1
|
Hong A, Boukthir S, Levé C, Joachim J, Mateo J, Le Gall A, Mebazaa A, Gayat E, Cartailler J, Vallée F. "Association of velocity-pressure loop-derived values recorded during neurosurgical procedures with postoperative organ failure biomarkers: a retrospective single-center study". Anaesth Crit Care Pain Med 2024:101405. [PMID: 38997007 DOI: 10.1016/j.accpm.2024.101405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 05/24/2024] [Accepted: 06/02/2024] [Indexed: 07/14/2024]
Abstract
BACKGROUND Perioperative renal and myocardial protection primarily depends on preoperative prediction tools, along with intraoperative optimization of cardiac output (CO) and mean arterial pressure (MAP). We hypothesise that monitoring the intraoperative global afterload angle (GALA), a proxy of ventricular afterload derived from the velocity pressure (VP) loop, could better predict changes in postoperative biomarkers than the recommended traditional MAP and CO. METHOD This retrospective monocentric study included patients programmed for neurosurgery with continuous VP loop monitoring. Patients with hemodynamic instability were excluded. Those presenting a 1-day post-surgery increase in creatinine, B-type natriuretic peptide, or troponin Ic us were labelled Bio+, Bio- otherwise. Demographics, intra-operative data and comorbidities were considered as covariates. The study aimed to determine if intraoperative GALA monitoring could predict early postoperative biomarker disruption. RESULT From November 2018 to November 2020, 86 patients were analysed (Bio+/Bio- = 47/39). Bio + patients were significantly older (62[54-69] versus 42[34-57] years, p < 0.0001), More often hypertensive (25% vs. 9%, p = 0.009), and more frequently treated with antihypertensive drugs (31.9% vs. 7.7%, p = 0.013). GALA was significantly larger in Bio+ patients (40[31-56] vs. 23[19-29] °, p < 0.0001), while CO, MAP, and cumulative time spent <65mmHg were similar between groups. GALA exhibited strong predictive performances for postoperative biological deterioration (AUC=0.88[0.80-0.95]), significantly outperforming MAP (MAP AUC=0.55[0.43-0.68], p < 0.0001). CONCLUSION GALA under general anaesthesia prove more effective in detecting patients at risk of early cardiac or renal biological deterioration, compared to classical hemodynamic parameters.
Collapse
Affiliation(s)
- Alex Hong
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; Cambodia China friendship preah kossamak hospital 316d St 150, Phnom Penh, Cambodia
| | - Sonia Boukthir
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.
| | - Charlotte Levé
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Jona Joachim
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Joaquim Mateo
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Arthur Le Gall
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Alexandre Mebazaa
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; Inserm, UMRS-942, Paris. France
| | - Etienne Gayat
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; Inserm, UMRS-942, Paris. France
| | - Jérôme Cartailler
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; Inserm, UMRS-942, Paris. France
| | - Fabrice Vallée
- Department of Anaesthesiology, Burn and Critical Care. Saint-Louis-Lariboisière University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France; Inserm, UMRS-942, Paris. France; Laboratoire de Mécanique des Solides (LMS), Ecole Polytechnique, CNRS, Palaiseau, France
| |
Collapse
|
2
|
Chew MS, Puelacher C, Lurati-Buse G. Managing perioperative myocardial injury. Intensive Care Med 2024:10.1007/s00134-024-07477-6. [PMID: 38805043 DOI: 10.1007/s00134-024-07477-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 05/03/2024] [Indexed: 05/29/2024]
Affiliation(s)
- Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, 58185, Linköping, Sweden.
| | - Christian Puelacher
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Innsbruck, Medical University Innsbruck, Innsbruck, Austria
- Cardiovascular Research Institute Basel, University Hospital Basel, University Basel, Basel, Switzerland
| | - Giovanna Lurati-Buse
- Department of Anaesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
| |
Collapse
|
3
|
Gutierrez Del Arroyo A, Patel A, Abbott TEF, Begum S, Dias P, Somanath S, Middleditch A, Cleland S, Brealey D, Pearse RM, Ackland GL. Preoperative N-terminal pro-B-type natriuretic peptide and myocardial injury after stopping or continuing renin-angiotensin system inhibitors in noncardiac surgery: a prespecified analysis of a phase 2 randomised controlled multicentre trial. Br J Anaesth 2024; 132:857-866. [PMID: 38341283 PMCID: PMC11103084 DOI: 10.1016/j.bja.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/27/2023] [Accepted: 01/04/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Patients with elevated preoperative plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP >100 pg ml-1) experience more complications after noncardiac surgery. Individuals prescribed renin-angiotensin system (RAS) inhibitors for cardiometabolic disease are at particular risk of perioperative myocardial injury and complications. We hypothesised that stopping RAS inhibitors before surgery increases the risk of perioperative myocardial injury, depending on preoperative risk stratified by plasma NT-proBNP concentrations. METHODS In a preplanned analysis of a phase 2a trial in six UK centres, patients ≥60 yr old undergoing elective noncardiac surgery were randomly assigned either to stop or continue RAS inhibitors before surgery. The pharmacokinetic profile of individual RAS inhibitors determined for how long they were stopped before surgery. The primary outcome, masked to investigators, clinicians, and patients, was myocardial injury (plasma high-sensitivity troponin-T ≥15 ng L-1 or a ≥5 ng L-1 increase, when preoperative high-sensitivity troponin-T ≥15 ng L-1) within 48 h after surgery. The co-exposures of interest were preoperative plasma NT-proBNP (< or >100 pg ml -1) and stopping or continuing RAS inhibitors. RESULTS Of 241 participants, 101 (41.9%; mean age 71 [7] yr; 48% females) had preoperative NT-proBNP >100 pg ml -1 (median 339 [160-833] pg ml-1), of whom 9/101 (8.9%) had a formal diagnosis of cardiac failure. Myocardial injury occurred in 63/101 (62.4%) subjects with NT-proBNP >100 pg ml-1, compared with 45/140 (32.1%) subjects with NT-proBNP <100 pg ml -1 {odds ratio (OR) 3.50 (95% confidence interval [CI] 2.05-5.99); P<0.0001}. For subjects with preoperative NT-proBNP <100 pg ml-1, 30/75 (40%) who stopped RAS inhibitors had myocardial injury, compared with 15/65 (23.1%) who continued RAS inhibitors (OR for stopping 2.22 [95% CI 1.06-4.65]; P=0.03). For preoperative NT-proBNP >100 pg ml-1, myocardial injury rates were similar regardless of stopping (62.2%) or continuing (62.5%) RAS inhibitors (OR for stopping 0.98 [95% CI 0.44-2.22]). CONCLUSIONS Stopping renin-angiotensin system inhibitors in lower-risk patients (preoperative NT-proBNP <100 pg ml -1) increased the likelihood of myocardial injury before noncardiac surgery.
Collapse
Affiliation(s)
- Ana Gutierrez Del Arroyo
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Akshaykumar Patel
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Tom E F Abbott
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Salma Begum
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Priyanthi Dias
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Sameer Somanath
- County Durham and Darlington NHS Foundation Trust, Durham, UK
| | | | | | - David Brealey
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK; UCL Hospitals NHS Foundation Trust, London, UK
| | - Rupert M Pearse
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK.
| |
Collapse
|
4
|
Shelley B, McAreavey R, McCall P. Epidemiology of perioperative RV dysfunction: risk factors, incidence, and clinical implications. Perioper Med (Lond) 2024; 13:31. [PMID: 38664769 PMCID: PMC11046908 DOI: 10.1186/s13741-024-00388-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
In this edition of the journal, the Perioperative Quality Initiative (POQI) present three manuscripts describing the physiology, assessment, and management of right ventricular dysfunction (RVD) as pertains to the perioperative setting. This narrative review seeks to provide context for these manuscripts, discussing the epidemiology of perioperative RVD focussing on definition, risk factors, and clinical implications. Throughout the perioperative period, there are many potential risk factors/insults predisposing to perioperative RVD including pre-existing RVD, fluid overload, myocardial ischaemia, pulmonary embolism, lung injury, mechanical ventilation, hypoxia and hypercarbia, lung resection, medullary reaming and cement implantation, cardiac surgery, cardiopulmonary bypass, heart and lung transplantation, and left ventricular assist device implantation. There has however been little systematic attempt to quantify the incidence of perioperative RVD. What limited data exists has assessed perioperative RVD using echocardiography, cardiovascular magnetic resonance, and pulmonary artery catheterisation but is beset by challenges resulting from the inconsistencies in RVD definitions. Alongside differences in patient and surgical risk profile, this leads to wide variation in the incidence estimate. Data concerning the clinical implications of perioperative RVD is even more scarce, though there is evidence to suggest RVD is associated with atrial arrhythmias and prolonged length of critical care stay following thoracic surgery, increased need for inotropic support in revision orthopaedic surgery, and increased critical care requirement and mortality following cardiac surgery. Acute manifestations of RVD result from low cardiac output or systemic venous congestion, which are non-specific to the diagnosis of RVD. As such, RVD is easily overlooked, and the relative contribution of RV dysfunction to postoperative morbidity is likely to be underestimated.We applaud the POQI group for highlighting this important condition. There is undoubtedly a need for further study of the RV in the perioperative period in addition to solutions for perioperative risk prediction and management strategies. There is much to understand, study, and trial in this area, but importantly for our patients, we are increasingly recognising the importance of these uncertainties.
Collapse
Affiliation(s)
- Ben Shelley
- Department of Cardiothoracic Anaesthesia and Intensive Care, Golden Jubilee National Hospital, Clydebank, UK.
- Perioperative Medicine and Critical Care Research Group, University of Glasgow, Glasgow, UK.
| | - Rhiannon McAreavey
- Department of Cardiothoracic Anaesthesia and Intensive Care, Golden Jubilee National Hospital, Clydebank, UK
- Perioperative Medicine and Critical Care Research Group, University of Glasgow, Glasgow, UK
| | - Philip McCall
- Department of Cardiothoracic Anaesthesia and Intensive Care, Golden Jubilee National Hospital, Clydebank, UK
- Perioperative Medicine and Critical Care Research Group, University of Glasgow, Glasgow, UK
| |
Collapse
|
5
|
Bollen Pinto B, Ackland GL. Pathophysiological mechanisms underlying increased circulating cardiac troponin in noncardiac surgery: a narrative review. Br J Anaesth 2024; 132:653-666. [PMID: 38262855 DOI: 10.1016/j.bja.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 11/23/2023] [Accepted: 12/15/2023] [Indexed: 01/25/2024] Open
Abstract
Assay-specific increases in circulating cardiac troponin are observed in 20-40% of patients after noncardiac surgery, depending on patient age, type of surgery, and comorbidities. Increased cardiac troponin is consistently associated with excess morbidity and mortality after noncardiac surgery. Despite these findings, the underlying mechanisms are unclear. The majority of interventional trials have been designed on the premise that ischaemic cardiac disease drives elevated perioperative cardiac troponin concentrations. We consider data showing that elevated circulating cardiac troponin after surgery could be a nonspecific marker of cardiomyocyte stress. Elevated concentrations of circulating cardiac troponin could reflect coordinated pathological processes underpinning organ injury that are not necessarily caused by ischaemia. Laboratory studies suggest that matching of coronary artery autoregulation and myocardial perfusion-contraction coupling limit the impact of systemic haemodynamic changes in the myocardium, and that type 2 ischaemia might not be the likeliest explanation for cardiac troponin elevation in noncardiac surgery. The perioperative period triggers multiple pathological mechanisms that might cause cardiac troponin to cross the sarcolemma. A two-hit model involving two or more triggers including systemic inflammation, haemodynamic strain, adrenergic stress, and autonomic dysfunction might exacerbate or initiate acute myocardial injury directly in the absence of cell death. Consideration of these diverse mechanisms is pivotal for the design and interpretation of interventional perioperative trials.
Collapse
Affiliation(s)
- Bernardo Bollen Pinto
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.
| | - Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| |
Collapse
|
6
|
Ackland GL, Patel A, Abbott TEF, Begum S, Dias P, Crane DR, Somanath S, Middleditch A, Cleland S, Gutierrez del Arroyo A, Brealey D, Pearse RM. Discontinuation vs. continuation of renin-angiotensin system inhibition before non-cardiac surgery: the SPACE trial. Eur Heart J 2024; 45:1146-1155. [PMID: 37935833 PMCID: PMC10984566 DOI: 10.1093/eurheartj/ehad716] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 09/07/2023] [Accepted: 10/10/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND AND AIMS Haemodynamic instability is associated with peri-operative myocardial injury, particularly in patients receiving renin-angiotensin system (RAS) inhibitors (angiotensin-converting-enzyme inhibitors/angiotensin II receptor blockers). Whether stopping RAS inhibitors to minimise hypotension, or continuing RAS inhibitors to avoid hypertension, reduces peri-operative myocardial injury remains unclear. METHODS From 31 July 2017 to 1 October 2021, patients aged ≥60 years undergoing elective non-cardiac surgery were randomly assigned to either discontinue or continue RAS inhibitors prescribed for existing medical conditions in six UK centres. Renin-angiotensin system inhibitors were withheld for different durations (2-3 days) before surgery, according to their pharmacokinetic profile. The primary outcome, masked to investigators, clinicians, and patients, was myocardial injury [plasma high-sensitivity troponin-T (hs-TnT) ≥ 15 ng/L within 48 h after surgery, or ≥5 ng/L increase when pre-operative hs-TnT ≥15 ng/L]. Pre-specified adverse haemodynamic events occurring within 48 h of surgery included acute hypertension (>180 mmHg) and hypotension requiring vasoactive therapy. RESULTS Two hundred and sixty-two participants were randomized to continue (n = 132) or stop (n = 130) RAS inhibitors. Myocardial injury occurred in 58 (48.3%) patients randomized to discontinue, compared with 50 (41.3%) patients who continued, RAS inhibitors [odds ratio (for continuing): 0.77; 95% confidence interval (CI) 0.45-1.31]. Hypertensive adverse events were more frequent when RAS inhibitors were stopped [16 (12.4%)], compared with 7 (5.3%) who continued RAS inhibitors [odds ratio (for continuing): 0.4; 95% CI 0.16-1.00]. Hypotension rates were similar when RAS inhibitors were stopped [12 (9.3%)] or continued [11 (8.4%)]. CONCLUSIONS Discontinuing RAS inhibitors before non-cardiac surgery did not reduce myocardial injury, and could increase the risk of clinically significant acute hypertension. These findings require confirmation in future studies.
Collapse
Affiliation(s)
- Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Akshaykumar Patel
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Tom E F Abbott
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Salma Begum
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Priyanthi Dias
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - David R Crane
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Sameer Somanath
- County Durham and Darlington NHS Foundation Trust, Darlington, UK
| | | | | | - Ana Gutierrez del Arroyo
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - David Brealey
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
- UCL Hospitals NHS Foundation Trust, London, UK
- NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Rupert M Pearse
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| |
Collapse
|
7
|
Knight K, Wijeysundera DN, Abbott TEF. Self-reported fitness as a measure of perioperative cardiovascular risk: tension between subjective and objective assessments persists. Br J Anaesth 2024; 132:10-12. [PMID: 37925269 DOI: 10.1016/j.bja.2023.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/10/2023] [Accepted: 10/12/2023] [Indexed: 11/06/2023] Open
Abstract
Despite recent high-quality international studies, the optimal sum and sequence of subjective and objective assessments that build the complex picture of fitness for surgery remains to be defined. Physicians' subjective assessment of patient fitness after a typical unstructured interview has poor prognostic accuracy in predicting the risk of major cardiovascular events after noncardiac surgery. How does self-reported fitness assessed by structured questionnaire compare as an indicator of perioperative cardiovascular risk? Here we discuss the latest evidence in this evolving and fundamental aspect of perioperative care.
Collapse
Affiliation(s)
- Katrina Knight
- Academic Unit of Surgery, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK
| | - Duminda N Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesia, Unity Health Toronto - St. Michael's Hospital, Toronto, ON, Canada
| | - Tom E F Abbott
- William Harvey Research Institute, Queen Mary University of London, London, UK.
| |
Collapse
|
8
|
Lurati Buse G, Bollen Pinto B, Abelha F, Abbott TEF, Ackland G, Afshari A, De Hert S, Fellahi JL, Giossi L, Kavsak P, Longrois D, M'Pembele R, Nucaro A, Popova E, Puelacher C, Richards T, Roth S, Sheka M, Szczeklik W, van Waes J, Walder B, Chew MS. ESAIC focused guideline for the use of cardiac biomarkers in perioperative risk evaluation. Eur J Anaesthesiol 2023; 40:888-927. [PMID: 37265332 DOI: 10.1097/eja.0000000000001865] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND In recent years, there has been increasing focus on the use of cardiac biomarkers in patients undergoing noncardiac surgery. AIMS The aim of this focused guideline was to provide updated guidance regarding the pre-, post- and combined pre-and postoperative use of cardiac troponin and B-type natriuretic peptides in adult patients undergoing noncardiac surgery. METHODS The guidelines were prepared using Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology. This included the definition of critical outcomes, a systematic literature search, appraisal of certainty of evidence, evaluation of biomarker measurement in terms of the balance of desirable and undesirable effects including clinical outcomes, resource use, health inequality, stakeholder acceptance, and implementation. The panel differentiated between three different scopes of applications: cardiac biomarkers as prognostic factors, as tools for risk prediction, and for biomarker-enhanced management strategies. RESULTS In a modified Delphi process, the task force defined 12 critical outcomes. The systematic literature search resulted in over 25,000 hits, of which 115 full-text articles formed the body of evidence for recommendations. The evidence appraisal indicated heterogeneity in the certainty of evidence across critical outcomes. Further, there was relevant gradient in the certainty of evidence across the three scopes of application. Recommendations were issued and if this was not possible due to limited evidence, clinical practice statements were produced. CONCLUSION The ESAIC focused guidelines provide guidance on the perioperative use of cardiac troponin and B-type natriuretic peptides in patients undergoing noncardiac surgery, for three different scopes of application.
Collapse
Affiliation(s)
- Giovanna Lurati Buse
- From the Department of Anaesthesiology, University Hospital Dusseldorf, Dusseldorf, Germany (GLB, RMP, AN, SR), Division of Anaesthesiology, Geneva University Hospitals (HUG), Geneva, Switzerland (BBP, MS, BW), Department of Anesthesiology, Centro Hospitalar Universitário de São João, Porto, Portugal (FA), Cardiovascular Research and Development Center (UnIC@RISE), Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal (FA), William Harvey Research Institute, Queen Mary University of London, London, UK (TEA, GA), Department of Anaesthesia and Perioperative Medicine, Royal London Hospital, Barts Health NHS Trust, London, UK (GA), Department of Paediatric and Obstetric Anaesthesia, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Denmark (AA), Department of Anaesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium (SDH), Service d'Anesthésie-Réanimation, Hôpital Universitaire Louis Pradel, Hospices Civils de Lyon, 59 boulevard Pinel, 69500 Lyon, France (J-LF), "Patients as Partners" program, Geneva University Hospitals (HUG), Geneva, Switzerland (LG), Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada (PK), Department of Anesthesiology and Intensive Care, Bichat Claude-Bernard Hospital, Assistance Publique-Hopitaux de Paris - Nord, University of Paris, INSERM U1148, Paris, France (DL), Institut d'Investigació Biomèdica Sant Pau (IIB SANT PAU), Barcelona, Spain (EP), Centro Cochrane Iberoamericano, Barcelona, Spain (EP), Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel-Stadt, Switzerland (CP), Department of Internal Medicine, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Basel-Stadt, Switzerland (CP), Division of Surgery, University of Western Australia, Perkins South Building, Fiona Stanley Hospital, Murdoch, Perth, WA, Australia (TR), Institute of Clinical Trials and Methodology and Division of Surgery, University College London, UK (TR), Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland (WS), Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (JvW), Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University Hospital, Sweden (MSC)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Jia Y, Lin F, Li R, Chen Y, Yang J, Han H, Wang K, Yuan K, Zhao Y, Lu J, Li T, Nie Z, Zhou Y, Shi G, Li Y, Zhao Y, Chen X, Wang S. Insular cortex Hounsfield units predict postoperative neurocardiogenic injury in patients with aneurysmal subarachnoid hemorrhage. Ann Clin Transl Neurol 2023; 10:2373-2385. [PMID: 37853930 PMCID: PMC10723248 DOI: 10.1002/acn3.51926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/20/2023] [Accepted: 10/02/2023] [Indexed: 10/20/2023] Open
Abstract
OBJECTIVE Our study aims to investigate the association between the Hounsfield unit (Hu) value of the insular cortex (IC) during emergency admission and the subsequent occurrence of post-operative neurocardiogenic injury (NCI) among patients afflicted with aneurysmal subarachnoid hemorrhage (aSAH). METHODS Patients baseline characteristics were juxtaposed between those with and without NCI. The significant variables were incorporated into a multivariable stepwise logistic regression model. Receiver operating characteristic (ROC) curves were drafted for each significant variable, yielding cutoff values and the area under the curve (AUC). Subgroup and sensitivity analyses were performed to assess the predictive performance across various cohorts and ascertain result stability. Propensity score matching (PSM) was ultimately employed to redress any baseline characteristic disparities. RESULTS Patients displaying a right IC Hu value surpassing 28.65 exhibited an escalated risk of postoperative NCI upon confounder adjustment (p < 0.001). The ROC curve eloquently manifested the predictive capacity of right IC Hu in relation to NCI (AUC = 0.650, 95%CI, 0.591-0.709, p < 0.001). Further subgroup analysis revealed significant interactions between right IC Hu and factors such as age, history of heart disease, and Graeb 5-12 score. Sensitivity analysis further upheld the results' significant (p = 0.002). The discrepancy in NCI incidence between the two groups, both prior (p < 0.002) and post (p = 0.039) PSM, exhibited statistical significance. After PSM implementation, the likelihood of NCI displayed an ascending trend with increasing right IC Hu values, from the Hu1 cohort onward, receding post the Hu4 cohort. CONCLUSION This study definitively establishes an elevated right IC Hu value in the early stages of emergency admission as an autonomous predictor for ensuing NCI subsequent to aSAH.
Collapse
Affiliation(s)
- Yitong Jia
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
- Center of Stroke, Beijing Institute for Brain DisordersBeijingChina
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular DiseaseBeijingChina
| | - Fa Lin
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
- Center of Stroke, Beijing Institute for Brain DisordersBeijingChina
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular DiseaseBeijingChina
| | - Runting Li
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
- Center of Stroke, Beijing Institute for Brain DisordersBeijingChina
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular DiseaseBeijingChina
| | - Yu Chen
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
- Center of Stroke, Beijing Institute for Brain DisordersBeijingChina
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular DiseaseBeijingChina
| | - Jun Yang
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
- Center of Stroke, Beijing Institute for Brain DisordersBeijingChina
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular DiseaseBeijingChina
| | - Heze Han
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
- Center of Stroke, Beijing Institute for Brain DisordersBeijingChina
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular DiseaseBeijingChina
| | - Ke Wang
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
- Center of Stroke, Beijing Institute for Brain DisordersBeijingChina
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular DiseaseBeijingChina
| | - Kexin Yuan
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
- Center of Stroke, Beijing Institute for Brain DisordersBeijingChina
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular DiseaseBeijingChina
| | - Yang Zhao
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- Department of NeurosurgeryPeking University International HospitalBeijingChina
| | - Junlin Lu
- Department of NeurosurgeryWest China Hospital, Sichuan UniversitySichuanChina
| | - Tu Li
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
- Center of Stroke, Beijing Institute for Brain DisordersBeijingChina
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular DiseaseBeijingChina
| | - Zhaobo Nie
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- Beijing Shunyi HospitalShunyi Teaching Hospital of Capital Medical UniversityBeijingPeople's Republic of China
| | - Yunfan Zhou
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
- Center of Stroke, Beijing Institute for Brain DisordersBeijingChina
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular DiseaseBeijingChina
| | - Guangzhi Shi
- Department of Critical Care MedicineBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Youxiang Li
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Yuanli Zhao
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
- Center of Stroke, Beijing Institute for Brain DisordersBeijingChina
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular DiseaseBeijingChina
| | - Xiaolin Chen
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
- Center of Stroke, Beijing Institute for Brain DisordersBeijingChina
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular DiseaseBeijingChina
| | - Shuo Wang
- Department of NeurosurgeryBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
- Center of Stroke, Beijing Institute for Brain DisordersBeijingChina
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular DiseaseBeijingChina
| |
Collapse
|
10
|
Valadkhani A, Gupta A, Bell M. Perioperative myocardial injury is associated with increased postoperative non-cardiac complications in patients undergoing vascular surgery: a post hoc analysis of a randomised clinical pilot trial. Perioper Med (Lond) 2023; 12:58. [PMID: 37957761 PMCID: PMC10644402 DOI: 10.1186/s13741-023-00350-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/05/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Elevated cardiac biomarkers, such as high-sensitivity cardiac Troponin T and N-terminal pro-B-type natriuretic peptide improve the prediction of major adverse cardiac events. However, very few trials have investigated the association between perioperative cardiac injury and non-cardiac complications. The primary aim of this study was to determine the association between peri-operative myocardial injury and non-cardiac complications in patients undergoing vascular surgery. Additionally, the association between elevated pre-operative high-sensitivity cardiac Troponin T or N-terminal pro-B-type natriuretic peptide and non-cardiac complications was explored. METHODS This study is a post hoc analysis of a multicentre randomised controlled trial. Patients were recruited from three centres in Sweden between 2016 and 2019. Cardiac troponin level was measured pre-operatively and at 4, 24, and 48 h after the start of surgery in patients undergoing vascular surgery. N-terminal pro-B-type natriuretic peptide was measured pre-operatively. The primary outcome was a composite of major postoperative non-cardiac complications assessed at 30 days. RESULTS A total of 184 patients undergoing peripheral or aortic vascular surgery were included in this study. The primary endpoint occurred in 67 (36%) patients. Perioperative myocardial injury was significantly associated with non-cardiac complications, with an adjusted odds ratio (OR) of 2.71 (95% confidence interval 1.33-5.55, P = 0.01). Sensitivity and specificity were 0.40 and 0.81, respectively. No association was found between pre-operative hs-cTnT or NT-proBNP and non-cardiac complications. CONCLUSION In this pilot study, we found that new peri-operative myocardial injury is associated with an increased risk of non-cardiac complications within 30 days after index surgery in patients undergoing vascular surgery. Pre-operative high-sensitivity cardiac Troponin T or N-terminal pro-B-type natriuretic peptide did not appear to predict non-cardiac complications. Larger studies are needed to confirm our findings. TRIAL REGISTRATION EudraCT database: 2016-001584-36.
Collapse
Affiliation(s)
- A Valadkhani
- Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital, Stockholm, Sweden.
- Department of Pharmacology and Physiology, Karolinska Institutet, Stockholm, Sweden.
| | - A Gupta
- Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital, Stockholm, Sweden
- Department of Pharmacology and Physiology, Karolinska Institutet, Stockholm, Sweden
| | - M Bell
- Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital, Stockholm, Sweden
- Department of Pharmacology and Physiology, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
11
|
Hinton J, Mariathas MN, Gabara L, Allan R, Nicholas Z, Kwok CS, Ramamoorthy S, Calver A, Corbett S, Jabbour RJ, Mahmoudi M, Rawlins J, Sirohi R, Wilkinson JR, Cook P, Martin GP, Mamas MA, Curzen N. Association between troponin level and medium-term mortality in 20 000 hospital patients. Heart 2023; 109:1772-1777. [PMID: 37550072 DOI: 10.1136/heartjnl-2023-322463] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 06/20/2023] [Indexed: 08/09/2023] Open
Abstract
INTRODUCTION Cardiac troponin (cTn) concentrations above the manufacturer recommended upper limit of normal (ULN) are frequently seen in hospital patients without a clinical presentation consistent with type 1 myocardial infarction, and the significance of this is uncertain. The aim of this study was to assess the relationship between medium-term mortality and cTn concentration in a large consecutive hospital population, regardless of whether there was a clinical indication for performing the test. METHOD This prospective observational study included 20 000 consecutive in-hospital and outpatient patients who had a blood test for any reason at a large teaching hospital, and in whom a hs-cTnI assay was measured, regardless of the original clinical indication. Mortality was obtained via NHS Digital. RESULTS A total of 20 000 patients were included in the analysis and 18 282 of these (91.4%) did not have a clinical indication for cardiac troponin I (cTnI) testing. Overall, 2825 (14.1%) patients died at a median of 809 days. The mortality was significantly higher if the cTnI concentration was above the ULN (45.3% vs 12.3% p<0.001 log rank). Multivariable Cox analysis demonstrated that the log10 cTnI concentration was independently associated with mortality (HR 1.76 (95% CI 1.65 to 1.88)). Landmark analysis, excluding deaths within 30 days, showed the relationship between cTnI concentration and mortality persisted. CONCLUSION In a large, unselected hospital population, in 91.4% of whom there was no clinical indication for testing, cTnI concentration was independently associated with medium-term cardiovascular and non-cardiovascular mortality in the statistical model tested.
Collapse
Affiliation(s)
- Jonathan Hinton
- University of Southampton, Southampton, UK
- Cardiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Mark Nihal Mariathas
- University of Southampton, Southampton, UK
- Cardiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Lavinia Gabara
- University of Southampton, Southampton, UK
- Cardiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Rick Allan
- Biochemistry, University Hospital Southampton NHD Foundation Trust, Southampton, UK, Southampton, UK
| | - Zoe Nicholas
- Cardiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Chun Shing Kwok
- Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK
| | - Sanjay Ramamoorthy
- Emergency Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Alison Calver
- Cardiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Simon Corbett
- Cardiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Richard J Jabbour
- Cardiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Michael Mahmoudi
- Cardiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - John Rawlins
- Cardiology, University Hospital Southampton NHS Trust, Southampton, UK
| | - Rohit Sirohi
- Cardiology, University Hospital Southampton NHS Trust, Southampton, UK
| | | | - Paul Cook
- Biochemistry, University Hospital Southampton NHD Foundation Trust, Southampton, UK, Southampton, UK
| | - Glen Philip Martin
- Farr Institute, University of Manchester Institute of Population Health, Manchester, UK
| | - Mamas A Mamas
- Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK
- Keele University, Keele, UK
| | - Nick Curzen
- University of Southampton, Southampton, UK
- Cardiology, University Hospital Southampton NHS Trust, Southampton, UK
| |
Collapse
|
12
|
Stahlschmidt A, Passos SC, Dornelles DD, Polanczyk C, Gutierrez CS, Minuzzi RR, Castro SMJ, Stefani LC. Troponin elevation as a marker of short deterioration and one-year death in a high-risk surgical patient cohort in a low and middle income country setting: a postoperative approach to increase surveillance. Can J Anaesth 2023; 70:1776-1788. [PMID: 37853279 DOI: 10.1007/s12630-023-02558-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 04/02/2023] [Accepted: 04/28/2023] [Indexed: 10/20/2023] Open
Abstract
PURPOSE Myocardial injury after noncardiac surgery is common and mostly asymptomatic. The ideal target population that will benefit from routine troponin measurements in low and middle income countries (LMICs) is unclear. This study aims to evaluate the clinical outcomes of a cohort of high-risk surgical patients according to high-sensitivity troponin T (hsTnT) in an LMIC setting. METHODS We conducted a prospective cohort study of 442 high-risk patients undergoing noncardiac surgery at a Brazilian hospital between February 2019 and March 2020. High-sensitivity troponin T levels were measured preoperatively, 24 hr, and 48 hr after surgery and stratified into three groups: normal (< 20 ng·L-1); minor elevation (20-65 ng·L-1); and major elevation (> 65 ng·L-1). We performed survival analysis to determine the association between myocardial injury and one-year mortality. We described medical interventions and evaluated unplanned intensive care unit (ICU) admission and complications using multivariable models. RESULTS Postoperative myocardial injury occurred in 45% of patients. Overall, 30-day mortality was 8%. Thirty-day and one-year mortality were higher in patients with hsTnT ≥ 20 ng·L-1. One-year mortality was 18% in the unaltered troponin group vs 31% and 41% for minor and major elevation groups, respectively. Multivariable analysis of one-year survival showed a hazard ratio (HR) of 1.94 (95% confidence interval [CI], 1.22 to 3.09) for the minor elevation group and a HR of 2.73 (95% CI, 1.67 to 4.45) for the troponin > 65 ng·L-1 group. Patients with altered troponin had more unplanned ICU admissions (13% vs 5%) and more complications (78% vs 48%). CONCLUSION This study supports evidence that hsTnT is an important prognostic marker and a strong predictor of all-cause mortality after surgery. Troponin measurement in high-risk surgical patients could potentially be used as tool to scale-up care in LMIC settings. STUDY REGISTRATION ClinicalTrials.gov (NCT04187664); first submitted 5 December 2019.
Collapse
Affiliation(s)
- Adriene Stahlschmidt
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Sávio C Passos
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Debora D Dornelles
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Carisi Polanczyk
- Cardiology Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Claudia S Gutierrez
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Rosangela R Minuzzi
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Stela M J Castro
- Department of Statistics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Luciana C Stefani
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
- Department of Surgery, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Rua Ramiro Barcelos, 2350, Porto Alegre, RS, 90035-903, Brazil.
| |
Collapse
|
13
|
Patel ABU, Bibawy PPWM, Althonayan JIM, Majeed Z, Gan WL, Abbott TEF, Ackland GL. Effect of transauricular nerve stimulation on perioperative pain: a single-blind, analyser-masked, randomised controlled trial. Br J Anaesth 2023; 130:468-476. [PMID: 36822987 PMCID: PMC10080471 DOI: 10.1016/j.bja.2022.12.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/05/2022] [Accepted: 12/22/2022] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Activation of central autonomic pathways, including those regulating the arterial baroreflex, might reduce acute pain. We tested the hypothesis that transcutaneous auricular nerve stimulation (TAN) reduces pain after orthopaedic trauma surgery through autonomic modulation. METHODS A total of 86 participants aged >18 yr were randomly assigned to 50 min of either sham or active bilateral TAN, undertaken before, and again 24 h after, surgery for orthopaedic trauma. The primary outcome was absolute change in pain 24 h postoperatively, comparing the 100 mm visual analogue scale (VAS) before and after TAN. Secondary outcomes included the minimal clinically important difference in pain (>10 mm increase or reduction in VAS) before/after surgery, using intention-to-treat analysis. Holter monitoring, the analysis of which was masked to allocation, quantified autonomic modulation of heart rate. RESULTS From June 22, 2021 to July 7, 2022, 79/86 participants (49 yr; 45% female) completed TAN before and after surgery. For the primary outcome, the mean reduction in VAS was 19 mm (95% confidence interval [CI]: 12-26) after active TAN (n=40), vs 10 mm (95% CI: 3-17) after sham TAN (n=39; P=0.023). A minimally clinically important reduction in postoperative pain occurred in 31/40 (78%) participants after active TAN, compared with 15/39 (38%) allocated to sham TAN (odds ratio 5.51 [95% CI: 2.06-14.73]; P=0.001). Only active TAN increased heart rate variability (log low-frequency power increased by 0.19 ms2 [0.01-0.37 ms2]). Prespecified adverse events (auricular skin irritation) occurred in six participants receiving active TAN, compared with two receiving sham TAN. CONCLUSION Bilateral TAN reduces perioperative pain through autonomic modulation. These proof-of-concept data support a non-pharmacological, generalisable approach to improve perioperative analgesia.
Collapse
Affiliation(s)
- Amour B U Patel
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
| | - Phillip P W M Bibawy
- Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, UK
| | | | - Zehra Majeed
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
| | - Weng L Gan
- Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, UK
| | - Tom E F Abbott
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
| | - Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK.
| |
Collapse
|
14
|
Nandate H, Takasaki Y, Nakata Y, Hamada T, Konishi A, Abe N, Kitamura S, Nishihara T, Yorozuya T. Incidence and characteristics of early elevation of cardiac troponin I after intrathoracic surgery: A single-center retrospective observational study. Medicine (Baltimore) 2023; 102:e33361. [PMID: 37000092 PMCID: PMC10063319 DOI: 10.1097/md.0000000000033361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 02/14/2023] [Accepted: 03/03/2023] [Indexed: 04/01/2023] Open
Abstract
The early elevation of cardiac troponins within 24 hours after noncardiac surgery is reportedly associated with increased postoperative morbidities. Several predisposing factors, including the frequent occurrence of hypoxia and increased pulmonary arterial pressure, may likely contribute to this elevation, especially after intrathoracic surgery. Therefore, this retrospective study aimed to elucidate the incidence and characteristics of the early elevation of cardiac troponin I after intrathoracic surgery. This study included 320 patients who underwent intrathoracic surgery between January 1, 2018, and June 30, 2021. Specific perioperative variables were retrospectively collected from their electrical clinical records. The serum concentration of high-sensitivity cardiac troponin I (hs cTnI) was measured twice immediately after the intensive care unit arrival and on the following day. We grouped these patients into two: the early elevation of hs cTnI (EECT) group (hs cTnI value > 26.2 ng/L by at least 1 measurement) and the non-early elevation (non-EECT) group. Patient characteristics were then compared between these groups. The hs cTnI level elevated within 24 hours postoperatively in 103 patients (32.2%). In univariate analysis, intraoperative variables, including the duration of unilateral ventilation (199.2 minutes, P = .0025) and surgery (210.6 minutes, P = .0012), estimated blood loss volume (406.7 mL, P = .0022), percentage of stored red blood cell (RBC) transfusion (10.7%, P = .0059), and percentage of lobectomy or combination of other lung resection types (88.3%, P = .00188), were significantly higher in the EECT group than in the non-EECT group. In the log-rank test, prolonged hospitalization was more prevalent in the EECT group (P = .0485). Furthermore, multivariate analysis revealed 3 independent risk factors for the early elevation of hs cTnI: coexisting chronic renal failure (odds ratio [OR], 3.25), lobectomy or combined resections (OR, 2.65), and stored RBC transfusion (OR, 3.41). The early elevation of hs cTnI commonly occurs after intrathoracic surgery, with an incidence of 32.2%. Its 3 independent risk factors are coexisting chronic renal failure, lung resection type, and stored RBC transfusion.
Collapse
Affiliation(s)
- Hideyuki Nandate
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Japan
- Division of Intensive Care, Ehime University Hospital, Toon, Japan
| | - Yasushi Takasaki
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Japan
- Division of Intensive Care, Ehime University Hospital, Toon, Japan
| | - Yukihiro Nakata
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Japan
- Division of Intensive Care, Ehime University Hospital, Toon, Japan
| | - Taisuke Hamada
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Amane Konishi
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Naoki Abe
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Sakiko Kitamura
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Tasuku Nishihara
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| | - Toshihiro Yorozuya
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Toon, Japan
| |
Collapse
|
15
|
Perioperative troponin surveillance in major noncardiac surgery: a narrative review. Br J Anaesth 2023; 130:21-28. [PMID: 36464518 DOI: 10.1016/j.bja.2022.08.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 08/08/2022] [Accepted: 08/31/2022] [Indexed: 12/03/2022] Open
Abstract
Myocardial injury is now an acknowledged complication in patients undergoing noncardiac surgery. Heterogeneity in the definitions of myocardial injury contributes to difficulty in evaluating the value of cardiac troponins (cTns) measurement in perioperative care. Pre-, post-, and peri-operatively increased cTns are encompassed by the umbrella term 'myocardial injury' and are likely to reflect different pathophysiological mechanisms. Increased cTns are independently associated with cardiovascular and non-cardiovascular complications, poor short-term and long-term cardiovascular outcomes, and increased mortality. Preoperative measurement of cTns aids preoperative risk stratification beyond the Revised Cardiac Risk Index. Systematic measurement detects acute perioperative increases and allows early identification of acute myocardial injury. Common definitions and standards for reporting are a prerequisite for designing impactful future trials and perioperative management strategies.
Collapse
|
16
|
Fowler AJ, Wan YI, Prowle JR, Chew M, Campbell D, Cuthbertson B, Wijeysundera DN, Pearse R, Abbott T. Long-term mortality following complications after elective surgery: a secondary analysis of pooled data from two prospective cohort studies. Br J Anaesth 2022; 129:588-597. [PMID: 35989114 PMCID: PMC9575043 DOI: 10.1016/j.bja.2022.06.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/24/2022] [Accepted: 06/04/2022] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Complications after surgery affect survival and quality of life. We aimed to confirm the relationship between postoperative complications and death within 1 yr after surgery. METHODS We conducted a secondary analysis of pooled data from two prospective cohort studies of patients undergoing surgery in five high-income countries between 2012 and 2014. Exposure was any complication within 30 days after surgery. Primary outcome was death within 1 yr after surgery, ascertained by direct follow-up or linkage to national registers. We adjusted for clinically important covariates using a mixed-effect multivariable Cox proportional hazards regression model. We conducted a planned subgroup analysis by type of complication. Data are presented as mean with standard deviation (sd), n (%), and adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs). RESULTS The pooled cohort included 10 132 patients. After excluding 399 (3.9%) patients with missing data or incomplete follow-up, 9733 patients were analysed. The mean age was 59 [sd 16.8] yr, and 5362 (55.1%) were female. Of 9733 patients, 1841 (18.9%) had complications within 30 days after surgery, and 319 (3.3%) died within 1 yr after surgery. Of 1841 patients with complications, 138 (7.5%) died within 1 yr after surgery compared with 181 (2.3%) of 7892 patients without complications (aHR 1.94 [95% CI: 1.53-2.46]). Respiratory failure was associated with the highest risk of death, resulting in six deaths amongst 28 patients (21.4%). CONCLUSIONS Postoperative complications are associated with increased mortality at 1 yr. Further research is needed to identify patients at risk of complications and to reduce mortality.
Collapse
Affiliation(s)
- Alexander J Fowler
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Yize I Wan
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - John R Prowle
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Michelle Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Douglas Campbell
- Department of Anaesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Brian Cuthbertson
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesia, St Michael's Hospital, Toronto, ON, Canada
| | - Rupert Pearse
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Tom Abbott
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK.
| |
Collapse
|
17
|
Clerico A, Zaninotto M, Aimo A, Musetti V, Perrone M, Padoan A, Dittadi R, Sandri MT, Bernardini S, Sciacovelli L, Trenti T, Malloggi L, Moretti M, Burgio MA, Manno ML, Migliardi M, Fortunato A, Plebani M. Evaluation of the cardiovascular risk in patients undergoing major non-cardiac surgery: role of cardiac-specific biomarkers. Clin Chem Lab Med 2022; 60:1525-1542. [PMID: 35858238 DOI: 10.1515/cclm-2022-0481] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/05/2022] [Indexed: 11/15/2022]
Abstract
Major adverse cardiovascular events are frequently observed in patients undergoing major non-cardiac surgery during the peri-operative period. At this time, the possibility to predict cardiovascular events remains limited, despite the introduction of several algorithms to calculate the risk of adverse events, mainly death and major adverse cardiovascular events (MACE) based on the clinical history, risk factors (sex, age, lipid profile, serum creatinine) and non-invasive cardiac exams (electrocardiogram, echocardiogram, stress tests). The cardiac-specific biomarkers natriuretic peptides (NPs) and cardiac troponins (cTn) have been proposed as additional tools for risk prediction in the peri-operative period, particularly for the identification of myocardial injury in patients undergoing major non-cardiac surgery. The prognostic information from the measurement of BNP/NT-proBNP and hs-cTn is independent and complementary to other important indicators of risk, also including ECG and imaging techniques. Elevated levels of cardiac-specific biomarkers before surgery are associated with a markedly higher risk of MACE during the peri-operative period. BNP/NT-proBNP and hs-cTn should be measured in all patients during the clinical evaluation before surgery, particularly during intermediate- or high-risk surgery, in patients aged >65 years and/or with comorbidities. Several questions remain to be assessed in dedicated clinical studies, such as how to optimize the management of patients with raised cardiac specific biomarkers before surgery, and whether a strategy based on biomarker measurement improves patient outcomes and is cost-effective.
Collapse
Affiliation(s)
- Aldo Clerico
- Scuola Superiore Sant'Anna e Fondazione CNR-Regione Toscana G. Monasterio, Pisa, Italy
| | - Martina Zaninotto
- Dipartimento di Medicina di Laboratorio, Università-Ospedale di Padova e Azienda Ospedaliera Universitaria di Padova, e Dipartimento di Medicina-Università di Padova, Padova, Italy
| | - Alberto Aimo
- Scuola Superiore Sant'Anna e Fondazione CNR-Regione Toscana G. Monasterio, Pisa, Italy
| | - Veronica Musetti
- Scuola Superiore Sant'Anna e Fondazione CNR-Regione Toscana G. Monasterio, Pisa, Italy
| | - Marco Perrone
- Dipartimento di Medicina Sperimentale, Università di Roma Tor Vergata, Roma, Italy
| | - Andrea Padoan
- Dipartimento di Medicina di Laboratorio, Università-Ospedale di Padova e Azienda Ospedaliera Universitaria di Padova, e Dipartimento di Medicina-Università di Padova, Padova, Italy
| | | | | | - Sergio Bernardini
- Dipartimento di Medicina Sperimentale, Università di Roma Tor Vergata, Roma, Italy
| | - Laura Sciacovelli
- Dipartimento di Medicina di Laboratorio, Università-Ospedale di Padova e Azienda Ospedaliera Universitaria di Padova, e Dipartimento di Medicina-Università di Padova, Padova, Italy
| | - Tommaso Trenti
- Dipartimento di Medicina di Laboratorio e Anatomia Patologica, Azienda Ospedaliera Universitaria e USL di Modena, Modena, Italy
| | - Lucia Malloggi
- Laboratorio Analisi, Azienda Ospedaliera-Universitaria di Pisa, Pisa, Italy
| | - Marco Moretti
- Medicina di Laboratorio, AOU Ospedali Riuniti Ancona, Ancona, Italy
| | | | | | - Marco Migliardi
- Laboratorio Analisi, Ospedale Ordine Mauriziano, Torino, Italy
| | | | - Mario Plebani
- Dipartimento di Medicina di Laboratorio-DIMED, Università di Padova, Padova, Italy
| |
Collapse
|
18
|
Lan L, Shu Q, Yu C, Pei L, Zhang Y, Xu L, Huang Y. Incidence and risk factors for myocardial injury after laparoscopic adrenalectomy for pheochromocytoma: A retrospective cohort study. Front Oncol 2022; 12:979994. [PMID: 36172145 PMCID: PMC9511041 DOI: 10.3389/fonc.2022.979994] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPheochromocytoma is a rare catecholamine-secreting tumor. Tumor resection remains a high-risk procedure due to intraoperative hemodynamic instability nowadays, which may lead to myocardial injury. We aimed to determine the incidence and associated risk factors for myocardial injury after laparoscopic adrenalectomy for pheochromocytoma.MethodsAdult patients (n=350, American Society of Anesthesiology physical status 1–3) who underwent elective laparoscopic adrenalectomy for pheochromocytoma under general anesthesia between January 31, 2013 and January 31, 2020 were included in this observational, retrospective, single-center, cohort study. Blood troponin I levels were measured before and during the first 2 days after surgery. Myocardial injury was defined as an elevated troponin I level exceeding the 99th percentile upper reference limit due to cardiac ischemic causes.ResultsMyocardial injury occurred in 42/350 patients (12.0%, 95% confidence interval: 9.0%–15.9%). In multivariable analysis (adjusted odds ratios [95% confidence intervals]), previous ischemic heart disease or stroke (5.04 [1.40–18.08]; P=0.013), intraoperative heart rate >115 bpm (2.55 [1.06–6.12]; P=0.036), intraoperative systolic blood pressure >210 mmHg (2.38 [1.00–5.66]; P=0.049), and perioperative decrease in hemoglobin level(1.74 [1.15–2.64] per g/dL decrease; P=0.008) were associated with an increased risk of myocardial injury. For the cumulative duration of dichotomized intraoperative hemodynamics, multivariable analysis showed that intraoperative heart rate >115 bpm for >1 minute (2.67 [1.08–6.60]; P=0.034) and systolic blood pressure >210 mmHg for >1 minute (3.78 [1.47–9.73]; P=0.006) were associated with an increased risk of myocardial injury. The risk of myocardial injury progressively increased with a longer cumulative duration of intraoperative tachycardia and hypertension.ConclusionsThere is a high incidence of myocardial injury after laparoscopic adrenalectomy for pheochromocytoma. The identified risk factors may assist physicians in detecting high-risk patients and providing guidance for intraoperative hemodynamics and perioperative hemoglobin management.
Collapse
Affiliation(s)
- Ling Lan
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Qian Shu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Chunhua Yu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Lijian Pei
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yuelun Zhang
- Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Li Xu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- *Correspondence: Li Xu, ; Yuguang Huang,
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- *Correspondence: Li Xu, ; Yuguang Huang,
| |
Collapse
|
19
|
Surgery in older patients: learning from shared decision-making in intensive care. Br J Anaesth 2022; 129:652-655. [PMID: 36109204 DOI: 10.1016/j.bja.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 11/21/2022] Open
Abstract
An increasing number of older patients are having surgical treatments. Similar to older patients admitted to intensive care, they present with additional problems including multimorbidity, frailty, and cognitive impairment. In both intensive care and surgical settings, comprehensive assessment can inform targeted interventions and shared decision-making. We explore the challenges faced by older patients, and by the clinicians treating them.
Collapse
|
20
|
Patel AB, Bibawy PP, Majeed Z, Gan WL, Ackland GL. Trans-auricular vagus nerve stimulation to reduce perioperative pain and morbidity: protocol for a single-blind analyser-masked randomised controlled trial. BJA OPEN 2022; 2:None. [PMID: 35832337 PMCID: PMC9258962 DOI: 10.1016/j.bjao.2022.100017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 05/02/2022] [Accepted: 05/18/2022] [Indexed: 11/22/2022]
Abstract
Background Established or acquired loss of parasympathetic vagal tone is associated with complications, including pain, after noncardiac surgery. We describe a study protocol designed to test the hypothesis that transcutaneous auricular nerve stimulation may preserve efferent parasympathetic activity to reduce pain and morbidity after noncardiac surgery. Methods Participants aged >18 yr scheduled for urgent/elective orthopaedic surgery (n=86) will be randomly allocated to bilateral transcutaneous auricular nerve stimulation or sham protocol for 50 min at the same time of day, before and 24 h after surgery. Holter monitoring, the analysis of which is masked to allocation, will quantify autonomic modulation of HR. The primary outcome will be pain, quantified by absolute changes in VAS 24 h after surgery following sham or stimulation. Secondary outcomes include presence or absence of >10 mm change in the 100 mm VAS (which defines a minimum clinically important change) and postoperative morbidity (Postoperative Morbidity Survey) before and 24 h after surgery. The relationship between the explanatory variable (HR variability), VAS, and morbidity will be examined using a multilevel (mixed-error component) regression model. Safety and complications of the intervention will also be recorded. The study was approved by the NHS Research Ethics Committee (21/LO/0272). As of 25 December 2021, 34/86 participants (mean [standard deviation] age: 48 [19] yr; 14 females [41.2%]) have been recruited, with complete collection of Holter data. Conclusions This phase 2b study will explore whether noninvasive autonomic neuromodulation may reduce pain or morbidity using trans-auricular vagus nerve stimulation, providing proof-of-concept data for a non-pharmacological, generalisable approach to improve perioperative outcomes. Clinical trial registration Researchregistry7566.
Collapse
Affiliation(s)
- Amour B.U. Patel
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Phillip P.W.M. Bibawy
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Zehra Majeed
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Weng Liang Gan
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Gareth L. Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| |
Collapse
|
21
|
Natriuretic Peptides and Troponins to Predict Cardiovascular Events in Patients Undergoing Major Non-Cardiac Surgery. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19095182. [PMID: 35564577 PMCID: PMC9103429 DOI: 10.3390/ijerph19095182] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/17/2022] [Accepted: 04/19/2022] [Indexed: 02/01/2023]
Abstract
Patients undergoing major surgery have a substantial risk of cardiovascular events during the perioperative period. Despite the introduction of several risk scores based on medical history, classical risk factors and non-invasive cardiac tests, the possibility of predicting cardiovascular events in patients undergoing non-cardiac surgery remains limited. The cardiac-specific biomarkers, natriuretic peptides (NPs) and cardiac troponins (cTn) have been proposed as additional tools for risk prediction in the perioperative period. This review paper aims to discuss the value of preoperative levels and perioperative changes in cardiac-specific biomarkers to predict adverse outcomes in patients undergoing major non-cardiac surgery. Based on several prospective observational studies and six meta-analyses, some guidelines recommended the measurement of NPs to refine perioperative cardiac risk estimation in patients undergoing non-cardiac surgery. More recently, several studies reported a higher mortality in surgical patients presenting an elevation in high-sensitivity cardiac troponin T and I, especially in elderly patients or those with comorbidities. This evidence should be considered in future international guidelines on the evaluation of perioperative risk in patients undergoing major non-cardiac surgery.
Collapse
|
22
|
Reply to: Monitors are not a treatment. Ugeskr Laeger 2022; 39:180. [PMID: 34980852 DOI: 10.1097/eja.0000000000001534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
23
|
Patel ABU, Weber V, Gourine AV, Ackland GL. The potential for autonomic neuromodulation to reduce perioperative complications and pain: a systematic review and meta-analysis. Br J Anaesth 2022; 128:135-149. [PMID: 34801224 PMCID: PMC8787777 DOI: 10.1016/j.bja.2021.08.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/09/2021] [Accepted: 08/25/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Autonomic dysfunction promotes organ injury after major surgery through numerous pathological mechanisms. Vagal withdrawal is a key feature of autonomic dysfunction, and it may increase the severity of pain. We systematically evaluated studies that examined whether vagal neuromodulation can reduce perioperative complications and pain. METHODS Two independent reviewers searched PubMed, EMBASE, and the Cochrane Register of Controlled Clinical Trials for studies of vagal neuromodulation in humans. Risk of bias was assessed; I2 index quantified heterogeneity. Primary outcomes were organ dysfunction (assessed by measures of cognition, cardiovascular function, and inflammation) and pain. Secondary outcomes were autonomic measures. Standardised mean difference (SMD) using the inverse variance random-effects model with 95% confidence interval (CI) summarised effect sizes for continuous outcomes. RESULTS From 1258 records, 166 full-text articles were retrieved, of which 31 studies involving patients (n=721) or volunteers (n=679) met the inclusion criteria. Six studies involved interventional cardiology or surgical patients. Indirect stimulation modalities (auricular [n=23] or cervical transcutaneous [n=5]) were most common. Vagal neuromodulation reduced pain (n=10 studies; SMD=2.29 [95% CI, 1.08-3.50]; P=0.0002; I2=97%) and inflammation (n=6 studies; SMD=1.31 [0.45-2.18]; P=0.003; I2=91%), and improved cognition (n=11 studies; SMD=1.74 [0.96-2.52]; P<0.0001; I2=94%) and cardiovascular function (n=6 studies; SMD=3.28 [1.96-4.59]; P<0.00001; I2=96%). Five of six studies demonstrated autonomic changes after vagal neuromodulation by measuring heart rate variability, muscle sympathetic nerve activity, or both. CONCLUSIONS Indirect vagal neuromodulation improves physiological measures associated with limiting organ dysfunction, although studies are of low quality, are susceptible to bias and lack specific focus on perioperative patients.
Collapse
Affiliation(s)
- Amour B U Patel
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
| | - Valentin Weber
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
| | - Alexander V Gourine
- Centre for Cardiovascular and Metabolic Neuroscience, Neuroscience, Physiology and Pharmacology, University College London, London, UK
| | - Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK.
| |
Collapse
|
24
|
Wang X, Wang P, Cao R, Yang X, Xiao W, Zhang Y, Sheng L, Ye P. High-Sensitivity Cardiac Troponin T Is a Risk Factor for Major Adverse Cardiovascular Events and All-Cause Mortality: A 9.5-Year Follow-Up Study. Cardiol Res Pract 2021; 2021:6647987. [PMID: 34484819 PMCID: PMC8413051 DOI: 10.1155/2021/6647987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 08/17/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The relationship between high-sensitivity cardiac troponin T (hs-cTnT) and different cardiovascular events has been observed in several large community studies, and the results have been controversial. However, there is currently no cross-sectional or longitudinal follow-up study on hs-cTnT in the Chinese population. METHODS We analyzed the association of plasma hs-cTnT levels with major adverse cardiovascular events (MACEs) and all-cause mortality in 1325 subjects from a longitudinal follow-up community-based population in Beijing, China. RESULTS In the Cox proportional hazards models analysis, the risk of MACEs increased with the increase of hs-cTnT levels (HR, 1.223, 95% CI, 1.054-1.418, P=0.008). Increased hs-cTnT levels were associated with coronary events (HR, 1.391, 95% CI, 1.106-1.749, P=0.005) in Model 4. Cox proportional risk regression model analysis revealed that increased hs-cTnT levels were associated with an increased risk of mortality (HR, 1.763, 95% CI, 1.224-2.540, P=0.002), even after adjusting hs-CRP and NT-proBNP. The area under the ROC curve for predicting MACEs was 0.559 (95% CI, 0.523-0.595, P=0.001). The areas under the ROC curve for predicting coronary events and mortality were 0.629 (95% CI, 0.580-0.678, P < 0.001) and 0.644 (95% CI, 0.564-0.725, P < 0.001), respectively. CONCLUSIONS Our findings in the Chinese cohort support that hs-cTnT is a risk factor for major adverse cardiovascular events and all-cause mortality.
Collapse
Affiliation(s)
- Xiaona Wang
- Department of Geriatric Cardiology, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Peiqi Wang
- Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Ruihua Cao
- Department of Geriatric Cardiology, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Xu Yang
- Department of Geriatric Cardiology, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Wenkai Xiao
- Department of Geriatric Cardiology, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Yun Zhang
- Department of Geriatric Cardiology, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Li Sheng
- Department of Geriatric Cardiology, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Ping Ye
- Department of Geriatric Cardiology, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| |
Collapse
|
25
|
Lin F, Chen Y, He Q, Zeng C, Zhang C, Chen X, Zhao Y, Wang S, Zhao J. Prognostic Value of Elevated Cardiac Troponin I After Aneurysmal Subarachnoid Hemorrhage. Front Neurol 2021; 12:677961. [PMID: 34135855 PMCID: PMC8200557 DOI: 10.3389/fneur.2021.677961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/21/2021] [Indexed: 02/04/2023] Open
Abstract
Object: Patients with aneurysmal subarachnoid hemorrhage (aSAH) have an increased incidence of cardiac events and short-term unfavorable neurological outcomes during the acute phase of bleeding. We studied whether troponin I elevation after ictus can predict future major adverse cardiac events (MACEs) and long-term neurological outcomes after 2 years. Methods: Consecutive aSAH patients within 3 days of bleeding were eligible for review from a prospective observational cohort (ClinicalTrials.gov Identifier: NCT04785976). Potential predictors of future MACEs and unfavorable long-term neurological outcomes were calculated by Cox and logistic regression analyses. Additional Kaplan–Meier curves were performed. Results: A total of 213 patients were enrolled with an average follow-up duration of 34.3 months. Individuals were divided into two groups: elevated cTnI group and unelevated cTnI group. By the last available follow-up, 20 patients had died, with an overall all-cause mortality rate of 9.4% and an annual all-cause mortality rate of 3.8%. Patients with elevated cTnI had a significantly higher risk of future MACEs (10.6 vs. 2.1%, p = 0.024, and 95% CI: 1.256–23.875) and unfavorable neurological outcomes at discharge, 3-month, 1-, 2-years, and last follow-up (p = 0.001, p < 0.001, p = 0.001, p < 0.001, and p < 0.001, respectively). In the Cox analysis for future MACE, elevated cTnI was the only independent predictor (HR = 5.980; 95% CI: 1.428–25.407, and p = 0.014). In the multivariable logistic analysis for unfavorable neurological outcomes, peak cTnI was significant (OR = 2.951; 95% CI: 1.376–6.323; p = 0.005). Kaplan–Meier analysis indicated that the elevated cTnI was correlated with future MACE (log-rank test, p = 0.007) and subsequent death (log-rank test, p = 0.004). Conclusion: cTnI elevation after aSAH could predict future MACEs and unfavorable neurological outcomes.
Collapse
Affiliation(s)
- Fa Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Qiheng He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chaofan Zeng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chaoqi Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Savaid Medical School, University of the Chinese Academy of Sciences, Beijing, China
| |
Collapse
|
26
|
Abstract
PURPOSE OF REVIEW After successfully reducing mortality in the operating room, the time has come for anesthesiologists to conquer postoperative complications. This review aims to raise awareness about myocardial injury after noncardiac surgery (MINS), its definition, diagnosis, clinical importance, and treatment. RECENT FINDINGS MINS, defined as an elevated postoperative troponin judged to be due to myocardial ischemia (with or without ischemic features), occurs in up to one in five patients having noncardiac surgery and is responsible for 16% of all postoperative deaths within 30 days of surgery. New evidence on risk factors, etiology, potential prevention strategies, treatment options, and the economic impact of MINS highlights the actionability of perioperative clinicians in caring for adult patients who are considered to be at risk of cardiovascular complications. SUMMARY Millions of patients safely going through surgery suffer MINS and die shortly after the procedure every year. Without a structured approach to predicting, preventing, diagnosing, and treating MINS, we lose the opportunity to provide our patients with the best chance of deriving benefit from noncardiac surgery. The perioperative community needs to come together, appreciate the clinical relevance of MINS, and step up with high-quality research in the future.
Collapse
|
27
|
Abbott TEF, Howell S, Pearse RM, Ackland GL. Mode of blood pressure monitoring and morbidity after noncardiac surgery: A prospective multicentre observational cohort study. Eur J Anaesthesiol 2021; 38:468-476. [PMID: 33443380 DOI: 10.1097/eja.0000000000001443] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Control of blood pressure remains a key goal of peri-operative care, because hypotension is associated with adverse outcomes after surgery. OBJECTIVES We explored whether increased vigilance afforded by intra-arterial blood pressure monitoring may be associated with less morbidity after surgery. DESIGN A prospective observational cohort study. SETTING Four UK secondary care hospitals. PATIENTS A total of 4342 patients ≥45 years who underwent noncardiac surgery. METHODS We compared outcome of patients who received peri-operative intra-arterial blood pressure monitoring with those whose blood pressure was measured noninvasively. OUTCOMES The primary outcome was peri-operative myocardial injury (high-sensitivity troponin-T ≥ 15 ng l-1 within 72 h after surgery), compared between patients who received intra-arterial versus noninvasive blood pressure monitoring. Secondary outcomes were morbidity within 72 h of surgery (postoperative morbidity survey), and vasopressor and fluid therapy. Multivariable logistic regression analysis explored associations between morbidity and age, sex, location of postoperative care, mode of blood pressure/haemodynamic monitoring and Revised Cardiac Risk Index. RESULTS Intra-arterial monitoring was used in 1137/4342 (26.2%) patients. Myocardial injury occurred in 440/1137 (38.7%) patients with intra-arterial monitoring compared with 824/3205 (25.7%) with noninvasive monitoring [OR 1.82 (95% CI 1.58 to 2.11), P < 0.001]. Intra-arterial monitoring remained associated with myocardial injury when adjusted for potentially confounding variables [adjusted OR 1.56 (1.29 to 1.89), P < 0.001). The results were similar for planned ICU versus ward postoperative care. CONCLUSIONS Intra-arterial monitoring is associated with greater risk of morbidity after noncardiac surgery, after controlling for surgical and patient factors. These data provide useful insights into the design of a definitive monitoring trial.
Collapse
Affiliation(s)
- Tom E F Abbott
- From the Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, EC1 M 6BQ (Abbott, Pearse, Ackland), and Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK (Howell)
| | | | | | | |
Collapse
|
28
|
Lamidi S, Baker DM, Wilson MJ, Lee MJ. Remote Ischemic Preconditioning in Non-cardiac Surgery: A Systematic Review and Meta-analysis. J Surg Res 2021; 261:261-273. [PMID: 33460972 DOI: 10.1016/j.jss.2020.12.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/10/2020] [Accepted: 12/16/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Remote ischemic preconditioning (RIPC) may mitigate physiological stress related to surgery. There is no clear consensus on conduct of RIPC studies, or whether it is effective. The aim of this study was to (i) assess delivery of RIPC, (ii) identify reported outcomes, (iii) measure effect on key clinical outcomes. METHODS This review was registered on PROSPERO (CRD:42020180725). EMBASE and Medline databases were searched, and results screened by two reviewers. Full-texts were assessed for eligibility by two reviewers. Data extracted were methods of RIPC and outcomes reported. Meta-analysis of key clinical events was performed using a Mantel-Haenszel random effects model. The TIDieR framework was used to assess intervention reporting, and Cochrane risk of bias tool was used for all studies included. RESULTS Searches identified 25 studies; 25 were included in the narrative analysis and 18 in the meta-analysis. RIPC was frequently performed by occluding arm circulation (15/25), at 200 mmHg (9/25), with three cycles of 5 min ischemia and 5 min of reperfusion (16/25). No study fulfilled all 12 TIDieR items (mean score 7.68). Meta-analysis showed no benefit of RIPC on MI (OR 0.71 95% CI 0.48-1.04, I2 = 0%), mortality (OR 0.56, 95% CI 0.31-1.01, I2 = 0%), or acute kidney injury (OR 0.72 95% CI 0.48-1.08). CONCLUSIONS RIPC could be standardized as 200 mmHg pressure in 3 × 5 min on and off cycles. The signal of benefit should be explored in a larger well-designed randomized trial.
Collapse
Affiliation(s)
- Segun Lamidi
- The Medical School, University of Sheffield, Sheffield, UK
| | - Daniel M Baker
- Academic Directorate of General Surgery, Sheffield Teaching Hospitals NHS FT, Sheffield, UK
| | - Matthew J Wilson
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Matthew J Lee
- Academic Directorate of General Surgery, Sheffield Teaching Hospitals NHS FT, Sheffield, UK; Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, UK.
| |
Collapse
|
29
|
Sanders RD, Craigova L, Schessler B, Casey C, White M, Parker M, Kunkel D, Blennow K, Zetterberg H, Pearce RA, Lennertz R. Postoperative troponin increases after noncardiac surgery are associated with raised neurofilament light: a prospective observational cohort study. Br J Anaesth 2020; 126:791-798. [PMID: 33158499 DOI: 10.1016/j.bja.2020.10.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 10/07/2020] [Accepted: 10/10/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Myocardial and neuronal injury occur commonly after noncardiac surgery. We examined whether patients who had perioperative myocardial injury (PMI) also incurred neuronal injury, and whether myocardial and neuronal injury were associated with similar changes in inflammatory markers or overlapping clinical predictors. METHODS A total of 114 individuals >65 yr old were recruited from two ongoing perioperative cohort studies (NCT02926417; NCT03124303). Plasma samples were collected before and daily after surgery to process assays for troponin I (PMI), neurofilament light (NfL; neuronal injury) and multiplexed plasma cytokines (inflammation). The primary outcome was the change in NfL in individuals with PMI (>40 pg ml-1 increase in troponin above preoperative values). We conducted logistic regression to identify if there were shared clinical predictors for myocardial and neuronal injury. RESULTS Ninety-six patients had paired NfL and troponin data. Twenty-three of 94 subjects (24%) with PMI had greater increases in NfL (median [inter-quartile range, IQR]: 29 pg ml-1 [3-95 pg ml-1]; 2.8-fold increase) compared with subjects with no troponin increase (8 pg ml-1 [3-20]; 1.3-fold increase; P=0.008). PMI was associated with increased interleukin (IL)-1ra (P=0.005), IL-2 (P=0.045), IL-8 (P=0.002), and IL-10 (P<0.001). Logistic regression showed that intraoperative hypotension was associated with PMI (P=0.043). Preoperative stroke (P=0.041) and blood loss (P=0.002), but not intraoperative hypotension, were associated with increased NfL. CONCLUSIONS Postoperative troponin increases were associated with changes in NfL and inflammatory cytokines. Increases in troponin, but not NfL, were associated with intraoperative hypotension, suggesting differences in the mechanisms contributing to neuronal and myocardial injury.
Collapse
Affiliation(s)
- Robert D Sanders
- University of Sydney, Sydney, NSW, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, NSW, Australia; Institute of Academic Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.
| | - Lenka Craigova
- Medical Student Training Program, University of Wisconsin, Madison, WI, USA
| | | | - Cameron Casey
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Marissa White
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Margaret Parker
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - David Kunkel
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden; Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK; UK Dementia Research Institute at UCL, London, UK
| | - Robert A Pearce
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Richard Lennertz
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| |
Collapse
|
30
|
May SM, Abbott TEF, Del Arroyo AG, Reyes A, Martir G, Stephens RCM, Brealey D, Cuthbertson BH, Wijeysundera DN, Pearse RM, Ackland GL. MicroRNA signatures of perioperative myocardial injury after elective noncardiac surgery: a prospective observational mechanistic cohort study. Br J Anaesth 2020; 125:661-671. [PMID: 32718726 PMCID: PMC7678162 DOI: 10.1016/j.bja.2020.05.066] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/08/2020] [Accepted: 05/31/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Elevated plasma or serum troponin, indicating perioperative myocardial injury (PMI), is common after noncardiac surgery. However, underlying mechanisms remain unclear. Acute coronary syndrome (ACS) is associated with the early appearance of circulating microRNAs, which regulate post-translational gene expression. We hypothesised that if PMI and ACS share pathophysiological mechanisms, common microRNA signatures should be evident. METHODS We performed a nested case control study of samples obtained before and after noncardiac surgery from patients enrolled in two prospective observational studies of PMI (postoperative troponin I/T>99th centile). In cohort one, serum microRNAs were compared between patients with or without PMI, matched for age, gender, and comorbidity. Real-time polymerase chain reaction quantified (qRT-PCR) relative microRNA expression (cycle quantification [Cq] threshold <37) before and after surgery for microRNA signatures associated with ACS, blinded to PMI. In cohort two, we analysed (EdgeR) microRNA from plasma extracellular vesicles using next-generation sequencing (Illumina HiSeq 500). microRNA-messenger RNA-function pathway analysis was performed (DIANA miRPath v3.0/TopGO). RESULTS MicroRNAs were detectable in all 59 patients (median age 67 yr [61-75]; 42% male), who had similar clinical characteristics independent of developing PMI. In cohort one, serum microRNA expression increased after surgery (mean fold-change) hsa-miR-1-3p: 3.99 (95% confidence interval [CI: 1.95-8.19]; hsa-miR-133-3p: 5.67 [95% CI: 2.94-10.91]; P<0.001). These changes were not associated with PMI. Bioinformatic analysis of differentially expressed microRNAs from cohorts one (n=48) and two (n=11) identified pathways associated with adrenergic stress and calcium dysregulation, rather than ischaemia. CONCLUSIONS Circulating microRNAs associated with cardiac ischaemia were universally elevated in patients after surgery, independent of development of myocardial injury.
Collapse
Affiliation(s)
- Shaun M May
- Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Tom E F Abbott
- Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Ana G Del Arroyo
- Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Anna Reyes
- University College London NHS Hospitals Trust, London, UK
| | - Gladys Martir
- University College London NHS Hospitals Trust, London, UK
| | | | - David Brealey
- University College London NHS Hospitals Trust, London, UK
| | - Brian H Cuthbertson
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Science Centre, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Rupert M Pearse
- Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Gareth L Ackland
- Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK.
| |
Collapse
|
31
|
|
32
|
Hinton J, Gabara L, Curzen N. Is the true clinical value of high-sensitivity troponins as a biomarker of risk? The concept that detection of high-sensitivity troponin 'never means nothing'. Expert Rev Cardiovasc Ther 2020; 18:843-857. [PMID: 32966128 DOI: 10.1080/14779072.2020.1828063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION High-sensitivity troponin (hs-cTn) assays are central to the diagnosis of myocardial infarction (MI). Their increased sensitivity has facilitated rapid pathways for the exclusion of MI. However, hs-cTn is now more readily detectable in patients without symptoms typical of MI, in whom a degree of myocardial injury is assumed. Recently, the practice of using the 99th centile of hs-cTn as a working 'upper reference limit' has been challenged. There is increasing evidence that hs-cTn may provide useful prognostic information, regardless of any suspicion of MI, and as such these assays may have potential as a general biomarker for mortality. This raises the concept that detection of hs-cTn 'never means nothing.' AREAS COVERED In this review, we will evaluate the evidence for the use of hs-cTn assays outside their common clinical indication to rule out or diagnose acute MI. EXPERT OPINION The data presented suggest that hs-cTn testing may in the future have a generalized role as a biomarker of mortality risk and may be used less as a test for ruling in acute MI, but will remain a frontline test to exclude that diagnosis in ED. Further, the data suggest that the detection of hs-cTn 'never means nothing.'
Collapse
Affiliation(s)
- Jonathan Hinton
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust , Southampton, UK.,Faculty of Medicine, University of Southampton , Southampton, UK
| | - Lavinia Gabara
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust , Southampton, UK.,Faculty of Medicine, University of Southampton , Southampton, UK
| | - Nick Curzen
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust , Southampton, UK.,Faculty of Medicine, University of Southampton , Southampton, UK
| |
Collapse
|