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Zare-Zadeh S, Manns BJ, Chew DS, Harrison TG, Au F, Quinn AE. Low-value preoperative cardiac testing before low-risk surgical procedures: a population-based cohort study. CMAJ Open 2023; 11:E451-E458. [PMID: 37220955 PMCID: PMC10212574 DOI: 10.9778/cmajo.20220049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Choosing Wisely Canada (CWC) recommends avoiding noninvasive advanced cardiac testing (e.g., exercise stress testing [EST], echocardiography and myocardial perfusion imaging [MPI]) for preoperative assessment in patients scheduled to undergo low-risk noncardiac surgery. In this study, we assessed the temporal trends in testing, overlapping with the introduction of the CWC recommendations in 2014, and patient and provider factors associated with low-value testing. METHODS In this population-based retrospective cohort study, we used linked health administrative data in Alberta, Canada, to identify adult patients who underwent elective noncardiac surgery between Apr. 1, 2011, and Mar. 31, 2019, who had preoperative noninvasive advanced cardiac tests (EST, echocardiography or MPI) within 6 months before surgery. We included electrocardiography as an exploratory outcome. We excluded patients at high risk using the Revised Cardiac Risk Index (score ≥ 1 considered to indicate high risk), and modelled patient and temporal factors associated with the number of tests. RESULTS We identified 1 045 896 elective noncardiac operations performed in 798 599 patients and 25 599 advanced preoperative cardiac tests; 2.1% of operations were preceded by advanced cardiac testing. The incidence of testing increased over the study period, and, by 2018/19, patients were 1.3 times (95% confidence interval 1.2-1.4) more likely to receive a preoperative advanced test compared to 2011/12. Urban patients were more likely to receive a preoperative advanced cardiac test than their rural counterparts. Electrocardiography was the most common preoperative cardiac test, preceding 182 128 procedures (17.4%). INTERPRETATION Preoperative advanced cardiac testing was infrequent in adult Albertans who underwent low-risk elective noncardiac operations. Despite CWC recommendations, the use of some tests appears to be increasing, and there was substantial variation across geographic areas.
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Affiliation(s)
- Siavash Zare-Zadeh
- Cumming School of Medicine (Zare-Zadeh, Manns, Chew, Harrison, Au), Department of Community Health Sciences (Manns, Harrison, Quinn), Libin Cardiovascular Institute (Manns, Chew) and O'Brien Institute for Public Health (Manns), University of Calgary, Calgary, Alta
| | - Braden J Manns
- Cumming School of Medicine (Zare-Zadeh, Manns, Chew, Harrison, Au), Department of Community Health Sciences (Manns, Harrison, Quinn), Libin Cardiovascular Institute (Manns, Chew) and O'Brien Institute for Public Health (Manns), University of Calgary, Calgary, Alta.
| | - Derek S Chew
- Cumming School of Medicine (Zare-Zadeh, Manns, Chew, Harrison, Au), Department of Community Health Sciences (Manns, Harrison, Quinn), Libin Cardiovascular Institute (Manns, Chew) and O'Brien Institute for Public Health (Manns), University of Calgary, Calgary, Alta
| | - Tyrone G Harrison
- Cumming School of Medicine (Zare-Zadeh, Manns, Chew, Harrison, Au), Department of Community Health Sciences (Manns, Harrison, Quinn), Libin Cardiovascular Institute (Manns, Chew) and O'Brien Institute for Public Health (Manns), University of Calgary, Calgary, Alta
| | - Flora Au
- Cumming School of Medicine (Zare-Zadeh, Manns, Chew, Harrison, Au), Department of Community Health Sciences (Manns, Harrison, Quinn), Libin Cardiovascular Institute (Manns, Chew) and O'Brien Institute for Public Health (Manns), University of Calgary, Calgary, Alta
| | - Amity E Quinn
- Cumming School of Medicine (Zare-Zadeh, Manns, Chew, Harrison, Au), Department of Community Health Sciences (Manns, Harrison, Quinn), Libin Cardiovascular Institute (Manns, Chew) and O'Brien Institute for Public Health (Manns), University of Calgary, Calgary, Alta
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2
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Strickland SS, Quintela EM, Wilson MJ, Lee MJ. Long-term major adverse cardiovascular events following myocardial injury after non-cardiac surgery: meta-analysis. BJS Open 2023; 7:zrad021. [PMID: 37104754 PMCID: PMC10129390 DOI: 10.1093/bjsopen/zrad021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/12/2022] [Accepted: 01/27/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Myocardial injury after non-cardiac surgery is diagnosed following asymptomatic troponin elevation in the perioperative interval. Myocardial injury after non-cardiac surgery is associated with high mortality rates and significant rates of major adverse cardiac events within the first 30 days following surgery. However, less is known regarding its impact on mortality and morbidity beyond this time. This systematic review and meta-analysis aimed to establish the rates of long-term morbidity and mortality associated with myocardial injury after non-cardiac surgery. METHODS MEDLINE, Embase and Cochrane CENTRAL were searched, and abstracts screened by two reviewers. Observational studies and control arms of trials, reporting mortality and cardiovascular outcomes beyond 30 days in adult patients diagnosed with myocardial injury after non-cardiac surgery, were included. Risk of bias was assessed using the Quality in Prognostic Studies tool. A random-effects model was used for the meta-analysis of outcome subgroups. RESULTS Searches identified 40 studies. The meta-analysis of 37 cohort studies found a rate of major adverse cardiac events-associated myocardial injury after non-cardiac surgery of 21 per cent and mortality following myocardial injury after non-cardiac surgery was 25 per cent at 1-year follow-up. A non-linear increase in mortality rate was observed up to 1 year after surgery. Major adverse cardiac event rates were also lower in elective surgery compared with a subgroup including emergency cases. The analysis demonstrated a wide variety of accepted myocardial injury after non-cardiac surgery and major adverse cardiac events diagnostic criteria within the included studies. CONCLUSION A diagnosis of myocardial injury after non-cardiac surgery is associated with high rates of poor cardiovascular outcomes up to 1 year after surgery. Work is needed to standardize diagnostic criteria and reporting of myocardial injury after non-cardiac surgery-related outcomes. REGISTRATION This review was prospectively registered with PROSPERO in October 2021 (CRD42021283995).
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Affiliation(s)
- Scarlett S Strickland
- Academic Directorate of General Surgery, Sheffield Teaching Hospitals, Sheffield, UK
| | - Ella M Quintela
- Department of Anaesthesia, Sheffield Teaching Hospitals, Sheffield, UK
- Centre for Urgent and Emergency Care Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Matthew J Wilson
- Department of Anaesthesia, Sheffield Teaching Hospitals, Sheffield, UK
- Centre for Urgent and Emergency Care Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Matthew J Lee
- Academic Directorate of General Surgery, Sheffield Teaching Hospitals, Sheffield, UK
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, UK
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Duceppe E, Borges FK, Tiboni M, Pearse R, Chan MTV, Srinathan S, Kavsak PA, Garg AX, Sessler DI, Sapsford R, Heels-Ansdell D, Pettit S, Vasquez J, Mueller C, Walsh M, Szczeklik W, Rodseth R, Lalu M, Thabane L, Guyatt G, Devereaux PJ. High-Sensitivity Cardiac Troponin I Thresholds to Identify Myocardial Injury After Noncardiac Surgery: A Cohort Study. Can J Cardiol 2023; 39:311-318. [PMID: 36682485 DOI: 10.1016/j.cjca.2023.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Myocardial injury after noncardiac surgery (MINS) is common and associated with short- and long-term major cardiovascular events. Diagnostic criteria for MINS using Abbott high-sensitivity cardiac troponin I (hs-cTnI) are unknown. METHODS We performed a prospective cohort study of adults who had in-patient noncardiac surgery and measured hs-cTnI (Abbott Laboratories) on postoperative serum samples collected up to postoperative day 3. The objective was to determine prognostically important hs-cTnI thresholds associated with major cardiac events and death at 30 days after noncardiac surgery. Using Cox proportional iterative analyses, we determined peak postoperative hs-cTnI thresholds associated with the occurrence of the 30-day composite of major cardiac events (ie, nonfatal myocardial infarction after 3 postoperative days, cardiac arrest, and congestive heart failure) and death. RESULTS Of 3953 included patients, 66 (1.7%) experienced the primary outcome at 30 days. Peak hs-cTnI values and associated incidence of major cardiac events and death were as follows: < 60 ng/L: 1.0% (95% CI 0.7-1.3); 60 to < 700 ng/L: 8.6% (5.6-13.0); and ≥ 700 ng/L: 27.3% (16.4-41.9). Compared with peak hs-cTnI < 60 ng/L, adjusted hazard ratios were 7.54 (95% CI% 4.27-13.32) for hs-cTnI values of 60 to < 700 ng/L and 26.87 (13.27-54.41) for values ≥ 700 ng/L. CONCLUSIONS Hs-cTnI elevation within the first 3 days after noncardiac surgery independently predicts major cardiac events and death at 30 days. A postoperative hs-cTnI ≥ 60 ng/L was associated with a > 7-fold increase in the risk of subsequent major cardiac events and mortality at 30 days.
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Affiliation(s)
- Emmanuelle Duceppe
- Department of Medicine, Centre Hospitalier de l'Universite de Montréal, Montréal, Québec, Canada; Population Health Research Institute, Hamilton, Ontario, Canada.
| | - Flavia K Borges
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Maria Tiboni
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Rupert Pearse
- Translational Medicine and Therapeutics William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | | | - Sadeesh Srinathan
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amit X Garg
- Department of Medicine, Western University, London, Ontario, Canada
| | - Daniel I Sessler
- Department of Outcome Research, Cleveland Clinic, Cleveland, Ohio, United States
| | - Robert Sapsford
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Shirley Pettit
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Javiera Vasquez
- Anaesthesiology Department, Clinica Santa Maria, Santiago. Universidad de los Andes, Santiago, Chile
| | - Christian Mueller
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Micheal Walsh
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Reitze Rodseth
- Department of Anaesthesia, University of KwaZulu-Natal, Durban, South Africa
| | - Manoj Lalu
- Department of Anaesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - P J Devereaux
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Sumin AN. Assessment and Correction of the Cardiac Complications Risk in Non-cardiac Operations – What's New? RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2022-10-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Cardiovascular complications after non-cardiac surgery are the leading cause of 30-day mortality. The need for surgical interventions is approximately 5,000 procedures per 100,000 population, according to experts, the risks of non-cardiac surgical interventions are markedly higher in the elderly. It should be borne in mind that the aging of the population and the increased possibilities of medicine inevitably lead to an increase in surgical interventions in older people. Recent years have been characterized by the appearance of national and international guidelines with various algorithms for assessing and correcting cardiac risk, as well as publications on the validation of these algorithms. The purpose of this review was to provide new information about the assessment and correction of the risk of cardiac complications in non-cardiac operations. Despite the proposed new risk assessment scales, the RCRI scale remains the most commonly used, although for certain categories of patients (with oncopathology, in older age groups) the possibility of using specific questionnaires has been shown. In assessing the functional state, it is proposed to use not only a subjective assessment, but also the DASI questionnaire, 6-minute walking test and cardiopulmonary exercise test). At the next stage, it is proposed to evaluate biomarkers, primarily BNP or NT-proBNP, with a normal level – surgery, with an increased level – either an additional examination by a cardiologist or perioperative troponin screening. Currently, the prevailing opinion is that there is no need to examine patients to detect hidden lesions of the coronary arteries (non-invasive tests, coronary angiography), since this leads to excessive examination of patients, delaying the implementation of non-cardiac surgery. The extent to which this approach has an advantage over the previously used one remains to be studied.
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Affiliation(s)
- A. N. Sumin
- Research Institute for Complex Issues of Cardiovascular Diseases
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Conway R, Byrne D, O'Riordan D, Silke B. Prognostic value and clinical utility of NT-proBNP in acute emergency medical admissions. Ir J Med Sci 2022:10.1007/s11845-022-03198-1. [PMID: 36279040 DOI: 10.1007/s11845-022-03198-1] [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: 06/30/2022] [Accepted: 10/18/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND NT-proB-type natriuretic peptide (NT-proBNP) is a frequently utilized test in congestive cardiac failure. There is little data on its utility in unselected emergency medical admissions. AIM This study aims to investigate the clinical utility and prognostic value of NT-proBNP in emergency medical admissions and to determine whether such testing influenced downstream investigations and length of stay (LOS). METHODS We report on NT-proBNP tests performed in emergency medical admissions in a 2005/2006 and subsequent 7-year (2014-2020) retrospective cohort. We assessed 30-day in-hospital mortality with a multivariable logistic regression model. The utilization of procedures/services was related to LOS with zero-truncated Poisson regression. RESULTS There were 64,212 admissions in 36,252 patients. Patients with a NT-proBNP test were significantly older at 75.3 years vs. 63.0 years and had longer LOS -9.4 days vs. 4.9 days. They had higher acute illness severity and comorbidity scores. Thirty-day in-hospital mortality was higher in those with a NT-proBNP test (8.8%) vs. no request (3.2%). NT-proBNP test level was prognostic in univariate - OR 2.87 (2.61, 3.15), and multivariate analyses - OR 1.40 (1.26, 1.56). Higher NT-proBNP levels predicted higher 30-day in-hospital mortality. Multivariable thirty-day in-hospital mortality was 3.8% (3.6%, 3.9%) for those without a test, increasing to 4.9% (4.7%, 5.2%) for ≥ 250 ng/L and 5.8% (5.8%, 6.3%) for ≥ 3000 ng/L. LOS was linearly related to the total number of procedures/services performed. CONCLUSION NT-proBNP is prognostic in emergency medical admissions. Downstream resource utilization differed following an NT-proBNP test; this may reflect different case complexity or the 'uncertainty' surrounding such admissions.
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Affiliation(s)
- Richard Conway
- Department of Internal Medicine, St James's Hospital, Dublin 8, Ireland
- Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland
| | - Declan Byrne
- Department of Internal Medicine, St James's Hospital, Dublin 8, Ireland
- Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland
| | - Deirdre O'Riordan
- Department of Internal Medicine, St James's Hospital, Dublin 8, Ireland
- Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland
| | - Bernard Silke
- Department of Internal Medicine, St James's Hospital, Dublin 8, Ireland.
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6
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Myocardial injury after noncardiac surgery. Can J Anaesth 2022; 69:561-567. [DOI: 10.1007/s12630-022-02220-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 01/06/2022] [Accepted: 01/06/2022] [Indexed: 10/19/2022] Open
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Buse GL, Matot I. Pro-Con Debate: Cardiac Troponin Measurement as Part of Routine Follow-up of Myocardial Damage Following Noncardiac Surgery. Anesth Analg 2022; 134:257-265. [PMID: 35030121 DOI: 10.1213/ane.0000000000005714] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Elevated troponin levels within 3 days of surgery, independent of the presence of symptoms, are strongly linked to increased risk of short- and long-term morbidity and mortality. However, the value of screening with troponin measurements is controversial. The Canadian Cardiovascular Society guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery recommends measuring daily troponin for 48 to 72 hours after surgery in high-risk patients. Nevertheless, others doubt this recommendation, in part because postoperative elevated levels of troponin describe very little in terms of disease or event-specific pathogenesis and etiology, and thus, tailoring an intervention remains a challenge. This Pro-Con debate offers evidence-based data to stimulate physician understanding of daily practice and its significance in this matter, and assist in determining whether to use (Pro) or not to use (Con) this surveillance.
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Affiliation(s)
- Giovanna Lurati Buse
- From the Anesthesiology Department, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Idit Matot
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel Aviv Medical School, Tel Aviv University, Tel-Aviv, Israel
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8
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Gouda P, Wang X, Youngson E, McGillion M, Mamas MA, Graham MM. Beyond the revised cardiac risk index: Validation of the hospital frailty risk score in non-cardiac surgery. PLoS One 2022; 17:e0262322. [PMID: 35045122 PMCID: PMC8769314 DOI: 10.1371/journal.pone.0262322] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/22/2021] [Indexed: 12/12/2022] Open
Abstract
Frailty is an established risk factor for adverse outcomes following non-cardiac surgery. The Hospital Frailty Risk Score (HFRS) is a recently described frailty assessment tool that harnesses administrative data and is composed of 109 International Classification of Disease variables. We aimed to examine the incremental prognostic utility of the HFRS in a generalizable surgical population. Using linked administrative databases, a retrospective cohort of patients admitted for non-cardiac surgery between October 1st, 2008 and September 30th, 2019 in Alberta, Canada was created. Our primary outcome was a composite of death, myocardial infarction or cardiac arrest at 30-days. Multivariable logistic regression was undertaken to assess the impact of HFRS on outcomes after adjusting for age, sex, components of the Charlson Comorbidity Index (CCI), Revised Cardiac Risk Index (RCRI) and peri-operative biomarkers. The final cohort consisted of 712,808 non-cardiac surgeries, of which 55·1% were female and the average age was 53·4 +/- 22·4 years. Using the HFRS, 86.3% were considered low risk, 10·7% were considered intermediate risk and 3·1% were considered high risk for frailty. Intermediate and high HFRS scores were associated with increased risk of the primary outcome with an adjusted odds ratio of 1·61 (95% CI 1·50-1.74) and 1·55 (95% CI 1·38-1·73). Intermediate and high HFRS were also associated with increased adjusted odds of prolonged hospital stay, in-hospital mortality, and 1-year mortality. The HFRS is a minimally onerous frailty assessment tool that can complement perioperative risk stratification in identifying patients at high risk of short- and long-term adverse events.
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Affiliation(s)
- Pishoy Gouda
- University of Alberta, Division of Cardiology and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Xiaoming Wang
- Research Facilitation, Alberta Health Services, Edmonton, Alberta, Canada
| | - Erik Youngson
- Research Facilitation, Alberta Health Services, Edmonton, Alberta, Canada
| | - Michael McGillion
- School of Nursing, Faculty of Health Sciences and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, Newcastle, United Kingdom
| | - Michelle M. Graham
- University of Alberta, Division of Cardiology and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
- * E-mail:
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9
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Beattie WS. The emergence of a postoperative myocardial injury epidemic: true or false? Can J Anaesth 2021; 68:1109-1119. [PMID: 34008088 DOI: 10.1007/s12630-021-02027-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 04/05/2021] [Accepted: 04/12/2021] [Indexed: 02/06/2023] Open
Affiliation(s)
- W Scott Beattie
- Department of Anesthesia and Pain Management, University of Toronto, Toronto, ON, Canada.
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10
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Azizi PM, Wijeysundera DN, Wijeysundera HC, Austin PC, Jerath A, Han L, Koh M, Ko DT. Troponin Testing After Noncardiac Surgery in Ontario: An Observational Study. CJC Open 2021; 3:904-912. [PMID: 34401697 PMCID: PMC8348325 DOI: 10.1016/j.cjco.2021.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 03/08/2021] [Indexed: 11/25/2022] Open
Abstract
Background In 2017, the Canadian Cardiovascular Society (CCS) published guidelines recommending postoperative troponin surveillance in higher-risk patients having major noncardiac surgery. The objective of this study was to evaluate the proportion of major noncardiac surgery patients that would meet recommendations for troponin testing and to assess the rates of troponin testing before guideline adoption. Methods We conducted a retrospective observational study of patients age 40 to 105 undergoing a subset of major noncardiac surgeries that included orthopedics, gynecology, general, urology, vascular, and thoracic surgeries in Ontario, Canada from January 1, 2010 to December 31, 2017. The primary outcomes were the proportion of patients recommended for testing based on the guidelines and rates of troponin testing within 2 days of surgery. Results We identified 257,704 patients who underwent noncardiac surgery. Mean age was 66.4 ± 11.9 years, and 12.4% underwent urgent surgery. Applying the CCS guidelines, 71.2% of elective surgery patients and 81.0% of urgent surgery patients would have met recommendations for postoperative troponin screening, whereas 10.8% and 27.1% received postoperative troponin testing, respectively. Most elective surgery patients met recommendations for testing based on the age criterion (54.9%), followed by diabetes (24.6%) and high-risk surgery (22.7%) criteria. Troponin testing varied substantially by types of surgery: highest for open abdominal aortic aneurisms and lowest for hysterectomies. Conclusions Based on the CCS guidelines, most patients undergoing the subset of surgeries assessed would have met recommendations for routine troponin testing. In contrast, routine troponin testing before guideline adoption was done infrequently in Ontario, with substantial variations based on the surgery type.
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Affiliation(s)
- Paymon M Azizi
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Duminda N Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia, St Michael's Hospital, Toronto, Ontario, Canada
| | - Harindra C Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Peter C Austin
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | | | - Lu Han
- ICES, Toronto, Ontario, Canada
| | | | - Dennis T Ko
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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11
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Roshanov PS, Sessler DI, Chow CK, Garg AX, Walsh MW, Lam NN, Hildebrand AM, Biccard BM, Acedillo RR, MacNeil SD, Lee VW, Szczeklik W, Mrkobrada M, Thabane L, Devereaux PJ. Predicting Myocardial Injury and Other Cardiac Complications After Elective Noncardiac Surgery with the Revised Cardiac Risk Index: The VISION Study. Can J Cardiol 2021; 37:1215-1224. [PMID: 33766613 DOI: 10.1016/j.cjca.2021.03.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/01/2021] [Accepted: 03/17/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The Revised Cardiac Risk Index (RCRI) is widely used to estimate risk of cardiac complications after noncardiac surgery; its estimates do not capture myocardial injury after noncardiac surgery (MINS). We evaluated the incidence of cardiac complications including MINS across RCRI risk classes and the RCRI's ability to discriminate, before surgery, between patients who will experience these complications and those who will not. METHODS This was a secondary analysis of a prospective cohort study of 35,815 patients ≥ 45 years old who had elective inpatient noncardiac surgery from 2007 to 2013 at 28 centres in 14 countries. The primary outcome was a composite of MINS, myocardial infarction, nonfatal cardiac arrest, or cardiac death within 30 days after surgery. The secondary outcome was this composite without MINS. RESULTS The primary outcome occurred in 4725 patients (13.2%); its incidences across RCRI classes I (no risk factors), II (1 risk factor), III (2 risk factors), and IV (≥ 3 risk factors) were, respectively, 8.2%, 15.4%, 26.6%, and 40.2% (C-statistic for discrimination 0.65 [95% confidence interval 0.62-0.68]). The secondary outcome occurred in 1174 patients (3.3%) with incidences of 1.6%, 4.0%, 7.9%, and 12.9%, respectively (C-statistic 0.69 [0.65-0.72]). Thirty-five percent of primary outcome events and 26.9% of secondary outcome events occurred in patients with no RCRI risk factors. CONCLUSION The RCRI alone is not sufficient to guide postoperative cardiac monitoring because 1 in 12 patients ≥ 45 years of age without any RCRI risk factors have a cardiac complication after major noncardiac surgery, and most of them would be missed without systematic troponin testing.
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Affiliation(s)
- Pavel S Roshanov
- Division of Nephrology, London Health Sciences Centre, London, Ontario, Canada.
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, United States
| | - Clara K Chow
- Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Amit X Garg
- Division of Nephrology, London Health Sciences Centre, London, Ontario, Canada
| | - Michael W Walsh
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ngan N Lam
- Division of Nephrology, University of Calgary, Calgary, Alberta, Canada
| | | | - Bruce M Biccard
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town, Western Cape, South Africa
| | - Rey R Acedillo
- Department of Nephrology, Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ontario, Canada
| | - S Danielle MacNeil
- Department of Otolaryngology Head and Neck Surgery, Western University, London, Ontario, Canada; Department of Oncology, Western University, London, Ontario, Canada
| | - Vincent W Lee
- Department of Renal Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Wojciech Szczeklik
- Centre for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Marko Mrkobrada
- Department of Medicine, London Health Sciences Centre, London, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - P J Devereaux
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Big Data for a Big Problem: How Can We Enhance the Implementation of Perioperative Cardiovascular Guidelines? Can J Cardiol 2020; 37:11-13. [PMID: 33309207 DOI: 10.1016/j.cjca.2020.07.229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 07/21/2020] [Accepted: 07/21/2020] [Indexed: 11/23/2022] Open
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