1
|
Horcicka A, Fischer L, Weigand MA, Larmann J. [Cardiac biomarkers prior to noncardiac surgery]. DIE ANAESTHESIOLOGIE 2024; 73:365-375. [PMID: 38829520 DOI: 10.1007/s00101-024-01417-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/18/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Cardiac biomarkers, such as high-sensitivity cardiac troponin (hs-cTn) and brain natriuretic peptide (BNP) or N‑terminal prohormone of brain natriuretic peptide (NT-proBNP) are measured perioperatively to improve the prognosis and risk prediction. The European Society of Cardiology (ESC), European Society of Anesthesiology and Intensive Care (ESAIC) and the German Society of Anesthesiology and Intensive Care Medicine (DGAI) have recently published guidelines on the use of cardiac biomarkers prior to surgery. OBJECTIVE/RESEARCH QUESTION This article provides an overview of the available evidence on perioperative troponin and BNP/NT-proBNP measurements. Current guideline recommendations are presented and discussed. MATERIAL AND METHODS MEDLINE, Cochrane and google.scholar were searched for relevant keywords. Titles and abstracts of identified papers were checked for relevance and published results were summarized. Guideline recommendations from the ESC, ESAIC and DGAI are presented, compared and evaluated based on the available literature. In addition, the significance of new perioperative cardiac biomarkers is discussed based on the existing evidence. RESULTS The definitions, diagnosis and management of cardiovascular events in the perioperative context differ from those in the nonsurgical setting. The evidence for the measurement of hs-cTn and BNP/NT-proBNP is evaluated differently in the guidelines and the resulting recommendations are partly contradictory. In particular, recommendations for changes in perioperative management based on biomarker measurements diverge. The ESC guidelines propose an algorithm that uses preoperative biomarkers as the basis for additional cardiac investigations. In particular, invasive coronary angiography is recommended for patients with stable chronic coronary syndrome who have no preoperative cardiac symptoms but elevated biomarkers. In contrast, the ESAIC guidelines emphasize that the available evidence is not sufficient to use perioperative biomarker measurements as a basis for a change in perioperative management. DISCUSSION Treating physicians should coordinate interdisciplinary (surgery, anesthesiology, cardiology) recommendations for clinical practice based on the aforementioned guidelines. If cardiac biomarkers are routinely determined in high-risk patients, this should be done in accordance with the ESC algorithm.
Collapse
Affiliation(s)
- Anna Horcicka
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Universität Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
| | - Lilli Fischer
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Universität Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
| | - Markus A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Universität Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
| | - Jan Larmann
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Universität Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland.
| |
Collapse
|
2
|
Wang B, Su Y, Ma C, Xu L, Mao Q, Cheng W, Lu Q, Zhang Y, Wang R, Lu Y, He J, Chen S, Chen L, Li T, Gao L. Impact of perioperative low-molecular-weight heparin therapy on clinical events of elderly patients with prior coronary stents implanted > 12 months undergoing non-cardiac surgery: a randomized, placebo-controlled trial. BMC Med 2024; 22:171. [PMID: 38649992 PMCID: PMC11036782 DOI: 10.1186/s12916-024-03391-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/15/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Little is known about the safety and efficacy of discontinuing antiplatelet therapy via LMWH bridging therapy in elderly patients with coronary stents implanted for > 12 months undergoing non-cardiac surgery. This randomized trial was designed to compare the clinical benefits and risks of antiplatelet drug discontinuation via LMWH bridging therapy. METHODS Patients were randomized 1:1 to receive subcutaneous injections of either dalteparin sodium or placebo. The primary efficacy endpoint was cardiac or cerebrovascular events. The primary safety endpoint was major bleeding. RESULTS Among 2476 randomized patients, the variables (sex, age, body mass index, comorbidities, medications, and procedural characteristics) and percutaneous coronary intervention information were not significantly different between the bridging and non-bridging groups. During the follow-up period, the rate of the combined endpoint in the bridging group was significantly lower than in the non-bridging group (5.79% vs. 8.42%, p = 0.012). The incidence of myocardial injury in the bridging group was significantly lower than in the non-bridging group (3.14% vs. 5.19%, p = 0.011). Deep vein thrombosis occurred more frequently in the non-bridging group (1.21% vs. 0.4%, p = 0.024), and there was a trend toward a higher rate of pulmonary embolism (0.32% vs. 0.08%, p = 0.177). There was no significant difference between the groups in the rates of acute myocardial infarction (0.81% vs. 1.38%), cardiac death (0.24% vs. 0.41%), stroke (0.16% vs. 0.24%), or major bleeding (1.22% vs. 1.45%). Multivariable analysis showed that LMWH bridging, creatinine clearance < 30 mL/min, preoperative hemoglobin < 10 g/dL, and diabetes mellitus were independent predictors of ischemic events. LMWH bridging and a preoperative platelet count of < 70 × 109/L were independent predictors of minor bleeding events. CONCLUSIONS This study showed the safety and efficacy of perioperative LMWH bridging therapy in elderly patients with coronary stents implanted > 12 months undergoing non-cardiac surgery. An alternative approach might be the use of bridging therapy with half-dose LMWH. TRIAL REGISTRATION ISRCTN65203415.
Collapse
Affiliation(s)
- Bin Wang
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yanhui Su
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Cong Ma
- Health Management Institute, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Lining Xu
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Qunxia Mao
- National Research Institute for Family Planning, Beijing, China
| | - Wenjia Cheng
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Qingming Lu
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Ying Zhang
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Rong Wang
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yan Lu
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Jing He
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Shihao Chen
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Lei Chen
- Department of Thoracic Surgery of The First Medical Center, General Hospital of Chinese People's Liberation Army, Beijing, 100853, China.
| | - Tianzhi Li
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China.
| | - Linggen Gao
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China.
| |
Collapse
|
3
|
Souza FD, Barbato KBG, Ferreira VBM, Gualandro DM, Caramelli B. Prognostic value of perioperative high sensitivity troponin in patients undergoing hip and knee arthroplasty. Clinics (Sao Paulo) 2024; 79:100342. [PMID: 38484585 PMCID: PMC10950797 DOI: 10.1016/j.clinsp.2024.100342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 10/25/2023] [Accepted: 02/08/2024] [Indexed: 03/23/2024] Open
Abstract
The authors conducted a prospective observational study to investigate the prognostic value of high-sensitivity Troponin I (hs-TnI) in the short- and long-term periods after orthopedic surgery, including Total Hip and Knee Arthroplasty (THA and TKA, respectively), in a tertiary orthopedic center in Brazil. Perioperative Myocardial Injury (PMI) was defined as an absolute increase in hs-TnI of ≥ 26 ng/L above preoperative values. The primary endpoint was all-cause mortality assessed at 30 days and 18 months after surgery. The secondary endpoint consisted of a composite outcome: cardiovascular death, acute myocardial infarction, angina requiring revascularization, and/or stroke. The authors compared Relative Risks (RR) of all-cause mortality and composite outcomes in patients with or without PMI at 30 days and 18 months. A Cox proportional hazards model for long-term outcomes was calculated and adjusted for age > 70 years, gender, and Revised Cardiac Risk Index (RCRI) class ≥ 2. PMI occurred in 3.4 % of all surgeries. At 30-days, 6.6 % of patients with PMI had died versus none without PMI. At 18 months, 20.0 % of PMI versus 4.7 % without PMI had died (RR = 5.0; 95 % Confidence Interval [95 % CI 1.3-19.3]). Based on composite outcomes in short and long-term periods, the RRs were 16.2 (95 % CI 2.7-96.5) and 7.7 (95 % CI 2.2-26.6), respectively. PMI was associated with all-cause mortality after 18 months and increased risk for a composite outcome (Hazard Ratio [HR = 3.97], 95 % CI 1.13-13.89 and HR = 5.80, 95 % CI 1.93-17.45, respectively). Patients with PMI who underwent THA or TKA presented worse short- and long-term prognoses compared to those without PMI.
Collapse
Affiliation(s)
- Fábio de Souza
- Department of Internal Medicine, Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad, Rio de Janeiro, RJ, Brazil; Cardiology Discipline, Departamento de Medicina Especializada (DEMESP), Escola de Medicina e Cirurgia, Universidade Federal do Estado do Rio de Janeiro (UNIRIO), Rio de Janeiro, RJ, Brazil
| | | | | | - Danielle Menosi Gualandro
- Cardiology Department and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Bruno Caramelli
- Interdisciplinary Medicine in Cardiology Unit, Cardiology Department, Instituto do Coração (InCor), Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP, Brazil.
| |
Collapse
|
4
|
Lurati Buse G, Bollen Pinto B, Abelha F, Abbott TEF, Ackland G, Afshari A, De Hert S, Fellahi JL, Giossi L, Kavsak P, Longrois D, M'Pembele R, Nucaro A, Popova E, Puelacher C, Richards T, Roth S, Sheka M, Szczeklik W, van Waes J, Walder B, Chew MS. ESAIC focused guideline for the use of cardiac biomarkers in perioperative risk evaluation. Eur J Anaesthesiol 2023; 40:888-927. [PMID: 37265332 DOI: 10.1097/eja.0000000000001865] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND In recent years, there has been increasing focus on the use of cardiac biomarkers in patients undergoing noncardiac surgery. AIMS The aim of this focused guideline was to provide updated guidance regarding the pre-, post- and combined pre-and postoperative use of cardiac troponin and B-type natriuretic peptides in adult patients undergoing noncardiac surgery. METHODS The guidelines were prepared using Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology. This included the definition of critical outcomes, a systematic literature search, appraisal of certainty of evidence, evaluation of biomarker measurement in terms of the balance of desirable and undesirable effects including clinical outcomes, resource use, health inequality, stakeholder acceptance, and implementation. The panel differentiated between three different scopes of applications: cardiac biomarkers as prognostic factors, as tools for risk prediction, and for biomarker-enhanced management strategies. RESULTS In a modified Delphi process, the task force defined 12 critical outcomes. The systematic literature search resulted in over 25,000 hits, of which 115 full-text articles formed the body of evidence for recommendations. The evidence appraisal indicated heterogeneity in the certainty of evidence across critical outcomes. Further, there was relevant gradient in the certainty of evidence across the three scopes of application. Recommendations were issued and if this was not possible due to limited evidence, clinical practice statements were produced. CONCLUSION The ESAIC focused guidelines provide guidance on the perioperative use of cardiac troponin and B-type natriuretic peptides in patients undergoing noncardiac surgery, for three different scopes of application.
Collapse
Affiliation(s)
- Giovanna Lurati Buse
- From the Department of Anaesthesiology, University Hospital Dusseldorf, Dusseldorf, Germany (GLB, RMP, AN, SR), Division of Anaesthesiology, Geneva University Hospitals (HUG), Geneva, Switzerland (BBP, MS, BW), Department of Anesthesiology, Centro Hospitalar Universitário de São João, Porto, Portugal (FA), Cardiovascular Research and Development Center (UnIC@RISE), Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal (FA), William Harvey Research Institute, Queen Mary University of London, London, UK (TEA, GA), Department of Anaesthesia and Perioperative Medicine, Royal London Hospital, Barts Health NHS Trust, London, UK (GA), Department of Paediatric and Obstetric Anaesthesia, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Denmark (AA), Department of Anaesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium (SDH), Service d'Anesthésie-Réanimation, Hôpital Universitaire Louis Pradel, Hospices Civils de Lyon, 59 boulevard Pinel, 69500 Lyon, France (J-LF), "Patients as Partners" program, Geneva University Hospitals (HUG), Geneva, Switzerland (LG), Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada (PK), Department of Anesthesiology and Intensive Care, Bichat Claude-Bernard Hospital, Assistance Publique-Hopitaux de Paris - Nord, University of Paris, INSERM U1148, Paris, France (DL), Institut d'Investigació Biomèdica Sant Pau (IIB SANT PAU), Barcelona, Spain (EP), Centro Cochrane Iberoamericano, Barcelona, Spain (EP), Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel-Stadt, Switzerland (CP), Department of Internal Medicine, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Basel-Stadt, Switzerland (CP), Division of Surgery, University of Western Australia, Perkins South Building, Fiona Stanley Hospital, Murdoch, Perth, WA, Australia (TR), Institute of Clinical Trials and Methodology and Division of Surgery, University College London, UK (TR), Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland (WS), Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (JvW), Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University Hospital, Sweden (MSC)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
5
|
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] [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.
Collapse
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
| |
Collapse
|
6
|
Yang L, Shi S, Li J, Fang Z, Guo J, Kang W, Shi J, Yuan S, Yan F, Zhou C. Postoperative elevated cardiac troponin levels predict all-cause mortality and major adverse cardiovascular events following noncardiac surgery: A dose-response meta-analysis of prospective studies. J Clin Anesth 2023; 90:111229. [PMID: 37573706 DOI: 10.1016/j.jclinane.2023.111229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/24/2023] [Accepted: 08/08/2023] [Indexed: 08/15/2023]
Abstract
STUDY OBJECTIVE To perform a dose-response meta-analysis for the association between postoperative myocardial injury (PMI) in noncardiac surgery and the risk of all-cause mortality or major adverse cardiovascular event (MACE). DESIGN Dose-response meta-analysis of prospective studies with weighted (WL) or generalized (GL) linear and restricted cubic spline (RCS) regression. SETTING Teaching hospitals. PATIENTS Adult patients undergoing noncardiac surgery. INTERVENTIONS No. MEASUREMENTS The primary outcome was all-cause mortality. The secondary outcome was MACE. MAIN RESULTS 29 studies (53,518 patients) were included. The overall incidence of PMI was 26.0% (95% CI 21.0% to 32.0%). Compared to those without PMI, patients with PMI had an increased risk of all-cause mortality at short- (<12 months) (cardiac troponin[cTn]I: unadj OR 1.71,95%CI 1.22 to 2.41, P < 0.001; cTnT: unadj OR 2.33,95%CI 2.07 to 2.63, P < 0.001), and long-term (≥ 12 months) (cTnI: unadj OR 1.80, 95%CI 1.63 to 1.99; cTnT: unadj OR 1.47,95%CI 1.33 to 1.62) (All P < 0.001) follow-up. For MACE, the group with elevated values was associated with an increased risk (cTnI: unadj OR 1.98, 95% CI 1.13 to 3.47, P = 0.018; cTnT: unadj OR 2.29, 95% CI 1.88 to 2.79, P < 0.001). Dose-response analysis showed positive associations between PMI (per 1× upper reference limit[URL] increment) and all-cause mortality both at short- (unadj OR) (WL, OR 1.09, 95% CI 1.09 to 1.10; GL, OR 1.06, 95% CI 1.06 to 1.07; RCS in the range of 1-2× URL, OR = 2.43, 95%CI 2.25 to 2.62) and long-term follow-up (unadj HR) (WL, OR 1.16, 95% CI 1.14 to 1.17; GL, OR 1.15, 95% CI 1.13 to 1.16; RCS in the range of 1-2.75× URL, OR = 1.23, 95%CI 1.13 to 1.33), and MACE at longest follow-up (unadj OR) (WL: OR 1.53, 95% CI 1.49 to 1.57; GL: OR 1.46, 95% CI 1.42 to 1.50; RCS in the range of 1-2 x URL, OR = 3.10, 95%CI 2.51 to 3.81) (All P < 0.001). For mild cTn increase below URL, the risk of mortality increased with every increment of 0.25xURL (WL, OR 1.03, 95% CI 1.02 to 1.03; GL, OR 1.05, 95% CI 1.03 to 1.07; RCS in the range of 0-0.5 URL, OR = 9.41, 95% CI 7.41 to 11.95) (All P < 0.001). CONCLUSIONS This study shows positive WL or GL and RCS dose-response relationships between PMI and all-cause mortality at short (< 12 mons)- and long-term (≥ 12 mons) follow-up, and MACE at longest follow-up. For mild cTn increase below URL, the risk of mortality also increases even with every increment of 0.25× URL.
Collapse
Affiliation(s)
- Lijing Yang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Sheng Shi
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Jun Li
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Zhongrong Fang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Jingfei Guo
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Wenying Kang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Jia Shi
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Su Yuan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Fuxia Yan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Chenghui Zhou
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China; Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China.
| |
Collapse
|
7
|
Glarner N, Puelacher C, Gualandro DM, Lurati Buse G, Hidvegi R, Bolliger D, Lampart A, Burri K, Pargger M, Gerhard H, Weder S, Maiorano S, Meister R, Tschan C, Osswald S, Steiner LA, Guerke L, Kappos EA, Clauss M, Filipovic M, Arenja N, Mueller C. Guideline adherence to statin therapy and association with short-term and long-term cardiac complications following noncardiac surgery: A cohort study. Eur J Anaesthesiol 2023; 40:854-864. [PMID: 37747427 DOI: 10.1097/eja.0000000000001903] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
BACKGROUND Peri-operative complications are common and associated with high morbidity and mortality. Optimising the use of statins might be of important benefit in peri-operative care and reduce morbidity and mortality. OBJECTIVE To evaluate adherence to current guideline recommendations regarding statin therapy and its association with peri-operative and long-term cardiac complications. DESIGN Prospective cohort study. SETTING Multicentre study with enrolment from October 2014 to February 2018. PATIENTS Eight thousand one hundred and sixteen high-risk inpatients undergoing major noncardiac surgery who were eligible for the institutional peri-operative myocardial injury/infarction (PMI) active surveillance and response program. MAIN OUTCOME MEASURES Class I indications for statin therapy were derived from the current ESC Clinical Practice Guidelines during the time of enrolment. PMI was prospectively defined as an absolute increase in cTn concentration of the 99th percentile in healthy individuals above the preoperative concentration within the first three postoperative days. Long-term cardiac complications included cardiovascular death and spontaneous myocardial infarction (MI) within 120 days. RESULTS The mean age was 73.7 years; 45.2% were women. Four thousand two hundred and twenty-seven of 8116 patients (52.1%) had a class I indication for statin therapy. Of these, 2440 of 4227 patients (57.7%) were on statins preoperatively. Adherence to statins was lower in women than in men (46.9 versus 63.9%, P < 0.001). PMI due to type 1 myocardial infarction/injury (T1MI; n = 42), or likely type 2 MI (lT2MI; n = 466) occurred in 508 of 4170 (12.2%) patients. The weighted odds ratio in patients on statin therapy was 1.15 [95% confidence interval (CI) 1.01 to 1.31, P = 0.036]. During the 120-day follow-up, 192 patients (4.6%) suffered cardiovascular death and spontaneous MI. After multivariable adjustment, preoperative use of statins was associated with reduced risk; weighted hazard ratio 0.59 (95% CI 0.41 to 0.86, P = 0.006). CONCLUSION Adherence to guideline-recommended statin therapy was suboptimal, particularly in women. Statin use was associated with an increased risk of PMI due to T1MI and lT2MI but reduced risk of cardiovascular death and spontaneous MI within 120 days. TRIAL REGISTRATION Clinicaltrials.gov identifier NCT02573532.
Collapse
Affiliation(s)
- Noemi Glarner
- From the Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland (NG, CP, DMG, KB, MP, HG, SW, SM, RM, CT, SO, NA, CM), GREAT Network (NG, CP, DMG, KB, MP, HG, SW, SM, RM, NA, CM), Department of Anaesthesiology, University Hospital Dusseldorf, Germany (GLB), Department of Anaesthesiology, Cantonal Hospital St. Gallen, Switzerland (RH, MF), Department of Anaesthesiology, University Hospital Basel, University of Basel, Switzerland (DB, AL, KB, LAS), Department of Clinical Research, University Hospital Basel, University of Basel, Switzerland (LAS), Department of Vascular Surgery, University Hospital Basel, University of Basel, Switzerland (LG), Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, University of Basel, Switzerland (EAK), Department of Orthopaedics and Trauma Surgery, University Hospital Basel, University of Basel, Switzerland (MC), Centre for Musculoskeletal Infections, University Hospital Basel, University of Basel, Switzerland (MC), Department of Cardiology, Cantonal Hospital Olten, Switzerland (NA)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Chang Y, Zhou M, Huang J, Wang Y, Shao J. Incidence and risk factors of postoperative acute myocardial injury in noncardiac patients: A systematic review and meta-analysis. PLoS One 2023; 18:e0286431. [PMID: 37319136 PMCID: PMC10270363 DOI: 10.1371/journal.pone.0286431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/16/2023] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION Postoperative myocardial injury after noncardiac surgery is common and is associated with short- and long-term morbidity and mortality. However, the incidence and risk factors for postoperative acute myocardial injury (POAMI) are currently unknown due to inconsistent definitions. METHODS We systematically searched PubMed and Web of Science to identify studies that applied the change value of preoperative and postoperative cardiac troponins to define cardiac injury. We estimated the pooled incidence, risk factors, and 30-day and long-term mortality of POAMI in noncardiac patients. The study protocol was registered with PROSPERO, CRD42023401607. RESULTS Ten cohorts containing 11,494 patients were included for analysis. The pooled incidence of POAMI was 20% (95% CI: 16% to 23%). Preoperative hypertension (OR: 1.47; 95% CI: 1.30 to 1.66), cardiac failure (OR: 2.63; 95% CI: 2.01 to 3.44), renal impairment (OR: 1.66; 95% CI: 1.48 to 1.86), diabetes (OR: 1.43; 95% CI: 1.27 to 1.61), and preoperative beta-blocker intake (OR: 1.65; 95% CI: 1.10 to 2.49) were the risk factors for POAMI. Age (mean difference: 2.08 years; 95% CI: -0.47 to 4.62), sex (male, OR: 1.16; 95% CI: 0.77 to 1.76), body mass index (mean difference: 0.35; 95% CI: -0.86 to 1.57), preoperative coronary artery disease (OR: 2.10; 95% CI: 0.85 to 5.21), stroke (OR: 0.90; 95% CI: 0.50 to 1.59) and preoperative statins intake (OR: 0.65; 95% CI: 0.21 to 2.02) were not associated with POAMI. Patients with POAMI had higher preoperative hsTnT levels (mean difference: 5.92 ng/L; 95% CI: 4.17 to 7.67) and lower preoperative hemoglobin levels (mean difference: -1.29 g/dL; 95% CI: -1.43 to -1.15) than patients without. CONCLUSION Based on this meta-analysis, approximately 1 in 5 of noncardiac patients develop POAMI. However, the lack of a universally recognized definition for POAMI, which incorporates diverse cardiac biomarkers and patient groups, poses a challenge in accurately characterizing its incidence, risk factors, and clinical outcomes.
Collapse
Affiliation(s)
- Yuan Chang
- Department of Anesthesiology, the First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Mengjiao Zhou
- Department of Anesthesiology, the First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jing Huang
- Department of Anesthesiology, the First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yanqiong Wang
- Department of Anesthesiology, the First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jianlin Shao
- Department of Anesthesiology, the First Affiliated Hospital of Kunming Medical University, Kunming, China
| |
Collapse
|
9
|
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] [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.
Collapse
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
| |
Collapse
|
10
|
Conen D, Popova E, Wang MK, Chan MTV, Landoni G, Reimer C, Srinathan SK, Cata JP, McLean SR, Trujillo Reyes JC, Grande AM, Gonzalez Tallada A, Sessler DI, Fleischmann E, Maziak DE, Kabon B, Voltolini L, Gutiérrez-Soriano L, Tandon V, DuMerton D, Kidane B, Rajaram R, Shargall Y, Neary JD, Wells JR, McIntyre WF, Blum S, Ofori SN, Vincent J, Xu L, Li Z, Healey JS, Garg AX, Devereaux PJ. Rationale and design of the colchicine for the prevention of perioperative atrial fibrillation in patients undergoing major noncardiac thoracic surgery (COP-AF) trial. Am Heart J 2023; 259:87-96. [PMID: 36754105 DOI: 10.1016/j.ahj.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/23/2023] [Accepted: 01/26/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Perioperative atrial fibrillation (AF) and myocardial injury after noncardiac surgery (MINS) are common complications after noncardiac surgery. Inflammation has been implicated in the pathogenesis of both disorders. The COP-AF trial tests the hypothesis that colchicine reduces the incidence of perioperative AF and MINS in patients undergoing major noncardiac thoracic surgery. METHODS AND RESULTS The 'COlchicine for the Prevention of Perioperative Atrial Fibrillation' (COP-AF) trial is an international, blinded, randomized trial that compares colchicine to placebo in patients aged at least 55 years and undergoing major noncardiac thoracic surgery with general anesthesia. Exclusion criteria include a history of AF and a contraindication to colchicine (eg, severe renal dysfunction). Oral colchicine at a dose of 0.5 mg or matching placebo is given within 4 hours before surgery. Thereafter, patients receive colchicine 0.5 mg or placebo twice daily for a total of 10 days. The 2 independent co-primary outcomes are clinically important perioperative AF (including atrial flutter) and MINS during 14 days of follow-up. The main safety outcomes are sepsis or infection and non-infectious diarrhea. We aim to enroll 3,200 patients from approximately 40 sites across 11 countries to have at least 80% power for the independent evaluation of the 2 co-primary outcomes. The COP-AF main results are expected in 2023. CONCLUSIONS COP-AF is a large randomized and blinded trial designed to determine whether colchicine reduces the risk of perioperative AF or MINS in patients who have major noncardiac thoracic surgery.
Collapse
Affiliation(s)
- David Conen
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
| | - Ekaterine Popova
- Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain; Iberoamerican Cochrane Centre, Barcelona, Spain
| | - Michael Ke Wang
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Matthew T V Chan
- The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Cara Reimer
- Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | | | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Sean R McLean
- Department of Anesthesia, Vancouver Acute (Vancouver General Hospital and UBC Hospital), The University of British Columbia, Vancouver, British Columbia, Canada; Department of Anesthesia, Pharmacology and Therapeutics, The University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Edith Fleischmann
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Barbara Kabon
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Luca Voltolini
- Thoracic Surgery Unit, Careggi University Hospital, Florence, Italy
| | - Laura Gutiérrez-Soriano
- Department of Anesthesiology, Fundación CardioInfantil - Instituto de Cardiología, Bogotá, Colombia
| | - Vikas Tandon
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Biniam Kidane
- Departments of Surgery, Physiology and Pathophysiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ravi Rajaram
- Department of Cardiothoracic Surgery, The University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Yaron Shargall
- Division of Thoracic Surgery, Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - John D Neary
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - William F McIntyre
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Steffen Blum
- Population Health Research Institute, Hamilton, Ontario, Canada; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Sandra N Ofori
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; University of Port Harcourt, Choba, Nigeria
| | - Jessica Vincent
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Lizhen Xu
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Zhuoru Li
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jeff S Healey
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Amit X Garg
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Departments of Medicine, Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - P J Devereaux
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
11
|
Gualandro DM, Puelacher C, Chew MS, Andersson H, Lurati Buse G, Glarner N, Mueller D, Cardozo FAM, Burri-Winkler K, Mork C, Wussler D, Shrestha S, Heidelberger I, Fält M, Hidvegi R, Bolliger D, Lampart A, Steiner LA, Schären S, Kindler C, Gürke L, Rikli D, Lardinois D, Osswald S, Buser A, Caramelli B, Mueller C. Acute heart failure after non-cardiac surgery: incidence, phenotypes, determinants and outcomes. Eur J Heart Fail 2023; 25:347-357. [PMID: 36644890 DOI: 10.1002/ejhf.2773] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 11/27/2022] [Accepted: 01/08/2023] [Indexed: 01/17/2023] Open
Abstract
AIMS Primary acute heart failure (AHF) is a common cause of hospitalization. AHF may also develop postoperatively (pAHF). The aim of this study was to assess the incidence, phenotypes, determinants and outcomes of pAHF following non-cardiac surgery. METHODS AND RESULTS A total of 9164 consecutive high-risk patients undergoing 11 262 non-cardiac inpatient surgeries were prospectively included. The incidence, phenotypes, determinants and outcome of pAHF, centrally adjudicated by independent cardiologists, were determined. The incidence of pAHF was 2.5% (95% confidence interval [CI] 2.2-2.8%); 51% of pAHF occurred in patients without known heart failure (de novo pAHF), and 49% in patients with chronic heart failure. Among patients with chronic heart failure, 10% developed pAHF, and among patients without a history of heart failure, 1.5% developed pAHF. Chronic heart failure, diabetes, urgent/emergent surgery, atrial fibrillation, cardiac troponin elevations above the 99th percentile, chronic obstructive pulmonary disease, anaemia, peripheral artery disease, coronary artery disease, and age, were independent predictors of pAHF in the logistic regression model. Patients with pAHF had significantly higher all-cause mortality (44% vs. 11%, p < 0.001) and AHF readmission (15% vs. 2%, p < 0.001) within 1 year than patients without pAHF. After Cox regression analysis, pAHF was an independent predictor of all-cause mortality (adjusted hazard ratio [aHR] 1.7 [95% CI 1.3-2.2]; p < 0.001) and AHF readmission (aHR 2.3 [95% CI 1.5-3.7]; p < 0.001). Findings were confirmed in an external validation cohort using a prospective multicentre cohort of 1250 patients (incidence of pAHF 2.4% [95% CI 1.6-3.3%]). CONCLUSIONS Postoperative AHF frequently developed following non-cardiac surgery, being de novo in half of cases, and associated with a very high mortality.
Collapse
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
| | - Michelle S Chew
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Henrik Andersson
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Giovanna Lurati Buse
- Department of Anesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Noemi Glarner
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Daria Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Francisco A M Cardozo
- Unidade de Medicina Interdisciplinar em Cardiologia, Instituto do Coração, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Katrin Burri-Winkler
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Constantin Mork
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Desiree Wussler
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Samyut Shrestha
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Isabelle Heidelberger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Mikael Fält
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Reka Hidvegi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Anesthesiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Daniel Bolliger
- Department of Anesthesiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Andreas Lampart
- Department of Anesthesiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Luzius A Steiner
- Department of Anesthesiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Stefan Schären
- Department of Spinal Surgery, University Hospital Basel, Basel, Switzerland
| | - Christoph Kindler
- Department of Anesthesiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Lorenz Gürke
- Department of Vascular Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Daniel Rikli
- Clinic for Orthopedics and Trauma Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Didier Lardinois
- Department of Thoracic Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Stefan Osswald
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Andreas Buser
- Department of Hematology and Blutspendezentrum, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Bruno Caramelli
- Unidade de Medicina Interdisciplinar em Cardiologia, Instituto do Coração, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| |
Collapse
|
12
|
Álvarez-Garcia J, Popova E, Vives-Borrás M, de Nadal M, Ordonez-Llanos J, Rivas-Lasarte M, Moustafa AH, Solé-González E, Paniagua-Iglesias P, Garcia-Moll X, Viladés-Medel D, Leta-Petracca R, Oristrell G, Zamora J, Ferreira-González I, Alonso-Coello P, Carreras-Costa F. Myocardial injury after major non-cardiac surgery evaluated with advanced cardiac imaging: a pilot study. BMC Cardiovasc Disord 2023; 23:78. [PMID: 36765313 PMCID: PMC9911951 DOI: 10.1186/s12872-023-03065-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 01/13/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Myocardial injury after non-cardiac surgery (MINS) is a frequent complication caused by cardiac and non-cardiac pathophysiological mechanisms, but often it is subclinical. MINS is associated with increased morbidity and mortality, justifying the need to its diagnose and the investigation of their causes for its potential prevention. METHODS Prospective, observational, pilot study, aiming to detect MINS, its relationship with silent coronary artery disease and its effect on future adverse outcomes in patients undergoing major non-cardiac surgery and without postoperative signs or symptoms of myocardial ischemia. MINS was defined by a high-sensitive cardiac troponin T (hs-cTnT) concentration > 14 ng/L at 48-72 h after surgery and exceeding by 50% the preoperative value; controls were the operated patients without MINS. Within 1-month after discharge, cardiac computed tomography angiography (CCTA) and magnetic resonance imaging (MRI) studies were performed in MINS and control subjects. Significant coronary artery disease (CAD) was defined by a CAD-RADS category ≥ 3. The primary outcomes were prevalence of CAD among MINS and controls and incidence of major cardiovascular events (MACE) at 1-year after surgery. Secondary outcomes were the incidence of individual MACE components and mortality. RESULTS We included 52 MINS and 12 controls. The small number of included patients could be attributed to the study design complexity and the dates of later follow-ups (amid COVID-19 waves). Significant CAD by CCTA was equally found in 20 MINS and controls (30% vs 33%, respectively). Ischemic patterns (n = 5) and ischemic segments (n = 2) depicted by cardiac MRI were only observed in patients with MINS. One-year MACE were also only observed in MINS patients (15.4%). CONCLUSION This study with advanced imaging methods found a similar CAD frequency in MINS and control patients, but that cardiac ischemic findings by MRI and worse prognosis were only observed in MINS patients. Our results, obtained in a pilot study, suggest the need of further, extended studies that screened systematically MINS and evaluated its relationship with cardiac ischemia and poor outcomes. Trial registration Clinicaltrials.gov identifier: NCT03438448 (19/02/2018).
Collapse
Affiliation(s)
- Jesús Álvarez-Garcia
- grid.411347.40000 0000 9248 5770Department of Cardiology, Hospital Universitario Ramon y Cajal, M-607, 9,100, 28034 Madrid, Spain ,grid.413396.a0000 0004 1768 8905Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Sant Quintí 89, 08026 Barcelona, Spain ,grid.512890.7Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Madrid, Spain
| | - Ekaterine Popova
- IIB SANT PAU, Institut d'Investigació Biomèdica Sant Pau, Sant Quintí 77, 08041, Barcelona, Spain. .,Centro Cochrane Iberoamericano, Sant Antoni Maria Claret, 167, 08025, Barcelona, Spain.
| | - Miquel Vives-Borrás
- grid.413396.a0000 0004 1768 8905Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Sant Quintí 89, 08026 Barcelona, Spain ,grid.507085.fFundació Institut d’Investigació Sanitària Illes Balears (IdISBa), Department of Cardiology, Carretera de Valldemossa, 79, 07120 Palma, Balearic Islands Spain ,grid.411164.70000 0004 1796 5984Department of Cardiology, Hospital Universitari Son Espases, Carretera de Valldemossa, 79, Palma, Illes Balears Spain
| | - Miriam de Nadal
- Department of Anaesthesiology and Intensive Care, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron, 119, 08035, Barcelona, Spain.
| | - Jordi Ordonez-Llanos
- grid.413396.a0000 0004 1768 8905Department of Biochemistry, Hospital de la Santa Creu i Sant Pau, Sant Quintí 89, 08026 Barcelona, Spain ,Foundation for Clinical Biochemistry & Molecular Pathology, Barcelona, Spain
| | - Mercedes Rivas-Lasarte
- grid.413396.a0000 0004 1768 8905Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Sant Quintí 89, 08026 Barcelona, Spain ,grid.73221.350000 0004 1767 8416Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, C. Joaquín Rodrigo, 1, 28222 Majadahonda, Madrid, Spain
| | - Abdel-Hakim Moustafa
- grid.413396.a0000 0004 1768 8905Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Sant Quintí 89, 08026 Barcelona, Spain
| | - Eduard Solé-González
- grid.413396.a0000 0004 1768 8905Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Sant Quintí 89, 08026 Barcelona, Spain ,grid.410458.c0000 0000 9635 9413Department of Cardiology, Hospital Clinic i Provincial, C. de Villarroel, 170, 08036 Barcelona, Spain
| | - Pilar Paniagua-Iglesias
- grid.413396.a0000 0004 1768 8905Department of Anaesthesia and Pain Management, Hospital de la Santa Creu i Sant Pau, Sant Quintí 89, 08026 Barcelona, Spain
| | - Xavier Garcia-Moll
- grid.413396.a0000 0004 1768 8905Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Sant Quintí 89, 08026 Barcelona, Spain
| | - David Viladés-Medel
- grid.413396.a0000 0004 1768 8905Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Sant Quintí 89, 08026 Barcelona, Spain
| | - Rubén Leta-Petracca
- grid.413396.a0000 0004 1768 8905Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Sant Quintí 89, 08026 Barcelona, Spain
| | - Gerard Oristrell
- grid.411083.f0000 0001 0675 8654Department of Cardiology, Hospital Universitari Vall d’Hebron, Passeig de la Vall d’Hebron, 119, 08035 Barcelona, Spain
| | - Javier Zamora
- grid.411347.40000 0000 9248 5770Clinical Biostatistics Unit, IRYCIS, Hospital Universitario Ramon y Cajal, M-607, 9,100, 28034 Madrid, Spain ,grid.466571.70000 0004 1756 6246CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Ignacio Ferreira-González
- grid.411083.f0000 0001 0675 8654Department of Cardiology, Hospital Universitari Vall d’Hebron, Passeig de la Vall d’Hebron, 119, 08035 Barcelona, Spain ,grid.466571.70000 0004 1756 6246CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Pablo Alonso-Coello
- IIB SANT PAU, Institut d’Investigació Biomèdica Sant Pau, Sant Quintí 77, 08041 Barcelona, Spain ,grid.466571.70000 0004 1756 6246CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Francesc Carreras-Costa
- grid.413396.a0000 0004 1768 8905Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Sant Quintí 89, 08026 Barcelona, Spain ,grid.512890.7Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Madrid, Spain
| |
Collapse
|
13
|
Kouz K, Bergholz A, Diener O, Leistenschneider M, Thompson C, Pichotka F, Trepte C, Schwedhelm E, Renné T, Krause L, Nicklas JY, Saugel B. Effect of intraoperative personalized goal-directed hemodynamic management on acute myocardial injury in high-risk patients having major abdominal surgery: a post-hoc secondary analysis of a randomized clinical trial. J Clin Monit Comput 2022; 36:1775-1783. [PMID: 35201549 PMCID: PMC9637594 DOI: 10.1007/s10877-022-00826-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 01/31/2022] [Indexed: 11/29/2022]
Abstract
Acute myocardial injury is common after noncardiac surgery and associated with mortality. Impaired intraoperative cardiovascular dynamics are a risk factor for acute myocardial injury. Optimizing intraoperative cardiovascular dynamics may thus reduce acute myocardial injury. We aimed to investigate the effect of intraoperative personalized goal-directed hemodynamic management on the incidence of acute myocardial injury. We hypothesized that personalized goal-directed hemodynamic management reduces the incidence of acute myocardial injury compared to routine hemodynamic management in high-risk patients having major abdominal surgery. We performed a post-hoc secondary analysis of a randomized clinical trial including 180 high-risk major abdominal surgery patients that were randomized to personalized goal-directed hemodynamic management or routine hemodynamic management. We compared the incidences of acute myocardial injury-defined according to the Fourth Universal Definition of Myocardial Infarction (2018)-between patients randomized to personalized goal-directed hemodynamic management or routine hemodynamic management by calculating the relative and absolute risk reduction together with 95% Wald confidence intervals and P values. Acute myocardial injury occurred in 4 of 90 patients (4%) in the personalized goal-directed hemodynamic management group and in 12 of 90 patients (13%) in the routine hemodynamic management group (relative risk: 0.33, 95% confidence interval: 0.11 to 0.99, P = 0.036; absolute risk reduction: - 9%, 95% confidence interval: - 17% to - 0.68%, P = 0.034). In this post-hoc secondary analysis, intraoperative personalized goal-directed hemodynamic management reduced the incidence of acute myocardial injury compared to routine hemodynamic management in high-risk patients having major abdominal surgery. This needs to be confirmed in larger prospective trials.
Collapse
Affiliation(s)
- Karim Kouz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Alina Bergholz
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Oliver Diener
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Maximilian Leistenschneider
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Christina Thompson
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Friederike Pichotka
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Constantin Trepte
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Edzard Schwedhelm
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Renné
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Center for Thrombosis and Hemostasis (CTH), Johannes Gutenberg University Medical Center, Mainz, Germany.,Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Linda Krause
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Y Nicklas
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany. .,Outcomes Research Consortium, Cleveland, OH, USA.
| |
Collapse
|
14
|
Diagnostic significance of highly sensitive troponins in cardiac surgery. КЛИНИЧЕСКАЯ ПРАКТИКА 2022. [DOI: 10.17816/clinpract111002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: The level of troponins after cardiac surgery always exceeds the reference values, however, the interpretation of these changes is difficult. Aim: To determine the relationship between the high-sensitivity cardiac troponin I and troponin T levels and the risk of heart failure (HF) development within 24 hours after the heart surgery. Methods: A prospective, observational, single-center study included 70 patients undergoing elective heart surgery. The patients were retrospectively divided into two groups based on the development of HF in the first 12 hours after the surgery. The group without HF included 57 patients, the group with HF included 13 patients. Results: The levels of highly sensitive Troponin I (HsTI) in patients who underwent elective heart surgery without complications were 61 times higher than the upper limit of the normal values, in those with the development of HF they were 111 times higher than the upper limit of the normal values. The levels of highly sensitive Troponin T (HsTT) were 25.5 times and 51 times the upper limit of the normal values, respectively. The level of HsTI at the end of the surgery can be a predictor of the HF development, regardless of the use of cardiac bypass (threshold value =1483 ng/l), as well as a predictor of the need for inotropic support for 2 days or more, regardless of the operation type (threshold value = 1573 ng/l). There was a direct moderate correlation of the HsTI level at the end of the operation and 6 hours after the operation with cumulative hemohydrobalance for 24 hours, which was 60% higher in patients with HF than that in patients without complications. Conclusion: In uncomplicated patients, the level of highly sensitive troponins T and I in the postoperative period is 2561 times higher than the upper limit of the normal values, and with the HF development it is 51111 times higher. Highly sensitive troponins can be considered as predictors of the HF development and the duration of inotropic support. The increase in the level of troponins is influenced by the duration of cardiac bypass and the volume of infusion therapy in the perioperative period.
Collapse
|
15
|
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: 247] [Impact Index Per Article: 123.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
|
16
|
Readmission Following Perioperative Myocardial Injury: Clinical Predictors and Impact on Mortality. Crit Care Res Pract 2022; 2022:7674962. [PMID: 35996536 PMCID: PMC9392591 DOI: 10.1155/2022/7674962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/08/2022] [Indexed: 11/17/2022] Open
Abstract
Background. Perioperative myocardial injury (PMI) following noncardiac surgery is associated with a high risk for mortality, and readmission within 30 days of PMI increases this risk. Identifying risk factors for readmission among survivors of PMI is critical to improving outcomes in PMI. We examined risk factors for readmission following discharge after surgery complicated by PMI and the effect of readmission on 1-year mortality. Methods. The study is a retropective cohort analysis of patients diagnosed with PMI in a single health system over a 10-year period. Univariate predictors of readmission were used to construct a multivariable logistic regression model. Mortality was assessed using Kaplan–Meyer survival analysis. Results. Of the 207,729 surgical patients, 5159 (2.5%) had PMI. By 30 days following PMI, 1254 patients (24.3%) died, 1142 (22.2%) were readmitted but alive at 30 days, and 2763 patients (53.5%) were alive and had not been readmitted. Readmitted patients were older, had higher peak troponin levels, and were more likely to have prior coronary, neoplastic, lung, and kidney disease. Multivariable logistic regression revealed increasing age and peak troponin, prior cancer diagnosis, and chronic lung and kidney disease as independent predictors of readmission. Readmitted patients had higher 1-year mortality than those not readmitted (33.9% vs. 22.2%,
). Conclusions. Readmission following PMI is associated with increased mortality in the following year. Patients suffering from PMI who are at risk of readmission are older, have a greater extent of myocardial injury, and are more likely to have chronic comorbidities. Identification of patients at risk of readmission following PMI is critical to improving both outcomes and utilization of hospital resources.
Collapse
|
17
|
Gao L, Chen L, He J, Wang B, Liu C, Wang R, Fan L, Cheng R. Perioperative Myocardial Injury/Infarction After Non-cardiac Surgery in Elderly Patients. Front Cardiovasc Med 2022; 9:910879. [PMID: 35665266 PMCID: PMC9160386 DOI: 10.3389/fcvm.2022.910879] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/28/2022] [Indexed: 12/15/2022] Open
Abstract
At present, we have entered an aging society. Many diseases suffered by the elderly, such as malignant tumors, cardiovascular diseases, fractures, surgical emergencies and so on, need surgical intervention. With the improvement of Geriatrics, surgical minimally invasive technology and anesthesia level, more and more elderly patients can safely undergo surgery. Elderly surgical patients are often complicated with a variety of chronic diseases, and the risk of postoperative myocardial injury/infarction (PMI) is high. PMI is considered to be the increase of cardiac troponin caused by perioperative ischemia, which mostly occurs during operation or within 30 days after operation, which can increase the risk of short-term and long-term death. Therefore, it is suggested to screen troponin in elderly patients during perioperative period, timely identify patients with postoperative myocardial injury and give appropriate treatment, so as to improve the prognosis. The pathophysiological mechanism of PMI is mainly due to the increase of myocardial oxygen consumption and / the decrease of myocardial oxygen supply. Preoperative and postoperative risk factors of myocardial injury can be induced by mismatch of preoperative and postoperative oxygen supply. The treatment strategy should first control the risk factors and use the drugs recommended in the guidelines for treatment. Application of cardiovascular drugs, such as antiplatelet β- Receptor blockers, statins and angiotensin converting enzyme inhibitors can effectively improve postoperative myocardial ischemia. However, the risk of perioperative bleeding should be fully considered before using antiplatelet and anticoagulant drugs. This review is intended to describe the epidemiology, diagnosis, pathophysiology, risk factors, prognosis and treatment of postoperative myocardial infarction /injury.
Collapse
Affiliation(s)
- Linggen Gao
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
| | - Lei Chen
- Department of Thoracic Surgery, General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Jing He
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
| | - Bin Wang
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
| | - Chaoyang Liu
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
| | - Rong Wang
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
| | - Li Fan
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
- *Correspondence: Li Fan
| | - Rui Cheng
- Department of Comprehensive Surgery, General Hospital of Chinese People's Liberation Army and National Clinical Research Center for Geriatric Disease, Beijing, China
- Rui Cheng
| |
Collapse
|