Any Need for Preoperative Cardiac Testing in Intermediate-Risk Patients With Tight Beta-Adrenergic Blockade?⁎⁎Editorials published in the Journal of American College of Cardiologyreflect the views of the authors and do not necessarily represent the views of JACCor the American College of Cardiology

Intense cardiac troponin surveillance for long-term benefits is cost-effective in patients undergoing open abdominal aortic surgery: a decision analysis model

BACKGROUND

Strategies to limit adverse cardiac events after vascular surgery continue to evolve. Early recognition and treatment of myocardial ischemia may be a key to improving postoperative survival rates. Cardiac troponin I (cTnI) screening is an effective means of surveillance for postoperative myocardial ischemic injury and has long-term prognostic value.

METHODS

We designed a Markov-based decision analysis model to determine the cost-effectiveness of routine surveillance with cTnI on postoperative Days 0, 1, 2, and 3, with an aim to institute tight heart rate control (60-65 bpm) with close monitoring and coronary care in the intensive care unit for 5 days in patients with cTnI >1.5 ng/mL. The key input variables obtained from published literature were as follows: probability of myocardial infarction, 0.049; cost of cTnI surveillance, $357; cost and efficacy of interventions, $13,145 and 0.55, respectively. The time horizon was lifetime and the target population being individuals aged 65 yr (median) undergoing elective open abdominal aortic surgery. The perspective for analysis was third-party payer.

RESULTS

The incremental cost-effectiveness ratio for cTnI surveillance was $12,641 per quality-adjusted life year compared with standard care without cTnI surveillance. During one-way sensitivity analysis, probability of myocardial infarction and efficacy of interventions were found to influence the cost-effectiveness. Multivariate sensitivity analysis with second-order Monte Carlo simulation revealed that cTnI surveillance was favored in 90.75% of simulations at a commonly used threshold of $50,000 per quality-adjusted life year.

CONCLUSIONS

In patients presenting for elective open abdominal aortic surgery, intensive surveillance with cTnI and early institution of aggressive beta-blockade is cost-effective.

How to prevent perioperative myocardial injury: the conundrum continues

BACKGROUND

Perioperative myocardial injury (PMI) remains a major cause of perioperative morbidity and mortality but clinical strategies to prevent PMI are still uncertain.

METHODS AND RESULTS

We comprehensively searched PubMed for major research articles concerning clinical strategies to prevent PMI. The key findings are as follows: (1) the American College of Cardiology/American Heart Association guideline update for perioperative cardiovascular evaluation for noncardiac surgery is very useful to stratify cardiac risk preoperatively; (2) cardiac troponin has emerged as a biomarker to diagnose postoperative PMI and to predict clinical outcomes; (3) coronary revascularization before noncardiac surgery probably would provide cardiac protection in select patients, especially in patients with high-risk coronary artery disease; (4) elective noncardiac surgery should be postponed in patients who received coronary stenting recently because of high incidence of serious cardiac complications (minimum 6-8 weeks for bare metal stents and 6-12 months for drug-eluting stents); and (5) beta-blockers and statins are very promising drugs and probably would prevent PMI in a select patient population, especially in patients with intermediate risk and stable coronary artery disease.

CONCLUSIONS

Further studies, especially randomized clinical trials and mechanistic investigation are needed to find the best and effective clinical strategies to prevent/reduce PMI.