Long-term prognosis after peri-operative cardiac complications

N-terminal pro-brain natriuretic peptide is a prognostic marker for response to intensive chemotherapy, early death, and overall survival in acute myeloid leukemia

Patient-related factors are of prognostic importance in acute myeloid leukemia (AML). Likewise, cardiac disorders may limit the tolerance of intensive therapy. Little is known about the prognostic value of N-terminal pro-brain natriuretic peptide (NT-proBNP). We analyzed NT-proBNP levels at diagnosis in 312 AML patients (median age: 61 years; range 17-89 years) treated with 3 + 7-based induction-chemotherapy and consolidation with up to four cycles of intermediate or high-dose ARA-C. NT-proBNP levels were elevated in 199 patients (63.8%), normal (0-125 pg/ml) in 113 (36.2%), and highly elevated (>2000 pg/ml) in 20 patients (6.4%). Median NT-proBNP levels differed significantly among patients with complete remission (153.3 pg/ml), no remission (225.9 pg/ml), or early death (735.5 pg/ml) (p = .002). In multivariate analysis, NT-proBNP, age, and the 2009 European LeukemiaNet (ELN-2009) classification were independent predictors of outcome after induction chemotherapy. Overall survival (OS) differed significantly between patients with normal, moderately elevated, and highly elevated NT-proBNP (p < .001). These differences were observed in all patients and in patients <60 years but not in those ≥60 years. In multivariate analysis, NT-proBNP, age, and ELN-2009 remained independent prognostic variables for OS (p < .01). Together, NT-proBNP is an independent prognostic factor indicating the risk of induction failure, early death, and reduced OS in patients with AML.

Total hip arthroplasty for destructive septic arthritis of the hip using a two-stage protocol without spacer placement

INTRODUCTION

The optimal treatment of patients with a degenerative joint disease secondary to an active or chronic septic arthritis of the hip is unclear. The aim of the present study was to report on our experience with two-stage total hip arthroplasty (THA) using a contemporary treatment protocol without spacer insertion.

MATERIALS AND METHODS

Our prospective institutional database was used to identify all patients with degenerative septic arthritis treated with a non-spacer two-stage protocol between 2011 and 2017. Clinical outcomes included interim revision, periprosthetic infection (PJI) and aseptic revision rates. Restoration of leg-length and offset were assessed radiographically. Modified Harris hip score (mHHS) were obtained. Treatment success was defined using the modified Delphi consensus criteria. Mean follow-up was 62 months (13-110).

RESULTS

A total of 33 patients with a mean age of 60 years (13-85) were included. 55% of the cohort was male and average Charlson Comorbidity Index (CCI) was 3.7 (0-12). 21 patients (64%) had an active/acute infection and 12 patients (36%) were treated for chronic/quiescent septic arthritis. Overall, 11 patients (33%) had treatment failure, including 5 patients who failed to undergo THA, 2 interim re-debridement for persistent infection, and 4 patients who developed PJI after an average of 7 months (0.3-13) following THA. The most common identified pathogen was Staphylococcus aureus (42.4%). No aseptic revision was recorded following THA. Leg-length and offset were successfully restored. Mean mHHS improved from 35.2 points to 73.4 points.

CONCLUSION

Two-stage THA without spacer placement is a viable treatment option for destructive septic arthritis of the hip, demonstrating comparable rates of infection control and functional outcome. However, definitive resection arthroplasty is not uncommon in these often critically ill patients.

Elevated COVID19 mortality risk in detroit area hospitals among patients from census tracts with extreme socioeconomic vulnerability

BACKGROUND

the incidence of novel coronavirus disease (COVID19) is elevated in areas with heightened socioeconomic vulnerability. Early reports from US hospitals also implicated social disadvantage and chronic disease history as COVID19 mortality risk factors. However, the relationship between race and COVID19 mortality remains unclear.

METHODS

we examined in-hospital COVID19 mortality risk factors in a multi-hospital tertiary health care system that serves greater Detroit, Michigan, a predominantly African American city with high rates of poverty and chronic disease. Consecutive adult patients who presented to emergency departments and tested positive for COVID19 from 3/11/2020 through 4/18/2020 were included. Using log-binomial regression, we assessed the relationship between in-hospital mortality and residence in census tracts that were flagged for extreme socioeconomic vulnerability, patient-level demographics, and clinical comorbidities.

FINDINGS

a total of 1,015 adults tested positive for COVID19 during the study period; 80% identified as Black people, 52% were male and 53% were ≥ 65 years of age. The median body mass index was 30•4 and the median Charlson Comorbidity Index score was 4. Patients from census tracts that were flagged for vulnerability related to socioeconomic status had a higher mortality rate than their peers who resided in less vulnerable census tracts (β 0.26, standard error (SE) 0.11, degrees of freedom (df) 378, t-value (t) 2.27, exp(β) 1.29, p-value 0.02). Adjustment for age category, Black race, sex and/or the Charlson Comorbidity Index score category reduced the magnitude of association by less than 10% [exp(β) 1.29 vs. 1.21]. Black race [p = 0.38] and sex [p = 0.62] were not associated with mortality in this sample.

INTERPRETATION

people who lived in areas flagged for extreme socioeconomic vulnerability had elevated mortality risk in our predominantly African-American cohort of COVID19 patients who were able to seek hospital care during the so-called 'first wave' of the pandemic. By contrast, Black race was not associated with mortality in our sample.

The impact of coronavirus disease 2019 (COVID-19) response on central-line-associated bloodstream infections and blood culture contamination rates at a tertiary-care center in the Greater Detroit area

We conducted a comparative retrospective study to quantify the impact of coronavirus disease 2019 (COVID-19) on patient safety. We found a statistically significant increase in central-line–associated bloodstream infections and blood culture contamination rates during the pandemic. Increased length of stay and mortality were also observed during the COVID-19 pandemic.

Improving Identification of Patients at Low Risk for Major Cardiac Events After Noncardiac Surgery Using Intraoperative Data

BACKGROUND/OBJECTIVE

Risk-stratification tools for cardiac complications after noncardiac surgery based on preoperative risk factors are used to inform postoperative management. However, there is limited evidence on whether risk stratification can be improved by incorporating data collected intraoperatively, particularly for low-risk patients.

METHODS

We conducted a retrospective cohort study of adults who underwent noncardiac surgery between 2014 and 2018 at four hospitals in the United States. Logistic regression with elastic net selection was used to classify in-hospital major adverse cardiovascular events (MACE) using preoperative and intraoperative data ("perioperative model"). We compared model performance to standard risk stratification tools and professional society guidelines that do not use intraoperative data.

RESULTS

Of 72,909 patients, 558 (0.77%) experienced MACE. Those with MACE were older and less likely to be female. The perioperative model demonstrated an area under the receiver operating characteristic curve (AUC) of 0.88 (95% CI, 0.85-0.92). This was higher than the Lee Revised Cardiac Risk Index (RCRI) AUC of 0.79 (95% CI, 0.74-0.84; P < .001 for AUC comparison). There were more MACE complications in the top decile (n = 1,465) of the perioperative model's predicted risk compared with that of the RCRI model (n = 58 vs 43). Additionally, the perioperative model identified 2,341 of 7,597 (31%) patients as low risk who did not experience MACE but were recommended to receive postoperative biomarker testing by a risk factor-based guideline algorithm.

CONCLUSIONS

Addition of intraoperative data to preoperative data improved prediction of cardiovascular complication outcomes after noncardiac surgery and could potentially help reduce unnecessary postoperative testing.

Drugs That May Cause or Exacerbate Heart Failure: A Scientific Statement From the American Heart Association

Heart failure is a common, costly, and debilitating syndrome that is associated with a highly complex drug regimen, a large number of comorbidities, and a large and often disparate number of healthcare providers. All of these factors conspire to increase the risk of heart failure exacerbation by direct myocardial toxicity, drug-drug interactions, or both. This scientific statement is designed to serve as a comprehensive and accessible source of drugs that may cause or exacerbate heart failure to assist healthcare providers in improving the quality of care for these patients.

Long-term effects of the multidisciplinary risk assessment and management program for patients with diabetes mellitus (RAMP-DM): a population-based cohort study

BACKGROUND

Studies on the long-term effectiveness of multidisciplinary risk-stratification based management in Chinese population were rare. This study aimed to evaluate the effectiveness of a multidisciplinary risk assessment and management program for patients with diabetes mellitus (RAMP-DM) in reducing the risks of cardiovascular complications and all-cause mortality.

METHODS

A prospective cohort study was conducted in 18,188 propensity score matched RAMP-DM participants and subjects with diabetes under usual primary care (9,094 subjects in each group). The study endpoints were the first occurrence of coronary heart disease (CHD), stroke, heart failure (HF), total cardiovascular disease (CVD) and all-cause mortality. We constructed multivariable Cox proportional hazard regressions to estimate the association between the RAMP-DM intervention and the first occurrence of study endpoints.

RESULTS

The median follow-up period was 36 months. Three hundred and ninety-nine CVD events occurred in the RAMP-DM group, as compared with 608 in the control group [adjusted hazard ratio, 0.629; 95% confidence interval (CI) 0.554-0.715; P < 0.001]. The total number of all-cause deaths in RAMP-DM group was less than half that of control group (202 vs 552, adjusted hazard ratio, 0.363; 95% CI, 0.308-0.428; P < 0.001). The adjusted hazard ratios of the RAMP-DM group for CHD, stroke, and HF were 0.570 (95% CI, 0.470-0.691; P < 0.001), 0.652 (95% CI, 0.546-0.780; P < 0.001), and 0.598 (95%CI, 0.446-0.802; P = 0.001), respectively.

CONCLUSIONS

The RAMP-DM intervention was associated with lower incidences of individual and total cardiovascular complications, as well as all-cause mortality over 3 years follow-up. The encouraging results provided evidence to support that the structured risk-stratification management leading by a multidisciplinary clinical team was an effective approach to reduce future cardiovascular complications in people with diabetes.

CLINICAL TRIAL REGISTRY

NCT02034695, http://www.ClinicalTrials.gov.

A prospective Phase 2a pilot study investigating focal percutaneous irreversible electroporation (IRE) ablation by NanoKnife in patients with localised renal cell carcinoma (RCC) with delayed interval tumour resection (IRENE trial)

INTRODUCTION

Focal ablation therapy is playing an increasing role in oncology and may reduce the toxicity of current surgical treatments while achieving adequate oncological benefit. Irreversible electroporation (IRE) has been proposed to be tissue-selective with potential advantages compared with current thermal-ablation technologies or radiotherapy. The aim of this pilot trial is to determine the effectiveness and feasibility of focal percutaneous IRE in patients with localised renal cell cancer as a uro-oncological tumour model.

METHODS

Prospective, monocentric Phase 2a pilot study following current recommendations, including those of the International Working Group on Image-Guided Tumor Ablation. Twenty patients with kidney tumour (T1aN0M0) will be recruited. This sample permits an appropriate evaluation of the feasibility and effectiveness of image-guided percutaneous IRE ablation of locally confined kidney tumours as well as functional outcomes. Percutaneous biopsy for histopathology will be performed before IRE, with magnetic-resonance imaging one day before and 2, 7, 27 and 112 days after IRE; at 28 days after IRE the tumour region will be completely resected and analysed by ultra-thin-layer histology.

DISCUSSION

The IRENE study will investigate over a short-term observation period (by magnetic-resonance imaging, post-resection histology and assessment of technical feasibility) whether focal IRE, as a new ablation procedure for soft tissue, is feasible as a percutaneous, tissue-sparing method for complete ablation and cure of localised kidney tumours. Results from the kidney-tumour model can provide guidance for designing an effectiveness and feasibility trial to assess this new ablative technology, particularly in uro-oncology.

Resident participation in laparoscopic hysterectomy: impact of trainee involvement on operative times and surgical outcomes

OBJECTIVE

The purpose of this study was to determine the impact of resident involvement on morbidity after total laparoscopic hysterectomy for benign disease.

STUDY DESIGN

We performed a retrospective review of a National Surgical Quality Improvement Program database of total laparoscopic hysterectomy for benign disease that was performed with resident involvement vs attending alone between Jan. 1, 2008, and Dec. 31, 2011. Surgical operative times and morbidity and mortality rates were compared. Binary logistic regression was used to control for covariates that were significant on univariate analysis (P < .05).

RESULTS

A total of 3441 patients were identified as having undergone a total laparoscopic hysterectomy for benign disease. The mean age of patients was 47.4 ± 11.1 years; the mean body mass index was 30.6 ± 7.9 kg/m(2). A resident participated in 1591 of cases (46.2%); 1850 of the procedures (53.8%) were done by an attending physician alone. Cases with resident involvement had higher mean age, Charlson morbidity scoring, and American Society of Anesthesiologists classification and were more likely to be inpatient cases. With resident involvement, the mean operative time was increased (179.29 vs 135.46 minutes; P < .0001). There were no differences in the rates of experiencing at least 1 complication (6.8% for resident involvement vs 5.4% for attending alone; P = .5), composite severe morbidity (1.3% resident vs 1.0% attending alone), or 30-day mortality rate (0% resident vs 0.1% attending alone). Additionally, there were no differences between groups in the infectious, wound, neurorenal, thromboembolic, septic, and cardiopulmonary complications. Cases with resident involvement had significantly increased rates of postoperative transfusion of packed red blood cells (2% vs 0.4%; P < .0001), reoperation (2.2% vs 1.3%; P = .048), and a 30-day readmission (5.5% vs 2.9%; P = .015). In models that were adjusted for factors that differed between the 2 groups, cases with resident involvement had increased odds of receiving postoperative blood transfusion (odds ratio [OR], 4.98; 95% confidence interval [CI], 2.18-11.33), reoperation (OR, 1.7, 95% CI, 1.01-2.89) and readmission (OR, 1.93, 95% CI, 1.09-3.42).

CONCLUSION

Resident involvement in total laparoscopic hysterectomy for benign disease was associated with clinically appreciable longer surgical time and small differences in the rates of postoperative transfusions, reoperation, and readmission. However, the rates of overall complications, severe complications, and 30-day mortality rate remain comparable.

The role of FDG-PET/CT imaging in early detection of extra-cardiac complications of infective endocarditis

The exact incidence of extra-cardiac complications (ECC) in patients with infective endocarditis (IE) is unknown but presumed to be high. These patients, although mostly asymptomatic, may require a more aggressive therapeutic approach. (18)fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) is used for the diagnosis of infections, but its role in the early diagnosis of IE complications is still unclear. This study aimed to evaluate the role of FDG-PET/CT in the early diagnosis of ECC in IE and its implications for medical management. We prospectively studied 40 consecutive patients with a confirmed diagnosis of IE (according to the modified Duke criteria) who underwent a whole body FDG-PET/CT study within 14 days from diagnosis. The FDG-PET/CT demonstrated ECC in 17 (42.5%) patients, while 8 (38.1%) of them were asymptomatic. The most frequent embolic sites were musculoskeletal and splenic. Owing to the FDG-PET/CT findings, treatment planning was modified in 14 (35%) patients. This included antibiotic treatment prolongation (27.5%), referral to surgical procedures (15%) and, most substantially, prevention of unnecessary device extraction (17.7%). According to our experiences, FDG-PET/CT imaging was useful in the detection of embolic and metastatic infections in IE. This clinical information had a significant diagnostic and therapeutic impact in managing IE disease.

Economic trends from 2003 to 2010 for perioperative myocardial infarction: a retrospective, cohort study

BACKGROUND

Perioperative myocardial infarction (PMI) is a major surgical complication that is costly and causes much morbidity and mortality. Diagnosis and treatment of PMIs have evolved over time. Many treatments are expensive but may reduce ancillary expenses including the duration of hospital stay. The time-dependent economic impact of novel treatments for PMI remains unexplored. The authors thus evaluated absolute and incremental costs of PMI over time and discharge patterns.

METHODS

Approximately 31 million inpatient discharges were analyzed between 2003 and 2010 from the California State Inpatient Database. PMI was defined using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Propensity matching generated 21,637 pairs of comparable patients. Quantile regression modeled incremental charges as the response variable and year of discharge as the main predictor. Time trends of incremental charges adjusted to 2012 dollars, mortality, and discharge destination was evaluated.

RESULTS

Median incremental charges decreased annually by $1,940 (95% CI, $620 to $3,250); P < 0.001. Compared with non-PMI patients, the median length of stay of patients who experienced PMI decreased significantly over time: yearly decrease was 0.16 (0.10 to 0.23) days; P < 0.001. No mortality differences were seen; but over time, PMI patients were increasingly likely to be transferred to another facility.

CONCLUSIONS

Reduced incremental cost and unchanged mortality may reflect improving efficiency in the standard management of PMI. An increasing fraction of discharges to skilled nursing facilities seems likely a result from hospitals striving to reduce readmissions. It remains unclear whether this trend represents a transfer of cost and risk or improves patient care.

The impact of first- and second-eye cataract surgery on injurious falls that require hospitalisation: a whole-population study

BACKGROUND

cataract is a leading cause of reversible vision impairment and may increase falls in older adults.

OBJECTIVE

to assess the risk of an injury due to a fall among adults aged 60+, 2 years before first-eye cataract surgery, between first-eye surgery and second-eye surgery and 2 years after second-eye surgery.

DESIGN

a retrospective cohort study.

SETTING

Western Australian Hospital Morbidity Data System and the Western Australian Death Registry.

SUBJECTS

there were 28,396 individuals aged 60+ years who underwent bilateral cataract surgery in Western Australia between 2001 and 2008.

METHODS

Poisson regression analysis based on generalised estimating equations compared the frequency of falls 2 years before first-eye cataract surgery, between first- and second-eye surgery and 2 years after second-eye cataract surgery after accounting for potential confounders.

RESULTS

the risk of an injurious fall that required hospitalisation doubled (risk ratio: 2.14, 95% confidence interval: 1.82 to 2.51) between first- and second-eye cataract surgery compared with the 2 years before first-eye surgery. There was a 34% increase in the number of injurious falls that required hospitalisation in the 2 years after second-eye cataract surgery compared with the 2 years before first-eye surgery (risk ratio: 1.34, 95% confidence interval: 1.16-1.55).

CONCLUSIONS

there was an increased risk of injurious falls after first- and second-eye cataract surgery which has implications for the timely provision of second-eye surgery as well as appropriate refractive management between surgeries.

The impact of first eye cataract surgery on mental health contacts for depression and/or anxiety: a population-based study using linked data

PURPOSE

Cataract is the leading cause of reversible blindness worldwide, and the incidence of cataract surgery is projected to increase as the population ages. Gaining an understanding of the effects of cataract surgery on a range of health outcomes is important for maintaining the health and safety of older adults.

METHODS

A before and after cohort study was conducted using the Western Australian Hospital Morbidity Data System, Mental Health Information System and the Western Australian Death Registry.

RESULTS

Of the 21 110 patients who underwent cataract surgery in one eye only, 295 had mental health contacts for depression and/or anxiety 1 year before (n = 158) or 1 year after (n = 137) surgery. Results from Poisson generalized estimating equations showed a significant decrease of 18.80% (p ≤ 0.001) in the number of mental health contacts for depression and/or anxiety the year after cataract surgery after accounting for potential confounding factors. A 27.46% increase in mental health contacts the year after cataract surgery was reported by women compared with men (95% CI: 1.08-1.50). Those living in remote areas had less contact with mental health services compared with those living in metropolitan areas (adjusted risk ratio 0.62, 95% CI: 0.46-0.84). The corresponding reduction in health care costs for treatment of depression and/or anxiety was 28%.

CONCLUSION

Further research should be conducted to collect information on the utilization of health care resources not captured in this study, namely community-based services, visits to general practitioners and/or emergency departments as well as medication usage such as antidepressants.

First eye cataract surgery and hospitalization from injuries due to a fall: a population-based study

OBJECTIVES

To assess the association between first eye cataract surgery and hospitalization from injuries due to a fall in older adults at the population level.

DESIGN

Retrospective population-based study.

SETTING

Western Australian Hospital Morbidity Data System and Western Australian mortality data.

PARTICIPANTS

Six hundred individuals aged 60 and older hospitalized from injuries due to a fall between 2004 and 2008 in Western Australia.

MEASUREMENTS

Hospital admission from injuries due to a fall.

RESULTS

Of the 15,295 individuals who underwent cataract surgery in one eye only, 600 (3.9%) were involved in 625 hospital admissions from injuries due to a fall 1 year before (n = 273) or 1 year after (n = 352) first eye cataract surgery; 30% of these hospitalizations were for femoral neck fractures. Poisson generalized estimating equations confirmed 27% more (adjusted risk ratio = 1.27, 95% confidence interval = 1.04-1.56 P = .02) hospitalizations from injuries due to a fall in the year after first eye cataract surgery than in the year before.

CONCLUSION

First eye cataract surgery was associated with more hospital admissions from injuries due to a fall in the year after cataract surgery than in the year before. Further research is needed to determine the underlying causes and reasons.

Adrenomedullin attenuates aortic cross-clamping-induced myocardial injury in rats

BACKGROUND

In this study we investigate the effects of adrenomedullin on myocardial injury after ischemia-reperfusion (I/R) after abdominal aortic surgery.

METHODS

Thirty-two Wistar rats were randomized into 4 groups (n = 8) as follows: control group (sham laparotomy), the aortic I/R group, aortic I/R plus adrenomedullin group (underwent aortic I/R periods, and received a bolus intravenous injection of .05 μg/kg/min adrenomedullin), and the control plus adrenomedullin group.

RESULTS

Biochemical analysis showed that aortic I/R significantly increased (P < .05) the plasma levels of troponin-I and tumor necrosis factor-α, and the myocardial tissue levels of malondialdehyde, superoxide dismutase, catalase, and angiotensin II, whereas aortic I/R plus adrenomedullin significantly decreased these same factors (P < .05). Aortic I/R significantly increased (P < .05) myocardial tissue levels of nitric oxide whereas aortic I/R plus adrenomedullin significantly increased the same factor (P < .05).

CONCLUSIONS

These results indicate that adrenomedullin has protective effects against myocardial injury induced by abdominal aortic I/R in rats.

Pulmonary imaging of pandemic influenza H1N1 infection: relationship between clinical presentation and disease burden on chest radiography and CT

The potential for pulmonary involvement among patients presenting with novel swine-origin influenza A (H1N1) is high. To investigate the utility of chest imaging in this setting, we correlated clinical presentation with chest radiographic and CT findings in patients with proven H1N1 cases. Subjects included all patients presenting with laboratory-confirmed H1N1 between 1 May and 10 September 2009 to one of three urban hospitals. Clinical information was gathered retrospectively, including symptoms, possible risk factors, treatment and hospital survival. Imaging studies were re-read for study purposes, and CXR findings compared with CT scans when available. During the study period, 157 patients presented with subsequently proven H1N1 infection. Hospital admission was necessary for 94 (60%) patients, 16 (10%) were admitted to intensive care and 6 (4%) died. An initial CXR, carried out for 123 (78%) patients, was abnormal in only 40 (33%) cases. Factors associated with increased likelihood for radiographic lung abnormalities were dyspnoea (p<0.001), hypoxaemia (p<0.001) and diabetes mellitus (p = 0.023). Chest CT was performed in 21 patients, and 19 (90%) showed consolidation, ground-glass opacity, nodules or a combination of these findings. 4 of 21 patients had negative CXR and positive CT. Compared with CT, plain CXR was less sensitive in detecting H1N1 pulmonary disease among immunocompromised hosts than in other patients (p = 0.0072). A normal CXR is common among patients presenting to the hospital for H1N1-related symptoms without evidence of respiratory difficulties. The CXR may significantly underestimate lung involvement in the setting of immunosuppression.

Cardiac screening before noncardiac surgery

Cardiovascular complications are infrequent but can result in significant morbidity following noncardiac surgery, especially in patients with peripheral vascular disease or increased age. All patients require some level of preoperative screening to identify and minimize immediate and future risk, with a careful focus on known coronary artery disease or risks for coronary artery disease and functional capacity. The 2007 American College of Cardiology/American Heart Association Guidelines are clear that noninvasive and invasive testing should be limited to circumstances in which results will clearly affect patient management or in which testing would otherwise be indicated. beta-Blocker therapy has become controversial in light of recent publications but should be continued in patients already on therapy, and started in patients with high cardiac risk undergoing intermediate- or high-risk surgery.

Novel uses for statins in surgical patients

BACKGROUND

Aside from their cholesterol-lowering effects statins are known to have a range of other 'pleiotropic' effects. We present an overview of the basic science behind these effects and then review clinical trials and the current role of statins relevant to modern surgical practice.

METHODS

A systematic review of the literature was performed using the keywords surgery and the MeSH term for statins. All clinical studies relating to statin use in surgical patients were evaluated. An overview of the literature on statin use and cardiac outcomes was performed.

CONCLUSIONS

Statins are safe and have a wide range of pleiotropic effects relevant to surgical practice. Strongest evidence for their clinical use comes in primary cardiac risk reduction in many types of vascular surgery. There is a large body of evidence showing their benefit perioperatively in high-risk vascular and cardiac surgery but the picture is less clear for low-risk patients. Further studies are needed to evaluate exact dosage regimes and timing of administration. Novel uses of their anti-inflammatory properties in sepsis and vasomotor properties in subarachnoid haemorrhage are being further investigated by randomised trials.

A comparative study of myocardial injury during conventional and endovascular aortic aneurysm repair: measurement of cardiac troponin T and plasma cytokine release

BACKGROUND

Major aortic surgery results in significant haemodynamic and oxidative stress to the myocardium. Cytokine release is a major factor in causing cardiac injury during aortic surgery. Endovascular aortic aneurysm repair (EVAR) has the potential to reduce the severity of the ischaemia reperfusion syndrome and its systemic consequences.

AIM

The aim of this study was to investigate the occurrence of myocardial injury during conventional and endovascular abdominal aortic aneurysm repair using measurement of the myocardial-specific protein, cardiac troponin T. Interleukin-6 was also measured in both groups and haemodynamic responses to surgery assessed.

METHODS

Nine consecutive patients undergoing conventional infra-renal aortic aneurysm surgery were compared with 13 patients who underwent EVAR. Patients were allocated on the basis of aneurysm morphology and suitability for endovascular repair.

RESULTS

Patients undergoing open repair had significantly more haemodynamic disturbance than those having endovascular repair (mean arterial pressure at 5 min following unclamping or balloon deflation: open (69.6 + 3.3 mmHg); endovascular (86 + 4.4 mmHg), P < 0.05 vs. pre-op). Troponin T levels at 48 h post-operatively were higher in patients who underwent open repair (open 0.164 + 0.1 ng/ml; endovascular 0.008 + 0.0005 ng/ml, P < 0.04). Significantly more patients in the open repair group had troponin T levels > 0.1 ng/l when compared with the endovascular group (P < 0.01, chi (2) test)

CONCLUSION

Endovascular aortic surgery produces significantly less myocardial injury than the open technique of aortic aneurysm repair.

Statins for surgical patients

OBJECTIVE

To evaluate perioperative statin treatment, to explore the rapidly increasing body of literature on the pleiotropic effects of statins, and to suggest a rational strategy of perioperative risk reduction.

SUMMARY OF BACKGROUND DATA

Vascular, cerebrovascular, and cardiovascular complications are all too common in surgery. Although treatment with beta-blockers is a well-established strategy for perioperative cardiac risk reduction, prophylaxis with statins enjoys a firm pathophysiologic basis.

METHODS

A PubMed search for studies evaluating outcomes of statin treatment in surgical series was accomplished by evaluating all articles found with the keyword "surgery" and the MeSH term for statins "hydroxymethylglutaryl-CoA reductase inhibitors." Studies where no outcome was relatable to statin treatment were excluded as were studies dealing primarily with transplant surgery. An overview of the medical literature on statin use and cardiac outcome was also performed. Basic science investigations elucidating the mechanisms and effects of statins that may reduce perioperative risk were included.

RESULTS

The pharmacology and pleiotropic effects of statins are delineated. Multiple beneficial outcomes are elucidated and explored. Statins prescribed in the perioperative period appear beneficial though only one clinical trial is available from which to make clinical recommendations.

CONCLUSION

Evidence supports a rebound effect. Statin treatment should be instituted and must not be discontinued in surgical patients. Current literature suggests that statins are protective in the preoperative period.

A peri-operative statin update for non-cardiac surgery. Part II: Statin therapy for vascular surgery and peri-operative statin trial design

This is the second of two review articles evaluating peri-operative statin therapy. In surgical patients, the utility of peri-operative statin therapy is strongly suggested by retrospective studies, although it is probably overestimated, as important confounding factors have not been controlled for and hence the literature is considered to be currently inconclusive. This review examines the potential mechanisms and indications for peri-operative statin protection, the efficacy of acute peri-operative beta-blockade in addition to statin therapy, the effect of peri-operative statin therapy withdrawal and the implications of comorbidities associated with peri-operative cardiovascular risk on statin therapy. Recommendations concerning appropriate dosing, duration, therapeutic targets and necessary investigations when prescribing peri-operative statins are made. Peri-operative study design recommendations are suggested, so that future meta-analyses may be more informative. Recommendations are made regarding retrospective reporting of statin studies to minimise the bias inherent in a number of the current retrospective studies on this subject.

A single health status question had important prognostic value among outpatients with chronic heart failure

OBJECTIVE

Health status is an important marker of the impact of disease on function among patients with chronic heart failure (CHF). However, the prognostic value of CHF-specific health status on long-term mortality has not been adequately evaluated. Our objective was to assess CHF-specific health status and 5-year mortality among outpatients with CHF.

STUDY DESIGN AND SETTING

We analyzed data from 494 Veterans Affairs outpatients with diagnoses of CHF and objective evidence of left ventricular dysfunction who enrolled in a quality improvement intervention. We extracted information about comorbid diagnoses, severity of illness (Charlson index), health care utilization, drug therapy, laboratory, and vital sign data along with generic and CHF-specific health status. We then identified multivariate correlates of subsequent mortality at 5 years.

RESULTS

Five-year mortality was 44%. Age (chi2=26.1, hazard ratio [HR]=1.63, confidence interval [CI]: 1.35, 1.97; P<0.0001) and Charlson index (chi2=12.9, HR=1.39, CI: 1.16, 1.67; P=0.0003) were significantly associated with 5-year mortality. Controlling for clinical, lab, medication, and administrative data, a single-item assessing change in CHF-specific health status was independently associated with 5-year mortality (chi2=11.4, HR=0.87, CI: 0.80, 0.94, P=0.0007).

CONCLUSIONS

Given the strength of the association with mortality, health care providers should routinely assess this single-item change in health status among outpatients with CHF to identify higher risk patients and guide therapy.

Hemoconcentration and pancreatic necrosis: further defining the relationship

OBJECTIVES

In the setting of acute pancreatitis, an admission hematocrit greater than or equal to 44% and/or a failure of hematocrit to drop at 24 hours have been reported as useful markers to predict subsequent necrosis. We aimed to validate the use of hemoconcentration as a marker to predict necrosis in adult patients presenting with acute pancreatitis.

METHODS

Patients admitted to our medical center from 1990 to 2003 with a first presentation of acute pancreatitis were identified. Charts were abstracted for baseline demographic and clinical information, including admission and 24-hour hematocrit, and subsequent hospital course. Necrosis was determined based on computed tomography scan. We calculated the sensitivity, specificity, positive and negative predictive values (NPV) for different admissions, and 24-hour hematocrit levels in predicting the subsequent development of necrosis.

RESULTS

Two hundred thirty patients were identified. Admission hematocrit (> or = 44%) was a poor predictor of subsequent necrosis with a sensitivity of 52.9%. The absence of hemoconcentration at admission or a drop in 24-hour hematocrit level was reliable in predicting that patients would not develop necrosis (NPV of 94.7% for hematocrit > or = 44%). Results were similar when we compared a range of admission and 24-hour hematocrit values.

CONCLUSIONS

In a community setting with low rates of necrosis, admission and 24-hour hematocrit levels were not helpful in predicting subsequent necrosis. The absence of admission hemoconcentration had strong NPV for necrosis. However, the actual clinical utility of this test to direct clinical decision making may be limited.

Clinical outcomes with unfractionated heparin or low-molecular-weight heparin as bridging therapy in patients on long-term oral anticoagulants: the REGIMEN registry

BACKGROUND

Patients who receive long-term oral anticoagulant (OAC) therapy often require interruption of OAC for an elective surgical or an invasive procedure. Heparin bridging therapy has been used in these situations, although the optimal method has not been established. No large prospective studies have compared unfractionated heparin (UFH) with low-molecular-weight heparin (LMWH) for the perioperative management of patients at risk of thromboembolism requiring temporary interruption of long-term OAC therapy.

PATIENTS/METHODS

This multicenter, observational, prospective registry conducted in North America enrolled 901 eligible patients on long-term OAC who required heparin bridging therapy for an elective surgical or invasive procedure. Practice patterns and clinical outcomes were compared between patients who received either UFH alone (n = 180) or LMWH alone (n = 721).

RESULTS

Overall, the majority of patients (74.5%) requiring heparin bridging therapy had arterial indications for OAC. LMWH, in mostly twice-daily treatment doses, represented approximately 80% of the study population. LMWH-bridged patients had significantly fewer arterial indications for OAC, a lower mean Charlson comorbidity score, and were less likely to undergo major or cardiothoracic surgery, receive intraprocedural anticoagulants or thrombolytics, or receive general anesthesia than UFH-bridged patients (all P < 0.05). The LMWH group had significantly more bridging therapy completed in an outpatient setting or with a < 24-h hospital stay vs. the UFH group (63.6% vs. 6.1%, P < 0.001). In the LMWH and UFH groups, similar rates of overall adverse events (16.2% vs. 17.1%, respectively, P = 0.81), major composite adverse events (arterial/venous thromboembolism, major bleed, and death; 4.2% vs. 7.9%, respectively, P = 0.07) and major bleeds (3.3% vs. 5.5%, respectively, P = 0.25) were observed. The thromboembolic event rates were 2.4% for UFH and 0.9% for LMWH. Logistic regression analysis revealed that for postoperative heparin use a Charlson comorbidity score > 1 was an independent predictor of a major bleed and that vascular, general, and major surgery were associated with non-significant trends towards an increased risk of major bleed.

CONCLUSIONS

Treatment-dose LMWH, mostly in the outpatient setting, is used substantially more often than UFH as bridging therapy in patients with predominately arterial indications for OAC. Overall adverse events, including thromboembolism and bleeding, are similar for patients treated with LMWH or UFH. Postoperative heparin bridging should be used with caution in patients with multiple comorbidities and those undergoing vascular, general, and major surgery. These findings need to be confirmed using large randomized trials for specific patient groups undergoing specific procedures.

Defining the high-risk patient for carotid endarterectomy: An analysis of the prospective National Surgical Quality Improvement Program database

BACKGROUND

Carotid endarterectomy (CEA) is the gold standard for the treatment of carotid stenosis, but carotid angioplasty and stenting has been advocated in high-risk patients. The definition of such a population has been elusive, particularly because the data are largely retrospective. Our study examined results for CEA in the National Surgical Quality Improvement Program database (both Veterans Affairs and private sector).

METHODS

National Surgical Quality Improvement Program data were gathered prospectively for all patients undergoing primary isolated CEA during the interval 2000 to 2003 at 123 Veterans Affairs and 14 private sector academic medical centers. Study end points included the 30-day occurrence of any stroke, death, or cardiac event. A variety of clinical, demographic, and operative variables were assessed with multivariate models to identify risk factors associated with the composite (stroke, death, or cardiac event) end point. Adjudication of end points was by trained nurse reviewers (previously validated).

RESULTS

A total of 13,622 CEAs were performed during the study period; 95% were on male patients, and 91% of cases were conducted within the Veterans Affairs sector. The average age was 68.6 +/- 0.1 years, and 42.1% of the population had no prior neurologic event. The composite stroke, death, or cardiac event rate was 4.0%; the stroke/death rate was 3.4%. Multivariate correlates of the composite outcome were (odds ratio, P value) as follows: deciles of age (1.13, .018), insulin-requiring diabetes (1.73, <.001), oral agent-controlled diabetes (1.39, .003), decade of pack-years smoking (1.04, >.001), history of transient ischemic attack (1.41, >.001), history of stroke (1.51, >.001), creatinine >1.5 mg/dL (1.48, >.001), hypoalbuminemia (1.49, >.001), and fourth quartile of operative time (1.44, >.001). Cardiopulmonary comorbid features did not affect the composite outcome in this model. Regional anesthesia was used in 2437 (18%) cases, with a resultant relative risk reduction for stroke (17%), death (24%), cardiac event (33%), and the composite outcome (31%; odds ratio, 0.69; P = .008).

CONCLUSIONS

Carotid endarterectomy results across a spectrum of Veterans Affairs and private sector hospitals compare favorably to contemporary studies. These data will assist in selecting patients who are at an increased risk for adverse outcomes. Use of regional anesthetic significantly reduced perioperative complications in a risk-adjusted model, thus suggesting that it is the anesthetic of choice when CEA is performed in high-risk patients.

The pharmacoeconomics of peri-operative beta-blocker therapy

It is widely recommended that beta-blockade be used peri-operatively as it may reduce the incidence of postoperative cardiovascular complications including death. However, there are few data concerning the cost-effectiveness of such strategies. We have analysed the pharmacoeconomics of acute beta-blockade using data from eight prospective peri-operative studies in which patients underwent elective non-cardiac surgery, and in which the incidence of adverse side-effects of treatment, as well as clinical outcomes, have been reported. The costs of treatment were based on the NHS reference costs for 2004. From these data, the number-needed-to-treat (NNT) to prevent a major cardiovascular complication (including cardiovascular death) in high-risk patients was 18.5. This is comparable to the NNT for peri-operative statin therapy. The incremental cost of peri-operative beta-blockade (costs of drug acquisition and of treating associated adverse drug events) was 67.80 pounds sterling per patient. This results in a total cost of 1254.30 pounds sterling per peri-operative cardiovascular complication prevented. However, there is evidence that in patients at lower cardiovascular risk, beta-blockers may be potentially harmful, since their adverse effects (hypotension, bradycardia) may outweigh their potential cardioprotective effects.

The pharmaco-economics of peri-operative statin therapy

We analysed the pharmaco-economics of the prospective peri-operative studies of statin administration for major elective vascular surgery, using the NHS reference costs for 2004. This analysis suggests that peri-operative statin therapy for patients undergoing vascular surgery may present the most cost-effective use of statin therapy yet described, with a number-needed-to-treat of 15 and almost 60% of the total cost of atorvastatin therapy recovered through a reduction in peri-operative adverse events.

Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk

This is the first of 2 articles evaluating cardiac events in patients undergoing noncardiac surgery. In this article, we review the magnitude of the problem, the pathophysiology of these events, approaches to risk assessment and communication of risk. The number of patients undergoing noncardiac surgery worldwide is growing, and annually 500,000 to 900,000 of these patients experience perioperative cardiac death, nonfatal myocardial infarction (MI) or nonfatal cardiac arrest. Although the evidence is limited, a substantial proportion of fatal perioperative MIs may not share the same pathophysiology as nonoperative MIs. A clearer understanding of the pathophysiology is needed to direct future research evaluating prophylactic, acute and long-term interventions. Researchers have developed tools to facilitate the estimation of perioperative cardiac risk. Studies suggest that the Lee index is the most accurate generic perioperative cardiac risk index. The limitations of the studies evaluating the ability of noninvasive cardiac tests to predict perioperative cardiac risk reveals considerable uncertainty as to the role of these popular tests. Similarly, there is uncertainty as to the predictive accuracy of the American College of Cardiology/American Heart Association algorithm for cardiac risk assessment. Patients are likely to benefit from improved estimation and communication of cardiac risk because the majority of noncardiac surgeries are elective and accurate risk estimation is important to allow informed patient and physician decision-making.

The assessment of patient life-expectancy: how accurate are urologists and oncologists?

OBJECTIVE

To assess the degree of accuracy, precision and consistency with which consultant urologists, oncologists and junior doctors predict a patient's 10-year life-expectancy.

SUBJECTS AND METHODS

Eighteen doctors of varying seniority independently examined 70 patient case scenarios containing detailed medical histories; 13 of these cases were duplicate scenarios. Bland-Altman analyses were used to compare doctors' estimates of the probability of each hypothetical patient surviving 10 years with that calculated using actuarial methods. Intra- and interdoctor reliability were also assessed.

RESULTS

Compared with actuarial estimates, doctors underestimated the 10-year survival probability by an overall mean of 10.8% (95% confidence interval, 10.1-11.5%). The 18 individual doctors ranged from a mean underestimation of 33.2% to a mean overestimation of 3.9%. Variation around these means was considerable for each doctor, the standard deviations being 14.5-20.9%. Inter-doctor reliability was 0.58, while overall intra-doctor reliability was 0.74, but for individual doctors was 0.31-0.94. Junior doctors were less accurate in their predictions than the senior doctors. Five doctors tended to overestimate where life-expectancy was poor and underestimate where it was good.

CONCLUSIONS

Doctors were poor at predicting 10-year survival, tending to underestimate when compared with actuarial estimates. There was also substantial variability both within and between doctors. The inaccuracy, imprecision and inconsistency amongst the doctors in assessing patient life-expectancy is an important finding and has significant implications for managing patients. Many patients may be denied treatment after a pessimistic assessment of life-expectancy and (less commonly) some may inappropriately be offered treatment after an optimistic assessment. The particular inaccuracy in junior doctors compared with their senior colleagues also highlights the need for training. The development of a tool to assist in both training and clinical practice has the potential to improve doctors' decision-making and patient care.

Estimates of future physical functioning by seriously ill hospitalized patients, their families, and their physicians

OBJECTIVES

To compare prognostic estimates made by seriously ill hospitalized patients, their surrogates, and their physicians about the patients' activities of daily living (ADLs) 2 months after admission; compare the accuracy of their estimates; and identify factors associated with the optimism and accuracy of these estimates.

DESIGN

Prospective cohort study.

SETTING

Five teaching hospitals.

PARTICIPANTS

A subset (n = 716) of patients in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment.

MEASUREMENTS

Prognostic estimates of ADL function.

RESULTS

Physicians were less likely than patients or surrogates to give very high or very low estimates for future functioning. Seven of ten (69.3) patients who survived 2 months estimated that they would be functionally independent at Month 2, compared with 58.5 of their surrogates and 49.2 of their physicians. Agreement on prognosis was highest between patients and surrogates (64.2) and lowest between patients and physicians (48.4). Factors significantly associated with an optimistic estimate of independent functioning were better baseline ADL function, male gender, and higher level of education. Patients were significantly more accurate than surrogates and even more so than physicians in predicting independent functioning at Month 2. Worse baseline function and higher income were significantly associated with accurate estimation.

CONCLUSION

At hospital admission, seriously ill patients were more optimistic about their prognosis for physical functioning at 2 months, and more accurate in their estimates, than surrogates and physicians. Physicians tended to underestimate the prognosis for future functioning. Physicians should consider patients' and families' estimates before giving advice about treatment options and discharge planning.

Comparison of cardiac troponin I and creatine kinase ratios in the detection of myocardial injury after aortic surgery

BACKGROUND

Perioperative myocardial infarction may not be diagnosed correctly because World Health Organization criteria are often not met and creatinine kinase myocardial fraction (creatinine kinase/creatinine kinase MB isoenzyme; CK/CK-MB) ratios can be difficult to interpret. Cardiac troponin (cTn) I and cTnT are the most sensitive and specific markers of myocardial cell necrosis currently available but are not widely used in surgical practice. The aim was to compare cTnI and CK/CK-MB ratios in the detection of myocardial injury following aortic surgery.

METHODS

This was a prospective study of 59 patients undergoing elective (n = 28) or ruptured (n = 24) abdominal aortic aneurysm repair or elective aortofemoral bypass (n = 7). cTnI level was measured before operation and at 6, 24 and 48 h after surgery. The CK/CK-MB ratio was measured where cTnI was detectable.

RESULTS

Some 14 of 24 emergency and ten of 35 elective patients had detectable cTnI (greater than 0.5 ng/ml) at one or more time-points. The CK/CK-MB ratio was greater than 5 per cent in only four of 24 patients having an emergency operation and in none of the elective patients with detectable cTnI.

CONCLUSION

Over half of patients undergoing emergency operation and more than a quarter of those having elective aortic surgery suffered myocardial necrosis as determined by detectable cTnI levels. This was accompanied by a raised CK/CK-MB ratio in less than one-fifth of patients.

Myocardial injury in major aortic surgery

PURPOSE

The purpose of this study was to examine the effects of major aortic surgery and its associated oxidative stress and injury on the myocardium.

METHODS

Plasma from 27 patients who underwent thoracoabdominal aortic aneurysm (TAAA) repair and 17 patients who underwent infrarenal aortic aneurysm (AAA) repair was collected at incision, aortic crossclamping, and reperfusion and 1, 8, and 24 hours thereafter. Samples were assayed for the myocardial specific protein troponin-T, total antioxidant status, and lipid hydroperoxides.

RESULTS

Ten patients experienced cardiac dysfunction in the first 24 hours after surgery (eight patients in the TAAA group and two patients in the AAA group). Immediately after reperfusion, total antioxidant status levels dropped in all patients with TAAA and with AAA; this was more marked in patients with TAAA, leading to a significant difference between the two groups at this time point and for up to 1 hour thereafter (P <.01). Patients with TAAA showed a sharp rise in lipid hydroperoxide levels immediately after reperfusion, and levels were significantly higher than in patients with AAA (P =.0007). In patients with AAA, no significant change in troponin-T was observed throughout the study period; whereas in patients with TAAA, levels were significantly elevated at 8 and 24 hours after reperfusion (P <.01). Troponin-T levels significantly correlated with total antioxidant status (r = -0.5) and lipid hydroperoxides (r = 0.78) but not with systolic blood pressure.

CONCLUSION

Supracoeliac aortic crossclamping is associated with a significant release of the myocardial injury marker troponin-T. This seems to correlate with the severity of oxidative rather than hemodynamic stresses. Ameliorating oxidative injury during TAAA surgery may therefore have a cardioprotective effect.

Predictors and outcomes of cardiac complications following elective coronary bypass grafting

Our objective was to determine the predictors of cardiac complications among a cohort of elective coronary artery bypass graft (CABG) surgery patients and to determine the relationship of such complications to subsequent quality of life and symptoms. A total of 248 patients were enrolled and 237 completed 6 month follow-up. The combined rate of both major and minor cardiac complications was 9.7% (n = 24). Patients in this study were evaluated preoperatively, monitored intraoperatively, followed immediately postoperatively and at 6 months. Major cardiac complications accounted for 3.6% (n = 9) and minor complications for 6% (n = 15). Using multivariable logistic regression analysis, the predictors of major cardiac complications were receiving diuretics preoperatively (p = .01) and increased time during cross-clamping (p = .006). At 6 months after surgery, 19% of the patients with postoperative cardiac complications experienced worsening of symptoms, in contrast to only 8% of those without cardiac complications (p = .03). We concluded that patients who were on preoperative diuretics and those who had longer cross-clamp times were at higher risk of cardiac complications. The majority of patients who had acute cardiac complications had improved function and symptoms at 6 months postoperatively.

Impact of new guidelines on physicians' ordering of preoperative tests

OBJECTIVE

To compare the number of preoperative tests ordered for elective ambulatory surgery patients during the 2 years before and the 2 years after the establishment of new hospital testing guidelines.

MEASUREMENTS

The patterns of preoperative testing by surgeons and a medical consultant during the 2 years before and the 2 years after the establishment of new guidelines at one orthopedic hospital were reviewed. All tests ordered preoperatively were determined by review of medical records. Preoperative medical histories, physical examinations, and comorbidities were obtained according to a protocol by the medical consultant (author). Perioperative complications were determined by review of intraoperative and postoperative events, which also were recorded according to a protocol.

MAIN RESULTS

A total of 640 patients were enrolled, 361 before and 279 after the new guidelines. The mean number of tests decreased from 8.0 before to 5.6 after the new guidelines ( p =.0001) and the percentage decrease for individual tests varied from 23% to 44%. Except for patients with more comorbidity and patients receiving general anesthesia, there were decreases across all patient groups. In multivariate analyses only time of surgery (before or after new guidelines), age, and type of surgery remained statistically significant ( p =.0001 for all comparisons). Despite decreases in surgeons' ordering of tests, the medical consultant did not order more tests after the new guidelines ( p =.60) The majority of patients had no untoward events intraoperatively and postoperatively throughout the study period, with only 6% overall requiring admission to the hospital after surgery, mainly for reasons not related to abnormal tests. Savings from charges totaled $34,000 for the patients in the study.

CONCLUSIONS

Although there was variable compliance among physicians, new hospital guidelines were effective in reducing preoperative testing and did not result in increases in untoward perioperative events or in test ordering by the medical consultant.

Risk factors in patients undergoing major nonvascular abdominal operations that predict perioperative myocardial infarction

BACKGROUND

Perioperative myocardial infarction (PMI) is an uncommon but serious complication of major abdominal surgery. Identifying the patients at risk may potentially reduce morbidity and mortality. In this study we determined risk factors associated with PMI in patients undergoing abdominal, nonvascular surgery (ANVS).

METHODS

The utility of risk factors for PMI using Goldman's criteria and nine other variables were compared in patients diagnosed with PMI after ANVS (group I) and a control group (group II) matched for age, gender, and type of operation.

RESULTS

Thirty-four patients, 21 men and 13 women, with a mean age of 70 years were diagnosed with PMI, which was associated with a 41% mortality rate (14 of 34). Risk factors for PMI included poor general condition, congestive heart failure, abnormal cardiac rhythm, smoking, previous myocardial infarction (MI), and emergent operation.

CONCLUSION

Although PMI following ANVS is uncommon, the mortality rate remains high. Patients classified as Goldman's class III and IV, or with a history of cigarette smoking, previous MI, or angina merit further evaluation in order to reduce the incidence of this complication.

Predictors of survival and the role of gender in postoperative myocardial infarction

PURPOSE

To identify risk factors for mortality after postoperative myocardial infarction.

METHOD

Retrospective study of 266 patients.

RESULTS

The crude in-hospital mortality rate was 25%. This was more than twice as high as the mortality rate in patients admitted from home with an acute myocardial infarction. Women with postoperative infarction were the same age as men, but had a lower Acute Physiology and Chronic Health Evaluation (APACHE) II score prior to infarction (P = 0.03) and a higher crude mortality rate. Multivariate analysis showed that female gender (relative risk 2.2, 95% confidence limits 1.2 to 4.2), current cigarette smoking (relative risk 2.3 [1.2 to 4.7]), a history of congestive heart failure (relative risk 2.1 [1.04 to 4.1], resuscitation status (relative risk 8.1 [2.0 to 32.9]), and high preoperative APACHE II score were significant independent predictors of in-hospital mortality.

CONCLUSION

Postoperative myocardial infarction is one of the most serious events a patient can experience. Women and current smokers are at especially high risk for mortality after postoperative myocardial infarction.