Usefulness of N-terminal pro-brain natriuretic peptide to predict postoperative cardiac complications and long-term mortality after emergency lower limb orthopedic surgery

ESAIC focused guideline for the use of cardiac biomarkers in perioperative risk evaluation

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.

Using preoperative N-terminal pro-B-type natriuretic peptide levels for predicting major adverse cardiovascular events and myocardial injury after noncardiac surgery in Chinese advanced-age patients

BACKGROUND

N-terminal pro-B-type natriuretic peptide (NT-proBNP) is often viewed as an indicator for heart failure. However, the prognostic association and the predictive utility of NT-proBNP for postoperative major adverse cardiovascular events (MACEs) and myocardial injury after noncardiac surgery (MINS) among older patients are unclear.

METHODS

In this study, we included 5033 patients aged 65 years or older who underwent noncardiac surgery with preoperative NT-proBNP recorded. Logistic regression was adopted to model the associations between preoperative NT-proBNP and the risk of MACEs and MINS. The receiver operating characteristic curve was used to determine the predictive value of NT-proBNP.

RESULTS

A total of 5033 patients were enrolled, 63 patients (1.25%) and 525 patients (10.43%) had incident postoperative MACEs and MINS, respectively. Analysis of the receiver operating characteristic curve indicated that the cutoff values of ln (NT-proBNP) for MACEs and MINS were 5.16 (174 pg/mL) and 5.30 (200 pg/mL), respectively. Adding preoperative ln (NT-proBNP) to the Revised Cardiac Risk Index score and the Cardiac and Stroke Risk Model boosted the area under the receiver operating characteristic curves from 0.682 to 0.726 and 0.787 to 0.804, respectively. The inclusion of preoperative NT-proBNP in the prediction models significantly increased the reclassification and discrimination.

CONCLUSIONS

Increased preoperative NT-proBNP was associated with a higher risk of postoperative MACEs and MINS. The inclusion of NT-proBNP enhances the predictive ability of the preexisting models.

The Influence of Perioperative Fluid Therapy on N-terminal-pro-brain Natriuretic Peptide and the Association With Heart and Lung Complications in Patients Undergoing Colorectal Surgery: Secondary Results of a Clinical Randomized Assessor-blinded Multicenter Trial

OBJECTIVE

To investigate the influence of intravenous (iv) fluid volumes on the secretion of N-terminal-pro-brain natriuretic peptide (NT-Pro-BNP) in colorectal surgical patients and its association with cardiopulmonary complications (CPC). In addition, to examine if preoperative NT-Pro-BNP can predict the risk for postoperative CPC.

METHODS

Blood samples from patients enrolled in a previously published clinical randomized assessor-blinded multicenter trial were analyzed. Included were adult patients undergoing elective colorectal surgery with the American-Society-of-Anesthesiologists-scores of 1-3. Samples from 135 patients were available for analysis. Patients were allocated to either a restrictive (R-group) or a standard (S-group) iv-fluid regimen, commencing preoperatively and continuing until discharge. Blood was sampled every morning until the fourth postoperative day. The primary outcome for this study was NT-Pro-BNP changes and its association with fluid therapy and CPC.

RESULTS

The S-group received more iv-fluid than the R-group on the day-of-surgery [milliliter, median (range) 6485 (4401-10750) vs 3730 (2250-8510); P < 0.001] and on the first postoperative day. NT-Pro-BNP was elevated in the S-group compared with the R-group on all postoperative days [area under the curve: median (interquartile range) pg/mL: 3285 (1697-6179) vs 1290 (758-3719); P < 0.001 and in patients developing CPC vs no-CPC (area under the curve), median (interquartile range): 5196 (1823-9061) vs 1934 (831-5301); P = 0.005]. NT-pro-BNP increased with increasing fluid volumes all days (P < 0.003). Preoperative NT-Pro-BNP predicted CPC [odds ratio (confidence interval): 1.573 (0.973-2.541), P = 0.032; positive predictive value = 0.257, negative predictive value = 0.929].

CONCLUSIONS

NT-pro-BNP increases with iv-fluid volumes given to colorectal surgical patients, and the level of NT-Pro-BNP is associated with CPC. Preoperative NT-Pro-BNP is predictive for CPC, but the diagnostic value is low.Clinicaltrials.gov NCT03537989.

Risk factors for major adverse cardiovascular events after osteoporotic hip fracture repair surgery

Osteoporotic hip fracture (OHF) is an increasingly frequent age-related pathology, which results in high rates of functional loss and mortality within the first year after surgery. This study assessed whether preoperative levels of brain natriuretic peptide (NT-proBNP) and troponin I were related to early occurrence (30d) of major adverse cardio-vascular events (MACE) after OHF repair surgery. During a 6-month period, perioperative clinical and analytical data from consecutive patients, without known history of cardiovascular disease and undergoing surgery for OHF repair at a single centre, were prospectively collected. MACE was defined as acute myocardial ischaemia or infarction, acute heart failure or cardiovascular death. amongst the 140 patients included, 23 (16.4%) developed postoperative MACE (MACE group) and 117 did not (Control group). Compared to those from control group, patients from MACE group were older, had poorer physical status (ASA III-IV), received preoperative red blood cell transfusion (RBCT) more frequently, presented with lower haemoglobin concentrations and higher NT-proBNP, creatinine and troponin I concentrations. Overall, RBCT requirements and 30d mortality rate were also higher in MACE group. However, in multivariate analysis, only preoperative RBCT, creatinine >1 mg/dL and NT-proBNP >450 pg/mL remained as independent preoperative risks factors for postoperative MACE, while 95% confidence intervals of odds ratios were wide. Though our findings require confirmation in a larger multicentre cohort, identifying risk factors for early postoperative MACE after OHF repair surgery, might facilitate assessing patients' risk prior to and following surgery, and targeting them the appropriate preventive and/or therapeutic interventions.

Usefulness of Serum Cardiac Biomarkers for Predicting In-Hospital Cardiac Complications in Acute Hip Fracture: A Prospective Cohort in 20 High Surgical Risk patients with Age over 55 Years

Background. Serum cardiac biomarkers have recently been demonstrated to be useful for predicting perioperative complication after hip fracture (HF). However, no previous study has revealed the comparative efficacy of different cardiac biomarkers in high surgical risk HF patients. Methods. A prospective study was conducted, from June to December 2016, in 20 acute HF patients with American Society of Anesthesiologists (ASA) grade 3 or 4. All patients received blood test for high sensitivity Troponin-I (hsTnI) and N-terminal fragment of pro-B-type natriuretic peptide (NT-proBNP) at the time of admission and 24 hours postoperatively. Perioperative data and in-hospital, 3-month, and 6-month postoperative complications were collected. The complications were classified as cardiac and noncardiac HF-related complications. Results. The average patients' age was 79±8 years. Six patients (30%) were male. The incidence of PCI was 30% (n=6). None of the patients (0%) died during the 6-month postoperative followup period. In-hospital overall cardiac and noncardiac complications were found in 12(60%), 5(30%), and 7(45%), respectively. The mean serum hsTnI levels in the patients with cardiac complication were significantly greater than those in the patients without cardiac complication at both time of admission (99.5 ng/mL vs 5.5 ng/mL, p=0.006) and 24 hours postoperatively (28.6 ng/mL vs 9.4 ng/mL, p=0.013). The mean serum NT-proBNP levels in patients with cardiac complication were also greater but nonsignificantly compared to those in the patients without cardiac complication at both time of admission (2299 pg/mL vs 281 pg/mL, p=0.239) and 24 hours postoperatively (2266 pg/mL vs 586 pg/mL, p=0.061). The other significant preoperative predictors for cardiac complication were low hemoglobin level (p=0.014), low glomerular filtration rate level (p=0.039), and ASA grade 4 (p=0.005). Conclusion. In-hospital cardiac complication in high-risk HF patients was significantly associated with the abnormal rise of serum hsTnI level. Therefore, we recommended using the hsTnI test in the perioperative evaluation in high-risk HF patients. Trial registration number is TCTR20160711002.

Elevated admission N-terminal pro-brain natriuretic peptide level predicts the development of atrial fibrillation in general surgical intensive care unit patients

BACKGROUND

New onset atrial fibrillation (AF) in critically ill surgical patients is associated with significant morbidity and increased mortality. N-terminal pro-B type natriuretic peptide (NT-proBNP) is released by cardiomyocytes in response to stress and may predict AF development after surgery. We hypothesized that elevated NT-proBNP level at surgical intensive care unit (ICU) admission predicts AF development in a general surgical and trauma population.

METHODS

From July to October 2015, NT-proBNP concentrations were measured at ICU admission. Abnormal NT-proBNP concentrations were defined by age-adjusted cut-offs. We examined the relationship between the development of AF and demographics, clinical variables, and NT-proBNP level using univariate analysis and a multivariable logistic regression model.

RESULTS

Three hundred eighty-seven subjects were included in the cohort, none of whom were in AF at ICU admission. The median age was 63 years (52-73 years), and 40.3% were women. The risk of developing AF was higher for abnormal versus normal NT-proBNP (22% vs. 4%; p < 0.0001). Using optimal derived cutoffs (regardless of age), the risk of developing AF was 2% for NT-proBNP less than 600 ng/L, 15% for NT-proBNP of 600 ng/L to 1,999 ng/L, and 27% for NT-proBNP of 2,000 ng/L or greater. Multiple logistic regression analysis identified three independent predictors for new-onset AF: age, older than 70 years (odds ratio [OR], 3.7, 95% confidence interval [CI], 1.5-9.3), history of AF (OR, 25.3; 95% CI, 9.6-67.0), and NT-proBNP of 600 or greater (OR, 4.3; 95% CI, 1.3-14.2). When none or only one predictor was present, AF incidence was less than 1%. When all three predictors were present, AF incidence was 66%. For subjects 70 years or older but no history of AF, AF incidence was 12.8% when NT-proBNP was 600 or greater compared with 0% when NT-proBNP was less than 600. For subjects younger than 70 years with a history of AF, AF incidence was 44.4% when NT-proBNP was 600 or higher compared to 0% when NT-proBNP was less than 600.

CONCLUSION

Elevated NT-proBNP at ICU admission in general surgical and trauma patients is predictive of AF development in the first 3 ICU days. Addition of NT-proBNP measurement to known risk factors can improve predictive power and identify patients who might potentially benefit from evidence-based prophylactic treatment for AF.

Does N-terminal Pro-brain Type Natriuretic Peptide Predict Cardiac Complications After Hip Fracture Surgery?

BACKGROUND

Elderly patients with hip fracture are at risk for cardiac complications. N-terminal pro-brain type natriuretic peptide (NT-proBNP) has been shown to predict cardiac complications in surgical patients; however, to our knowledge, only two studies have evaluated the utility of this test in patients with hip fracture. We believe it is important to assess a more accurate cutoff value of NT-proBNP with exclusion of patients with renal failure.

QUESTIONS/PURPOSES

To assess the association between preoperative NT-proBNP and cardiac complications after hip fracture surgery.

METHODS

We performed 450 surgical procedures in patients with hip fractures between January 2011 and December 2014. Exclusion criteria were renal dysfunction and inadequate laboratory tests. The final study population consisted of 328 patients (mean age, 83 years; 80% women). Preoperatively, measurement of NT-proBNP level was performed. The primary endpoint was the occurrence of cardiac complications within 14 days after surgery based on a chart review. The predictive value of NT-proBNP was assessed using multivariate logistic regression analysis, controlling for relevant confounding variables such as age, gender, body weight, and renal function; we also performed receiver operating characteristic (ROC) curve analysis. Postoperative cardiac complications were encountered in 7% of patients (24 of 328).

RESULTS

The median preoperative NT-proBNP level was higher in patients with complications than in those without (1090 [interquartile range, 614-3191 pg/mL] vs 283 pg/mL [interquartile range, 137-507 pg/mL], p < 0.001). The cutoff level of NT-proBNP determined by ROC curve analysis was 600 pg/mL, with a sensitivity, specificity, positive predictive value, and negative predictive value of 79%, 81%, 25%, and 98%, respectively, and the area under the ROC curve was 0.87 (95% CI, 0.80-0.94; p < 0.001). After controlling for potentially relevant confounding variables, we found a preoperative NT-proBNP greater than 600 pg/mL was associated with an increased risk of cardiac complications (odds ratio, 13; 95% CI, 4-38; p < 0.001) compared with those with NT-proBNP less than 600 pg/mL.

CONCLUSIONS

Preoperative NT-proBNP greater than 600 pg/mL is independently associated with postoperative cardiac complications in patients with hip fracture without renal dysfunction. NT-proBNP measurement provides additional information and is clinically useful for predicting cardiac complications during the early phase after hip fracture surgery. Future studies might develop a simple index for prediction of postoperative cardiac complication including cutoff values of NT-proBNP.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Sleep apnea in total joint arthroplasty patients and the role for cardiac biomarkers for risk stratification: an exploration of feasibility

Obstructive sleep apnea (OSA) is highly prevalent in patients undergoing total joint arthroplasty (TJA) and is a major risk factor for postoperative cardiovascular complications and death. Recognizing this, the American Society of Anesthesiologists urges clinicians to implement special considerations in the perioperative care of OSA patients. However, as the volume of patients presenting for TJA increases, resources to implement these recommendations are limited. This necessitates mechanisms to efficiently risk stratify patients having OSA who may be susceptible to post-TJA cardiovascular complications. We explore the role of perioperative measurement of cardiac troponins (cTns) and brain natriuretic peptides (BNPs) in helping determine which OSA patients are at increased risk for post-TJA cardiovascular-related morbidity.

Predictive value of B-type natriuretic peptide (BNP) for adverse cardiac events in patients undergoing primary total knee arthroplasty (TKA)

BACKGROUND

B-type natriuretic peptide (BNP) is a well-known biomarker to predict cardiac events following orthopedic procedures. However, further information regarding BNP can be completed. The present study aims to determine which of preoperative, postoperative or the difference between them (DVPPB) can best predict adverse cardiac events following TKA procedure and detect possible risk factors of high level of BNP.

METHODS

Between Jan. 2012 and Jan. 2014. 1120 included patients in 3 institutions have a minimum of 2-years follow-up. All clinical characteristics related to TKA procedure were put in total joint arthroplasty registry system and analyzed finally. The cut-off value of BNP predicting patients at increased risks of cardiac events after TKA was evaluated by the Receiver Operating Characteristic (ROC) curve analysis.

RESULTS

Our results reveal DVPPB in comparison to preoperative and postoperative BNP can best predict cardiac events following primary TKA, and the optimal cut-off value was 825.5 pg/ml with the highest Youden index of 0.62. Cigarette smoking, ASA III/IV/V, prior history of cardiac events, general anesthesia, surgery time, and tourniquet time are risk factors for DVPPB > 825.5 pg/ml.

CONCLUSIONS

DVPPB in comparison to preoperative and postoperative BNP can best predict cardiac events following primary TKA. Cigarette smoking, ASA III/IV/V, prior history of cardiac events, general anesthesia, surgery time, and tourniquet time are risk factors for DVPPB > 825.5 pg/ml. We hope these results could be helpful to optimize health care among patients undergoing primary TKA.

Plasma BNP level combined with surgical Apgar score to predict operative major cardiac adverse events in malignant obstructive jaundice patients

Objective:

To investigate the predictive effect of major adverse cardiac events (MACE) in malignant obstructive jaundice (OJ) patients using plasma brain natriuretic peptide (BNP) level and surgical Apgar scoring (SAS) system.

Methods:

Forty one malignant OJ patients undergoing surgical treatments were studied at a single center. Pre-and postoperative plasma BNP level, total bilirubin (TBil) and data of cardiac function (HR, CVP, CI, LVEF%) were detected, the SAS was calculated during the surgery, the relationship of both plasma BNP level and SAS with MACE after surgery was analyzed.

Results:

Thirteen patients out of 41 (31.71%) experienced MACE without cardiac death. OJ patients had a higher plasma BNP level than baseline before operation (191.61±105.76 pg/ml VS 175 pg/ml, P<0.05), the cardiac function data was improved (CVP: t=4.761, p=0.000; CI: t=3.539, p=0.001; LVEF%: t=3.632, p=0.001) after the operation. Patients with lower SAS had increasing incidence of MACE after surgery.

Conclusion:

Malignant OJ patients with higher preoperative BNP level and lower surgical Apgar score were identified at high risk of MACE after surgery.

Predicting the outcome of hip fracture patients by using N-terminal fragment of pro-B-type natriuretic peptide

OBJECTIVE

To examine the prognostic value of perioperative N-terminal fragment of pro-brain natriuretic peptide (NT-proBNP) in hip fracture patients.

DESIGN

Blinded prospective cohort study.

SETTING

Single centre trial at Turku University Hospital in Finland.

PARTICIPANTS

Inclusion criterion was admittance to the study hospital due to hip fracture during the trial period of October 2009--May 2010. Exclusion criteria were the patient's refusal and inadequate laboratory tests. The final study population consisted of 182 patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

NT-proBNP was assessed once during the perioperative period and later if clinically indicated, and troponin T (TnT) and ECG recordings were evaluated repeatedly. The short-term (30-day) and long-term (1000 days) mortalities were studied.

RESULTS

Median (IQR) follow-up time was 3.1 (0.3) years. The median (IQR) NT-proBNP level was 1260 (2298) ng/L in preoperative and 1600 (3971) ng/L in postoperative samples (p=0.001). TnT was elevated in 66 (36%) patients, and was significantly more common in patients with higher NT-proBNP. Patients with high (>2370 ng/L) and intermediate (806-2370 ng/L) NT-proBNP level had significantly higher short-term mortality compared with patients having a low (<806 ng/L) NT-proBNP level (15 vs 11 vs 2%, p=0.04), and the long-term mortality remained higher in these patients (69% vs 49% vs 27%, p<0.001). Intermediate or high NT-proBNP level (HR 7.8, 95% CI 1.03 to 59.14, p<0.05) was the only independent predictor of short-term mortality, while intermediate or high NT-proBNP level (HR 2.27, 95% CI 1.30 to 3.96, p=0.004), the presence of dementia (HR 1.74, 95% CI 1.13 to 2.66, p=0.01) and higher preoperative American Society of Anesthesiologists' (ASA) classification (HR 1.59, 95% CI 1.06 to 2.38, p=0.02) were independent predictors of long-term mortality.

CONCLUSION

An elevated perioperative NT-proBNP level is common in hip fracture patients, and it is an independent predictor of short-term and long-term mortality superior to the commonly used clinical risk scores.

TRIAL REGISTRATION NUMBER

NCT01015105; Results.

N-terminal pro-B-type Natriuretic Peptides’ Prognostic Utility Is Overestimated in Meta-analyses Using Study-specific Optimal Diagnostic Thresholds

Background:

N-terminal fragment B-type natriuretic peptide (NT-proBNP) prognostic utility is commonly determined post hoc by identifying a single optimal discrimination threshold tailored to the individual study population. The authors aimed to determine how using these study-specific post hoc thresholds impacts meta-analysis results.

Methods:

The authors conducted a systematic review of studies reporting the ability of preoperative NT-proBNP measurements to predict the composite outcome of all-cause mortality and nonfatal myocardial infarction at 30 days after noncardiac surgery. Individual patient-level data NT-proBNP thresholds were determined using two different methodologies. First, a single combined NT-proBNP threshold was determined for the entire cohort of patients, and a meta-analysis conducted using this single threshold. Second, study-specific thresholds were determined for each individual study, with meta-analysis being conducted using these study-specific thresholds.

Results:

The authors obtained individual patient data from 14 studies (n = 2,196). Using a single NT-proBNP cohort threshold, the odds ratio (OR) associated with an increased NT-proBNP measurement was 3.43 (95% CI, 2.08 to 5.64). Using individual study-specific thresholds, the OR associated with an increased NT-proBNP measurement was 6.45 (95% CI, 3.98 to 10.46). In smaller studies (&lt;100 patients) a single cohort threshold was associated with an OR of 5.4 (95% CI, 2.27 to 12.84) as compared with an OR of 14.38 (95% CI, 6.08 to 34.01) for study-specific thresholds.

Conclusions:

Post hoc identification of study-specific prognostic biomarker thresholds artificially maximizes biomarker predictive power, resulting in an amplification or overestimation during meta-analysis of these results. This effect is accentuated in small studies.

Prediction of perioperative cardiac events through preoperative NT-pro-BNP and cTnI after emergent non-cardiac surgery in elderly patients

Objectives

Clinical risk stratification has an important function in preoperative evaluation of patients at risk for cardiac events prior to non-cardiac surgery. The aim of this study was to determine whether the combined measurement of pre-operative N-terminal pro-brain natriuretic peptide (NT-pro-BNP) and cardiac troponin I (cTnI) could provide useful prognostic information about postoperative major adverse cardiac events (MACE) within 30 days in patients aged over 60 years undergoing emergent non-cardiac surgery.

Methods

The study group comprised 2519 patients aged over 60 years that were undergoing emergent non-cardiac surgery between December 2007 and December 2013. NT-pro-BNP and cTnI were measured during hospital admission. The patients were monitored for MACE (cardiac death, non-fatal myocardial infarction, or cardiac arrest) during the 30-day postoperative follow-up period.

Results

MACE occurred in 251 patients (10.0%). Preoperative NT-pro-BNP and cTNI level were significantly higher in the individuals that experienced MACE than in those who did not (P < 0.001). The confounding factors of age, sex, co-morbidities and preoperative medications were adjusted in a multivariate logistic regression analysis. This analysis showed that preoperative NT-proBNP level > 917 pg/mL (OR 4.81, 95% CI 3.446–6.722, P < 0.001) and cTnI ≥ 0.07 ng/mL (OR 8.74, 95% CI 5.881–12.987, P < 0.001) remained significantly and independently associated with MACE after the adjustment of the confounding factors. Kaplan-Meier event-free survival curves demonstrated that patients with preoperative simultaneous NT-proBNP level > 917 pg/mL and cTnT ≥0.07 ng/mL had worse event-free survival than individual assessments of either biomarker.

Conclusion

Preoperative plasma NT-proBNP and cTnI are both independently associated with an increased risk of MACE in elderly patients after emergent non-cardiac surgery. The combination of these biomarkers provides better prognostic information than using either biomarker separately.

Use of ivabradine and atorvastatin in emergent orthopedic lower limb surgery and computed tomography coronary plaque imaging and novel biomarkers of cardiovascular stress and lipid metabolism for the study and prevention of perioperative myocardial infarction: study protocol for a randomized controlled trial

Background

The incidence of perioperative myocardial infarction (PMI) globally is known to be around 2 to 3% and can prolong hospitalization, increased morbidity and mortality. Little is known about the pathophysiology and risk factors for PMI. We investigate the presence of elevated novel cardiac markers and preoperative coronary artery plaque through contemporary laboratory techniques to determine the correlation with PMI, as well as studying ivabradine and atorvastatin as protective pharmacotherapies against PMI in the context of orthopedic surgery.

Methods/Design

We aim to enroll 200 patients aged above 60 years who suffer from neck of femur fracture requiring surgery. Patients will be randomized to four arms (no study drugs, atorvastatin only, ivabradine only and ivabradine and atorvastatin). Our primary outcome is incidence of PMI. All patients will receive an electrocardiogram, cardiac echocardiography, measurement of novel cardiac biomarkers and computed tomography (CT) coronary angiography. A telephone interview post discharge will be conducted at 30 days, 60 days and 1 year.

Discussion

We postulate that ivabradine and atorvastatin will reduce the rate and magnitude of PMI following surgery by reducing heart rate and attenuating catecholamine-induced tachycardia postoperatively. Secondly, we postulate that postoperative reduction in heart rate and catecholamine-induced tachycardia with ivabradine will correlate with a reduction in cardiovascular novel biomarkers which will reduce atrial stretch and postoperative incidence of arrhythmia. We aim to demonstrate that treatment with ivabradine and atorvastatin will cause a reduction in the incidence and magnitude of PMI, the benefit of which is derived primarily in patients with greater atherosclerotic burden as measured by higher CT coronary calcium scores.

Trial registration

This study protocol has been listed in the Australia New Zealand Clinical Trial Registry (registration number: ACTRN12612000340831) on 23 March 2012.

Echocardiographic predictor of acute heart failure after spine surgery: a novel tissue Doppler index associated with a potentially fatal complication of the operation

BACKGROUND CONTEXT

Acute heart failure (HF) is a potentially fatal complication after spine surgery.

PURPOSE

We sought to identify clinical and echocardiographic predictors of postoperative HF in spine surgery patients.

STUDY DESIGN

Retrospective observational study.

PATIENT SAMPLE

A total of 305 patients (128 men; age, 65 ± 9 years) who underwent spine surgery were consecutively enrolled. A transthoracic echocardiography was performed to all patients before the index operation. Patients with a history of HF or with left ventricular (LV) systolic dysfunction (LV ejection fraction <50%) were excluded.

OUTCOME MEASURES

Heart failure was defined according to the Framingham criteria. The presence of postoperative dyspneic symptom and the sign of bilateral ankle edema were recorded by the physicians. Chest X-ray was mandatory for all patients and interpreted by the two physicians, including at least one radiologist.

METHODS

Clinical, operative, and echocardiographic parameters were compared between patents with and without acute HF during the postoperative period (duration, 11 ± 9 days). This study was supported by Boryung Pharmaceutical Company (Seoul, Republic of Korea; 13,440 USD).

RESULTS

Postoperative HF occurred in 31 patients (10%). Compared with those without postoperative HF, these patients were older (73 ± 7 vs. 64 ± 9 years), had longer anesthesia time (7.4 ± 4.2 vs. 3.6 ± 2.1 hours), and were treated with a greater volume of fluid replacement during the operation (3.8 ± 0.7 vs. 1.3 ± 0.1 L) (p<.05 for all). On echocardiographic evaluation, the ratio of early diastolic mitral inflow velocity to early diastolic mitral annular velocity (E/E') was higher (11 vs. 8) and left atrial volume index was larger (20 ± 6 vs. 17 ± 6 mL/m(2)) in patients with HF than in the control group (p<.05 for all), whereas the differences in LV ejection fraction and LV size were not significant. In multivariate analysis, E/E' (odds ratio, 1.399; 95% confidence interval, 1.169-1.674; p<.0001), age, and quantity of replaced volume during surgery were independent predictors of postoperative HF.

CONCLUSIONS

Acute HF after spine surgery was rather common even in previously healthy patients. E/E' reflecting LV filling pressure predicted postoperative HF in patients who underwent spine surgery.

Predictive value of plasma brain natriuretic peptide for postoperative cardiac complications--a systemic review and meta-analysis

BACKGROUND

We aimed to undertake a systematic review and meta-analysis of studies addressing perioperative natriuretic peptide (NP) levels to predict postoperative major adverse cardiac events (MACE) after major surgery.

METHODS

We searched MEDLINE and Embase with no language restrictions up to May 2013. The end points were major cardiac complications. We summarized test performance characteristics with the use of forest plots, hierarchical summary receiver operating characteristic curves, and bivariate random effects models.

RESULTS

Of the 662 retrieved articles, 24 studies satisfied the predefined eligibility criteria, including 5438 patients along with 712 (13.1%) events. After major surgery, the diagnostic odds ratio (DOR) of NP in predicting postoperative MACE was 14.3 (95% confidence interval [CI], 9.87-20.7) for overall population, 13.9 (8.43-22.8) for patients undergoing cardiac surgery, and 15.0 (8.84-25.5) for patients undergoing noncardiac surgery. The pooled sensitivity was 0.84 (95% CI, 0.79-0.88) and specificity was 0.76 (95% CI, 0.71-0.81). Postoperative measurement (DOR, 18.9; 7.68-46.3) was associated with higher predictive value than preoperative measurement (DOR, 13.6; 7.68-46.3). Results were similar for a subgroup with the composite outcome including mortality (DOR, 16.4; 10.6-25.5). B-type natriuretic peptide was associated with higher predictive accuracy (area under the summary receiver operating characteristic, 0.84; 0.81-0.87) than N-terminal pro-b-type natriuretic peptide (area under the summary receiver operating characteristic, 0.90; 0.87-0.92).

CONCLUSIONS

The existing literature suggests that perioperative NP testing have reasonable accuracy and can be useful in perioperative risk stratification. Natriuretic peptide testing has high rule-out value and low rule-in value for predicting postoperative MACE. Medical decisions should be made in the context of these characteristics.

Prediction of early postoperative major cardiac events after elective orthopedic surgery: the role of B-type natriuretic peptide, the revised cardiac risk index, and ASA class

BACKGROUND

The aim of this study was to evaluate pre- and post-operative brain natriuretic peptide (BNP) levels and compare the power of this test in predicting in-hospital major adverse cardiac events (MACE: atrial fibrillation, flutter, acute heart failure or non-fatal/fatal myocardial infarction) in patients undergoing elective prosthesis orthopedic surgery to that of the Revised Cardiac Risk Index (RCRI) and American Society of Anesthesiology (ASA) class, the most useful scores identified to date.

METHODS

The study was an observational study of consecutive patients undergoing elective prosthesis orthopedic surgery. Surgical risk was established using RCRI score and ASA class criteria. Venous blood was sampled before surgery and on postoperative day 1 for the measurement of BNP. The intraoperative data collected included details of the surgery and anesthesia and any MACE experienced up until hospital discharge.

RESULTS

MACE occurred in 14 of the 227 patients treated (6.2%). Age was statistical associated with MACE (p < 0.004). Preoperative BNP levels were higher (p < 0.0007) in patients who experienced MACE than in event-free patients (median values: 92 and 35 pg/mL, respectively). Postoperative BNP levels were also greater (p < 0.0001) in patients sustaining MACE than in event-free patients (median values: 165 and 45 pg/mL, respectively). ROC curve analysis demonstrated that for a cut-off point ≥ 39 pg/mL, the area under the curve for preoperative BNP was equal to 0.77, while a postoperative BNP cut-off point ≥ 69 pg/mL gave an AUC of 0.82.

CONCLUSIONS

Both pre- and post-operative BNP concentrations are predictors of MACE in patients undergoing elective prosthesis orthopedic surgery.

ProANP plasma measurement predicts all-cause mortality in acutely hospitalised patients: a cohort study

IMPORTANCE

The association of natriuretic peptide measurement with all-cause mortality in a broad selection of acutely admitted patients has not yet been examined.

OBJECTIVE

To test the risk association between pro-atrial natriuretic peptide (ANP) and short-term and long-term mortality and its predictive value in acutely hospitalised patients and compare this to N-terminal B-type natriuretic peptide (NT-proBNP).

DESIGN, SETTING AND PATIENTS

Participants were selected from the Copenhagen Hospital Heart Failure Study (n=3644). Medical history, satisfactory echocardiography and blood samples were available on 2193 participants in 1998-1999 where NT-proBNP was measured. Vital status after discharge was obtained from national central data registers. A total of 1337 participants with eligible blood samples were selected in 2010-2011 for proANP measurement. Among these, 1255 (94%) were acutely hospitalised in 1998-1999.

MAIN OUTCOME MEASURE(S)

1-year and long-term mortality.

RESULTS

Median follow-up period was 11.5 years. At the end of follow-up, 926 patients had died, 239 during the first year. ProANP quartiles to 2-4 (median proANP levels 594 pmol/L, 990 pmol/L and 2052 pmol/L, respectively) associated with a stepwise increase in risk of 1-year and long-term mortality compared to the first quartile (336 pmol/L) in multivariable adjusted Cox proportional regression models (HR 1.53 95% CI 1.30 to 1.81 and HR 1.26 95% CI 1.17 to 1.36, respectively). An addition of NT-proBNP attenuated proANP's association with mortality in the models (HR 1.24 95% CI 1.01 to 1.53 and 1.14 95% CI 1.03 to 1.26, respectively). The increased risk was observed in participants with the highest proANP levels (fourth quartile). Similar results were observed in subgroups of participants with no evidence of cardiovascular disease (CVD). ProANP in quartiles improved discrimination when added to traditional risk factors in prediction models for 1-year (integrated discrimination improvement (IDI) 0.141 95% CI 0.085 to 0.197; C-index 0.753 95% CI 0.724 to 0.783, P for improvement 0.003) and long-term mortality (IDI 0.053 95% CI 0.032 to 0.074; C-index 0.736 95% CI 0.720 to 0.752, P for improvement <0.001) with similar results in subgroups. Discrimination was best in a combined model with proANP as well as NT-proBNP included.

CONCLUSIONS AND RELEVANCE

High plasma proANP concentrations are associated with and predict short-term and long-term all-cause mortality in acutely hospitalised patients irrespective of CVD status at admission.

Postoperative B-type natriuretic peptide for prediction of major cardiac events in patients undergoing noncardiac surgery: systematic review and individual patient meta-analysis

BACKGROUND

It is unclear whether postoperative B-type natriuretic peptides (i.e., BNP and N-terminal proBNP) can predict cardiovascular complications in noncardiac surgery.

METHODS

The authors undertook a systematic review and individual patient data meta-analysis to determine whether postoperative BNPs predict postoperative cardiovascular complications at 30 and 180 days or more.

RESULTS

The authors identified 18 eligible studies (n = 2,051). For the primary outcome of 30-day mortality or nonfatal myocardial infarction, BNP of 245 pg/ml had an area under the curve of 0.71 (95% CI, 0.64-0.78), and N-terminal proBNP of 718 pg/ml had an area under the curve of 0.80 (95% CI, 0.77-0.84). These thresholds independently predicted 30-day mortality or nonfatal myocardial infarction (adjusted odds ratio [AOR] 4.5; 95% CI, 2.74-7.4; P < 0.001), mortality (AOR, 4.2; 95% CI, 2.29-7.69; P < 0.001), cardiac mortality (AOR, 9.4; 95% CI, 0.32-254.34; P < 0.001), and cardiac failure (AOR, 18.5; 95% CI, 4.55-75.29; P < 0.001). For greater than or equal to 180-day outcomes, natriuretic peptides independently predicted mortality or nonfatal myocardial infarction (AOR, 3.3; 95% CI, 2.58-4.3; P < 0.001), mortality (AOR, 2.2; 95% CI, 1.67-86; P < 0.001), cardiac mortality (AOR, 2.1; 95% CI, 0.05-1,385.17; P < 0.001), and cardiac failure (AOR, 3.5; 95% CI, 1.0-9.34; P = 0.022). Patients with BNP values of 0-250, greater than 250-400, and greater than 400 pg/ml suffered the primary outcome at a rate of 6.6, 15.7, and 29.5%, respectively. Patients with N-terminal proBNP values of 0-300, greater than 300-900, and greater than 900 pg/ml suffered the primary outcome at a rate of 1.8, 8.7, and 27%, respectively.

CONCLUSIONS

Increased postoperative BNPs are independently associated with adverse cardiac events after noncardiac surgery.

The prognostic value of pre-operative and post-operative B-type natriuretic peptides in patients undergoing noncardiac surgery: B-type natriuretic peptide and N-terminal fragment of pro-B-type natriuretic peptide: a systematic review and individual patient data meta-analysis

OBJECTIVES

The objective of this study was to determine whether measuring post-operative B-type natriuretic peptides (NPs) (i.e., B-type natriuretic peptide [BNP] and N-terminal fragment of proBNP [NT-proBNP]) enhances risk stratification in adult patients undergoing noncardiac surgery, in whom a pre-operative NP has been measured.

BACKGROUND

Pre-operative NP concentrations are powerful independent predictors of perioperative cardiovascular complications, but recent studies have reported that elevated post-operative NP concentrations are independently associated with these complications. It is not clear whether there is value in measuring post-operative NP when a pre-operative measurement has been done.

METHODS

We conducted a systematic review and individual patient data meta-analysis to determine whether the addition of post-operative NP levels enhanced the prediction of the composite of death and nonfatal myocardial infarction at 30 and ≥180 days after surgery.

RESULTS

Eighteen eligible studies provided individual patient data (n = 2,179). Adding post-operative NP to a risk prediction model containing pre-operative NP improved model fit and risk classification at both 30 days (corrected quasi-likelihood under the independence model criterion: 1,280 to 1,204; net reclassification index: 20%; p < 0.001) and ≥180 days (corrected quasi-likelihood under the independence model criterion: 1,320 to 1,300; net reclassification index: 11%; p = 0.003). Elevated post-operative NP was the strongest independent predictor of the primary outcome at 30 days (odds ratio: 3.7; 95% confidence interval: 2.2 to 6.2; p < 0.001) and ≥180 days (odds ratio: 2.2; 95% confidence interval: 1.9 to 2.7; p < 0.001) after surgery.

CONCLUSIONS

Additional post-operative NP measurement enhanced risk stratification for the composite outcomes of death or nonfatal myocardial infarction at 30 days and ≥180 days after noncardiac surgery compared with a pre-operative NP measurement alone.

N-terminal pro-brain natriuretic peptide and angiotensin-converting enzyme-2 levels and their association with postoperative cardiac complications after emergency orthopedic surgery

The prognostic usefulness of the cardiac biomarkers N-terminal pro-brain natriuretic peptide (NT-proBNP) and angiotensin-converting enzyme 2 (ACE-2), in predicting adverse cardiac outcomes after orthopedic surgery is not well studied. The aim of our study was to determine the usefulness of perioperative NT-proBNP and ACE-2 for predicting cardiac events after emergency orthopedic surgery. The perioperative NT-proBNP and ACE-2 levels were determined in 187 consecutive patients aged >60 years who underwent orthopedic surgery with 1 year of follow-up for any cardiac complications (defined as acute myocardial infarction, congestive cardiac failure, atrial fibrillation, or major arrhythmia) and death. Of the 187 patients, 20 (10.7%) sustained an in-hospital postoperative cardiac complication. The total all-cause in-hospital and 1-year mortality rate was 1.6% (3 of 187) and 8.6% (16 of 187), respectively. The median preoperative and postoperative NT-proBNP level was greater in patients who sustained an in-hospital cardiac event than in those who had not (386 vs 2,273 pg/ml, p <0.001, and 605 vs 4,316 pg/ml, p <0.001, respectively). Similarly, the postoperative median ACE-2 levels were significantly greater in the patients with an in-hospital cardiac event than in those without (25.3 vs 39.5 pmol/ml/min, p = 0.012). A preoperative NT-proBNP level of ≥741 pg/ml (odds ratio 4.5, 95% confidence interval 1.3 to 15.2, p = 0.017), postoperative troponin elevation (odds ratio 4.9, 95% confidence interval 1.3 to 18.9, p = 0.022), and number of co-morbidities (odds ratio 1.8, 95% confidence interval 1.2 to 2.8, p = 0.009) independently predicted in-hospital cardiac complications on multivariate analysis. The pre- and postoperative NT-proBNP level independently predicted 1-year cardiovascular complications but not the ACE-2 levels. In conclusion, elevated perioperative NT-proBNP predicted in-hospital and 1-year cardiac events in an emergency orthopedic population but the ACE-2 levels did not, which requires additional study for validation.

N-terminal pro B-type natriuretic peptide (NT pro-BNP) is a predictor of long-term survival in male patients of 75 years and older with high-grade asymptomatic internal carotid artery stenosis

BACKGROUND

Carotid endarterectomy (CEA) is commonly performed for asymptomatic high-grade internal carotid artery (ICA) stenosis to prevent stroke. However, despite advancing age of the society, for patients older than 75 years, there is no recommendation by the European guidelines for CEA, as this age group might not benefit from this intervention due to a limited life expectancy.

OBJECTIVE

We assessed N-terminal pro B-type natriuretic peptide (NT pro-BNP) as a predictive marker for long-term survival in this particular patient population in order to stratify patients for an improved surgical outcome.

METHODS

In a nonrandomized single-center clinical trial, we prospectively studied mortality rates of 205 consecutive patients (80 women, 125 men; mean age, 75 ± 10 years) with asymptomatic high-grade ICA stenosis in relation to preoperative plasma NT pro-BNP levels. We estimated cumulative survival over 5 years by Kaplan-Meier curves and established a proportional hazard-model by Cox regression.

RESULTS

In male patients, higher levels of preoperative NT pro-BNP levels were associated with a significantly increased long-term mortality. Those 75 years or older had the same survival rate as younger patients, if NT pro-BNP levels were low, making them thus eligible for CEA.

CONCLUSIONS

The results of our study suggest that preoperative plasma levels of NT pro-BNP are a valuable tool for the stratification of male patients. Male patients older than 75 years with low levels of NT pro-BNP should be referred for carotid revascularization, as they will most likely enjoy the benefit of surgery.