology, Hospital del Mar, Barcelona, Spain
| | - Sergi Sabaté
- Department of Anesthesiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Chew MS, Longrois D. Cost-effectiveness of detection of peri-operative myocardial injury: Beat to the punch or jumping the gun? Eur J Anaesthesiol 2023; 40:886-887. [PMID: 37909156 DOI: 10.1097/eja.0000000000001852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Affiliation(s)
- Michelle S Chew
- From the Department of Anaesthesia and Intensive Care, Linköping University Hospital, Linköping, Sweden (MSC); and Department of Anesthesiology and Intensive Care, Bichat Claude-Bernard Hospital, Assistance Publique-Hopitaux de Paris - Nord, University of Paris, INSERM U1148, Paris, France (DL)
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Atar D, Rosseland LA, Jammer I, Aakre KM, Wiseth R, Molund M, Gualandro DM, Omland T. Implementing screening for myocardial injury in non-cardiac surgery: perspectives of an ad-hoc interdisciplinary expert group. SCAND CARDIOVASC J 2023; 57:31-39. [PMID: 37141087 DOI: 10.1080/14017431.2022.2112071] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Objectives. Perioperative myocardial injury (PMI) is increasingly recognised as an important complication of non-cardiac surgery, with often clinically silent presentation, but detrimental prognosis. Active screening for PMI, involving the detection of dynamic and elevated levels of cardiac troponin, has recently been advocated by an increasing number of guidelines; however, active PMI screening has not been reflected in clinical practice. Design. As consensus on a common screening and management pathway is lacking, we synthesise the current evidence to provide suggestions on the selection of patients for screening, organisation of a screening program, and a potential management pathway, building upon a recently published perioperative screening algorithm. Results. Screening should be performed using high-sensitivity assays both preoperatively and postoperatively (postoperative Days 1 and 2) in patients at high-risk of experiencing perioperative complications. Conclusion. This expert opinion piece by an interdisciplinary group of predominantly Norwegian clinicians aims to assist healthcare professionals planning to implement guideline-recommended PMI screening at a local level in order to improve patient outcomes following non-cardiac surgery.
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Affiliation(s)
- Dan Atar
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Leiv Arne Rosseland
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Ib Jammer
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kristin Moberg Aakre
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Rune Wiseth
- Clinic of Cardiology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Marius Molund
- Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway
| | - Danielle M Gualandro
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
| | - Torbjørn Omland
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
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Stahlschmidt A, Passos SC, Dornelles DD, Polanczyk C, Gutierrez CS, Minuzzi RR, Castro SMJ, Stefani LC. Troponin elevation as a marker of short deterioration and one-year death in a high-risk surgical patient cohort in a low and middle income country setting: a postoperative approach to increase surveillance. Can J Anaesth 2023; 70:1776-1788. [PMID: 37853279 DOI: 10.1007/s12630-023-02558-4] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 04/02/2023] [Accepted: 04/28/2023] [Indexed: 10/20/2023] Open
Abstract
PURPOSE Myocardial injury after noncardiac surgery is common and mostly asymptomatic. The ideal target population that will benefit from routine troponin measurements in low and middle income countries (LMICs) is unclear. This study aims to evaluate the clinical outcomes of a cohort of high-risk surgical patients according to high-sensitivity troponin T (hsTnT) in an LMIC setting. METHODS We conducted a prospective cohort study of 442 high-risk patients undergoing noncardiac surgery at a Brazilian hospital between February 2019 and March 2020. High-sensitivity troponin T levels were measured preoperatively, 24 hr, and 48 hr after surgery and stratified into three groups: normal (< 20 ng·L-1); minor elevation (20-65 ng·L-1); and major elevation (> 65 ng·L-1). We performed survival analysis to determine the association between myocardial injury and one-year mortality. We described medical interventions and evaluated unplanned intensive care unit (ICU) admission and complications using multivariable models. RESULTS Postoperative myocardial injury occurred in 45% of patients. Overall, 30-day mortality was 8%. Thirty-day and one-year mortality were higher in patients with hsTnT ≥ 20 ng·L-1. One-year mortality was 18% in the unaltered troponin group vs 31% and 41% for minor and major elevation groups, respectively. Multivariable analysis of one-year survival showed a hazard ratio (HR) of 1.94 (95% confidence interval [CI], 1.22 to 3.09) for the minor elevation group and a HR of 2.73 (95% CI, 1.67 to 4.45) for the troponin > 65 ng·L-1 group. Patients with altered troponin had more unplanned ICU admissions (13% vs 5%) and more complications (78% vs 48%). CONCLUSION This study supports evidence that hsTnT is an important prognostic marker and a strong predictor of all-cause mortality after surgery. Troponin measurement in high-risk surgical patients could potentially be used as tool to scale-up care in LMIC settings. STUDY REGISTRATION ClinicalTrials.gov (NCT04187664); first submitted 5 December 2019.
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Affiliation(s)
- Adriene Stahlschmidt
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Sávio C Passos
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Debora D Dornelles
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Carisi Polanczyk
- Cardiology Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Claudia S Gutierrez
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Rosangela R Minuzzi
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Stela M J Castro
- Department of Statistics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Luciana C Stefani
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
- Department of Surgery, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Rua Ramiro Barcelos, 2350, Porto Alegre, RS, 90035-903, Brazil.
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Popova E, Paniagua-Iglesias P, Álvarez-García J, Vives-Borrás M, González-Osuna A, García-Osuna Á, Rivas-Lasarte M, Hermenegildo-Chavez G, Diaz-Jover R, Azparren-Cabezon G, Barceló-Trias M, Moustafa AH, Aguilar-Lopez R, Ordonez-Llanos J, Alonso-Coello P. The Relevance of Implementing the Systematic Screening of Perioperative Myocardial Injury in Noncardiac Surgery Patients. J Clin Med 2023; 12:5371. [PMID: 37629413 PMCID: PMC10455326 DOI: 10.3390/jcm12165371] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/10/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
Perioperative myocardial injury (PMI) is a common cardiac complication. Recent guidelines recommend its systematic screening using high-sensitivity cardiac troponin (hs-cTn). However, there is limited evidence of local screening programs. We conducted a prospective, single-center study aimed at assessing the feasibility and outcomes of implementing systematic PMI screening. Hs-cTn concentrations were measured before and after surgery. PMI was defined as a postoperative hs-cTnT of ≥14 ng/L, exceeding the preoperative value by 50%. All patients were followed-up during the hospitalization, at one month and one year after surgery. The primary outcome was the incidence of death and major cardiovascular and cerebrovascular events (MACCE). The secondary outcomes focused on the individual components of MACCE. We included two-thirds of all eligible high-risk patients and achieved almost complete compliance with follow-ups. The prevalence of PMI was 15.7%, suggesting a higher presence of cardiovascular (CV) antecedents, increased perioperative CV complications, and higher preoperative hs-cTnT values. The all-cause death rate was 1.7% in the first month, increasing up to 11.2% at one year. The incidence of MACCE was 9.5% and 8.6% at the same time points. Given the observed elevated frequencies of PMI and MACCE, implementing systematic PMI screening is recommendable, particularly in patients with increased cardiovascular risk. However, it is important to acknowledge that achieving optimal screening implementation comes with various challenges and complexities.
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Affiliation(s)
- Ekaterine Popova
- Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), 08041 Barcelona, Spain; (R.A.-L.); (P.A.-C.)
- Centro Cochrane Iberoamericano, 08025 Barcelona, Spain
| | - Pilar Paniagua-Iglesias
- Department of Anesthesia and Pain Management, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (P.P.-I.); (G.H.-C.); (R.D.-J.); (G.A.-C.)
| | - Jesús Álvarez-García
- Department of Cardiology, Hospital Universitario Ramon y Cajal, 28034 Madrid, Spain
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (M.V.-B.); (M.R.-L.); (A.-H.M.)
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), 29010 Madrid, Spain
| | - Miquel Vives-Borrás
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (M.V.-B.); (M.R.-L.); (A.-H.M.)
- Department of Cardiology, Fundació Institut d’Investigació Sanitària Illes Balears (IdISBa), 07120 Palma, Spain
| | - Aránzazu González-Osuna
- Department of Orthopedic Surgery and Traumatology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain;
| | - Álvaro García-Osuna
- Department of Biochemistry, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (Á.G.-O.); (J.O.-L.)
| | - Mercedes Rivas-Lasarte
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (M.V.-B.); (M.R.-L.); (A.-H.M.)
- Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, 28222 Majadahonda, Spain
| | - Gisela Hermenegildo-Chavez
- Department of Anesthesia and Pain Management, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (P.P.-I.); (G.H.-C.); (R.D.-J.); (G.A.-C.)
| | - Ruben Diaz-Jover
- Department of Anesthesia and Pain Management, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (P.P.-I.); (G.H.-C.); (R.D.-J.); (G.A.-C.)
| | - Gonzalo Azparren-Cabezon
- Department of Anesthesia and Pain Management, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (P.P.-I.); (G.H.-C.); (R.D.-J.); (G.A.-C.)
| | - Montserrat Barceló-Trias
- Geriatric Unit, Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain;
| | - Abdel-Hakim Moustafa
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (M.V.-B.); (M.R.-L.); (A.-H.M.)
| | - Raul Aguilar-Lopez
- Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), 08041 Barcelona, Spain; (R.A.-L.); (P.A.-C.)
- Cardiovascular Epidemiology Unit, Department of Cardiology, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain
| | - Jordi Ordonez-Llanos
- Department of Biochemistry, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (Á.G.-O.); (J.O.-L.)
- Foundation for Clinical Biochemistry & Molecular Pathology, 08025 Barcelona, Spain
| | - Pablo Alonso-Coello
- Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), 08041 Barcelona, Spain; (R.A.-L.); (P.A.-C.)
- Centro Cochrane Iberoamericano, 08025 Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), 28034 Madrid, Spain
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Daza JF, Bartoszko J, Van Klei W, Ladha KS, McCluskey SA, Wijeysundera DN. Improved Re-estimation of Perioperative Cardiac Risk Using the Surgical Apgar Score: A Retrospective Cohort Study. Ann Surg 2023; 278:65-71. [PMID: 35801710 DOI: 10.1097/sla.0000000000005509] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess whether the Surgical Apgar Score (SAS) improves re-estimation of perioperative cardiac risk. BACKGROUND The SAS is a novel risk index that integrates three relevant and easily measurable intraoperative parameters (blood loss, heart rate, mean arterial pressure) to predict outcomes. The incremental prognostic value of the SAS when used in combination with standard preoperative risk indices is unclear. METHODS We conducted a retrospective cohort study of adults (18 years and older) who underwent elective noncardiac surgery at a quaternary care hospital in Canada (2009-2014). The primary outcome was postoperative acute myocardial injury. The SAS (range 0-10) was calculated based on intraoperative estimated blood loss, lowest mean arterial pressure, and lowest heart rate documented in electronic medical records. Incremental prognostic value of the SAS when combined with the Revised Cardiac Risk Index was assessed based on discrimination (c-statistic), reclassification (integrated discrimination improvement, net reclassification index), and clinical utility (decision curve analysis). RESULTS The cohort included 16,835 patients, of whom 607 (3.6%) patients had acute postoperative myocardial injury. Addition of the SAS to the Revised Cardiac Risk Index improved risk estimation based on the integrated discrimination improvement [2.0%; 95% confidence interval (CI): 1.5%-2.4%], continuous net reclassification index (54%; 95% CI: 46%-62%), and c-index, which increased from 0.68 (95% CI: 0.65-0.70) to 0.75 (95% CI: 0.73-0.77). On decision curve analysis, addition of the SAS to the Revised Cardiac Risk Index resulted in a higher net benefit at all decision thresholds. CONCLUSIONS When combined with a validated preoperative risk index, the SAS improved the accuracy of cardiac risk assessment for noncardiac surgery. Further research is needed to delineate how intraoperative data can better guide postoperative decision-making.
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Affiliation(s)
- Julian F Daza
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Justyna Bartoszko
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital-University Health Network, Toronto, ON, Canada
| | - Wilton Van Klei
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital-University Health Network, Toronto, ON, Canada
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Karim S Ladha
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital-University Health Network, Toronto, ON, Canada
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada
| | - Stuart A McCluskey
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital-University Health Network, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital-University Health Network, Toronto, ON, Canada
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada
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8
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Tveit SH, Myhre PL, Omland T. The clinical importance of high-sensitivity cardiac troponin measurements for risk prediction in non-cardiac surgery. Expert Rev Mol Diagn 2023:1-10. [PMID: 37162108 DOI: 10.1080/14737159.2023.2211267] [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] [Indexed: 05/11/2023]
Abstract
INTRODUCTION The global healthcare burden associated with surgery is substantial, with many patients experiencing perioperative complications. Cardiac troponin I and T measured with high-sensitivity assays are cardiac specific biomarkers that associate closely with adverse outcomes in most patient populations. Perioperative physiological stress can induce troponin release from cardiomyocytes, a condition known as perioperative myocardial injury (PMI). PMI is associated with increased risk of poor short- and long-term outcomes, and current European guidelines recommend screening for PMI in at-risk individuals undergoing non-cardiac surgery. AREAS COVERED In this review we summarize current knowledge of the prognostic attributes of cardiac troponins, as well as the challenges associated with their application as biomarkers in the perioperative phase. EXPERT OPINION Measurement of circulating levels of cardiac troponins identify individuals at increased risk of poor postoperative outcomes. Systematic screening of at-risk individuals undergoing non-cardiac surgery will result in a large proportion of patients in need of further diagnostic workup to establish the exact nature of their PMI. The lack of concrete evidence of clinical benefit and the increased cost associated with such a strategy is concerning and underscore the need for further research.
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Affiliation(s)
- Sjur H Tveit
- Department of Anesthesia, Division of Surgery, Akershus University Hospital,Lørenskog, Norway
- K.G. Jebsen Centre for Cardiac Biomarkers, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Peder L Myhre
- K.G. Jebsen Centre for Cardiac Biomarkers, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Torbjørn Omland
- K.G. Jebsen Centre for Cardiac Biomarkers, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
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9
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Gualandro DM, Puelacher C, Mueller C. Reply to the letter regarding the article 'Acute heart failure after non-cardiac surgery: incidence, phenotypes, determinants and outcomes'. Eur J Heart Fail 2023; 25:771-772. [PMID: 37013342 DOI: 10.1002/ejhf.2850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 04/05/2023] Open
Affiliation(s)
- Danielle M Gualandro
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- Unidade de Medicina Interdisciplinar em Cardiologia, Instituto do Coração, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
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10
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Popova E, Alonso-Coello P, Álvarez-García J, Paniagua-Iglesias P, Rué-Monné M, Vives-Borrás M, Font-Gual A, Gich-Saladich I, Martínez-Bru C, Ordóñez-Llanos J, Carles-Lavila M. Cost-effectiveness of a high-sensitivity cardiac troponin T systematic screening strategy compared with usual care to identify patients with peri-operative myocardial injury after major noncardiac surgery. Eur J Anaesthesiol 2023; 40:179-189. [PMID: 36722187 DOI: 10.1097/eja.0000000000001793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND About 300 million surgeries are performed worldwide annually and this figure is increasing constantly. Peri-operative myocardial injury (PMI), detected by cardiac troponin (cTn) elevation, is a common cardiac complication of noncardiac surgery, strongly associated with short- and long-term mortality. Without systematic peri-operative cTn screening, most cases of PMI may go undetected. However, little is known about cost effectiveness of a systematic PMI screening strategy with high-sensitivity cardiac troponin T (hs-cTnT) after noncardiac surgery. OBJECTIVE To assess, in patients with high cardiovascular risk, the cost-effectiveness of a systematic screening strategy using a hs-cTnT assay, to identify patients with PMI after major noncardiac surgery, compared with usual care. DESIGN Cost-effectiveness analysis; single centre prospective cohort study. SETTING Spanish University Hospital. PATIENTS From July 2016 to March 2019, we included 1477 consecutive surgical patients aged ≥65 or if <65, with documented history of cardiovascular disease or impaired renal function, who underwent major noncardiac surgery and required at least an overnight hospital stay. We excluded patients aged <65 years without cardiovascular disease, undergoing minor surgery, or with an expected <24 h hospital stays. INTERVENTIONS We conducted a decision-tree analysis, comparing a systematic screening strategy measuring hs-cTnT before surgery, and at the 2nd and 3rd days after surgery vs. a usual care strategy. We considered a third-party payer perspective and the outcomes of both strategies in the short-term (30 days follow-up). Information about costs was expressed in Euros-2021. We calculated the incremental cost-effectiveness ratio (ICER) of the systematic hs-cTnT strategy, defined as the expected cost per any additional PMI detected, and explored the robustness of the model using deterministic and probabilistic sensitivity analysis. MAIN OUTCOME MEASURES ICER of the systematic hs-cTnT screening strategy. RESULTS The ICER was €425 per any additionally detected PMI. The deterministic sensitivity analysis showed that a 15% variation in costs, and a 1% variation in the predictive values, had a minor impact over the ICER, except in case of the negative predictive value of the systematic hs-cTnT screening strategy. Monte Carlo simulations (probabilistic sensitivity analysis) showed that systematic hs-cTnT screening would be cost-effective in 100% of cases with a 'willingness to pay' of €780. CONCLUSIONS Our results suggest that systematic peri-operative PMI screening with hs-cTnT may be cost-effective in the short-term in patients undergoing major noncardiac surgery. Economic evaluations, with a long-term horizon, are still needed. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT03438448.
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Affiliation(s)
- Ekaterine Popova
- From the IIB SANT PAU, Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain (EP, PA-C, IG-S), Centro Cochrane Iberoamericano, Barcelona, Spain (EP, PA-C), CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain (PA-C, IG-S), Hospital de la Santa Creu i Sant Pau, Department of Cardiology, Barcelona, Spain (JÁ-G, MV-B), Hospital Universitario Ramon y Cajal, Department of Cardiology, Madrid, Spain (JÁ-G), Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Madrid, Spain (JÁ-G), Hospital de la Santa Creu i Sant Pau, Department of Anaesthesia and Pain Management, Barcelona, Spain (PP-I, AF-G), Institut de Recerca Biomèdica de Lleida (IRBLleida), Department of Basic Medical Sciences, Lleida, Spain (MR-M), Research Group in Statistical and Economic Analysis in Health (GRAEES), Lleida, Spain (MR-M), Fundació Institut d'Investigació Sanitària Illes Balears (IdISBa), Department of Cardiology, Palma, Balearic Islands, Spain (MV-B), Hospital de la Santa Creu i Sant Pau, Department of Clinical Epidemiology and Public Health, Barcelona, Spain (IG-S), Hospital de la Santa Creu i Sant Pau, Department of Biochemistry, Barcelona, Spain (CM-B, JO-L), Fundación para la Bioquímica Clínica y Patología Molecular. Barcelona, Spain (JO-L), Universitat Rovira i Virgili, Economy Faculty, Reus, Spain (MC-L), Centro de Investigación en Economía y Sostenibilidad (ECO-SOS), Reus, Spain (MC-L)
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Oh AR, Park J, Shin SJ, Choi B, Lee JH, Lee SH, Yang K. Prediction model for myocardial injury after non-cardiac surgery using machine learning. Sci Rep 2023; 13:1475. [PMID: 36702844 PMCID: PMC9879966 DOI: 10.1038/s41598-022-26617-w] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 12/16/2022] [Indexed: 01/27/2023] Open
Abstract
Myocardial injury after non-cardiac surgery (MINS) is strongly associated with postoperative outcomes. We developed a prediction model for MINS and have provided it online. Between January 2010 and June 2019, a total of 6811 patients underwent non-cardiac surgery with normal preoperative level of cardiac troponin (cTn). We used machine learning techniques with an extreme gradient boosting algorithm to evaluate the effects of variables on MINS development. We generated two prediction models based on the top 12 and 6 variables. MINS was observed in 1499 (22.0%) patients. The top 12 variables in descending order according to the effects on MINS are preoperative cTn level, intraoperative inotropic drug infusion, operation duration, emergency operation, operation type, age, high-risk surgery, body mass index, chronic kidney disease, coronary artery disease, intraoperative red blood cell transfusion, and current alcoholic use. The prediction models are available at https://sjshin.shinyapps.io/mins_occur_prediction/ . The estimated thresholds were 0.47 in 12-variable models and 0.53 in 6-variable models. The areas under the receiver operating characteristic curves are 0.78 (95% confidence interval [CI] 0.77-0.78) and 0.77 (95% CI 0.77-0.78), respectively, with an accuracy of 0.97 for both models. Using machine learning techniques, we demonstrated prediction models for MINS. These models require further verification in other populations.
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Affiliation(s)
- Ah Ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seo Jeong Shin
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Korea
| | - Byungjin Choi
- Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon, Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Hwa Lee
- Heart Vascular Stroke Institute, Rehabilitation & Prevention Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
- Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, Korea.
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, Korea.
| | - Kwangmo Yang
- Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon, Korea.
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, Korea.
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12
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Chew MS, Saugel B, Lurati-Buse G. Perioperative troponin surveillance in major noncardiac surgery: a narrative review. Br J Anaesth 2023; 130:21-8. [PMID: 36464518 DOI: 10.1016/j.bja.2022.08.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 08/08/2022] [Accepted: 08/31/2022] [Indexed: 12/03/2022] Open
Abstract
Myocardial injury is now an acknowledged complication in patients undergoing noncardiac surgery. Heterogeneity in the definitions of myocardial injury contributes to difficulty in evaluating the value of cardiac troponins (cTns) measurement in perioperative care. Pre-, post-, and peri-operatively increased cTns are encompassed by the umbrella term 'myocardial injury' and are likely to reflect different pathophysiological mechanisms. Increased cTns are independently associated with cardiovascular and non-cardiovascular complications, poor short-term and long-term cardiovascular outcomes, and increased mortality. Preoperative measurement of cTns aids preoperative risk stratification beyond the Revised Cardiac Risk Index. Systematic measurement detects acute perioperative increases and allows early identification of acute myocardial injury. Common definitions and standards for reporting are a prerequisite for designing impactful future trials and perioperative management strategies.
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Halvorsen S, Mehilli J, Cassese S, Hall TS, Abdelhamid M, Barbato E, De Hert S, de Laval I, Geisler T, Hinterbuchner L, Ibanez B, Lenarczyk R, Mansmann UR, McGreavy P, Mueller C, Muneretto C, Niessner A, Potpara TS, Ristić A, Sade LE, Schirmer H, Schüpke S, Sillesen H, Skulstad H, Torracca L, Tutarel O, Van Der Meer P, Wojakowski W, Zacharowski K. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J 2022; 43:3826-3924. [PMID: 36017553 DOI: 10.1093/eurheartj/ehac270] [Citation(s) in RCA: 225] [Impact Index Per Article: 112.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Dovzhanskiy DI, Bischoff MS, Jäckel P, Boeckler D. [Diagnosis and Management of Perioperative Myocardial Ischemia after Elective Aortic Aneurysm Surgery]. Zentralbl Chir 2022. [PMID: 35915925 DOI: 10.1055/a-1880-1586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Perioperative myocardial ischemia (PMI) is a serious postoperative complication. Aortic operations represent an especially high-risk surgery concerning cardiac complications. This aim of this study was to analyse the clinical features of PMI after elective aortic aneurysm surgery. PATIENTS AND METHODS This study is a retrospective analysis of 863 patients who underwent elective aortic aneurysm surgery between 2005 and 2012 in the Department of Vascular and Endovascular Surgery of Heidelberg University Hospital with regard to PMI. The PMI diagnosis was based on a positive serum troponin diagnostic test. We evaluated the clinical course, time point of the diagnosis and features of diagnostics to characterise PMI. Moreover, we analysed the treatment options and management of the patients' discharge. RESULTS Thirty-one patients (3.6% of 863) with PMI after elective aortic aneurysm surgery were identified. Of these, 21 patients (67.7%) underwent open surgery and 10 patients (32.3%) received endovascular treatment. PMI was diagnosed in 24 patients (77%) during the first 3 days. More than half of these patients (16/31) were clinically asymptomatic. Electrocardiogram did not show pathological findings in 24 cases (77.4%). The first troponin measurement was not elevated in eight patients (25.8%). Drug therapy alone was used in 17 cases (54.8%) of PMI, coronary catheterisation was performed in 12 patients (38.7%) and two patients (6.5%) received aortocoronary bypass. Fourteen patients (45.1%) were discharged home and another 14 patients (44.1%) were transferred to another hospital or to a rehabilitation institution. Two patients died because of multi-organ failure. CONCLUSION PMI is not a rare complication after elective aortic surgery. The diagnosis of PMI can be challenging because of occult symptoms especially in a perioperative setting. Due to the potentially serious consequences, cardiac enzyme diagnostics should be initiated immediately if there is suspicion of PMI or routinely in defined at-risk patients after aortic surgery.
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Affiliation(s)
- Dmitriy I Dovzhanskiy
- Department of Vascular and Endovascular Surgery, Heidelberg University, Heidelberg, Deutschland
| | - Moritz S Bischoff
- Department of Vascular and Endovascular Surgery, Heidelberg University, Heidelberg, Deutschland
| | - Petra Jäckel
- Department of Vascular and Endovascular Surgery, Heidelberg University, Heidelberg, Deutschland
| | - Dittmar Boeckler
- Department of Vascular and Endovascular Surgery, Heidelberg University, Heidelberg, Deutschland
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Manthou P, Lioliousis G, Korobeli A, Vasileiou P, Fildisis G. The Predictive Role of Cardiac Troponin in Non-cardiac Surgery: A Study in the Greek Population. Cureus 2022; 14:e25408. [PMID: 35765400 PMCID: PMC9233922 DOI: 10.7759/cureus.25408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction The incidence of postoperative myocardial ischemia (POMI) remains uncertain and underdiagnosed despite significant morbidity and mortality rates. Methods This study included patients who underwent non-cardiac surgery. Troponin T (TnT) was measured on the first three postoperative days. The revised cardiac risk index, HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio (INR), elderly, drugs/alcohol concomitantly) bleeding score, and CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke or transient ischemic attack (TIA), vascular disease, age 65 to 74 years, sex category) score were combined. The receiver operating characteristic (ROC) curve was used to estimate the discriminative ability of preoperative troponin for myocardial ischemia (MI). Results Of 105 patients with a mean age of 69.1 years, 32.4% had MI. Hypertension, diabetes mellitus, and dyslipidemia were the main risk factors. A ROC analysis indicated that a preoperative value of 17.2 pg/ml or higher of troponin was significantly associated with MI. Moreover, a higher CHA2DS2-VASc score was associated with POMI. Conclusions POMI is associated with high mortality and a long stay in the intensive care unit. Routine use of different scores before surgery can be very useful.
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Devereaux PJ, Sessler D, Lalu M. Myocardial injury after noncardiac surgery. Can J Anaesth 2022; 69:561-567. [DOI: 10.1007/s12630-022-02220-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 01/06/2022] [Accepted: 01/06/2022] [Indexed: 10/19/2022] Open
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Ruetzler K, Smilowitz NR, Berger JS, Devereaux PJ, Maron BA, Newby LK, de Jesus Perez V, Sessler DI, Wijeysundera DN. Diagnosis and Management of Patients With Myocardial Injury After Noncardiac Surgery: A Scientific Statement From the American Heart Association. Circulation 2021; 144:e287-e305. [PMID: 34601955 DOI: 10.1161/cir.0000000000001024] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Myocardial injury after noncardiac surgery is defined by elevated postoperative cardiac troponin concentrations that exceed the 99th percentile of the upper reference limit of the assay and are attributable to a presumed ischemic mechanism, with or without concomitant symptoms or signs. Myocardial injury after noncardiac surgery occurs in ≈20% of patients who have major inpatient surgery, and most are asymptomatic. Myocardial injury after noncardiac surgery is independently and strongly associated with both short-term and long-term mortality, even in the absence of clinical symptoms, electrocardiographic changes, or imaging evidence of myocardial ischemia consistent with myocardial infarction. Consequently, surveillance of myocardial injury after noncardiac surgery is warranted in patients at high risk for perioperative cardiovascular complications. This scientific statement provides diagnostic criteria and reviews the epidemiology, pathophysiology, and prognosis of myocardial injury after noncardiac surgery. This scientific statement also presents surveillance strategies and treatment approaches.
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Jorge AJL, Mesquita ET, Martins WDA. Myocardial Injury after Non-cardiac Surgery - State of the Art. Arq Bras Cardiol 2021; 117:544-553. [PMID: 34550241 PMCID: PMC8462967 DOI: 10.36660/abc.20200317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 11/04/2020] [Indexed: 11/18/2022] Open
Abstract
Aproximadamente 300 milhões de cirurgias não cardíacas são realizadas anualmente no mundo, e eventos cardiovasculares adversos são as principais causas de morbimortalidade no período perioperatório e pós-operatório. A lesão miocárdica após cirurgia não cardíaca (MINS, do inglês myocardial injury after non-cardiac surgery) é uma nova entidade clínica associada com desfechos cardiovasculares adversos. MINS é definida como uma lesão miocárdica que pode resultar em necrose secundária à isquemia, com elevação dos biomarcadores. A lesão tem importância prognóstica e ocorre em até 30 dias após a cirurgia não cardíaca. Os critérios diagnósticos para MINS são: níveis elevados de troponina durante ou em até 30 dias após a cirurgia não cardíaca, sem evidência de etiologia não isquêmica, sem que haja necessariamente sintomas isquêmicos ou achados eletrocardiográficos de isquemia. Recentemente, pacientes com maior risco para MINS têm sido identificados por variáveis clínicas e biomarcadores, bem como por protocolos de vigilância quanto ao monitoramento eletrocardiográfico e dosagem de troponina cardíaca. Pacientes idosos com doença aterosclerótica prévia necessitam medir troponina diariamente no período pós-operatório. O objetivo deste trabalho é descrever este novo problema de saúde pública, seu impacto clínico e a abordagem terapêutica contemporânea.
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Affiliation(s)
| | - Evandro Tinoco Mesquita
- Centro de Ensino e Treinamento Edson de Godoy Bueno / UHG, Rio de Janeiro, RJ - Brasil.,UNIALFA / Colégio Brasileiro de Executivos em Saúde CBEXs, São Paulo, SP - Brasil.,Sociedad Interamericana de Cardiología (SIAC), Cidade do México - México.,DASA Complexo Hospitalar de Niterói, Niterói, RJ - Brasil
| | - Wolney de Andrade Martins
- Universidade Federal Fluminense (UFF), Niterói, RJ - Brasil.,DASA Complexo Hospitalar de Niterói, Niterói, RJ - Brasil
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Park J, Oh AR, Kwon JH, Kim S, Kim J, Yang K, Choi JH, Kim K, Ahn J, Sung J, Lee SH. Association between cardiologist evaluation and mortality in myocardial injury after non-cardiac surgery. Heart 2021; 108:695-702. [PMID: 34400475 DOI: 10.1136/heartjnl-2021-319511] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 07/26/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Myocardial injury after non-cardiac surgery (MINS) is strongly associated with mortality, but few studies assessed treatment strategies. This study aimed to identify whether evaluation by cardiologists could reduce mortality in MINS patients. METHODS From a single-centre retrospective cohort, we enrolled a total of 5633 adult patients diagnosed with MINS between January 2010 and June 2019. The patients were divided into two groups based on evaluation by cardiologist, which was defined as a cardiology consultation or transfer to the cardiology department. For the outcome, 30-day mortality was compared in crude and propensity-score matched populations. RESULTS Of a total of 5633 patients, 2120 (37.6%) were evaluated by cardiologists and 3513 (62.4%) were not. Mortality during the first 30 days after surgery was significantly lower in MINS patients who were evaluated by cardiologists compared with those who were not (5.8% vs 8.3%; HR, 0.64; 95% CI 0.51 to 0.80; p<0.001 for all-cause mortality and 1.6% vs 2.0; HR 0.62; 95% CI 0.40 to 0.96; p=0.03 for cardiovascular mortality). The propensity score matched analysis showed similar results (5.6% vs 8.6%; HR 0.64; 95% CI 0.50 to 0.81; p<0.001 for all-cause mortality and 1.3% vs 2.2%; HR 0.58; 95% CI 0.35 to 0.95; p=0.03 for cardiovascular mortality). CONCLUSIONS Cardiologist evaluation was associated with lower mortality in patients diagnosed with MINS. Further studies are needed to identify effective treatment strategies for MINS. TRIAL REGISTRATION NUMBER KCT0004244.
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Affiliation(s)
- Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ah Ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ji-Hye Kwon
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sojin Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeayoun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kwangmo Yang
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jin-Ho Choi
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kyunga Kim
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, South Korea.,Department of Digital Health, SAIHST, Sungkyunkwan University, Seoul, South Korea
| | - Joonghyun Ahn
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, South Korea
| | - Jidong Sung
- Rehabilitation & Prevention Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seung-Hwa Lee
- Rehabilitation & Prevention Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea .,Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, South Korea
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Serrano AB, Gomez-Rojo M, Ureta E, Nuñez M, Fernández Félix B, Velasco E, Burgos J, Popova E, Urrutia G, Gomez V, Del Rey JM, Sanjuanbenito A, Zamora J, Monteagudo JM, Pestaña D, de la Torre B, Candela-Toha Á. Preoperative clinical model to predict myocardial injury after non-cardiac surgery: a retrospective analysis from the MANAGE cohort in a Spanish hospital. BMJ Open 2021; 11:e045052. [PMID: 34348944 PMCID: PMC8340283 DOI: 10.1136/bmjopen-2020-045052] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To determine preoperative factors associated to myocardial injury after non-cardiac surgery (MINS) and to develop a prediction model of MINS. DESIGN Retrospective analysis. SETTING Tertiary hospital in Spain. PARTICIPANTS Patients aged ≥45 years undergoing major non-cardiac surgery and with at least two measures of troponin levels within the first 3 days of the postoperative period. All patients were screened for the MANAGE trial. PRIMARY AND SECONDARY OUTCOME MEASURES We used multivariable logistic regression analysis to study risk factors associated with MINS and created a score predicting the preoperative risk for MINS and a nomogram to facilitate bed-side use. We used Least Absolute Shrinkage and Selection Operator method to choose the factors included in the predictive model with MINS as dependent variable. The predictive ability of the model was evaluated. Discrimination was assessed with the area under the receiver operating characteristic curve (AUC) and calibration was visually assessed using calibration plots representing deciles of predicted probability of MINS against the observed rate in each risk group and the calibration-in-the-large (CITL) and the calibration slope. We created a nomogram to facilitate obtaining risk estimates for patients at pre-anaesthesia evaluation. RESULTS Our cohort included 3633 patients recruited from 9 September 2014 to 17 July 2017. The incidence of MINS was 9%. Preoperative risk factors that increased the risk of MINS were age, American Status Anaesthesiology classification and vascular surgery. The predictive model showed good performance in terms of discrimination (AUC=0.720; 95% CI: 0.69 to 0.75) and calibration slope=1.043 (95% CI: 0.90 to 1.18) and CITL=0.00 (95% CI: -0.12 to 0.12). CONCLUSIONS Our predictive model based on routinely preoperative information is highly affordable and might be a useful tool to identify moderate-high risk patients before surgery. However, external validation is needed before implementation.
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Affiliation(s)
- Ana Belen Serrano
- Department of Anesthesiology and Surgical Critical Care, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Maria Gomez-Rojo
- Department of Anesthesiology and Surgical Critical Care, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Eva Ureta
- Department of Anesthesiology and Surgical Critical Care, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Monica Nuñez
- Department of Anesthesiology and Surgical Critical Care, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Borja Fernández Félix
- Clinical Biostatistics Unit, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Elisa Velasco
- Department of Cardiology, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Javier Burgos
- Department of Urology, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Ekaterine Popova
- Biomedical Research Institute, Iberoamerican Cochrane Center, (IIB Sant Pau), Barcelona, Catalunya, Spain
| | - Gerard Urrutia
- CIBER Epidemiología y Salud Pública (CIBERESP), Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Cataluña, Spain
| | - Victoria Gomez
- Department of Urology, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Jose Manuel Del Rey
- Department of Biochemistry, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Alfonso Sanjuanbenito
- Department of General Surgery, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Javier Zamora
- Clinical Biostatistics Unit, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Comunidad de Madrid, Spain
- Institute of metabolism and systems researchs, University of Birmingham, Birmingham, UK
| | | | - David Pestaña
- Department of Anesthesiology and Surgical Critical Care, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
- Universidad Alcalá de Henares, Madrid, Spain
| | - Basilio de la Torre
- Department of Traumatology, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Ángel Candela-Toha
- Department of Anesthesiology and Surgical Critical Care, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
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Borges FK, Devereaux PJ. Physicians Should Obtain Perioperative Cardiac Troponin Measurements in At-Risk Patients Undergoing Noncardiac Surgery. Clin Chem 2021; 67:50-53. [PMID: 33221883 DOI: 10.1093/clinchem/hvaa218] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 08/25/2020] [Indexed: 11/14/2022]
Affiliation(s)
- Flavia K Borges
- Population Health Research Institute, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Philip J Devereaux
- Population Health Research Institute, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Outcomes Research Consortium, Cleveland, OH, USA
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Puelacher C, Bollen Pinto B, Mills NL, Duceppe E, Popova E, Duma A, Nagele P, Omland T, Hammerer-Lercher A, Lurati Buse G. Expert consensus on peri-operative myocardial injury screening in noncardiac surgery: A literature review. Eur J Anaesthesiol 2021; 38:600-608. [PMID: 33653981 DOI: 10.1097/eja.0000000000001486] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Peri-operative myocardial injury, detected by dynamic and elevated cardiac troponin (cTn) concentrations, is a common complication of noncardiac surgery that is strongly associated with 30-day mortality. Although active screening for peri-operative myocardial injury has been suggested in recent guidelines, clinical implementation remains tentative due to a lack of examples on how to tackle such an interdisciplinary project at a local level. Moreover, consensus on which assay and cTn cut-off values should be used has not yet been reached, and guidance on whom to screen is lacking. In this article, we aim to summarise local examples of successfully implemented cTn screening practices and review the current literature in order to provide information and suggestions for patient selection, organisation of a screening programme, caveats and a potential management pathway.
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Affiliation(s)
- Christian Puelacher
- From the Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital of Basel, University of Basel; Department of Internal Medicine, University Hospital Basel, University Basel, Basel (CP), Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland (CP, BBP), Geneva Perioperative Basic, Translational and Clinical Research Group (BB-P), BHF Centre for Cardiovascular Science and Usher Institute, University of Edinburgh, Edinburgh, UK (NLM), Department of Medicine, Centre Hospitalier de l'Universite de Montreal, Montreal, Quebec, Canada (ED), Iberoamerican Cochrane Centre, Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain (EP), Department of Anaesthesiology and Intensive Care, Medical University of Vienna, Vienna, Austria (AD), Departments of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois, USA (PN), Department of Cardiology, Division of Medicine, Akershus University Hospital and University of Oslo, Oslo, Norway (TO), Institute of Laboratory Medicine, County Hospital Aarau, Aarau, Switzerland (A-HL), Department of Anaesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany (GLB)
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McIsaac DI, Montroy J, Gagne S, Johnson C, Ernst J, Halman S, Oake J, Chan J, Madden S, Feng S, Moody M, Simard CG, Taljaard M, Foster M, Fergusson DA, Lalu MM. Implementation of the Canadian Cardiovascular Society guidelines for perioperative risk assessment and management: an interrupted time series study. Can J Anaesth 2021; 68:1135-45. [PMID: 34031808 DOI: 10.1007/s12630-021-02026-x] [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: 12/18/2020] [Revised: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 10/21/2022] Open
Abstract
PURPOSE The Canadian Cardiovascular Society (CCS) guidelines for patients undergoing non-cardiac surgery address the lack of standardized management for patients at risk of perioperative cardiovascular complications. Our interdisciplinary group evaluated the implementation of these guidelines. METHODS We used an interrupted time series design to evaluate the effect of implementation of the CCS guidelines, using routinely collected hospital data. The study population consisted of elective, non-cardiac surgery patients who were: i) inpatients following surgery and ii) age ≥ 65 or age 45-64 yr with a Revised Cardiac Risk Index ≥ 1. Outcomes included adherence to troponin I (TnI) monitoring (primary) and adherence to appropriate consultant care for patients with elevated TnI (secondary). Exploratory outcomes included cost measures and clinical outcomes such as length of stay. RESULTS We included 1,421 patients (706 pre- and 715 post-implementation). We observed a 67% absolute increase (95% confidence interval, 55 to 80; P < 0.001) in adherence to TnI testing following the implementation of the guidelines. In patients who had elevated TnI following guideline implementation (n = 64), the majority (85%) received appropriate follow-up care in the form of a general medicine or cardiology consult, all received at least one electrocardiogram, and half received at least one advanced cardiac test (e.g., cardiac perfusion scan, or percutaneous intervention). CONCLUSIONS Our study showed the ability to implement and adhere to the CCS guidelines. Large-scale multicentre evaluations of CCS guideline implementation are needed to gain a better understanding of potential effects on clinically relevant outcomes.
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Abstract
PURPOSE OF REVIEW After successfully reducing mortality in the operating room, the time has come for anesthesiologists to conquer postoperative complications. This review aims to raise awareness about myocardial injury after noncardiac surgery (MINS), its definition, diagnosis, clinical importance, and treatment. RECENT FINDINGS MINS, defined as an elevated postoperative troponin judged to be due to myocardial ischemia (with or without ischemic features), occurs in up to one in five patients having noncardiac surgery and is responsible for 16% of all postoperative deaths within 30 days of surgery. New evidence on risk factors, etiology, potential prevention strategies, treatment options, and the economic impact of MINS highlights the actionability of perioperative clinicians in caring for adult patients who are considered to be at risk of cardiovascular complications. SUMMARY Millions of patients safely going through surgery suffer MINS and die shortly after the procedure every year. Without a structured approach to predicting, preventing, diagnosing, and treating MINS, we lose the opportunity to provide our patients with the best chance of deriving benefit from noncardiac surgery. The perioperative community needs to come together, appreciate the clinical relevance of MINS, and step up with high-quality research in the future.
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Rostagno C, Cartei A, Rubbieri G, Ceccofiglio A, Magni A, Forni S, Civinini R, Boccaccini A. Perioperative Myocardial Infarction/Myocardial Injury Is Associated with High Hospital Mortality in Elderly Patients Undergoing Hip Fracture Surgery. J Clin Med 2020; 9:jcm9124043. [PMID: 33327599 PMCID: PMC7765049 DOI: 10.3390/jcm9124043] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 12/08/2020] [Accepted: 12/09/2020] [Indexed: 12/26/2022] Open
Abstract
Cardiovascular complications in patients undergoing non-cardiac surgery are associated with longer hospital stays and higher in-hospital mortality. The aim of this study was to assess the incidence of in-hospital myocardial infarction and/or myocardial injury in patients undergoing hip fracture surgery and their association with mortality. Moreover, we evaluated the prognostic value of troponin increase stratified on the basis of peak troponin value. The electronic records of 1970 consecutive hip fracture patients were reviewed. Patients <70 years, those with myocardial infarction <30 days, and those with sepsis or active cancer were excluded from the study. Troponin and ECG were obtained at admission and then at 12, 24, and 48 h after surgery. Echocardiography was made before and within 48 h after surgery. Myocardial injury was defined by peak troponin I levels > 99th percentile. A total of 1854 patients were included. An elevated troponin concentration was observed in 754 (40.7%) patients in the study population. Evidence of myocardial ischemia, fulfilling diagnosis of myocardial infarction, was found in 433 (57%). ECG and echo abnormalities were more frequent in patients with higher troponin values; however, mortality did not differ between patients with and without evidence of ischemia. Peak troponin was between 0.1 and 1 µg/L in 593 (30.3%). A total of 191 (10%) had peak troponin I ≥ 1 µg/L, and 98 died in hospital (5%). Mortality was significantly higher in both groups with troponin increase (HR = 1.37, 95% CI 1.1–1.7, p < 0.001 for peak troponin I between 0.1 and 1 µg/L; HR = 2.28, 95% CI 1.72–3.02, p < 0.0001 for peak troponin ≥1 µg/L) in comparison to patients without myocardial injury. Male gender, history of coronary heart disease, heart failure, and chronic kidney disease were also associated with in-hospital mortality. Myocardial injury/infarction is associated with increased mortality after hip fracture surgery. Elevated troponin values, but not ischemic changes, are related to early worse outcome.
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Affiliation(s)
- Carlo Rostagno
- SODc Medicina Interna e Post-Chirurgica, AOU Careggi, 50136 Firenze, Italy
| | - Alessandro Cartei
- SODc Medicina Interna e Post-Chirurgica, AOU Careggi, 50136 Firenze, Italy
| | - Gaia Rubbieri
- SODc Medicina Interna e Post-Chirurgica, AOU Careggi, 50136 Firenze, Italy
| | - Alice Ceccofiglio
- SODc Medicina Interna e Post-Chirurgica, AOU Careggi, 50136 Firenze, Italy
| | - Agnese Magni
- SODc Medicina Interna e Post-Chirurgica, AOU Careggi, 50136 Firenze, Italy
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Abstract
Worldwide, more than 200 million non-cardiac surgeries are performed annually, and this number is constantly increasing; cardiac complications are the leading cause of death in such surgeries. So, in a multicenter study conducted in 27 countries, cardiovascular complications were present in 68% of cases of death in the postoperative period. Registers of recent years have shown that the number of such complications remains high, for example, with a dynamic assessment of troponins, perioperative myocardial damage was detected in 13-18% of cases. This review provides a critical analysis of the step-by-step algorithm for assessing cardiac risk of non-cardiac operations considering the emergence of new publications on this topic. The review discusses new data on risk assessment scales, functional state assessment, the use of non-invasive tests, biomarkers, the role of preventive myocardial revascularization in the preoperative period, and drug therapy. The issues of non-cardiac operations after percutaneous coronary intervention, perioperative myocardial damage are considered separately. The review emphasizes the difficulties in obtaining evidence, conducting randomized clinical trials in this section of medicine, which do not allow obtaining unambiguous conclusions in most cases and lead to inconsistencies and ambiguities in the recommendations of various expert groups. This review will help practitioners navigate this issue and help to use the optimal diagnostic and treatment strategy before performing non-cardiac surgery.
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Affiliation(s)
- A. N. Sumin
- Research Institute for Complex Issues of Cardiovascular Diseases
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González LS, Izquierdo DA, Davidovich RM. Definition and diagnosis of intraoperative myocardial ischemia. Int Anesthesiol Clin 2021; 59:45-52. [PMID: 33122545 DOI: 10.1097/AIA.0000000000000302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pereira-Neves A, Barros D, Rocha-Neves J, Duarte-Gamas L, Dias-Neto M, Cerqueira A, Vidoedo J, Teixeira J. Impact of sarcopenia in aortoiliac occlusive disease in Mediterranean population. Turk Gogus Kalp Damar Cerrahisi Derg 2020; 28:615-22. [PMID: 33403134 DOI: 10.5606/tgkdc.dergisi.2020.20146] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 08/30/2020] [Indexed: 11/21/2022]
Abstract
Background This study aims to validate the psoas muscle area and psoas muscle density as morphometric predictors in cardiovascular and cerebrovascular endpoints in patients with extensive aortoiliac peripheral arterial disease. Methods A total of 57 patients (55 males, 2 females; mean age 60±8.2 years; range, 35 to 83 years) with Trans-Atlantic Inter-Society Consensus type D lesions who underwent revascularization at two Portuguese tertiary hospitals between January 2013 and July 2019 were retrospectively analyzed. The patients with a recent (<6 months) computed tomography scan prior to the revascularization procedure were included in the study. Both centers offered to their patients open and endovascular repair of aortoiliac peripheral arterial disease. Major adverse cardiovascular and cerebrovascular events and major adverse limb events were evaluated. Results The median follow-up was 20 months. The mean survival rate was 93±3.4% at 30 days and 62.7±8.6% at 48 months. The discriminative thresholds found in this population were 2,175.8 mm2 for total psoas area and 51.75 Hounsfield unit for psoas muscle density. There was a statistically significant difference in the one-year survival rate (p=0.003 and p=0.291, respectively) and major adverse cardiovascular and cerebrovascular events (p=0.005 and p=0.206, respectively) for total psoas area compared to psoas muscle density. Conclusion Total psoas area shows a prognostic value for survival and major adverse cardiovascular and cerebrovascular events in this patient population.
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Pereira-Macedo J, Machado N, Pereira-Neves A, Ferreira V, Oliveira-Pinto J, Dias-Neto M, Rocha-Neves J, Teixeira J, Andrade J. Myocardial injury after aortoiliac revascularization for extensive disease: A survival analysis. Turk Gogus Kalp Damar Cerrahisi Derg 2020; 28:426-434. [PMID: 32953204 PMCID: PMC7493606 DOI: 10.5606/tgkdc.dergisi.2020.20100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 06/23/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND This study aims to evaluate the incidence of myocardial injury after non-cardiac surgery for an extensive disease pattern (TASC II type D) and to examine its prognostic value. METHODS This prospective study included a total of 66 consecutive patients (62 males, 4 females; mean age 62.5±8.2 years) who underwent elective revascularization for aortoiliac TASC II type D lesions in the tertiary setting between January 2013 and March 2019. The patients were scheduled for revascularization either by open surgery or endovascular approach. Cardiac troponins were routinely measured in the postoperative period. Myocardial injury after non-cardiac surgery was defined as the elevation of cardiac troponin for at least one value above the 99th percentile upper reference limit. Myocardial infarction, acute heart failure, stroke, major adverse cardiovascular events, major adverse limb events, and all-cause mortality were assessed both postoperatively and during follow-up. RESULTS The incidence of myocardial injury after non-cardiac surgery was 25.8%. In the multivariate analysis, chronic heart failure was found to be a significant risk factor for myocardial injury after non-cardiac surgery (odds ratio: 10.3; 95% confidence interval 1.00-106.8, p=0.018). At 12 months after revascularization, the diagnosis of myocardial injury after non-cardiac surgery was significantly associated with myocardial infarction, stroke, major adverse cardiovascular events, major adverse limb events, and all-cause mortality. At 12 months after revascularization, the diagnosis of myocardial injury after non-cardiac surgery was significantly associated with myocardial infarction (log-rank p=0.002), stroke (log-rank p=0.007), major adverse cardiovascular events (log-rank p=0.000), major adverse limb events (log-rank p=0.007), and all-causemortality (log-rank p=0.000). CONCLUSION Our study results suggest that myocardial injury after non-cardiac surgery plays a role as a predictor of significant cardiovascular comorbidities and mortality after complex aortoiliac revascularization. The presence of chronic heart failure is also associated with a higher incidence of myocardial injury after aortoiliac TASC II type D revascularization. Therefore, preemptive strategies should be adopted to identify and treat these patients.
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Affiliation(s)
- Juliana Pereira-Macedo
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Neuza Machado
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - António Pereira-Neves
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Biomedicine - Unit of Anatomy, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Physiology and Surgery, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Vítor Ferreira
- Department of Angiology and Vascular Surgery, Centro Hospitalar Entre o Douro e Vouga, Santa Maria da Feira, Portugal
| | - José Oliveira-Pinto
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Physiology and Surgery, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Marina Dias-Neto
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Physiology and Surgery, Faculty of Medicine, University of Porto, Porto, Portugal
| | - João Rocha-Neves
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Biomedicine - Unit of Anatomy, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Physiology and Surgery, Faculty of Medicine, University of Porto, Porto, Portugal
| | - José Teixeira
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - José Andrade
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Physiology and Surgery, Faculty of Medicine, University of Porto, Porto, Portugal
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Thomas S, Borges F, Bhandari M, De Beer J, Urrútia Cuchí G, Adili A, Winemaker M, Avram V, Chan MTV, Lamas C, Cruz P, Aguilera X, Garutti I, Alonso-Coello P, Villar JC, Jacka M, Wang CY, Berwanger O, Chow C, Srinathan S, Pettit S, Heels-Ansdell D, Rubery P, Devereaux PJ. Association Between Myocardial Injury and Cardiovascular Outcomes of Orthopaedic Surgery: A Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) Substudy. J Bone Joint Surg Am 2020; 102:880-888. [PMID: 32118652 DOI: 10.2106/jbjs.18.01305] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Myocardial injury after noncardiac surgery (MINS) is common and of prognostic importance. Little is known about MINS in orthopaedic surgery. The diagnostic criterion for MINS was a level of ≥0.03 ng/mL on a non-high-sensitivity troponin T (TnT) assay due to myocardial ischemia. METHODS We undertook an international, prospective study of 15,103 patients ≥45 years of age who had inpatient noncardiac surgery; 3,092 underwent orthopaedic surgery. Non-high-sensitivity TnT assays were performed on postoperative days 0, 1, 2, and 3. Among orthopaedic patients, we determined (1) the prognostic relevance of the MINS diagnostic criteria, (2) the 30-day mortality rate for those with and without MINS, and (3) the probable proportion of MINS cases that would go undetected without troponin monitoring because of a lack of an ischemic symptom. RESULTS Three hundred and sixty-seven orthopaedic patients (11.9%) had MINS. MINS was associated independently with 30-day mortality including among those who had had orthopaedic surgery. Orthopaedic patients without and with MINS had a 30-day mortality rate of 1.0% and 9.8%, respectively (odds ratio [OR], 11.28; 95% confidence interval [CI], 6.72 to 18.92). The 30-day mortality rate was increased for patients with MINS who had an ischemic feature (i.e., symptoms, or evidence of ischemia on electrocardiography or imaging) (OR, 18.25; 95% CI, 10.06 to 33.10) and for those who did not have an ischemic feature (OR, 7.35; 95% CI, 3.37 to 16.01). The proportion of orthopaedic patients with MINS who were asymptomatic and in whom the myocardial injury would have probably gone undetected without TnT monitoring was 81.3% (95% CI, 76.3% to 85.4%). CONCLUSIONS One in 8 orthopaedic patients in our study had MINS, and MINS was associated with a higher mortality rate regardless of symptoms. Troponin levels should be measured after surgery in at-risk patients because most MINS cases (>80%) are asymptomatic and would go undetected without routine measurements. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sabu Thomas
- University of Rochester, Rochester, New York.,McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | | | | | | | | | - Claudia Lamas
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Patricia Cruz
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Ignacio Garutti
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | | | - C Y Wang
- University of Malaya, Kuala Lumpur, Malaysia
| | | | - Clara Chow
- University of Sydney, Sydney, New South Wales, Australia
| | | | | | | | - Paul Rubery
- University of Rochester, Rochester, New York
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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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Pereira-macedo J, Rocha-neves JP, Dias-neto MF, Andrade JPV. Prognostic effect of troponin elevation in patients undergoing carotid endarterectomy with regional anesthesia – A prospective study. Int J Surg 2019; 71:66-71. [DOI: 10.1016/j.ijsu.2019.09.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 09/07/2019] [Accepted: 09/16/2019] [Indexed: 01/21/2023]
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Abstract
In the future an increasing number of older patients with significant comorbidities will have to undergo major surgical procedures. Perioperative cardiovascular events account for many major complications and even fatalities. While perioperative myocardial infarction (PMI) is a generally well-known and recognized complication, the less severe myocardial injury after non-cardiac surgery (MINS) has not gained widespread scientific attention until recently; however, two large observational trials (VISION 1 and VISION 2) have shown a significantly increased mortality after MINS with even subtle increases in troponin T being associated with an increased risk of death. This review summarizes the current knowledge pertaining to PMI and MINS and proposes a diagnostic and therapeutic framework for optimally guiding patients at risk through the perioperative period.
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Devereaux PJ, Szczeklik W. Myocardial injury after non-cardiac surgery: diagnosis and management. Eur Heart J 2019; 41:3083-3091. [DOI: 10.1093/eurheartj/ehz301] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 02/21/2019] [Accepted: 05/06/2019] [Indexed: 01/13/2023] Open
Abstract
Abstract
Myocardial injury after non-cardiac surgery (MINS) is due to myocardial ischaemia (i.e. supply-demand mismatch or thrombus) and is associated with an increased risk of mortality and major vascular complications at 30 days and up to 2 years after non-cardiac surgery. The diagnostic criteria for MINS includes an elevated post-operative troponin measurement judged as resulting from myocardial ischaemia (i.e. no evidence of a non-ischaemic aetiology), during or within 30 days after non-cardiac surgery, and without the requirement of an ischaemic feature (e.g. ischaemic symptom, ischaemic electrocardiography finding). For patients with MINS who are not at high risk of bleeding, physicians should consider initiating dabigatran 110 mg twice daily and low-dose aspirin. Physicians should also consider initiating statin therapy in patients with MINS. Most MINS patients should only be referred to cardiac catheterization if they demonstrate recurrent instability (e.g. cardiac ischaemia, heart failure). Patients ≥65 years of age or with known atherosclerotic disease should have troponin measurements on days 1, 2, and 3 after surgery while the patient is in hospital to avoid missing >90% of MINS and the opportunity to initiate secondary prophylactic measures and follow-up.
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Affiliation(s)
- P J Devereaux
- Department of Health Research Methods, Evidence, and Impact, McMaster University, David Braley Research Building, c/o Hamilton General Hospital, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
- Population Health Research Institute, David Braley Research Building, c/o Hamilton General Hospital, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
- Department of Medicine, McMaster University, David Braley Research Building, c/o Hamilton General Hospital, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
- Outcomes Research Consortium, 109 Partridge Lane, Hunting Valley, Cleveland, OH 44022, USA
| | - Wojciech Szczeklik
- Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, ul. Skawinska 8, 31-066 Krakow, Poland
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