2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.

METHODS

A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

Prevalence and associated factors of preoperative abnormal electrocardiography among older surgical patients in southern Ethiopia: Multicenter cross-sectional study

BACKGROUND

The prevalence of abnormal electrocardiography (ECG) increases with aging, and these abnormalities may have an impact on anesthesia management. Although a normal ECG does not guarantee a healthy heart, an abnormal ECG can quickly identify a patient who is at high risk of cardiac complications.

OBJECTIVE

The aim of this study was to determine the prevalence and associated factors of preoperative abnormal electrocardiography among older surgical patients at selected teaching hospitals in southern Ethiopia, from February 15 to June 15, 2022.

METHODOLOGY

A multicenter cross-sectional study was conducted at three randomly selected teaching hospitals in southern Ethiopia on 246 elderly surgical patients recruited consecutively. Data were entered into Epidata version 4.6, then exported and analyzed in STATA version 16. A binary logistic regression model was used to examine factors associated with abnormal ECG, and variables with a P-value < 0.2 were entered into the multivariate analysis to identify independent factors. Both crude and adjusted odds ratios were reported, and a P-value < 0.05 was considered statistically significant. The data were presented using frequencies, tables, charts, and figures.

RESULT

In the current study, 120 (48.78%) of older surgical patients had abnormal preoperative ECGs. In terms of severity, 55.3% were classified as minor, while 44.16% were major ECG abnormalities. The most common ECG abnormalities were left axis deviation (LAD), left ventricular hypertrophy (LVH), and ST segment changes. The presence of comorbidity (AOR = 3.44, P = 0.001), age ≥ 70 years (AOR = 2.5, P = 0.011), history of angina (AOR = 5.9, P = 0.011), history of smoking (AOR = 5.07, P = 0.024) and urban residency (AOR = 1.89, P = 0.039) were the strongest risk factors for an abnormal ECG.

CONCLUSION AND RECOMMENDATION

Our study shows that older patients are more likely to have an abnormal ECG before surgery, regardless of symptoms or risk factors. Therefore, it is suggested that all older patients undergo preoperative ECG screening. Further prospective cohort studies are needed to investigate the impact and outcome of patients with preoperative abnormal ECG.

Approach to Patients with Cancer Going to Surgery

The preoperative care of patients with cancer plays a pivotal role in ensuring optimal outcomes and enhancing the overall quality of life for individuals undergoing surgical interventions. This review aims to provide a comprehensive overview of the key considerations, challenges, and strategies involved in the preoperative management of oncology patients. We delve into the multidisciplinary approach required to address the unique needs of this patient population, emphasizing the importance of collaboration among surgeons, oncologists, anesthesiologists, primary care physicians, hospitalists, and other health care professionals.

Perioperative Care of Heart Failure, Arrhythmias, and Valvular Heart Disease

Frequently, the question of whether or not a patient is stable for surgery boils down to the question, "Does this patient need a preoperative stress test?" However, coronary artery disease and ischemic heart disease are only some of the many cardiac conditions that patients present with preoperatively-and that can negatively impact their intraoperative management and postoperative outcomes. This article will explore the evidence based, patient centered best practices surrounding the perioperative evaluation and management of heart failure, arrhythmias, and valvular heart disease.

Heart failure diagnostic accuracy, intraoperative fluid management, and postoperative acute kidney injury: a single-centre prospective observational study

BACKGROUND

The accurate diagnosis of heart failure (HF) before major noncardiac surgery is frequently challenging. The impact of diagnostic accuracy for HF on intraoperative practice patterns and clinical outcomes remains unknown.

METHODS

We performed an observational study of adult patients undergoing major noncardiac surgery at an academic hospital from 2015 to 2019. A preoperative clinical diagnosis of HF was defined by keywords in the preoperative assessment or a diagnosis code. Medical records of patients with and without HF clinical diagnoses were reviewed by a multispecialty panel of physician experts to develop an adjudicated HF reference standard. The exposure of interest was an adjudicated diagnosis of heart failure. The primary outcome was volume of intraoperative fluid administered. The secondary outcome was postoperative acute kidney injury (AKI).

RESULTS

From 40 659 surgeries, a stratified subsample of 1018 patients were reviewed by a physician panel. Among patients with adjudicated diagnoses of HF, those without a clinical diagnosis (false negatives) more commonly had preserved left ventricular ejection fractions and fewer comorbidities. Compared with false negatives, an accurate diagnosis of HF (true positives) was associated with 470 ml (95% confidence interval: 120-830; P=0.009) lower intraoperative fluid administration and lower risk of AKI (adjusted odds ratio:0.39, 95% confidence interval 0.18-0.89). For patients without adjudicated diagnoses of HF, non-HF was not associated with differences in either fluids administered or AKI.

CONCLUSIONS

An accurate preoperative diagnosis of heart failure before noncardiac surgery is associated with reduced intraoperative fluid administration and less acute kidney injury. Targeted efforts to improve preoperative diagnostic accuracy for heart failure may improve perioperative outcomes.

Perioperative Management of Lower Limb Surgery in a Patient with Asymptomatic Left Ventricular Systolic Dysfunction: A Case Report

ABSTRACT

Heart failure poses significant challenges in perioperative settings, with an increasing prevalence in India. While much attention has been given to the management of symptomatic heart failure, there is a dearth of literature on asymptomatic left ventricular systolic dysfunction (ALVSD). In this case report, we present the successful perioperative management of a 35-year-old male with ALVSD and a low ejection fraction undergoing lower limb surgery under combined spinal epidural anesthesia. Our approach aimed to maintain hemodynamic stability, minimize myocardial overload, and mitigate the adverse effects of neuraxial blockade.

Vestibular schwannoma surgery in the ninth decade of life: a case series

BACKGROUND AND PURPOSE

Large symptomatic Vestibular Schwannoma (VS) often requires surgical resection, regardless the patient's age. The aim of this study was to assess the surgical outcomes of patients in their ninth decade of life.

METHODS

This monocenter retrospective observational study included patients aged 80 years or older who underwent VS surgery between 2009 and 2020. We retrospectively analyzed their immediate post-surgical and long-term outcomes and complications.

RESULTS

Thirteen octogenarians who underwent VS surgery were included, with average age of 83.2 ± 1.97 years old (median 83.5, range 80-86 years). One patient had a Koos-Grade II tumor, and 12 patients had a grade IV. All patients had a preoperative ASA score ≤ 3 and underwent surgery in the supine position. Twelve patients underwent a pre-planned partial resection (PR) and one had a gross-total resection (GTR). Good facial function (House-Brackmann grade ≤ 2) was achieved in 10 patients (77%). We reported three Clavien-Dindo grade ≤ 3 treatment-related complications and no life-threatening complication. Two patients experienced tumor recurrence after PR.

CONCLUSION

In this series of patients who underwent VS surgery in their ninth decade of life, surgical outcomes were acceptable. Therefore, age alone should not serve as a contraindication for surgery. Preplanned PR is a reasonable attitude in elderly patients.

Preoperative Congestive Heart Failure Is Associated with Higher 30-Day Myocardial Infarction and Pneumonia after Endovascular Repair of Abdominal Aortic Aneurysm

INTRODUCTION

Preoperative congestive heart failure (CHF) is associated with higher postoperative mortality and complications in noncardiac surgery. However, postoperative outcomes for patients with preoperative CHF undergoing endovascular aneurysm repair (EVAR) have not been thoroughly established. This study evaluated the effect of preoperative CHF on 30-day outcomes following nonemergent intact EVAR using a large-scale national registry.

METHODS

Patients who had infrarenal EVAR were identified in the ACS-NSQIP database from 2012 to 2022. A 1:5 propensity-score matching was used to match demographics, baseline characteristics, aneurysm diameter, distant aneurysm extent, anesthesia, and concomitant procedures between patients with and without preoperative CHF. Thirty-day postoperative outcomes were examined.

RESULTS

467 (2.84%) CHF patients underwent intact EVAR. Meanwhile, 15,996 non-CHF patients underwent EVAR, where 2,248 of them were matched to all CHF patients. Patients with and without preoperative CHF had comparable 30-day mortality (3.02% vs. 2.62%, p = 0.64). However, CHF patients had higher myocardial infarction (3.02% vs. 1.47%, p = 0.03), pneumonia (3.23% vs. 1.73%, p = 0.04), 30-day readmission (p = 0.01), and longer length of stay (p < 0.01).

CONCLUSION

While patients with and without preoperative CHF had comparable 30-day mortality rates, those with CHF faced higher risks of cardiopulmonary complications. Effective management of preoperative CHF may help prevent postoperative complications in these patients.

Impact of beta-blocker usage on delirium in patients with sepsis in ICU: a cross-sectional study

Introduction

Delirium in patients with sepsis can be life-threatening. This study aims to investigate the impact of the use of beta-blockers on the occurrence of delirium in patients with sepsis in the ICU by utilizing a comprehensive dataset.

Methods

This is a cross-sectional study conducted using the data obtained from a single ICU in the USA. Patients diagnosed with sepsis and receiving beta-blockers were compared with those not receiving beta-blockers. Propensity score matching (PSM) and multiple regression analysis were employed to adjust for potential confounders.

Results

Among the 19,660 patients hospitalized for sepsis, the beta-blocker and non-user groups comprised 13,119 (66.73%) and 6,541 (33.27%) patients, respectively. Multivariable logistic regression models revealed a significant reduction of 60% in 7-day delirium for beta-blocker users (OR = 0.40, 95% CI: 0.37-0.43, p < 0.001), for 30-day delirium (OR = 0.32, 95% CI: 0.29-0.35, p < 0.001), and for 90-day delirium (OR = 0.33, 95% CI: 0.30-0.35, p < 0.001). The PSM results further strengthen the validity of these findings. An analysis of safety issues demonstrated that beta-blockers may have an impact on the risk of acute kidney injury. However, following PSM, the results are not considered robust. Furthermore, there was no discernible change in the odds of renal replacement therapy and the length of ICU stays.

Discussion

Our findings suggest a potential protective effect of beta-blockers against delirium in patients with sepsis. Nevertheless, the observational design limits causal inference, necessitating future randomized controlled trials to validate these findings.

Cardiopulmonary exercise testing prior to radical cystectomy: a systematic review and meta-analysis

OBJECTIVE

To identify the association between cardiopulmonary exercise testing (CPET) and outcomes of radical cystectomy (RC), as RC is historically associated with high rates of short- and long-term morbidity and mortality.

METHODS

This quantitative systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. An electronic literature search was conducted to identify all relevant studies evaluating the relationship between CPET parameters and RC outcomes. The primary outcome was short-term mortality. Secondary outcomes included hospital length of stay (LOS) and rate of serious adverse events as defined by the Clavien-Dindo classification.

RESULTS

The search identified six studies for inclusion. A total of 546 patients underwent CPET prior to RC. There were significantly more deaths following RC observed in patients with poorer cardiopulmonary function (risk ratio RR 5.80, 95% confidence interval 4.96-6.78). There was no significant association between CPET parameters and adverse events or hospital LOS.

CONCLUSIONS

The present systematic review and meta-analysis identified a greater risk of 90-day mortality in patients with poorer cardiorespiratory function, as measured by CPET. However, there remains a paucity of robust clinical data and further high-quality studies are required to verify these results.

Pre-operative triAge proCedure to streaMline elective surgicAl patieNts (PACMAN) improves efficiency by selecting patients eligible for phone consultation: A retrospective cohort study

BACKGROUND

Pre-operative screening is a high volume task consuming time and resource. Streamlining patient flow by gathering information in advance reduces costs, optimises resources and diminishes patient burden whilst maintaining safety of care.

OBJECTIVE

To evaluate whether 'Pre-operative triAge proCedure to streaMline elective surgicAl patieNts' (PACMAN) is able to improve pre-operative screening by selecting patients eligible for evaluation by telephone.

DESIGN

A single-centre, retrospective, observational cohort analysis.

SETTING

A tertiary medical teaching hospital in 's-Hertogenbosch, The Netherlands.

PATIENTS AND METHODS

Adults scheduled for clinical interventions under procedural sedation and all types of elective medium or low risk surgery with anaesthetic guidance were eligible. Patients answered a questionnaire to calculate the PACMAN score. This score combined with risk factors related to surgery determines suitability for phone consultation (PhC) or the need for an in-person consultation (in-PC).

INTERVENTION

Evaluation of standard care.

MAIN OUTCOME MEASURES

Primary outcome was the reduction in number of in-PCs. Secondary outcomes included reliability of PACMAN, peri-operative patient outcomes and cost-effectiveness.

RESULTS

Of 965 patients triaged by PACMAN, 705 (73.1%) were identified as suitable for a PhC. Of those, 688 (97.6%) were classified American Society of Anesthesiologists Physical Status (ASA-PS) I to II or III with stable comorbidities. Of the 260 in-PC patients, 47.4% were classified ASA-PS III with unstable comorbidities or ASA-PS IV. The overall incidence of unanticipated adverse peri-operative events was 1.3%. Finally, implementation of PACMAN led to a 20% increase in pre-operative department efficiency due to better deployment of personnel and resources.

CONCLUSION

Implementation of PACMAN resulted in a 73.1% reduction in pre-operative in-PCs at our hospital. Given the increasing pressure on healthcare systems globally, we suggest developing further optimisation and integration of smart triage solutions into the pre-operative process.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT06148701.

Early Versus Delayed Laparoscopic Cholecystectomy, after Percutaneous Gall Bladder Drainage, for Grade II Acute Cholecystitis TG18 in Patients with Concomitant Cardiopulmonary Disease

Background: The advancement in medical care has led to an increase in patients with acute cholecystitis (AC) and cardiopulmonary comorbidities referred for surgery. Grade II AC, according to Tokyo Guidelines in 2018 (TG18), is characterized by severe local inflammation with no systemic affection. The optimal treatment for patients with high-risk grade II AC has not yet been clearly established, which is still a dilemma. For these patients, laparoscopic cholecystectomy (LC), despite being the only definitive treatment, is still a challenge. The introduction of percutaneous cholecystostomy as a temporary minimally invasive alternative technique allows an immediate gallbladder decompression with a rapid clinical improvement. However, the next step after percutaneous transhepatic gall bladder drainage (PTGBD) in these high-risk patients is still a debate, with no definitive consensus about the ideal treatment of choice as well as its optimal timing. In our study, we followed a treatment algorithm for high-risk patients that involved early gallbladder decompression by PTGBD, followed by LC at different intervals once the patient is considered fit for surgery. Method: A retrospective study of 58 patients with high-risk grade II AC with cardiopulmonary comorbidity from our medical records was included. They were managed initially with PTGBD, an LC was then performed either within 7 days after drain insertion (early group, 26 patients), while an LC was performed later for the remaining patients within 6-8 weeks after PTGBD (late group, 32 patients). The results of the two groups were analyzed. Result: Procalcitonin and C-reactive protein were significantly higher in the late group. No significant difference was found between both groups with regard to operative time, PTGBD-related complications, and major perioperative complications. Timing after PTGBD did not affect the incidence of operative complications. Total hospital stay was significantly shorter in the early group. Conclusion: PTGBD is a safe initial intervention for high-risk patients with AC with a low morbidity and high success rate. Urgent LC after PTGBD can be performed safely for well-selected high-risk patients with the timing of surgery is personalized according to each patient's clinical situation. Early LC (after PTGBD) has the advantage of shorter hospital stay, low cost, as well as avoiding the risk of biliary complications and mortality if waiting a delayed surgery with no significant difference in morbidity compared with late LC.

Kidney Transplant Candidacy: Addressing Common Medical and Psychosocial Barriers to Transplant

Improving access to kidney transplants remains a priority for the transplant community. However, many medical, psychosocial, geographic, and socioeconomic barriers exist that prevent or delay transplantation for candidates with certain conditions. There is a lack of consensus regarding how to best approach many of these issues and barriers, leading to heterogeneity in transplant centers' management and acceptance practices for a variety of pretransplant candidate issues. In this review, we address several of the more common contemporary patient medical and psychosocial barriers frequently encountered by transplant programs. The barriers discussed here include kidney transplant candidates with obesity, older age, prior malignancy, cardiovascular disease, history of nonadherence, and cannabis use. Improving understanding of how to best address these specific issues can empower referring providers, transplant programs, and patients to address these issues as necessary to progress toward eventual successful transplantation.

Evaluation of the Effectiveness of Canadian Cardiovascular Society Guidelines in Minimizing Cardiac Events After Total Hip Arthroplasty

BACKGROUND

The aim of the study was to analyze the Canadian Cardiovascular Society (CCS) guidelines for routine postoperative troponin testing after elective total hip arthroplasty (THA) to reduce the mortality rate resulting from myocardial injury. The purpose of this study was to assess the prognostic relevance of implementing these guidelines to minimize cardiac events in patients undergoing elective THA.

METHODS

Patients who underwent THA surgery in 2020 were included in the study. The inclusion criteria were elective THA patients aged ≥45 years, while emergency, revision, and simultaneous bilateral THA surgeries were excluded. The patients were categorized into 4 groups based on the CCS guidelines.

RESULTS

The study included 669 patients who had an average age of 67 years. There were 43 patients (6.4%), who experienced a rise in troponin levels ≥30 ng/L and developed myocardial injury after noncardiac surgery. Among these patients, 8 developed cardiac complications, and one experienced a serious cardiac event that resulted in death. Notably, there was a significant increase in the length of hospital stay for patients who received the postoperative screening protocol.

CONCLUSIONS

The implementation of the CCS guidelines for routine postoperative troponin testing in elective THA surgery did not significantly decrease the rate of cardiac events or mortality.

Evaluating the accuracy of ChatGPT-4 in predicting ASA scores: A prospective multicentric study ChatGPT-4 in ASA score prediction

BACKGROUND

This study investigates the potential of ChatGPT-4, developed by OpenAI, in enhancing medical decision-making processes, particularly in preoperative assessments using the American Society of Anesthesiologists (ASA) scoring system. The ASA score, a critical tool in evaluating patients' health status and anesthesia risks before surgery, categorizes patients from I to VI based on their overall health and risk factors. Despite its widespread use, determining accurate ASA scores remains a subjective process that may benefit from AI-supported assessments. This research aims to evaluate ChatGPT-4's capability to predict ASA scores accurately compared to expert anesthesiologists' assessments.

METHODS

In this prospective multicentric study, ethical board approval was obtained, and the study was registered with clinicaltrials.gov (NCT06321445). We included 2851 patients from anesthesiology outpatient clinics, spanning neonates to all age groups and genders, with ASA scores between I-IV. Exclusion criteria were set for ASA V and VI scores, emergency operations, and insufficient information for ASA score determination. Data on patients' demographics, health conditions, and ASA scores by anesthesiologists were collected and anonymized. ChatGPT-4 was then tasked with assigning ASA scores based on the standardized patient data.

RESULTS

Our results indicate a high level of concordance between ChatGPT-4 predictions and anesthesiologists' evaluations, with Cohen's kappa analysis showing a kappa value of 0.858 (p = 0.000). While the model demonstrated over 90% accuracy in predicting ASA scores I to III, it showed a notable variance in ASA IV scores, suggesting a potential limitation in assessing patients with more complex health conditions.

DISCUSSION

The findings suggest that ChatGPT-4 can significantly contribute to the medical field by supporting anesthesiologists in preoperative assessments. This study not only demonstrates ChatGPT-4's efficacy in medical data analysis and decision-making but also opens new avenues for AI applications in healthcare, particularly in enhancing patient safety and optimizing surgical outcomes. Further research is needed to refine AI models for complex case assessments and integrate them seamlessly into clinical workflows.

Preoperative cardiology consultations for geriatric patients with hip fractures rarely provide additional recommendations and are associated with prolonged hospital stays and delayed surgery: a retrospective case control study

OBJECTIVES

Hip fractures are increasingly common among the elderly population, who often present with a high burden of comorbidities necessitating preoperative stabilization. As a result, preoperative cardiology consultations are frequently conducted in clinical practice. The aim of this study was to investigate the additional recommendations provided by preoperative cardiology consultations and the impact of consultations on the management and outcomes of elderly patients undergoing hip fracture surgery.

PATIENTS AND METHODS

This matched cohort study was performed to retrospectively assess the clinical data of patients who were treated for hip fractures at our institution between January 2016 and December 2017. Individuals who were 60 years old or older with available clinical and radiological data were included. A total of 262 patients who met these criteria were included, with 192 undergoing cardiology consultation and 70 not. Through matching for age, sex, ASA grade, fracture type, and surgery type, two groups (Group A, preoperative cardiology consultation requested; Group B, preoperative cardiology consultation not requested) of 50 patients each were formed. The duration between hospital admission and surgery, recommendations provided by cardiology consultation, type of anaesthesia and surgery, length of hospital stay, incidence of medical and orthopaedic complications, and one-year mortality status were compared between the groups.

RESULTS

The mean age of Group A was 78.5 (± 7.4) years, whereas that of Group B was 78.4 (± 7.4) years (p = 0.99). Both groups included 30 female patients and 20 male patients each. There were no significant differences in anaesthesia type or the incidence of medical or orthopaedic complications between the groups. However, Group A experienced a significantly longer duration between admission and surgery (5 [1/9] days vs. 3 [0/7] days; p = 0.00) and a longer hospital stay (7 [3/15] days vs. 5 [1/19] days; p = 0.01) than did Group B. The one-year mortality rate did not significantly differ between the groups (30% vs. 20%; p = 0.36). Notably, only 3 out of 50 patients received additional treatments following cardiology consultation beyond routine recommendations.

CONCLUSION

Preoperative cardiology consultations before hip fracture surgery rarely leads to a change in treatment. Additionally, these evaluations delay surgery and extend the hospital stay.

Preoperative continuation of aspirin before isolated heart valve surgery and postoperative bleeding and transfusion: a single-center retrospective study

BACKGROUND

The risks and benefits of preoperative aspirin continuation in patients undergoing isolated heart valve replacement surgery are unclear. We investigated the effect of aspirin continuation on the risk of bleeding and transfusion in these patients.

METHODS

In this single center, retrospective study, among 474 adult patients who underwent isolated heart valve surgery between April 2013 and June 2018, 269 continued aspirin within 5 days before surgery (aspirin group) and 205 patients did not take or stopped aspirin no later than 5 days before surgery (non-aspirin group). The chi-square test, the Mann-Whitney U-test, and the Student's T-test were used to compare data between the groups. Univariate and Multivariate logistic regressions were used to assess crude and adjusted relationships between outcome and exposure.

RESULTS

The primary outcome, red blood cell (RBC) transfusion, occurred in 59 patients (22%) of the aspirin group and in 24 patients (12%) of the non-aspirin group (p = 0.004). After adjustment for confounding factors, continuation of aspirin was no longer associated with RBC transfusion (aOR1.8;95%CI,0.98-3.2;p = 0.06). The amount of allogenic blood products, the incidence of surgical re-exploration for bleeding, the volume of re-transfused cell-saved blood, and the cumulative chest tube drainage during the first 24 postoperative hours were similar between groups.

CONCLUSION

Preoperative continuation of aspirin in patients undergoing isolated heart valve surgery is neither associated with a higher incidence of RBC transfusion, nor with larger perioperative blood loss, or more frequent surgical revision for bleeding.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT05151796).

Full Guidelines-From the Medical Board of the National Psoriasis Foundation: Perioperative management of systemic immunomodulatory agents in patients with psoriasis and psoriatic arthritis

BACKGROUND

Systemic immunomodulatory agents are indicated in the treatment of moderate-to-severe plaque psoriasis and psoriatic arthritis. Perioperative use of these medications may increase the risk of surgical site infection (SSI) and complication.

OBJECTIVE

To evaluate the risk of SSI and complication in patients with chronic autoimmune inflammatory disease receiving immunomodulatory agents (tumor necrosis factor-alfa [TNF-α] inhibitors, interleukin [IL] 12/23 inhibitor, IL-17 inhibitors, IL-23 inhibitors, cytotoxic T-lymphocyte-associated antigen-4 costimulator, phosphodiesterase-4 inhibitor, Janus kinase inhibitors, tyrosine kinase 2 inhibitor, cyclosporine (CsA), and methotrexate [MTX]) undergoing surgery.

METHODS

We performed a search of the MEDLINE PubMed database of patients with chronic autoimmune inflammatory disease on immune therapy undergoing surgery.

RESULTS

We examined 48 new or previously unreviewed studies; the majority were retrospective studies in patients with rheumatoid arthritis and inflammatory bowel disease.

CONCLUSION

For low-risk procedures, TNF-α inhibitors, IL-17 inhibitors, IL-23 inhibitors, ustekinumab, abatacept, MTX, CsA, and apremilast can safely be continued. For intermediate- and high-risk surgery, MTX, CsA, apremilast, abatacept, IL-17 inhibitors, IL-23 inhibitors, and ustekinumab are likely safe to continue; however, a case-by-case approach is advised. Acitretin can be continued for any surgery. There is insufficient evidence to make firm recommendations on tofacitinib, upadacitinib, and deucravacitinib.

Myocardial Injury in Patients with Hip Fracture: A HIP ATTACK Randomized Trial Substudy

BACKGROUND

Myocardial injury after a hip fracture is common and has a poor prognosis. Patients with a hip fracture and myocardial injury may benefit from accelerated surgery to remove the physiological stress associated with the hip fracture. This study aimed to determine if accelerated surgery is superior to standard care in terms of the 90-day risk of death in patients with a hip fracture who presented with an elevated cardiac biomarker/enzyme measurement at hospital arrival.

METHODS

The HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) trial was a randomized controlled trial designed to determine whether accelerated surgery for hip fracture was superior to standard care in reducing death or major complications. This substudy is a post-hoc analysis of 1392 patients (from the original study of 2970 patients) who had a cardiac biomarker/enzyme measurement (>99.9% had a troponin measurement and thus "troponin" is the term used throughout the paper) at hospital arrival. The primary outcome was all-cause mortality. The secondary composite outcome included all-cause mortality and non-fatal myocardial infarction, stroke, and congestive heart failure 90 days after randomization.

RESULTS

Three hundred and twenty-two (23%) of the 1392 patients had troponin elevation at hospital arrival. Among the patients with troponin elevation, the median time from hip fracture diagnosis to surgery was 6 hours (interquartile range [IQR] = 5 to 13) in the accelerated surgery group and 29 hours (IQR = 19 to 52) in the standard care group. Patients with troponin elevation had a lower risk of mortality with accelerated surgery compared with standard care (17 [10%] of 163 versus 36 [23%] of 159; hazard ratio [HR] = 0.43 [95% confidence interval (CI) = 0.24 to 0.77]) and a lower risk of the secondary composite outcome (23 [14%] of 163 versus 47 [30%] of 159; HR = 0.43 [95% CI = 0.26 to 0.72]).

CONCLUSIONS

One in 5 patients with a hip fracture presented with myocardial injury. Accelerated surgery resulted in a lower mortality risk than standard care for these patients; however, these findings need to be confirmed.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

New Perspectives on Risk Assessment and Anticoagulation in Elective Spine Surgery Patients: The Impact of Ultra-Minimally Invasive Endoscopic Surgery Techniques on Patients with Cardiac Disease

The advent of ultra-minimally invasive endoscopic spine surgery, characterized by significantly reduced surgery times, minimal blood loss, and minimal tissue trauma, has precipitated a paradigm shift in the preoperative management of patients with cardiac disease undergoing elective spine procedures. This perspective article explores how these advancements have influenced the requirements for preoperative cardiac workups and the protocols surrounding the cessation of anticoagulation and antiplatelet therapies. Traditionally, extensive cardiac evaluations and the need to stop anticoagulation and antiplatelet agents have posed challenges, increasing the risk of cardiac events and delaying surgical interventions. However, the reduced invasiveness of endoscopic spine surgery presents a safer profile for patients with cardiac comorbidities, potentially minimizing the necessity for rigorous cardiac clearance and allowing for more flexible anticoagulation management. This perspective article synthesizes current research and clinical practices to provide a comprehensive overview of these evolving protocols. It also discusses the implications of these changes for patient safety, surgical outcomes, and overall healthcare efficiency. Finally, the article suggests directions for future research, emphasizing the need for updated guidelines that reflect the reduced perioperative risk associated with these innovative surgical techniques. This discussion is pivotal for primary care physicians, surgeons, cardiologists, and the broader medical community in optimizing care for this high-risk patient population.

Coronary artery calcium assessment on non-gated chest CT to optimize pre-operative cardiac screening in liver transplantation

BACKGROUND

Guidelines recommend standard pre-operative cardiac screening in all liver transplantation (LT) recipients, despite the relatively low prevalence of obstructive coronary artery disease. Most LT recipients often have non-gated computed tomography (CT) performed of the chest and abdomen. This study evaluated the ability of coronary artery calcification (CAC) assessment on consecutively available scans, to identify a selection of low-risk patients, in whom further cardiac imaging can be safely withheld.

METHODS

LT recipients with prior non-gated CT chest-abdomen were included. CAC was visually scored on a semi-quantitative ordinal scale. Stress myocardial perfusion, coronary CT angiography (CCTA) and invasive coronary angiography (ICA) were used as golden standard. The sensitivity and specificity of CAC to exclude and predict obstructive CAD were assessed. In addition, peri- and postoperative mortality and cardiac events were analyzed.

RESULTS

149 LT recipients (ranged 31-71 years) were included. In 75% of patients, no CAC and mild CAC could rule out obstructive CAD on CCTA and ICA with 100% certainty. The threshold of mild CAC had a sensitivity of 100% for both CCTA and ICA and a specificity of 91% and 68%, respectively. None of the patients with no or mild calcifications experienced peri- and post-operative cardiac events or died of cardiac causes.

CONCLUSION

Visual evaluation of CAC on prior non-gated CT can accurately and safely exclude obstructive CAD in LT recipients. Incorporation of these already available data can optimize cardiac screening, by safely withholding or correctly allocating dedicated cardiac imaging in LT recipients. Thereby, reducing patients' test burden and save health care expenses.

Pre-op considerations in neuromuscular scoliosis deformity surgery: proceedings of the half day course at the 58th annual meeting of the Scoliosis Research Society

Scoliosis is a common complication of neuromuscular disorders. These patients are frequently recalcitrant to nonoperative treatment. When treated surgically, they have the highest risk of complications of all forms of scoliosis. While recent studies have shown an improvement in the rate of complications, they still remain high ranging from 6.3 to 75% depending upon the underlying etiology and the treatment center (Mohamad et al. in J Pediatr Orthop 27:392-397, 2007; McElroy et al. in Spine, 2012; Toll et al. in J Neurosurg Pediatr 22:207-213, 2018; Cognetti et al. in Neurosurg Focus 43:E10, 2017). For those patients who are able to recover from the perioperative period without major complications, several recent studies have shown decreased long-term mortality and improved health-related quality of life in neuromuscular patients who have undergone spine fusion (Bohtz et al. in J Pediatr Orthop 31:668-673, 2011; Ahonen et al. in Neurology 101:e1787-e1792, 2023; Jain et al. in JBJS 98:1821-1828, 2016). It is critically important to optimize patients preoperatively to minimize the risk of post-operative complications and maximize long-term outcomes. In order to do so, one must familiarize themselves with the common complications and their treatment. The most common complications are pulmonary in nature. With reported rates as high as 23-29%, pre-operative optimization should be employed for these patients to minimize the risk of post-operative complications (Sharma et al. in Eur Spine J 22:1230-1249, 2013; Rumalla et al. in J Neurosurg Spine 25:500-508, 2016). The next most common cause of complications are implant related, with 13-23% of patients experiencing an implant-related complication that may require a second procedure (Toll et al. in J Neurosurg Pediatr 22:207-213, 2018; Sharma et al. in Eur Spine J 22:1230-1249, 2013) Therefore optimization of bone quality prior to surgical intervention is important to help minimize the risk of instrumentation failure. Optimization of muscle tone and spasticity may help to decrease the risk of instrumentation complications, but may also contribute to the progression of scoliosis. While only 3% of patients have neurologic complication, significant equipoise remains regarding whether or not patients should undergo prophylactic detethering procedures to minimize those risks (Sharma et al. in Eur Spine J 22:1230-1249, 2013). Although only 1.8% of complications are classified as cardiac related, they can be among the most devastating (Rumalla et al. in J Neurosurg Spine 25:500-508, 2016). Simply understanding the underlying etiology and the potential risks associated with each condition (i.e., conduction abnormalities in a patient with Rett syndrome or cardiomyopathies patients with muscular dystrophy) can be lifesaving. The following article is a summation of the half day course on neuromuscular scoliosis from the 58th annual SRS annual meeting, summarizing the recommendations from some of the world's experts on medical considerations in surgical treatment of neuromuscular scoliosis.

Pharmacotherapy for Coronary Artery Disease and Acute Coronary Syndrome in the Aging Population

PURPOSE OF REVIEW

To provide a comprehensive summary of relevant studies and evidence concerning the utilization of different pharmacotherapeutic and revascularization strategies in managing coronary artery disease and acute coronary syndrome specifically in the older adult population.

RECENT FINDINGS

Approximately 30% to 40% of hospitalized patients with acute coronary syndrome are older adults, among whom the majority of cardiovascular-related deaths occur. When compared to younger patients, these individuals generally experience inferior clinical outcomes. Most clinical trials assessing the efficacy and safety of various therapeutics have primarily enrolled patients under the age of 75, in addition to excluding those with geriatric complexities. In this review, we emphasize the need for a personalized and comprehensive approach to pharmacotherapy for coronary heart disease and acute coronary syndrome in older adults, considering concomitant geriatric syndromes and age-related factors to optimize treatment outcomes while minimizing potential risks and complications. In the realm of clinical practice, cardiovascular and geriatric risks are closely intertwined, with both being significant factors in determining treatments aimed at reducing negative outcomes and attaining health conditions most valued by older adults.

Cardiopulmonary exercise testing, computed tomography-derived body composition, systemic inflammation and survival after elective abdominal aortic aneurysm repair: A retrospective cohort study

BACKGROUND

Cardio-pulmonary exercise testing (CPEX) is selectively used before intervention for abdominal aortic aneurysm (AAA). Sarcopenia, a chronic condition defined by reduced skeletal muscle function and volume, can be assessed radiologically by computed tomography (CT)-derived body composition analysis (CT-BC), and is associated with systemic inflammation.

OBJECTIVE

The aim was to describe the association between CT-BC, CPEX, inflammation and survival in patients undergoing elective intervention for AAA.

SETTING

Patients were recruited retrospectively from a single, secondary-care centre-operative database. Cases undergoing elective endovascular aneurysm repair (EVAR) and open surgical repair (OSR) between 31 March 2015 and 25 June 2020 were included.

PATIENTS

There were 176 patients (130 EVAR, 46 OSR) available for analysis in the final study; median (interquartile range [IQR]) follow-up was 60.5 [27] months, and all completed a minimum of 2 years follow-up.

MAIN OUTCOME MEASURES

Preoperative CPEX tests were recorded. CT sarcopenia score [CT-SS, range 0 to 2, calculated based on normal/low SMI (0/1) and normal/low SMD (0/1)] assessed radiological sarcopenia. Preoperative modified Glasgow Prognostic score (mGPS) was used to assess systemic inflammation.

RESULTS

Mean [95% confidence interval (CI) survival in the CT-SS 0 vs. CT-SS 1 vs. CT-SS 2 subgroups was 80.1 (73.6 to 86.6) months vs. 70.3 (63.5 to 77.1) months vs. 63.8 (53.4 to 74.2) months] ( P  = 0.01). CT-SS was not associated with CPEX results ( P  > 0.05). Elevated CT-SS [hazard ratio (HR) 1.83, 95% CI, 1.16 to 2.89, P  < 0.01] was independently associated with increased hazard of long-term mortality; however, CPEX results were not ( P  > 0.05).

CONCLUSION

CPEX test results were not consistently associated with body composition and did not have significant prognostic value in patients undergoing elective treatment for AAA.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

Perioperative Management of Valvular Heart Disease in Patients Undergoing Non-Cardiac Surgery

Postoperative cardiovascular complications (either in a hospital or within 30 days after the operation) are among the most common problems with non-cardiac surgeries (NCSs). Pre-existing cardiac comorbidities add significant risk to the development of such complications. Valvular heart disease (VHD), a rather frequent cardiac comorbidity (especially in the elderly population), can pose serious life-threatening peri-/postoperative complications. Being familiar with the recommended perioperative management of patients with VHD or an implanted prosthetic heart valve who are scheduled for NCS is of great importance in daily clinical practice. Although recently published guidelines by the European Society of Cardiology (ESC) and the American College of Cardiology and American Heart Association (ACC/AHA) for the management of VHD and perioperative management of patients undergoing NCS addresses the mentioned problem, a comprehensive review of the guidelines that provides an easy-to-use summary of the recommendations and their similarities and differences is missing in the published literature. In this review article, we summarize all of the relevant important information based on the latest data published in both guidelines needed for practical decision-making in the perioperative management of patients with VHD or after valvular repair (with prosthetic heart valve) who are scheduled for NCS.

Pre-anaesthesia assessment in cataract surgery: Recommendations from the SEDAR Working Group

INTRODUCTION AND OBJECTIVES

Cataract surgery is one of the most common procedures in outpatient surgery units. The use of information and communication technologies (ICT) in clinical practice and the advent of new health scenarios, such as the Covid pandemic, have driven the development of pre-anaesthesia assessment models that free up resources to improve access to cataract surgery without sacrificing patient safety. The approach to cataract surgery varies considerably among public, subsidised and private hospitals. This raises the need for guidelines to standardise patient assessment, pre-operative tests, management of background medication, patient information and informed consent.

RESULTS

In this document, the SEDAR Clinical Management Division together with the Major Outpatient Surgery Division SEDAR Working Group put forward a series of consensus recommendations on pre-anaesthesia testing based on the use of ITCs, health questionnaires, patient information and informed consent supervised and evaluated by an anaesthesiologist.

CONCLUSIONS

This consensus document will effectivise pre-anaesthesia assessment in cataract surgery while maintaining the highest standards of quality, safety and legality.

Recapturing the Team Approach to Vascular Care

BACKGROUND

The care of the vascular patient remains decentralized rather than coordinated.

METHODS

We reviewed the current state of practice and published competency and care documents created by vascular professional societies.

RESULTS

Vascular professional societies routinely and repeatedly endorse both a team approach and the competency of specialists from disparate training backgrounds. The care of the vascular patient does not always reflect these public endorsements.

CONCLUSIONS

Centering the vascular patient as the mode of organization of care should improve care processes, expertise brought to bear, and outcomes.

Surgery-related outcomes from a close-knit surgeons' team in thoracic oncology

Reducing morbidity, length of hospital stay, and readmission rate are of paramount importance to improve patients' care. In the present paper, we aim to describe our experience in managing major oncologic thoracic surgery in clinical practice. This is a retrospective experience over the last 7 years. Data from 215 consecutive patients (performed by a single-team of two surgeon) undergoing thoracic surgery were reviewed and evaluated. The total hospital mean stay was 3,3 days. Complications were represented by 4 hemothorax, 1 pleural empyema without fistula, 3 arrhythmias (atrial fibrillation), 2 pnuemonias and 1 chylotorax. No 30-day severe surgery-related complication occurred, no mortality. In 169 Vats procedures, no convertion was necessary. We conclude that a united team work represented by two close-knit surgeons, with similar clinical background, propensity to share problems, no competitive behavior, allow to do faster surgery, to standardize the procedure improving the post-operative outcomes of cancer patients.

Preoperative Renin-Angiotensin System Antagonists Intake and Blood Pressure Responses During Ambulatory Surgical Procedures: A Prospective Cohort Study

BACKGROUND

There is limited evidence to inform the association between the intake of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs) and intraoperative blood pressure (BP) changes in an ambulatory surgery population.

METHODS

Adult patients who underwent ambulatory surgery and were discharged on the same day or within 24 hours of their procedure were enrolled in this prospective cohort study. The primary outcome of the study was early intraoperative hypotension (first 15 minutes of induction). Secondary outcomes included any hypotension, BP variability, and recovery. Hypotension was defined as a decrease in systolic BP of >30% from baseline for ≥5 minutes or a mean BP of <55 mm Hg. Four exposure groups were compared (no antihypertensives, ACEI/ARB intake <10 hours before surgery, ACEI/ARB intake ≥10 hours before surgery, and other antihypertensives).

RESULTS

Of the 537 participants, early hypotension was observed in 25% (n = 134), and any hypotension in 41.5% (n = 223). Early hypotension occurred in 30% (29 of 98) and 41% (17 of 41) with the intake of ACEI/ARBs <10 and ≥10 hours before surgery, respectively, compared to 30% (9 of 30) with other antihypertensives and 21% (79 of 368) with no antihypertensives ( P = .02). Those on antihypertensives also experienced any hypotension more frequently than those who were not on antihypertensives ( P < .001). After adjusting for age and baseline BP in a regression analysis, antihypertensive exposure groups were observed to be associated only with any intraoperative hypotension ( P = .012). In the ACEI/ARB subset, there was no evidence of an association between time since the last ACEI/ARB dose, and hypotension or minimum mean or systolic BP. Compared to normal baseline BP, BP ≥ 140/90 mm Hg increased the odds of early and any hypotension (odds ratio [OR], 3.9; 95% confidence interval [CI], 2.1-7.1 and OR, 7.7; 95% CI, 3.7-14.9, respectively; P < .001). Intraoperative variability in systolic and diastolic BP demonstrated significant differences with age, baseline BP, and antihypertensive exposure group ( P < .001).

CONCLUSIONS

Early and any hypotension occurred more frequently in those on antihypertensives than those not on antihypertensives. Unadjusted associations between antihypertensive exposure and intraoperative hypotension were largely explained by baseline hypertension rather than the timing of ACEI/ARBs or type of antihypertensive exposure. Patients with hypertension and on treatment experience more intraoperative BP variability and should be monitored appropriately.

Postoperative troponin surveillance to detect myocardial infarction: an observational cohort modelling study

BACKGROUND

Clinical presentation of postoperative myocardial infarction (POMI) is often silent. Several international guidelines recommend routine troponin surveillance in patients at risk. We compared how these different guidelines select patients for surveillance after noncardiac surgery with our established risk stratification model.

METHODS

We used outcome data from two prospective studies: Measurement of Exercise Tolerance before Surgery (METS) and Troponin Elevation After Major non-cardiac Surgery (TEAMS). We compared the major American, Canadian, and European guideline recommendations for troponin surveillance with our established risk stratification model. For each guideline and model, we quantified the number of patients requiring monitoring, % POMI detected, sensitivity, specificity, diagnostic odds ratio, and number needed to screen (NNS).

RESULTS

METS and TEAMS contributed 2350 patients, of whom 319 (14%) had myocardial injury, 61 (2.5%) developed POMI, and 14 (0.6%) died. Our risk stratification model selected fewer patients for troponin monitoring (20%), compared with the Canadian (78%) and European (79%) guidelines. The sensitivity to detect POMI was highest with the Canadian and European guidelines (0.85; 95% confidence interval [CI] 0.74-0.92). Specificity was highest using the American guidelines (0.91; 95% CI 0.90-0.92). Our risk stratification model had the best diagnostic odds ratio (2.5; 95% CI 1.4-4.2) and a lower NNS (21 vs 35) compared with the guidelines.

CONCLUSIONS

Most postoperative myocardial infarctions were detected by the Canadian and European guidelines but at the cost of low specificity and a higher number of patients undergoing screening. Patient selection based on our risk stratification model was optimal.

Anesthetic management for non-cardiac surgery in patients with left ventricular assist devices

With the growing number of patients undergoing left ventricular assist device (LVAD) implantation and improved survival in this population, more patients with LVADs are presenting for various types of non-cardiac surgery. Therefore, anesthesiologists need to understand the physiology and adequately prepare for the perioperative management of this unique patient population. This review addresses perioperative considerations and intraoperative management for the safe and successful management of patients with an LVAD undergoing non-cardiac surgery. Understanding the basic physiology of preload dependency and afterload sensitivity in these patients is essential. The main considerations include a collaborative preoperative multidisciplinary approach, perioperative care aimed at optimizing the intravascular volume and right ventricular function, and maintaining the afterload within recommended ranges for optimal LVAD function.

Perioperative Management of Novel Pharmacotherapies for Heart Failure and Pulmonary Hypertension

Heart failure (HF) and pulmonary hypertension (PH) are increasingly prevalent comorbidities in patients presenting for noncardiac surgery. The unique pathophysiology and pharmacotherapies associated with these syndromes have important perioperative implications. As new medications for HF and PH emerge, it is imperative that anesthesiologists and other perioperative providers understand their mechanisms of action, pharmacokinetics, and potential adverse effects. We present an overview of the novel HF and PH pharmacotherapies and strategies for their perioperative management.

How Long After Coronary Artery Bypass Surgery Can Patients Have Elective Safer Non-Cardiac Surgery?

Objective

To evaluate the complications and mortality after noncardiac surgeries in patients who underwent previous coronary artery bypass grafting (CABG).

Methods

We used insurance data and identified patients aged ≥20 years undergoing noncardiac surgeries between 2010 and 2017 in Taiwan. Based on propensity-score matching, we selected an adequate number of patients with a previous history of CABG (within preoperative 24 months) and those who did not have a CABG history, and both groups had balanced baseline characteristics. The association of CABG with the risk of postoperative complications and mortality was estimated (odds ratio [OR] and 95% confidence interval [CI]) using multiple logistic regression analysis.

Results

The matching procedure generated 2327 matched pairs for analyses. CABG significantly increased the risks of 30-day in-hospital mortality (OR 2.28, 95% CI 1.36-3.84), postoperative pneumonia (OR 1.49, 95% CI 1.12-1.98), sepsis (OR 1.49, 95% CI 1.17-1.89), stroke (OR 1.53, 95% CI 1.17-1.99) and admission to the intensive care unit (OR, 1.75, 95% CI 1.50-2.05). The findings were generally consistent across most of the evaluated subgroups. A noncardiac surgery performed within 1 month after CABG was associated with the highest risk for adverse events, which declined over time.

Conclusion

Prior history of CABG was associated with postoperative pneumonia, sepsis, stroke, and mortality in patients undergoing noncardiac surgeries. Although we raised the possibility regarding deferral of non-critical elective noncardiac surgeries among patients had recent CABG when considering the risks, critical or emergency surgeries were not in the consideration of delay surgery, especially cancer surgery.

Risk of Mortality Following Surgery in Patients With a Previous Cardiovascular Event

Importance

There is a lack of consensus regarding the interval of time-dependent postoperative mortality risk following acute coronary syndrome or stroke.

Objective

To determine the magnitude and duration of risk associated with the time interval between a preoperative cardiovascular event and 30-day postoperative mortality.

Design, Setting, and Participants

This is a longitudinal retrospective population-based cohort study. This study linked data from the Hospital Episode Statistics for National Health Service England, Myocardial Ischaemia National Audit Project and the Office for National Statistics mortality registry. All adults undergoing a National Health Service-funded noncardiac, nonneurologic surgery in England between April 1, 2007, and March 31, 2018, registered in Hospital Episode Statistics Admitted Patient Care were included. Data were analyzed from July 2021 to July 2022.

Exposure

The time interval between a previous cardiovascular event (acute coronary syndrome or stroke) and surgery.

Main Outcomes and Measures

The primary outcome was 30-day all-cause mortality. Secondary outcomes were postoperative mortality at 60, 90, and 365 days. Multivariable logistic regression models with restricted cubic splines were used to estimate adjusted odds ratios.

Results

There were 877 430 patients with and 20 582 717 without a prior cardiovascular event (overall mean [SD] age, 53.4 [19.4] years; 11 577 157 [54%] female). Among patients with a previous cardiovascular event, the time interval associated with increased risk of postoperative mortality was surgery within 11.3 months (95% CI, 10.8-11.7), with subgroup risks of 14.2 months before elective surgery (95% CI, 13.3-15.3) and 7.3 months for emergency surgery (95% CI, 6.8-7.8). Heterogeneity in these timings was noted across many surgical specialties. The time-dependent risk intervals following stroke and myocardial infarction were similar, but the absolute risk was greater following a stroke. Regarding surgical urgency, the risk of 30-day mortality was higher in those with a prior cardiovascular event for emergency surgery (adjusted hazard ratio, 1.35; 95% CI, 1.34-1.37) and an elective procedure (adjusted hazard ratio, 1.83; 95% CI, 1.78-1.89) than those without a prior cardiovascular event.

Conclusions and Relevance

In this study, surgery within 1 year of an acute coronary syndrome or stroke was associated with increased postoperative mortality before reaching a new baseline, particularly for elective surgery. This information may help clinicians and patients balance deferring the potential benefits of the surgery against the desire to avoid increased mortality from overly expeditious surgery after a recent cardiovascular event.

[Perioperative atrial fibrillation : Diagnosis with underestimated relevance]

Atrial fibrillation (AF) is the most common cardiac arrhythmia in adults, both in general and perioperatively and is associated with significant morbidity and mortality. The age of the patients is a major risk factor. The prevalence of AF in noncardiac surgery (NCS) varies widely from 0.4% to 30% and for cardiac surgery, especially major combined procedures, up to approximately 50%. Ectopic excitation centers and reentry mechanisms at the atrial level are favored as the main process of uncoordinated electrical atrial activity. The loss of atrial contraction can lead to a reduction in cardiac output of up to 20-25%. The increased risk of thromboembolism due to AF extends beyond the perioperative period. Medication-based prevention strategies have not yet gained widespread acceptance. Treatment strategies include frequency and rhythm control as well as the avoidance of thromboembolisms through anticoagulation.

Preparing for and Not Waiting for Surgery

Cancer surgery is an essential treatment strategy but can disrupt patients' physical and psychological health. With worldwide demand for surgery expected to increase, this review aims to raise awareness of this global public health concern, present a stepwise framework for preoperative risk evaluation, and propose the adoption of personalised prehabilitation to mitigate risk. Perioperative medicine is a growing speciality that aims to improve clinical outcome by preparing patients for the stress associated with surgery. Preparation should begin at contemplation of surgery, with universal screening for established risk factors, physical fitness, nutritional status, psychological health, and, where applicable, frailty and cognitive function. Patients at risk should undergo a formal assessment with a qualified healthcare professional which informs meaningful shared decision-making discussion and personalised prehabilitation prescription incorporating, where indicated, exercise, nutrition, psychological support, 'surgery schools', and referral to existing local services. The foundational principles of prehabilitation can be adapted to local context, culture, and population. Clinical services should be co-designed with all stakeholders, including patient representatives, and require careful mapping of patient pathways and use of multi-disciplinary professional input. Future research should optimise prehabilitation interventions, adopting standardised outcome measures and robust health economic evaluation.

Does preoperative multidisciplinary team assessment of high-risk patients improve the safety and outcomes of patients undergoing surgery?

BACKGROUND

International guidelines recommend preoperative multidisciplinary team (MDT) assessment for high-risk surgical patients. Preoperative MDT meetings can help to improve surgical care, but there is little evidence on whether they improve patient outcomes.

METHODS

This paper aims to share our experience of MDT meetings for high-risk surgical patients to underline their added value to the current standard of care. An observational study of a retrospective cohort of preoperative high-risk MDT meetings of a tertiary referral hospital between January 2015 and December 2020. For 249 patients the outcomes preoperative data, MDT decisions, and patient outcomes were collected from electronic health records.

MAIN RESULTS

A total of 249 patients were discussed at high-risk MDT meetings. Most of the patients (97%) were assessed as having an American Society of Anesthesiology score ≥ 3, and 219 (88%) had a European Society of Cardiology and European Society of Anaesthesiology risk score of intermediate or high. After MDT assessment, 154 (62%) were directly approved for surgery, and 39 (16%) were considered ineligible for surgery. The remaining 56 (23%) patients underwent additional assessments before reconsideration at a high-risk MDT meeting. The main reason for patients being discussed at the high-risk MDT meeting was to assess the risk-benefit ratio of surgery. Ultimately, 184 (74%) patients underwent surgery. Of the operated patients, 122 (66%) did not have a major complication in the postoperative period, and 149 patients (81%) were alive after one year.

CONCLUSIONS

This cohort study shows the vulnerability and complexity of high-risk patients but also shows that the use of an MDT assessment contributes too improved peri- and postoperative treatment strategies in high-risk patients. Most patients underwent surgery after careful risk assessment and, if deemed necessary, preoperative and perioperative treatment optimization to reduce their risk.

Electrocardiographic deep learning for predicting post-procedural mortality: a model development and validation study

BACKGROUND

Preoperative risk assessments used in clinical practice are insufficient in their ability to identify risk for postoperative mortality. Deep-learning analysis of electrocardiography can identify hidden risk markers that can help to prognosticate postoperative mortality. We aimed to develop a prognostic model that accurately predicts postoperative mortality in patients undergoing medical procedures and who had received preoperative electrocardiographic diagnostic testing.

METHODS

In a derivation cohort of preoperative patients with available electrocardiograms (ECGs) from Cedars-Sinai Medical Center (Los Angeles, CA, USA) between Jan 1, 2015 and Dec 31, 2019, a deep-learning algorithm was developed to leverage waveform signals to discriminate postoperative mortality. We randomly split patients (8:1:1) into subsets for training, internal validation, and final algorithm test analyses. Model performance was assessed using area under the receiver operating characteristic curve (AUC) values in the hold-out test dataset and in two external hospital cohorts and compared with the established Revised Cardiac Risk Index (RCRI) score. The primary outcome was post-procedural mortality across three health-care systems.

FINDINGS

45 969 patients had a complete ECG waveform image available for at least one 12-lead ECG performed within the 30 days before the procedure date (59 975 inpatient procedures and 112 794 ECGs): 36 839 patients in the training dataset, 4549 in the internal validation dataset, and 4581 in the internal test dataset. In the held-out internal test cohort, the algorithm discriminates mortality with an AUC value of 0·83 (95% CI 0·79-0·87), surpassing the discrimination of the RCRI score with an AUC of 0·67 (0·61-0·72). The algorithm similarly discriminated risk for mortality in two independent US health-care systems, with AUCs of 0·79 (0·75-0·83) and 0·75 (0·74-0·76), respectively. Patients determined to be high risk by the deep-learning model had an unadjusted odds ratio (OR) of 8·83 (5·57-13·20) for postoperative mortality compared with an unadjusted OR of 2·08 (0·77-3·50) for postoperative mortality for RCRI scores of more than 2. The deep-learning algorithm performed similarly for patients undergoing cardiac surgery (AUC 0·85 [0·77-0·92]), non-cardiac surgery (AUC 0·83 [0·79-0·88]), and catheterisation or endoscopy suite procedures (AUC 0·76 [0·72-0·81]).

INTERPRETATION

A deep-learning algorithm interpreting preoperative ECGs can improve discrimination of postoperative mortality. The deep-learning algorithm worked equally well for risk stratification of cardiac surgeries, non-cardiac surgeries, and catheterisation laboratory procedures, and was validated in three independent health-care systems. This algorithm can provide additional information to clinicians making the decision to perform medical procedures and stratify the risk of future complications.

FUNDING

National Heart, Lung, and Blood Institute.

Chronic heart failure in patients undergoing major head and neck surgery: A hospital-based study

OBJECTIVE

To investigate the effects of chronic heart failure on various post-operative outcomes in head and neck cancer patients undergoing major cancer surgery.

STUDY DESIGN

For this retrospective cohort study of patients undergoing major head and neck cancer surgery, a sample of 10,002 patients between 2017 and 2019 were identified through the Nationwide Inpatient Sample.

SETTING

Patients were selected as undergoing major head and neck cancer surgery, defined as laryngectomy, pharyngectomy, glossectomy, neck dissection, mandibulectomy, and maxillectomy, then separated based on pre-surgical diagnosis of chronic heart failure.

METHODS

The effects of pre-operative chronic heart failure on post-surgical outcomes in these patients were investigated by univariable and multivariable logistic regression using ICD-10 codes and SPSS.

RESULTS

A diagnosis of chronic heart failure was observed in 265 patients (2.6 %). Patients with chronic heart failure had more preexisting comorbidities when compared to patients without chronic heart failure (mean ± SD; 4 ± 1 vs. 2 ± 1). Multivariable logistic regression showed that chronic heart failure patients had significantly greater odds of dying during hospitalization (OR 2.86, 95 % CI 1.38-5.91) and experiencing non-routine discharge from admission (OR 1.89, 95 % CI 1.41-2.54) after undergoing major head and neck cancer surgery.

CONCLUSION

Chronic heart failure is associated with greater length of stay and hospital charges among head and neck cancer patients undergoing major head and neck cancer surgeries. Chronic heart failure patients have significantly greater rates of unfavorable post-operative outcomes, including death during hospitalization and non-routine discharge from admission.

Prognostic Value of Preoperative Electrocardiogram in Low-Risk Patients Undergoing Surgical Intervention and General Anesthesia

BACKGROUND

Patients aged over 50 years require four times more surgical interventions than younger groups. Many guidelines recommend the performance of preoperative electrocardiogram (ECG) in this population.

OBJECTIVES

To determine the value of preoperative ECG in patients aged over 50 years and classified as ASA I-II (surgical risk).

METHODS

Patients older than 50 years, without comorbidities, who underwent surgical intervention and general anesthesia were included in the study. Patients were randomized to undergo ECG (group A, n=214) or not (group B, n=213) in the preoperative period. The following variables were analyzed: sex, age, ECG, chest x-ray and laboratory tests results, surgical risk, surgery duration, adverse events and in-hospital mortality. The level of significance was set at 5%.

RESULTS

Adverse outcomes were reported in 23 (5.4%) patients, with a significant number of adverse events in male patients (OR=7.91 95%CI 3.3-18.90, p<0.001) and in those undergoing major surgeries (OR=30.02 95%CI 4.01-224.92, p<0.001). No differences were observed between patients who underwent ECG and those who did not (OR=1.59, 95%CI, 0.67-3.75, p=0.289). No significant differences were found in the other variables. In multivariate logistic regression, male sex (OR = 6.49; 95%CI 2.42-17.42, p<0.001) and major surgery (OR=22.62; 95%CI 2.95-173.41, p=0.002) were independent predictors of adverse outcomes, whereas undergoing (or not) ECG (OR=1.09; IC95% 0.41-2.90, p=0.867) remained without statistical significance.

CONCLUSION

Our findings suggest that preoperative ECG could not predict an increased risk of adverse outcomes in our study population during the hospital phase.

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Diabetes and Cardiovascular Disease-Part 3 of the Movement Is Life Special ONJ Series

Diabetes and cardiovascular disease are some of the most common risk factors for complications after total joint arthroplasty (TJA). Preoperative optimization programs are dependent on nurse navigators for coordination of interventions that improve patients' health and surgical outcomes. This article uses information regarding the current practices for diabetes and cardiovascular disease management to provide recommendations for nurse navigators when managing these risk factors prior to TJA. We consulted nurse navigators and conducted a literature review to learn about strategies for addressing diabetes and cardiovascular disease in preoperative optimization programs. Nurse navigators can play a critical role in addressing these conditions by providing patient education and implementing preoperative optimization protocols that incorporate discussion regarding guidelines for diabetes and cardiovascular disease management prior to surgery. This article shares recommendations and resources for nurse navigators to help address diabetes and cardiovascular disease as part of preoperative optimization programs.

Systems of Care Delivery and Optimization in the Preoperative Arena

Key elements of an effective preoperative process include the following: history-taking, risk assessment, shared decision making, effective interdisciplinary communication, preoperative optimization of modifiable conditions, longitudinal care coordination, contribution to population health aims, and collection of outcomes-driven metrics. Perioperative medicine tenets can be applied by health systems of all sizes and demographics to improve quality and safety.

Prediction of Acute Myocardial Injury in Noncardiac Surgery in Patients at Risk for Major Adverse Cardiovascular and Cerebrovascular Events: A Multivariable Risk Model

BACKGROUND

The best use of perioperative cardiac biomarkers assessment is still under discussion. Massive postoperative troponin surveillance can result in untenably high workloads and costs for health care systems and potentially harmful interventions for patients. In a cohort of patients at risk for major adverse cardiovascular and cerebrovascular events (MACCEs), we aimed to (1) determine whether preoperative biomarkers can identify patients at major risk for acute myocardial injury in noncardiac surgery, (2) develop a risk model for acute myocardial injury prediction, and (3) propose an algorithm to optimize postoperative troponin surveillance.

METHODS

Prospective, single-center cohort study enrolling consecutive adult patients (≥45 years) at risk for MACCE scheduled for intermediate-to-high-risk noncardiac surgery. Baseline high-sensitivity troponin T (hsTnT) and N-terminal fragment of pro-B-type natriuretic peptide (NT-proBNP), as well as hsTnT on the first 3 postoperative days were obtained. The main outcome was the occurrence of acute myocardial injury. Candidate predictors of acute myocardial injury were baseline concentrations of hsTnT ≥14 ng/L and NT-proBNP ≥300 pg/mL and preoperative and intraoperative variables. A multivariable risk model and a decision curve were constructed.

RESULTS

Of 732 patients, 42.1% had elevated hsTnT and 37.3% had elevated NT-proBNP levels at baseline. Acute myocardial injury occurred in 161 patients (22%). Elevated baseline hsTnT, found in 84% of patients with acute myocardial injury, was strongly associated with this outcome: odds ratio (OR), 12.08 (95% confidence interval [CI], 7.78-19.42). Logistic regression identified 6 other independent predictors for acute myocardial injury: age, sex, estimated glomerular filtration rate (eGFR) <45 mL·min -1 ·1.73 m -2 , functional capacity <4 METs or unknown, NT-proBNP ≥300 pg/mL, and estimated intraoperative blood loss. The c -statistic for the risk model was 77% (95% CI, 0.73-0.81). The net benefit of the model began at a risk threshold of 7%.

CONCLUSIONS

Baseline determination of cardiac biomarkers in patients at risk for MACCE shortly before intermediate- or high-risk noncardiac surgery helps identify those with the highest risk for acute myocardial injury. A baseline hsTnT ≥14 ng/L indicates the need for postoperative troponin surveillance. In patients with baseline hsTnT <14 ng/L, our 6-predictor model will identify additional patients at risk for acute myocardial injury who may also benefit from postoperative surveillance.

Perioperative cardiac risk reduction in non cardiac surgery

For patients undergoing nonemergent noncardiac surgery, care must be taken to identify patients at increased risk of major adverse cardiovascular events, as these remain a significant source of perioperative morbidity and mortality. Identification of at-risk patients requires careful attention to risk factors including assessment of functional status, medical comorbidities, and a medication assessment. After identification, to minimize perioperative cardiac risk, care should be taken through a combination of appropriate medication management, close monitoring for cardiovascular ischemic events, and optimization of pre-existing medical conditions. There are multiple society guidelines that aim to mitigate risk of cardiovascular morbidity and mortality in patients undergoing nonemergent noncardiac surgery. However, the rapid evolution of medical literature often creates gaps between the existing evidence and best practice recommendations. In this review, we aim to reconcile the recommendations made in the guidelines from the major cardiovascular and anesthesiology societies from the USA, Canada, and Europe, and to provide updated recommendations based on new evidence.

Natriuretic peptide testing strategies in heart failure: A 2023 update

Natriuretic peptides (NPs), including B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP), have been recommended as standard biomarkers for diagnosing heart failure (HF), and one of the strongest risk predictors for mortality and HF hospitalization regardless of ejection fraction (EF) and etiology of HF. BNP is an active neurohormone opposing renin-angiotensin-aldosterone and sympathetic nervous system overactivated in HF, whereas NT-proBNP is an inactive prohormone released from cardiomyocytes in response to wall stress. Despite substantial advances in the development of guideline-directed medical therapy (GDMT) for HF with reduced EF, studies demonstrating direct benefits of NP-guided chronic HF therapy on mortality, HF hospitalization, and GDMT optimization have yielded conflicting results. However, accumulating evidence shows that achieving prespecified BNP or NT-proBNP target over time is significantly associated with favorable outcomes, suggesting that benefits of serially measured NPs may be limited to particular groups of HF patients, such as those with extreme levels of baseline BNP or NT-proBNP, which could represent severe phenotypes of HF associated with natriuretic peptide resistance or cardiorenal syndrome. Over the past decade, clinical utilization of BNP and NT-proBNP has been expanded, especially using serial NP measurements for guiding HF therapy, optimizing GDMT and identifying at-risk patients with HF phenotypes who may be minimally symptomatic or asymptomatic.