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Martinez-Perez S, van Waes JAR, Vernooij LM, Cuthbertson BH, Beattie WS, Wijeysundera DN, van Klei WA. Postoperative troponin surveillance to detect myocardial infarction: an observational cohort modelling study. Br J Anaesth 2024; 132:667-674. [PMID: 38233301 DOI: 10.1016/j.bja.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/29/2023] [Accepted: 12/18/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Clinical presentation of postoperative myocardial infarction (POMI) is often silent. Several international guidelines recommend routine troponin surveillance in patients at risk. We compared how these different guidelines select patients for surveillance after noncardiac surgery with our established risk stratification model. METHODS We used outcome data from two prospective studies: Measurement of Exercise Tolerance before Surgery (METS) and Troponin Elevation After Major non-cardiac Surgery (TEAMS). We compared the major American, Canadian, and European guideline recommendations for troponin surveillance with our established risk stratification model. For each guideline and model, we quantified the number of patients requiring monitoring, % POMI detected, sensitivity, specificity, diagnostic odds ratio, and number needed to screen (NNS). RESULTS METS and TEAMS contributed 2350 patients, of whom 319 (14%) had myocardial injury, 61 (2.5%) developed POMI, and 14 (0.6%) died. Our risk stratification model selected fewer patients for troponin monitoring (20%), compared with the Canadian (78%) and European (79%) guidelines. The sensitivity to detect POMI was highest with the Canadian and European guidelines (0.85; 95% confidence interval [CI] 0.74-0.92). Specificity was highest using the American guidelines (0.91; 95% CI 0.90-0.92). Our risk stratification model had the best diagnostic odds ratio (2.5; 95% CI 1.4-4.2) and a lower NNS (21 vs 35) compared with the guidelines. CONCLUSIONS Most postoperative myocardial infarctions were detected by the Canadian and European guidelines but at the cost of low specificity and a higher number of patients undergoing screening. Patient selection based on our risk stratification model was optimal.
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Affiliation(s)
- Selene Martinez-Perez
- Department of Anesthesiology and Pain Management, Toronto General Hospital/University Health Network Toronto, Toronto, ON, Canada
| | - Judith A R van Waes
- Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lisette M Vernooij
- Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Anesthesiology, Intensive Care and Pain Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - W Scott Beattie
- Department of Anesthesiology and Pain Management, Toronto General Hospital/University Health Network Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesiology, St. Michael's Hospital, Toronto, ON, Canada
| | - Wilton A van Klei
- Department of Anesthesiology and Pain Management, Toronto General Hospital/University Health Network Toronto, Toronto, ON, Canada; Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
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Vernooij LM, van Waes JAR, Grobben RB, van Lier F, Feng S, Machina M, McKenny M, Nathoe HM, Wijeysundera DN, van Klei WA, Beattie WS. Postoperative myocardial injury phenotypes and self-reported disability in patients undergoing noncardiac surgery: a multicentre observational study. Br J Anaesth 2024; 132:35-44. [PMID: 38057252 DOI: 10.1016/j.bja.2023.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 10/10/2023] [Accepted: 10/13/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Postoperative myocardial injury (PMI) comprises a spectrum of mechanisms resulting in troponin release. The impact of different PMI phenotypes on postoperative disability remains unknown. METHODS This was a multicentre prospective cohort study including patients aged ≥50 yr undergoing elective major noncardiac surgery. Patients were stratified in five groups based on the occurrence of PMI and clinical information on postoperative adverse events: PMI classified as myocardial infarction (MI; according to fourth definition), PMI plus adverse event other than MI, clinically silent PMI (PMI without adverse events), adverse events without PMI, and neither PMI nor an adverse event (reference). The primary endpoint was 6-month self-reported disability (assessed by WHO Disability Assessment Schedule 2.0 [WHODAS]). Disability-free survival was defined as WHODAS ≤16%. RESULTS We included 888 patients of mean age 69 (range 53-91) yr, of which 356 (40%) were women; 151 (17%) patients experienced PMI, and 625 (71%) experienced 6-month disability-free survival. Patients with PMI, regardless of its phenotype, had higher preoperative disability scores than patients without PMI (difference in WHODAS; β: 3.3, 95% confidence interval [CI]: 0.5-6.2), but scores remained stable after surgery (β: 1.2, 95% CI: -3.2-5.6). Before surgery, patients with MI (n=36, 4%) were more disabled compared with patients without PMI and no adverse events (β: 5.5, 95% CI: 0.3-10.8). At 6 months, patients with MI and patients without PMI but with adverse events worsened in disability score (β: 11.2, 95% CI: 2.3-20.2; β: 8.1, 95% CI: 3.0-13.2, respectively). Patients with clinically silent PMI did not change in disability score at 6 months (β: 1.39, 95% CI: -4.50-7.29, P=0.642). CONCLUSIONS Although patients with postoperative myocardial injury had higher preoperative self-reported disability, disability scores did not change at 6 months after surgery. However, patients experiencing myocardial infarction worsened in disability score after surgery.
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Affiliation(s)
- Lisette M Vernooij
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands; Department of Anesthesiology, Intensive Care and Pain Medicine, St Antonius Hospital, Nieuwegein, The Netherlands.
| | - Judith A R van Waes
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Remco B Grobben
- Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Felix van Lier
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Simon Feng
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Matthew Machina
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada; Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Michael McKenny
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada; Department of Anesthesiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Hendrik M Nathoe
- Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Duminda N Wijeysundera
- Department of Anesthesia, St. Michael's Hospital - Unity Health Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Wilton A van Klei
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands; Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - W Scott Beattie
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada
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van Klei WA, van Waes JAR, Hollmann MW. Limitations of the PREHAB Randomized Clinical Trial. JAMA Surg 2023; 158:1355. [PMID: 37647061 DOI: 10.1001/jamasurg.2023.3755] [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: 09/01/2023]
Affiliation(s)
- Wilton A van Klei
- Department of Anesthesiology and Pain Medicine, Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada
| | - Judith A R van Waes
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam University Medical Center, Amsterdam, the Netherlands
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van Klei WA, van Waes JAR, Beattie WS. Routine post-operative troponin surveillance after non-cardiac surgery: are we ready? Eur Heart J 2023; 44:3440-3442. [PMID: 37525944 DOI: 10.1093/eurheartj/ehad487] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 01/24/2023] [Revised: 06/30/2023] [Accepted: 07/18/2023] [Indexed: 08/02/2023] Open
Affiliation(s)
- Wilton A van Klei
- Department of Anesthesiology, University Health Network Toronto, Toronto General Hospital, 200 Elizabeth Street, 3EN-464, Toronto, ON M5G 2C4, Canada
- Department of Anesthesiology, University of Toronto, Toronto, M5G 1E2 ON, Canada
- Department of Anesthesiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Judith A R van Waes
- Department of Anesthesiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - W Scott Beattie
- Department of Anesthesiology, University Health Network Toronto, Toronto General Hospital, 200 Elizabeth Street, 3EN-464, Toronto, ON M5G 2C4, Canada
- Department of Anesthesiology, University of Toronto, Toronto, M5G 1E2 ON, Canada
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Miggelbrink LA, Marsman M, Senff JR, van Waes JAR, Bronsveld I, van Klei W, Kappen T. [Dutch guideline to prevent perioperative pulmonal complications: how is the adherence?]. Ned Tijdschr Geneeskd 2022; 166:D6889. [PMID: 36300494] [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] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Patients with a history of chronic obstructive pulmonary disease (COPD) or asthma undergoing surgery are at risk for developing postoperative pulmonary complications, associated with morbidity and mortality. A national guideline was composed on preventive strategies in non-thoracic surgery, in which perioperative administration of corticosteroids are a cornerstone. We investigated the implementation in our hospital. METHOD Patients with a history of asthma and/or COPD who underwent non-thoracic surgery between January 2017 and July 2018 in our hospital, were included. Primary outcome was perioperative administration of intravenous prednisolone or oral prednisone as preventative treatment. The reasons for (non)adherence were investigated as secondary outcome. RESULTS 1,623 patients qualified for a preventative treatment. Overall, 653 patients (40%) received treatment according to protocol. The other 970 patients received no treatment (79%), another corticosteroid (12%) or received the other strategy (9%). Based on interviews and surveys, several barriers were found: fear of side effects of corticosteroids, indications for other types of corticosteroids, and lack of confidence in the literature. CONCLUSION The current guideline for prevention of postoperative pulmonary complications has not been implemented thoroughly at our hospital. The lack of adherence appears to be caused by lack in clarity in clinical practice, lack of confidence in the evidence on which the protocol is based, and fear of side effects of corticosteroids. There are also notable differences between the vision of pulmonologists and the anesthesiologists. Further research is needed to solidify the guideline, anticipating aforementioned compliance barriers to achieve better implementation.
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Wesselink EM, Wagemakers SH, van Waes JAR, Wanderer JP, van Klei WA, Kappen TH. Associations between intraoperative hypotension, duration of surgery and postoperative myocardial injury after noncardiac surgery: a retrospective single-centre cohort study. Br J Anaesth 2022; 129:487-496. [PMID: 36064492 DOI: 10.1016/j.bja.2022.06.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 04/09/2021] [Revised: 05/16/2022] [Accepted: 06/05/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Studies of intraoperative hypotension typically specify a blood pressure threshold associated with adverse outcomes. Such thresholds are likely to be study-biased, investigator-biased, or both. We hypothesised that a newly developed modelling method without a threshold, which is biologically more plausible than a threshold-based approach, would reveal a continuous association between exposure to intraoperative hypotension and adverse outcomes. METHODS Single-centre, retrospective cohort study of subjects ≥60 yr old undergoing noncardiac surgery. We modelled intraoperative hypotension using three different approaches: (1) unweighted, (2) weighted for degree of hypotension (depth), and (3) weighted for duration of hypotension. The primary outcome was myocardial injury, defined as elevated troponin I (>60 ng L-1) measured during the first 3 days after surgery. The associations between the three models, postoperative myocardial injury, and mortality (secondary outcome) were reported as penalised adjusted odds ratios (ORs) scaled between the 75th and 25th percentiles. RESULTS Myocardial injury occurred in 1812/15 452 (12%) procedures, with 554/15 452 (3.6%) procedures resulting in death before discharge from hospital. The unweighted lower blood pressure measure (OR: 0.26, 95% confidence interval [CI]: 0.12-0.53) and the depth-weighted measure (OR: 4.4, 95% CI: 2.6-7.4) were associated with myocardial injury. The duration-weighted measure was not associated with myocardial injury (OR: 0.89, 95% CI: 0.61-1.3). The unweighted measure (OR 0.08, 95% CI: 0.01-0.40) and the depth-weighted measure (OR: 12, 95% CI, 3.8-35) were associated with in-hospital mortality, but not the duration-weighted measure (OR: 1.3, 95% CI: 0.53-3.0). CONCLUSIONS Intraoperative hypotension appears to have a graded association with postoperative myocardial injury and mortality, with depth appearing to contribute more than duration.
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Affiliation(s)
- Esther M Wesselink
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Sjors H Wagemakers
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Judith A R van Waes
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Jonathan P Wanderer
- Departments of Anesthesiology and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wilton A van Klei
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Teus H Kappen
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
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Weersink CSA, van Waes JAR, Grobben RB, Nathoe HM, van Klei WA. Patient Selection for Routine Troponin Monitoring After Noncardiac Surgery. J Am Heart Assoc 2021; 10:e019912. [PMID: 34219462 PMCID: PMC8483467 DOI: 10.1161/jaha.120.019912] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Myocardial infarction is an important complication after noncardiac surgery. Therefore, perioperative troponin surveillance is recommended for patients at risk. The aim of this study was to identify patients at high risk of perioperative myocardial infarction (POMI), in order to aid appropriate selection and to omit redundant laboratory measurements in patients at low risk. Methods and Results This observational cohort study included patients ≥60 years of age who underwent intermediate to high risk noncardiac surgery. Routine postoperative troponin I monitoring was performed. The primary outcome was POMI. Classification and regression tree analysis was used to identify patient groups with varying risks of POMI. In each subgroup, the number needed to screen to identify 1 patient with POMI was calculated. POMI occurred in 216 (4%) patients and other myocardial injury in 842 (15%) of the 5590 included patients. Classification and regression tree analysis divided patients into 14 subgroups in which the risk of POMI ranged from 1.7% to 42%. Using a risk of POMI ≥2% to select patients for routine troponin I monitoring, this monitoring would be advocated in patients ≥60 years of age undergoing emergency surgery, or those undergoing elective surgery with a Revised Cardiac Risk Index class >2 (ie >1 risk factor). The number needed to screen to detect a patient with POMI would be 14 (95% CI 14–14) and 26% of patients with POMI would be missed. Conclusions To improve selection of high‐risk patients ≥60 years of age, routine postoperative troponin I monitoring could be considered in patients undergoing emergency surgery, or in patients undergoing elective surgery classified as having a revised cardiac risk index class >2.
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Affiliation(s)
- Corien S A Weersink
- Department of Anesthesiology University Medical Center Utrecht Utrecht The Netherlands
| | - Judith A R van Waes
- Department of Anesthesiology University Medical Center Utrecht Utrecht The Netherlands
| | - Remco B Grobben
- Department of Cardiology University Medical Center Utrecht Utrecht The Netherlands
| | - Hendrik M Nathoe
- Department of Cardiology University Medical Center Utrecht Utrecht The Netherlands
| | - Wilton A van Klei
- Department of Anesthesiology University Medical Center Utrecht Utrecht The Netherlands
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Marsman M, van Waes JAR, Grobben RB, Weersink CSA, van Klei WA. Added value of subjective assessed functional capacity before non-cardiac surgery in predicting postoperative myocardial injury. Eur J Prev Cardiol 2020; 28:262-269. [PMID: 33891688 DOI: 10.1177/2047487320906918] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 11/20/2019] [Accepted: 01/27/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Functional capacity is used as an indicator for cardiac testing before non-cardiac surgery and is often performed subjectively. However, the value of subjectively estimated functional capacity in predicting cardiac complications is under debate. We determined the predictive value of subjectively assessed functional capacity on postoperative cardiac complications and mortality. DESIGN An observational cohort study in patients aged 60 years and over undergoing elective inpatient non-cardiac surgery in a tertiary referral hospital. METHODS Subjective functional capacity was determined by anaesthesiologists. The primary outcome was postoperative myocardial injury. Secondary outcomes were postoperative inhospital myocardial infarction and one year mortality. Logistic regression analysis and area under the receiver operating curves were used to determine the added value of functional capacity. RESULTS A total of 4879 patients was included; 824 (17%) patients had a poor subjective functional capacity. Postoperative myocardial injury occurred in 718 patients (15%). Poor functional capacity was associated with myocardial injury (relative risk (RR) 1.7, 95% confidence interval (CI) 1.5-2.0; P < 0.001), postoperative myocardial infarction (RR 2.9, 95% CI 1.9-4.2; P < 0.001) and one year mortality (RR 1.7, 95% CI 1.4-2.0; P < 0.001). After adjustment for other predictors, functional capacity was still a significant predictor for myocardial injury (odds ratio (OR) 1.3, 95% CI 1.0-1.7; P = 0.023), postoperative myocardial infarction (OR 2.0, 95% CI 1.3-3.0; P = 0.002) and one year mortality (OR 1.4, 95% CI 1.1-1.8; P = 0.003), but had no added value on top of other predictors. CONCLUSIONS Subjectively assessed functional capacity is a predictor of postoperative myocardial injury and death, but had no added value on top of other preoperative predictors.
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Affiliation(s)
- Marije Marsman
- Department of Anesthesiology, Universitair Medisch Centrum Utrecht, The Netherlands
| | - Judith A R van Waes
- Department of Anesthesiology, Universitair Medisch Centrum Utrecht, The Netherlands
| | - Remco B Grobben
- Department of Cardiology, Universitair Medisch Centrum Utrecht, The Netherlands
| | - Corien S A Weersink
- Department of Anesthesiology, Universitair Medisch Centrum Utrecht, The Netherlands
| | - Wilton A van Klei
- Department of Anesthesiology, Universitair Medisch Centrum Utrecht, The Netherlands
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Meershoek AJA, Leunissen TC, van Waes JAR, Klei WA, Huisman A, de Groot MCH, Hoefer IE, van Solinge WW, Moll FL, de Borst GJ. Reticulated Platelets as Predictor of Myocardial Injury and 30 Day Mortality After Non-cardiac Surgery. Eur J Vasc Endovasc Surg 2019; 59:309-318. [PMID: 31812606 DOI: 10.1016/j.ejvs.2019.06.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 05/14/2018] [Revised: 04/09/2019] [Accepted: 06/22/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE A pre-operative marker for identification of patients at risk of peri-operative adverse events and 30 day mortality might be the percentage of young, reticulated platelets (pRP). This study aimed to determine the predictive value of pre-operative pRP on post-operative myocardial injury (PMI) and 30 day mortality, in patients aged ≥ 60 years undergoing moderate to high risk non-cardiac surgery. METHODS The incidence of PMI (troponin I > 0.06 μg/L) and 30 day mortality was compared for patients with normal and high pRP (≥2.82%) obtained from The Utrecht Patient Orientated Database. The predictive pRP value was assessed using logistic regression. A prediction model for PMI or 30 day mortality with known risk factors was compared with a model including increased pRP using the area under the receiving operator characteristics curve (AUROC). RESULTS In total, 26.5% (607/2289) patients showed pre-operative increased pRP. Increased pRP was associated with more PMI and 30 day mortality compared with normal pRP (36.1% vs. 28.3%, p < .001 and 8.6% vs. 3.6%, p < .001). The median pRP was higher in patients suffering PMI and 30 day mortality compared with not (2.21 [IQR: 1.57-3.11] vs. 2.07 [IQR: 1.52-1.78], p = .002, and 2.63 [IQR: 1.76-4.15] vs. 2.09 [IQR: 1.52-3.98], p < .001). pRP was independently related to PMI (OR: 1.28 [95% CI: 1.04-1.59], p = .02) and 30 day mortality (OR: 2.35 [95% CI: 1.56-3.55], p < .001). Adding increased pRP to the predictive model of PMI or 30 day mortality did not increase the AUROC 0.71 vs. 0.72, and 0.80 vs. 0.81. CONCLUSION In patients undergoing major non-cardiac surgery, increased pre-operative pRP is related to 30 day mortality and PMI.
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Affiliation(s)
- Armelle J A Meershoek
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Tesse C Leunissen
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands; Department of Clinical Chemistry and Haematology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Judith A R van Waes
- Department of Anaesthesiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Wilton A Klei
- Department of Anaesthesiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Albert Huisman
- Department of Clinical Chemistry and Haematology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Mark C H de Groot
- Department of Clinical Chemistry and Haematology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Imo E Hoefer
- Department of Clinical Chemistry and Haematology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Wouter W van Solinge
- Department of Clinical Chemistry and Haematology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Frans L Moll
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands.
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Grobben RB, van Waes JAR, Leiner T, Peelen LM, de Borst GJ, Vogely HC, Grobbee DE, Doevendans PA, van Klei WA, Nathoe HM. Unexpected Cardiac Computed Tomography Findings in Patients With Postoperative Myocardial Injury. Anesth Analg 2018; 126:1462-1468. [DOI: 10.1213/ane.0000000000002580] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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van Waes JAR, Grobben RB, Nathoe HM, Kemperman H, de Borst GJ, Peelen LM, van Klei WA. One-Year Mortality, Causes of Death, and Cardiac Interventions in Patients with Postoperative Myocardial Injury. Anesth Analg 2017; 123:29-37. [PMID: 27111647 DOI: 10.1213/ane.0000000000001313] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND To evaluate the role of routine troponin surveillance in patients undergoing major noncardiac surgery, unblinded screening with cardiac consultation per protocol was implemented at a tertiary care center. In this study, we evaluated 1-year mortality, causes of death, and consequences of cardiac consultation of this protocol. METHODS This observational cohort included 3224 patients ≥60 years old undergoing major noncardiac surgery. Troponin I was measured routinely on the first 3 postoperative days. Myocardial injury was defined as troponin I >0.06 μg/L. Regression analysis was used to determine the association between myocardial injury and 1-year mortality. The causes of death, the diagnoses of the cardiologists, and interventions were determined for different levels of troponin elevation. RESULTS Postoperative myocardial injury was detected in 715 patients (22%) and was associated with 1-year all-cause mortality (relative risk [RR] 1.4, P = 0.004; RR 1.6, P < 0.001; and RR 2.2, P < 0.001 for minor, moderate, and major troponin elevation, respectively). Cardiac death within 1 year occurred in 3%, 5%, and 11% of patients, respectively, in comparison with 3% of the patients without myocardial injury (P = 0.059). A cardiac consultation was obtained in 290 of the 715 patients (41%). In 119 (41%) of these patients, the myocardial injury was considered to be attributable to a predisposing cardiac condition, and in 111 patients (38%), an intervention was initiated. CONCLUSIONS Postoperative myocardial injury was associated with an increased risk of 1-year all-cause but not cardiac mortality. A cardiac consultation with intervention was performed in less than half of these patients. The small number of interventions may be explained by a low suspicion of a cardiac etiology in most patients and lack of consensus for standardized treatment in these patients.
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Affiliation(s)
- Judith A R van Waes
- From the *Department of Anesthesiology; †Department of Cardiology; ‡Department of Clinical Chemistry and Haematology; §Department of Surgery; and ‖Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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van Waes JAR, Peelen LM, Kemperman H, Grobben RB, Nathoe HM, van Klei WA. Kinetics of troponin I in patients with myocardial injury after noncardiac surgery. Clin Chem Lab Med 2017; 55:586-594. [PMID: 27732551 DOI: 10.1515/cclm-2016-0301] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 08/29/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Myocardial injury after noncardiac surgery, as measured by troponin elevation, is strongly associated with mortality. However, it is unknown in which patients prognosis can be improved. The presence of kinetic changes of troponin may be associated with a worse prognosis and warrant more aggressive management. Therefore, we aimed to study the kinetics of troponin in patients with postoperative myocardial injury, and to determine the added predictive value of kinetic changes of troponin on mortality. METHODS This cohort study included patients with myocardial injury after noncardiac surgery. Troponin I (TnI) was measured on the first three postoperative days. The primary outcome was all-cause 1-year mortality. We studied both absolute and relative TnI changes, and determined the delta TnI that was associated with mortality to distinguish a rise-and-fall TnI pattern from a stable TnI pattern. Next, we determined the added predictive value of a rise-and-fall TnI pattern for mortality. RESULTS In total, 634 patients were included. The risk ratio (RR) for mortality increased significantly with an absolute delta TnI of ≥200 ng/L (RR 1.5, 99.4% CI 1.0-2.2, p=0.003). Using this delta TnI to define a rise-and-fall pattern, 459 patients (72%) had a stable TnI pattern and 175 patients (28%) had a rise-and-fall pattern. When added to a model including the highest TnI value and variables from the revised cardiac risk index (RCRI), the TnI pattern did not increase the predictive value for mortality. CONCLUSIONS A postoperative TnI rise-and-fall pattern was associated with 1-year mortality, but had no added value in addition to the highest TnI level to predict 1-year mortality. Therefore, postoperative TnI kinetics are not useful for further mortality risk stratification in patients with myocardial injury after noncardiac surgery.
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van Klei WA, van Waes JAR, Pasma W, Kappen TH, van Wolfswinkel L, Peelen LM, Kalkman CJ. Relationship Between Preoperative Evaluation Blood Pressure and Preinduction Blood Pressure. Anesth Analg 2017; 124:431-437. [DOI: 10.1213/ane.0000000000001665] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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van Waes JAR, Nathoe HM, de Graaff JC, Kemperman H, de Borst GJ, Peelen LM, van Klei WA. Response to letter regarding article, "myocardial injury after noncardiac surgery and its association with short-term mortality". Circulation 2014; 129:e324. [PMID: 24493813 DOI: 10.1161/circulationaha.113.007269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Judith A R van Waes
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
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Grobben RB, van Waes JAR, van Klei WA, Nathoe HM. [Asymptomatic myocardial infarction after non-cardiac surgery; importance of routine testing of troponin concentration]. Ned Tijdschr Geneeskd 2013; 157:A5915. [PMID: 23676131] [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] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Perioperative myocardial infarction (PMI) is associated with a high mortality rate. Detection of PMI, however, is difficult due to a lack of typical anginal symptoms associated with the use of strong analgesics. Also, characteristic changes on the electrocardiogram may be minimal and/or transient. Recent studies have shown that postoperative troponin elevation is a strong, independent predictor of short- and intermediate-term mortality. In this article, we illustrate the importance of routine troponin measurements after major non-cardiac surgery with two patient cases. Moreover, we provide a brief overview of current evidence on perioperative myocardial infarction, and highlight current and future perspectives of troponin measurements.
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Affiliation(s)
- Remco B Grobben
- Universitair Medisch Centrum Utrecht, Afd. Cardiologie, Utrecht, the Netherlands.
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Kool NP, van Waes JAR, Bijker JB, Peelen LM, van Wolfswinkel L, de Graaff JC, van Klei WA. Artifacts in research data obtained from an anesthesia information and management system. Can J Anaesth 2012; 59:833-41. [PMID: 22806063 PMCID: PMC3425740 DOI: 10.1007/s12630-012-9754-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 06/21/2012] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Artifacts in anesthesia information management system (AIMS) databases may influence research results. Filtering during data capturing can prevent artifacts from being stored. In this prospective study, we assessed the reliability of AIMS data by determining the incidence of artifactual values stored in the AIMS. METHODS Vital parameter values regarding 86 surgical patients were collected in the AIMS both manually and automatically after filtering using the median value per minute. The percentage of artifactual values with a 95% confidence interval (CI) was calculated for each parameter. Secondary outcomes included the number of values that deviated from a predefined baseline, the percentage of these deviations that were caused by artifacts, the number of episodes across which these artifacts were distributed, and the most common causes of artifacts. RESULTS Altogether, 9,534 min of anesthesia time were recorded. The overall percentages of artifacts were: 0.0 for heart rate (95% CI: 0.0 to 0.1), 0.3 for oxygen saturation (95% CI: 0.2 to 0.4), 4.7 for ST-segment (95% CI: 4.3 to 5.2), 2.3 for noninvasive blood pressure values (95% CI: 1.8 to 2.9), and 14 for invasive blood pressure values (95% CI: 12 to 15). Artifacts as a percentage of deviations from baseline were: 1.6 for heart rate (95% CI: 0.4 to 5.7), 24 for saturation (95% CI: 18 to 32), 83 for ST-segment (95% CI: 76 to 87), 3.3 for noninvasive blood pressure values (95% CI: 2.5 to 87), and 27 for invasive blood pressure values (95% CI: 24 to 31). CONCLUSIONS Storing a median value per minute to filter capturing of vital parameter values in an AIMS database provides reliable data for heart rate and oxygen saturation and acceptable reliability for noninvasive blood pressure data. Knowledge about the method of artifact filtering is essential in studies using AIMS data.
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Affiliation(s)
- Nathalie P Kool
- Department of Anesthesiology, University Medical Center, Utrecht, The Netherlands.
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