Cardiac screening before noncardiac surgery

Total Hip Replacement Provokes Endothelial Dysfunction

Surgery represents an increased risk of different perioperative complications. Endothelial function (EF) is a key mechanism responsible for cardiovascular homeostasis and is involved in thromboembolic complications. We aimed to follow changes of EF in an early postoperative period in patients undergoing total hip replacement (THR). Endothelial function was assessed noninvasively in 70 consecutive patients who underwent an elective THR under spinal anesthesia. Flow-mediated dilation (FMD) and low flow-mediated constriction capability of the brachial artery, which are indicators of EF were measured before the operation (baseline), 24 hours after the operative procedure, and 5 to 7 days postoperatively. Baseline FMD was 12.3% and decreased a day after surgery to 7.3% ( P < .001). After 5 to 7 days, it gradually increased to 9.2%. However, on average, it was lower than before surgery ( P < .001). The median duration of THR was 85.0 (65.0-100.0) minutes, the average hospital length of stay was 7 days. Total hip replacement is associated with an immediate decrease in FMD which remains significantly decreased 5 to 7 days after the surgery compared with the preoperative value. These results indicate that surgery provokes endothelial dysfunction and deteriorates cardiovascular homeostasis. This effect could be involved in cardiovascular complications in the postoperative period.

Analysis of Risk Factors for Lower-limb Deep Venous Thrombosis in Old Patients after Knee Arthroplasty

Background:

Deep venous thrombosis (DVT) is a common complication of arthroplasty in old patients. We analyzed risk factors for lower-limb DVT after arthroplasty in patients aged over 70 years to determine controllable risk factors.

Methods:

This was a retrospective study of 1,025 patients aged >70 years treated with knee arthroplasty at our hospital between January 2009 and December 2013. Of 1,025 patients, 175 had postoperative lower-limb DVT. We compared medical history, body mass index (BMI), ambulatory blood pressure, preoperative and postoperative fasting blood glucose (FBG), preoperative blood total cholesterol, triglyceride, high- and low-density lipoprotein cholesterol, and preoperative homocysteine (Hcy) between thrombus and non-thrombus groups. B-mode ultrasonography was used to detect lower-limb DVT before the operation and 7 days after the operation in all patients. Logistic regression analysis was used to determine risk factors for DVT.

Results:

Incidence of diabetes (P = 0.014), BMI (P = 0.003), preoperative FBG (P = 0.004), postoperative FBG (P = 0.012), and preoperative Hcy (P < 0.001) were significantly higher in the thrombus group. A significantly greater proportion of patients in the non-thrombus group had early postoperative activity (P < 0.001) and used a foot pump (P < 0.001). Operative duration was significantly longer in the thrombus group (P = 0.012). Within the thrombus group, significantly more patients had bilateral than unilateral knee arthroplasty (P < 0.01). Multivariate logistic analysis revealed BMI, preoperative Hcy, postoperative FBG, long operative duration, bilateral knee arthroplasty, and time to the activity after the operation to be predictive factors of DVT. At 6-month follow-up of the thrombus group, 4.7% of patients had pulmonary embolism and 18.8% had recurrent DVT; there were no deaths.

Conclusions:

Obesity, inactivity after operation, elevated preoperative Hcy and postoperative FBG, long operative duration, and bilateral knee arthroplasty were risk factors for DVT in patients aged over 70 years.

Screening for cardiovascular disease before kidney transplantation

Pre-kidney transplant cardiac screening has garnered particular attention from guideline committees as an approach to improving post-transplant success. Screening serves two major purposes: To more accurately inform transplant candidates of their risk for a cardiac event before and after the transplant, thereby informing decisions about proceeding with transplantation, and to guide pre-transplant management so that post-transplant success can be maximized. Transplant candidates on dialysis are more likely to be screened for coronary artery disease than those not being considered for transplantation. Thorough history and physical examination taking, resting electrocardiography and echocardiography, exercise stress testing, myocardial perfusion scintigraphy, dobutamine stress echocardiography, cardiac computed tomography, cardiac biomarker measurement, and cardiac magnetic resonance imaging all play contributory roles towards screening for cardiovascular disease before kidney transplantation. In this review, the importance of each of these screening procedures for both coronary artery disease and other forms of cardiac disease are discussed.

Korean guidelines for the appropriate use of cardiac CT

The development of cardiac CT has provided a non-invasive alternative to echocardiography, exercise electrocardiogram, and invasive angiography and cardiac CT continues to develop at an exponential speed even now. The appropriate use of cardiac CT may lead to improvements in the medical performances of physicians and can reduce medical costs which eventually contribute to better public health. However, until now, there has been no guideline regarding the appropriate use of cardiac CT in Korea. We intend to provide guidelines for the appropriate use of cardiac CT in heart diseases based on scientific data. The purpose of this guideline is to assist clinicians and other health professionals in the use of cardiac CT for diagnosis and treatment of heart diseases, especially in patients at high risk or suspected of heart disease.

Acute myocardial infarctation in patients with critical ischemia underwent lower limb revascularization

BACKGROUND: Atherosclerosis is the main cause of peripheral artery occlusive disease (PAOD) of the lower limbs. Patients with PAOD often also have obstructive atherosclerosis in other arterial sites, mainly the coronary arteries. This means that patients who undergo infrainguinal bypass to treat critical ischemia have a higher risk of AMI. There are, however, few reports in the literature that have assessed this risk properly. OBJECTIVE: The aim of this study was to determine the incidence of acute myocardial infarction in patients who underwent infrainguinal bypass to treat critical ischemia of the lower limbs caused by PAOD. MATERIAL AND METHODS: A total of 64 patients who underwent 82 infrainguinal bypass operations, from February 2011 to July 2012 were studied. All patients had electrocardiograms and troponin I blood assays during the postoperative period (within 72 hours). RESULTS: There were abnormal ECG findings and elevated blood troponin I levels suggestive of AMI in five (6%) of the 82 operations performed. All five had conventional surgery. The incidence of AMI as a proportion of the 52 conventional surgery cases was 9.6%. Two patients died. CONCLUSION: There was a 6% AMI incidence among patients who underwent infrainguinal bypass due to PAOD. Considering only cases operated using conventional surgery, the incidence of AMI was 9.6%.

Changing risk of perioperative myocardial infarction

INTRODUCTION

Years ago, patients with recent myocardial infarction (MI) were reported to be at high risk of reinfarction (27%) and death after surgery. Therapy has changed in the 3 decades since those reports, so we reexamined that risk as well as other cardiac comorbidities and surgical work values in predicting adverse outcome.

METHODS

We used the National Surgical Quality Improvement Program Participant Use Data File for 2005 to 2009. We included all patients of all included specialties, for outpatient and inpatient surgery. Cardiac comorbidities included history of congestive heart failure (30 days) or MI (6 months), percutaneous coronary intervention, previous cardiac surgery, and history of angina (30 days). Other predictors included a frailty index and American Society of Anesthesiologists (ASA) class. Adverse cardiac events included cardiac arrest requiring cardiopulmonary resuscitation, MI, and death. Cases were stratified according to surgical work units. Univariate χ(2) analysis and multivariate logistic regression established simple relationships and interactions, with p < 0.05 significant.

RESULTS

Of patients who had recent MI, 2.1% had reinfarction perioperatively and 26% of those died. The odds ratio for infarction with vs without recent MI in inpatients age 40 years and older was 4.6. Frailty and ASA class were stronger predictors of perioperative MI and cardiac arrest than was history of MI, and risk increased as surgical work increased.

DISCUSSION

The risk caused by preoperative MI has improved by an order of magnitude in the last 30 years. The ASA class and especially frailty are better predictors of adverse cardiac events.

Standard perioperative management in gastrointestinal surgery

INTRODUCTION

The outcome of patients who are scheduled for gastrointestinal surgery is influenced by various factors, the most important being the age and comorbidities of the patient, the complexity of the surgical procedure and the management of postoperative recovery. To improve patient outcome, close cooperation between surgeons and anaesthesiologists (joint risk assessment) is critical. This cooperation has become increasingly important because more and more patients are being referred to surgery at an advanced age and with multiple comorbidities and because surgical procedures and multimodal treatment modalities are becoming more and more complex.

OBJECTIVE

The aim of this review is to provide clinicians with practical recommendations for day-to-day decision-making from a joint surgical and anaesthesiological point of view. The discussion centres on gastrointestinal surgery specifically.