Commentaires sur quelques problèmes méthodologiques liés à l’utilisation des biomarqueurs biologiques dans la recherche et la pratique cliniques

[Cardiac biomarkers in perioperative risk stratification]

OBJECTIVES

The field of new cardiac biomarkers has triggered physicians' enthusiasm because of their potential diagnostic and prognostic values for routine clinical practice in the surgical setting. The objective of the present article is to review the role of new cardiac biomarkers and their potential additive clinical value in predicting short- and long-term risk following cardiac and non-cardiac surgery.

DATA SOURCES

A PubMed(®) database research in English and French languages published until June 2010. Keywords were cardiac biomarkers, troponins, cardiac troponin I (cTnI), natriuretic peptides, B-type natriuretic peptide (BNP), C-reactive protein (CRP), multiple markers approach, risk stratification, clinical risk scores.

DATA SYNTHESIS

Numerous publications deal with the diagnostic and prognostic values of new cardiac biomarkers in cardiac and non-cardiac surgical settings and provide an increasing evidence of their interest, validating different hierarchical steps which are mandatory before recommending a wide use of biomarkers for routine practice. Even if the first studies demonstrating an additional prognostic value of serum postoperative cTnI and/or preoperative BNP when compared with clinical predictive models are now available, we still lack data concerning an actual positive impact of new biomarkers measurements on clinical decision making or practice, as well as patient care and outcome.

CONCLUSIONS

While use of new cardiac biomarkers in the perioperative period appears to be a simple and objective tool for risk stratification at the bedside, we still need to remain cautious concerning their additional clinical value on existing predictive models for routine practice.

Outcomes in perioperative care

PURPOSE OF REVIEW

The present review examines the trends and controversies on how perioperative care can influence outcome after anesthesia and surgery.

RECENT FINDINGS

Recent studies indicate that anesthesia and perioperative care may have a major impact on long-term postoperative mortality and major complications in surgical patients by decreasing the rate of individual decisions. The use of a surgical checklist in the operating room improves postoperative mortality by decreasing the rate of individual decisions and facilitating communication between anesthesiologists, surgeons and intensivists. Antiplatelet therapy should not be discontinued routinely before elective surgery in patients with coronary or vascular occlusive disease. Attenuation of the surgical stress response by beta-blockers decreases long-term major adverse cardiac events, but may increase the incidence of postoperative stroke. The long-term impact on outcome of tight glycemic control and intraoperative hemodynamic optimization requires further investigation.

SUMMARY

The use of a surgical checklist may reduce postoperative mortality and complications in surgical patients. The optimal dosing and timing of perioperative beta-blockade should decrease the incidence of postoperative stroke. However, to date, the long-term risk:benefit balance of attenuation of the perioperative stress response remains controversial. Red cell transfusion is unavoidable in some cases, but is associated with worsened outcome in various surgical situations. Future research should focus on the risk:benefit balance of anesthesia and surgery. This will contribute to promoting the role of anesthesiologists as physicians of the perioperative period.