Guidelines in review: 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines

The Effect of COVID-19 Infection on Clinical Outcomes in Patients Undergoing Surgical Repair of Humerus Fractures

Introduction Limited research exists on the association between coronavirus 2019 (COVID-19) infection and outcomes following surgical fixation for humerus fractures. The objective of this study was to evaluate the effects of COVID-19 on the clinical outcomes of patients undergoing humerus fracture surgery. Methods Approval to utilize insurance claim data from the Change Healthcare dataset was obtained from the Datavant COVID-19 Research Database. Patients older than 55 years old who underwent humerus fracture surgery from April 1, 2020, to March 1, 2022, were included in the analysis. COVID-19 status, comorbidities, and adverse events were identified using the International Classification of Diseases, 10th Revision (ICD-10) diagnostic codes. Propensity score matching with age, sex, and comorbidities was completed to create a 1:10 matched COVID-19-negative cohort. Univariate and multivariate logistic regressions were performed to assess the association of COVID-19 positivity with perioperative adverse events. Results A total of 18,365 patients underwent humerus fracture surgery in this study, of which 132 (0.72%) tested positive for COVID-19. Univariate analysis found that COVID-19-positive patients were at higher risk for myocardial infarction (5.30% vs. 1.74%, p = 0.015) and acute kidney injury (28.79% vs. 12.50%, p < 0.001) when compared to the 1:10 matched COVID-19-negative cohort. In addition, multivariate logistic regression found that COVID-19-positive patients had higher odds of experiencing any adverse event (2.57; 95% CI: 1.69-3.91; p < 0.001) or a minor adverse event (2.44; 95% CI: 1.57-3.79; p < 0.001). Conclusion COVID-19-positive patients have increased odds of experiencing adverse events after undergoing humerus fracture surgery in comparison to a matched COVID-19-negative control. Findings from this study stress the importance of using COVID-19 status as a factor in predicting outcomes following orthopedic surgery in this patient population.

Sarcopenic Obesity as a Risk Factor for Cardiovascular Disease: An Underrecognized Clinical Entity

Sarcopenic obesity (SO) is a chronic condition and an emerging health challenge, in view of the growing elderly population and the obesity epidemic. Due to a lack of awareness among treating doctors and the non-specific nauture of the associated symptoms, SO remains grossly underdiagnosed. There is no consensus yet on a standard definition or diagnostic criteria for SO, which limits the estimation of the global prevalence of this condition. It has been linked to numerous metabolic derangements, cardiovascular disease (CVD) and mortality. The treatment of SO is multimodal and requires expertise across multiple specialties. While dietary modifications and exercise regimens have shown a potential therapeutic benefit, there is currently no proven pharmacological management for SO. However, numerous drugs and the role of bariatric surgery are still under trial, and have great scope for further research. This article covers the available literature regarding the definition, diagnostic criteria, and prevalence of SO, with available evidence linking it to CVD, metabolic disease and mortality, and an overview of current directives on management.

Efficiency, Safety, Quality, and Empathy: Balancing Competing Perioperative Challenges in the Elderly

Although baby boomer generation accounts for a little more than 15% of the US population, the cohort represents a disproportionate percentage of patients undergoing surgery. As this group continues to age, a multitude of challenges have arisen in health care regarding the safest and most effective means of providing anesthesia services to these patients. Many elderly patients may be exquisitely sensitive to the effects of anesthesia and surgery and may experience cognitive and physical decline before, during, or after hospital admission. In this review article, the authors briefly examine the physiologic processes underlying aging and explore steps necessary to deliver safe, empathetic care.

Safety of Continuing Aspirin Use in Cervical Laminoplasty: A Propensity Score-Matched Analysis

Introduction

Aspirin is commonly used for the primary and secondary prevention of cardiovascular disease and stroke. Controversy exists concerning whether and when is the optimal time to stop aspirin before spinal surgery. Previous studies on this topic mainly focused on patients who received thoracolumbar spine surgeries. There are only a few literatures concerning the safety of aspirin use in cervical spine surgery patients.

Methods

This pilot study recruited patients who received cervical laminoplasty from January 2010 to December 2021. The operation time, intraoperative blood loss, and postoperative complications of the patients who had taken aspirin during the perioperative period were compared with age, sex, and comorbidity-matched control patients. Propensity score matching was utilized in the selection of control to minimize bias.

Results

Twenty-one patients who have received cervical laminoplasty while taking aspirin during the perioperative period were included. The control group included 21 age, sex, and comorbidity-matched patients who have not taken aspirin. The operation time and intraoperative and postoperative blood loss were higher in patients taking aspirin but were not statistically significant. There was no statistically significant difference in the wound infection rate. No case of epidural hematoma was found.

Conclusions

In patients undergoing cervical laminoplasty, a continuation of aspirin is safe and does not increase the difficulty of the surgery, wound complication, or hemorrhage.

Assessment and Correction of the Cardiac Complications Risk in Non-cardiac Operations – What's New?

Cardiovascular complications after non-cardiac surgery are the leading cause of 30-day mortality. The need for surgical interventions is approximately 5,000 procedures per 100,000 population, according to experts, the risks of non-cardiac surgical interventions are markedly higher in the elderly. It should be borne in mind that the aging of the population and the increased possibilities of medicine inevitably lead to an increase in surgical interventions in older people. Recent years have been characterized by the appearance of national and international guidelines with various algorithms for assessing and correcting cardiac risk, as well as publications on the validation of these algorithms. The purpose of this review was to provide new information about the assessment and correction of the risk of cardiac complications in non-cardiac operations. Despite the proposed new risk assessment scales, the RCRI scale remains the most commonly used, although for certain categories of patients (with oncopathology, in older age groups) the possibility of using specific questionnaires has been shown. In assessing the functional state, it is proposed to use not only a subjective assessment, but also the DASI questionnaire, 6-minute walking test and cardiopulmonary exercise test). At the next stage, it is proposed to evaluate biomarkers, primarily BNP or NT-proBNP, with a normal level – surgery, with an increased level – either an additional examination by a cardiologist or perioperative troponin screening. Currently, the prevailing opinion is that there is no need to examine patients to detect hidden lesions of the coronary arteries (non-invasive tests, coronary angiography), since this leads to excessive examination of patients, delaying the implementation of non-cardiac surgery. The extent to which this approach has an advantage over the previously used one remains to be studied.

Standardized Preoperative Pathways Determining Preoperative Echocardiogram Usage Continue to Improve Hip Fracture Quality

Introduction

The purpose of this study was to assess the hospital quality measures and outcomes of operative hip fracture patients before and after implementation of an anesthesiology department protocol assigning decision for a preoperative transthoracic echocardiogram (TTE) to the hospitalist co-managing physician.

Materials and Methods

Demographics, injury details, hospital quality measures, and outcomes were reviewed for a consecutive series of patients presenting to our institution with an operative hip fracture. In May of 2019, a new protocol assigning the responsibility to indicate a patient for preoperative TTE was mandated to the co-managing hospitalist at the institution. Patients were split into pre-protocol and post-protocol cohorts. Linear regression modeling and comparative analyses were conducted with a Bonferroni adjusted alpha as appropriate.

Results

Between September 2015 and June 2021, 1002 patients presented to our institution and were diagnosed with a hip fracture. Patients in the post-protocol cohort were less likely to undergo a preoperative echocardiogram, experienced a shorter time (days) to surgery, shorter length of stay, an increase in amount of home discharges, and lower complication risks for urinary tract infection and acute blood loss anemia as compared to those in the pre-protocol cohort. There were no differences seen in inpatient or 30-day mortality. Multivariable linear regression demonstrated a patient’s comorbidity profile (Charlson Comorbidity Index (CCI)) and their date of presentation (pre- or post-protocol), were both associated with (P<0.01) a patients' time to surgery.

Conclusion

A standardized preoperative work flow protocol regarding which physician evaluates and determines which patients require a preoperative TTE allows for a streamlined perioperative course for hip fracture patients. This allows for a shortened time to surgery and length of stay with an increase in home discharges and was associated with a reduced risk of common index hospitalization complications including UTI and anemia.

Direct Oral Anticoagulants for Venous Thromboembolism Prophylaxis Following Robot-assisted Radical Cystectomy: A Retrospective Feasibility Study at a Single Academic Medical Center

OBJECTIVES

To evaluate the use of direct oral anticoagulants following radical cystectomy for venous thromboembolism prophylaxis. We compared the experience of those who received venous thromboembolism prophylaxis following a robot-assisted radical cystectomy with either a direct oral anticoagulant or enoxaparin.

METHODS

Medical records of 66 patients who underwent robot-assisted radical cystectomy between July 2017 and May 2020 at a single academic institution were reviewed retrospectively. Patients received extended prophylaxis with either a direct oral anticoagulant or enoxaparin before or following surgical discharge. Venous thromboembolic events and complications resulting in emergency department visits and readmissions were reviewed over a 90-day postoperative period.

RESULTS

A total of 4 venous thromboembolic events within 90 days of surgery were observed. Among patients taking enoxaparin, 5% (2/37) developed a deep vein thrombosis and 3% (1/37) developed a pulmonary embolism. Among patients taking direct oral anticoagulants, 3% (1/29) developed a deep vein thrombosis. Zero patients in the enoxaparin group and 3% (1/29) of patients in the direct oral anticoagulant group experienced bleeding that required an emergency department visit.

CONCLUSION

Direct oral anticoagulants performed comparably to enoxaparin in this feasibility study following robot-assisted radical cystectomy in 66 patients. No significant differences in the number of venous thromboembolisms or bleeding complications were observed. These data encourage future studies and support the prospect of direct oral anticoagulants as a potentially suitable oral alternative to injectable low molecular weight heparins for venous thromboembolism prophylaxis following radical cystectomy.

Cardiac and Pulmonary Vascular Risk Stratification in Liver Transplantation

Cardiovascular disease complications are the leading cause of early (short-term) mortality among liver transplant recipients. The increasingly older candidate pool has multiple comorbidities necessitating cardiac and pulmonary vascular disease risk stratification of patients for optimal allocation of scarce donor livers. Arrhythmias, heart failure, stroke, and coronary artery disease are common pretransplant cardiovascular comorbidities and contribute to cardiovascular complications after liver transplant. Valvular heart disease and portopulmonary hypertension present intraoperative challenges during liver transplant surgery. The Cardiovascular Risk in Orthotopic Liver Transplantation score estimates the risk of cardiovascular complications in liver transplant candidates within the first year after transplant.

Guidelines in review: Comparison of the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes and the 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation

In this Guidelines in Review, we review side-by-side the recommendations provided by the 2014 AHA/ACC Guideline for the management of patients with non-ST-elevation acute coronary syndromes and the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. We review the recommendations for imaging in the evaluation of patients with possible ACS followed by the diagnostic evaluation of patients with proven NSTE-ACS, based on their risk for adverse clinical events.

Current Evidence about Nutrition Support in Cardiac Surgery Patients-What Do We Know?

Nutrition support is increasingly recognized as a clinically relevant aspect of the intensive care treatment of cardiac surgery patients. However, evidence from adequate large-scale studies evaluating its clinical significance for patients&rsquo; mid- to long-term outcome remains sparse. Considering nutrition support as a key component in the perioperative treatment of these critically ill patients led us to review and discuss our understanding of the metabolic response to the inflammatory burst induced by cardiac surgery. In addition, we discuss how to identify patients who may benefit from nutrition therapy, when to start nutritional interventions, present evidence about the use of enteral and parenteral nutrition and the potential role of pharmaconutrition in cardiac surgery patients. Although the clinical setting of cardiac surgery provides advantages due to its scheduled insult and predictable inflammatory response, researchers and clinicians face lack of evidence and several limitations in the clinical routine, which are critically considered and discussed in this paper.

Upregulation of microRNA-206 induces apoptosis of vascular smooth muscle cells and decreases risk of atherosclerosis through modulating FOXP1

Forkhead box protein subfamily P (FOXP) 1 has an important role in the control of gene transcription and is also reported to function as a tumor suppressor. The aim of the present study was to explore the regulatory mechanisms of atherosclerosis by investigating the function of microRNA-206 (miR-206) and the regulatory association between miR-206 and its potential target gene, FOXP1, in vascular smooth muscle cells (VSMCs). Bioinformatics tools were utilized to identify FOXP1 as a target of miR-206. Luciferase reporter analysis was used to confirm this relationship and to identify the miR-206 binding site in the FOXP1 3′-untranslated region. It was demonstrated that the relative survival rate of VSMCs was suppressed by miR-206 compared with scramble controls. Furthermore, reduced expression of miR-206 in atherosclerosis tissue samples was observed, and the mRNA and protein expression levels of FOXP1 were upregulated in atherosclerosis tissue samples, both compared with the controls, indicating a negative correlation between miR-206 and FOXP1. Additionally, when treated with miR-206 mimics, the relative survival rate of VSMCs was notably reduced, which was rescued by overexpression of FOXP1. These findings increased the understanding of the regulatory role of miR-206 in atherosclerosis in VSMCs via targeting the FOXP1 gene; therefore, intervention with miR-206 as a therapeutic technique may be a strategy for atherosclerosis treatment in the future.

Video-assisted thoracoscopic lobectomy after percutaneous coronary intervention in lung cancer patients with concomitant coronary heart disease

Background

In recent years, based on clinical observations, the number of lung cancer patients with concomitant coronary heart disease (CHD) has gradually increased. However, because of the requirement of long‐term anticoagulant therapy after percutaneous coronary intervention (PCI), some of these patients lose the opportunity for surgical treatment, resulting in tumor progression. The objective of this study was to determine the appropriate timing of video‐assisted thoracic surgery (VATS) lobectomy after PCI without increasing perioperative cardiovascular risk.

Methods

This study retrospectively analyzed clinical data of patients with a combination of NSCLC and CHD who underwent selective pulmonary lobectomy by VATS in the early postoperative PCI period between 2010 and 2015 at Beijing Chaoyang Hospital, China.

Results

Fourteen patients received VATS lobectomy after PCI. The disease had progressed to T stage in two patients after PCI. No perioperative death occurred. Two patients suffered postoperative atrial fibrillation: one had a pulmonary infection, and the other had acute coronary syndrome. All patients recovered and were discharged.

Conclusion

For NSCLC patients with severe CHD, the use of VATS lobectomy in the early postoperative PCI period could not only advance the timing of surgery, but may also control perioperative hemorrhage and CHD event risks within acceptable ranges, which could provide more patients with an opportunity to undergo surgical treatment.

Current status of nuclear cardiology in Japan: Ongoing efforts to improve clinical standards and to establish evidence

Nuclear cardiology imaging tests are widely performed in Japan as clinical practice. The Japanese nuclear cardiology community has developed new diagnostic imaging tests using (123)I-beta-methyl-p-iodophenyl-pentadecanoic acid, (123)I-metaiodobenzylguanidine, and (18)F-fluorodeoxyglucose PET for detecting cardiac involvement in sarcoidosis. These tests have become popular worldwide. The Japanese Circulation Society and the Japanese Society of Nuclear Cardiology have published clinical imaging guidelines showing indications and standards for the new imaging tests. JSNC is currently striving to improve the standard of clinical practice and is promoting research activities.