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Jaquenod De Giusti C, Santalla M, Das S. Exosomal non-coding RNAs (Exo-ncRNAs) in cardiovascular health. J Mol Cell Cardiol 2019; 137:143-151. [PMID: 31669445 DOI: 10.1016/j.yjmcc.2019.09.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 09/05/2019] [Accepted: 09/27/2019] [Indexed: 12/11/2022]
Abstract
Extracellular vesicles (EVs) play a role in the pathophysiological processes and in different diseases, including cardiovascular disease. Out of several categories of EVs, exosomes (smallest - 30 to 150 nm) are gaining most of the focus as the next generation of biomarkers and in therapeutic strategies. This is because exosomes can be differentiated from other types of EVs based on the expression of tetraspanin molecules on the surface. More importantly, exosomes can be traced back to the cell of origin by identifying the unique cellular marker(s) on the exosomal surface. Recently, several researchs have demonstrated an important and underappreciated mechanism of paracrine cell-cell communication involving exosomal transfer, and its subsequent functional impact on recipient cells. Exosomes are enriched in proteins, mRNAs, miRNAs, and other non-coding RNAs, which can potentially alter myocardial function. Additionally, different stages of tissue damage can also be identified by measuring these bioactive molecules in the circulation. There are several aspects of this new concept still unknown. Therefore, in this review, we have summarized the knowledge we have so far and highlighted the potential of this novel concept of next generation biomarkers and therapeutic intervention.
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Affiliation(s)
- Carolina Jaquenod De Giusti
- Centro de Investigaciones Cardiovasculares UNLP-CONICET, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, La Plata, Argentina.
| | - Manuela Santalla
- Centro de Investigaciones Cardiovasculares UNLP-CONICET, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, La Plata, Argentina; Departamento de Ciencias Básicas y Experimentales, Universidad Nacional del Noroeste de Buenos Aires, Pergamino, Argentina
| | - Samarjit Das
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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Emanueli C, Shearn AIU, Laftah A, Fiorentino F, Reeves BC, Beltrami C, Mumford A, Clayton A, Gurney M, Shantikumar S, Angelini GD. Coronary Artery-Bypass-Graft Surgery Increases the Plasma Concentration of Exosomes Carrying a Cargo of Cardiac MicroRNAs: An Example of Exosome Trafficking Out of the Human Heart with Potential for Cardiac Biomarker Discovery. PLoS One 2016; 11:e0154274. [PMID: 27128471 PMCID: PMC4851293 DOI: 10.1371/journal.pone.0154274] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 04/10/2016] [Indexed: 12/21/2022] Open
Abstract
Introduction Exosome nanoparticles carry a composite cargo, including microRNAs (miRs). Cultured cardiovascular cells release miR-containing exosomes. The exosomal trafficking of miRNAs from the heart is largely unexplored. Working on clinical samples from coronary-artery by-pass graft (CABG) surgery, we investigated if: 1) exosomes containing cardiac miRs and hence putatively released by cardiac cells increase in the circulation after surgery; 2) circulating exosomes and exosomal cardiac miRs correlate with cardiac troponin (cTn), the current “gold standard” surrogate biomarker of myocardial damage. Methods and Results The concentration of exosome-sized nanoparticles was determined in serial plasma samples. Cardiac-expressed (miR-1, miR-24, miR-133a/b, miR-208a/b, miR-210), non-cardiovascular (miR-122) and quality control miRs were measured in whole plasma and in plasma exosomes. Linear regression analyses were employed to establish the extent to which the circulating individual miRs, exosomes and exosomal cardiac miR correlated with cTn-I. Cardiac-expressed miRs and the nanoparticle number increased in the plasma on completion of surgery for up to 48 hours. The exosomal concentration of cardiac miRs also increased after CABG. Cardiac miRs in the whole plasma did not correlate significantly with cTn-I. By contrast cTn-I was positively correlated with the plasma exosome level and the exosomal cardiac miRs. Conclusions The plasma concentrations of exosomes and their cargo of cardiac miRs increased in patients undergoing CABG and were positively correlated with hs-cTnI. These data provide evidence that CABG induces the trafficking of exosomes from the heart to the peripheral circulation. Future studies are necessary to investigate the potential of circulating exosomes as clinical biomarkers in cardiac patients.
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Affiliation(s)
- Costanza Emanueli
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- * E-mail:
| | | | - Abas Laftah
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Francesca Fiorentino
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Barnaby C. Reeves
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Cristina Beltrami
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Andrew Mumford
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Aled Clayton
- Institute of Cancer & Genetics, University of Cardiff, Cardiff, United Kingdom
| | - Mark Gurney
- Institute of Cancer & Genetics, University of Cardiff, Cardiff, United Kingdom
| | - Saran Shantikumar
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Gianni D. Angelini
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Kim M, Son M, Lee DH, Park K, Park TH. Troponin-I Level After Major Noncardiac Surgery and Its Association With Long-Term Mortality. Int Heart J 2016; 57:278-84. [DOI: 10.1536/ihj.15-352] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Minkwan Kim
- Regional Cardiocerebrovascular Center, Dong-A University Hospital
| | - Minkook Son
- Regional Cardiocerebrovascular Center, Dong-A University Hospital
| | - Dong Hyun Lee
- Regional Cardiocerebrovascular Center, Dong-A University Hospital
| | - Kyungil Park
- Regional Cardiocerebrovascular Center, Dong-A University Hospital
- Division of Cardiology, Department of Internal Medicine, Dong-A University College of Medicine
| | - Tae-Ho Park
- Regional Cardiocerebrovascular Center, Dong-A University Hospital
- Division of Cardiology, Department of Internal Medicine, Dong-A University College of Medicine
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Leuzzi G, Facciolo F, Pastorino U, Rocco G. Methods for the postoperative management of the thoracic oncology patients: lessons from the clinic. Expert Rev Respir Med 2015; 9:751-67. [DOI: 10.1586/17476348.2015.1109453] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Valentijn TM, Galal W, Tjeertes EK, Hoeks SE, Verhagen HJ, Stolker RJ. The obesity paradox in the surgical population. Surgeon 2013; 11:169-76. [DOI: 10.1016/j.surge.2013.02.003] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 02/04/2013] [Accepted: 02/06/2013] [Indexed: 02/07/2023]
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Slack J, Boston R, Driessen B, Reef V. Effect of general anesthesia on plasma cardiac troponin I concentrations in healthy horses. J Vet Cardiol 2011; 13:163-9. [PMID: 21821476 DOI: 10.1016/j.jvc.2011.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Revised: 02/18/2011] [Accepted: 04/19/2011] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the effect of general anesthesia on plasma cTnI concentrations in horses. ANIMALS, MATERIALS AND METHODS Thirty-two horses undergoing general anesthesia and either elective surgery or MRI without surgery were prospectively studied. Twenty-nine horses (22 surgical, 7 imaging) completed the study. Plasma cTnI concentrations were determined prior to anesthesia and at 6, 12 and 24 h following discontinuation of the inhalant anesthetic. RESULTS All horses had cTnI values within the reference range at all time points. Six horses (21%) developed detectable cTnI 6 or 12 h following anesthesia. Risk factors for detectable cTnI include increasing age and dorsal recumbency. Horses with detectable cTnI had significantly lower mean and diastolic arterial blood pressures than those without detectable cTnI. CONCLUSION Uncomplicated general anesthesia with or without surgery does not result in cardiac troponin I elevations above the reference range in the first 24 h postoperatively.
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Affiliation(s)
- Joann Slack
- Department of Clinical Studies, New Bolton Center, University of Pennsylvania, Kennett Square, USA.
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Clinical and biochemical prediction of early fatal outcome following hip fracture in the elderly. INTERNATIONAL ORTHOPAEDICS 2010; 35:903-7. [PMID: 21079953 PMCID: PMC3103949 DOI: 10.1007/s00264-010-1149-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Revised: 10/22/2010] [Accepted: 10/22/2010] [Indexed: 11/27/2022]
Abstract
Hip fracture, a moderate musculoskeletal trauma, is associated with a high postoperative mortality. Most patients are elderly, with comorbid conditions and often with heart disease. The objective of this study was to find out if clinical parameters and analyses of specific muscle enzymes could predict three month postoperative mortality. A total of 302 patients above 75 years of age with hip fracture were consecutively enrolled. Baseline information on age, sex and comorbidity assessed with the American Society of Anesthesiologists (ASA) score was obtained before surgery. Creatine kinase (CK), myocardium-specific creatine kinase (CK-MB) and troponin T (TnT) were analysed from venous blood, collected the day before surgery (−1) and postoperatively, within 24 hours (0) and on days one (+1) and four (+4). The overall three month mortality was 19.5%. Multivariate analyses showed that age, male sex and comorbidity (ASA) correlated with mortality (p = 0.027, p = 0.002, p < 0.001, respectively). Surgery induced a two- to threefold increase of CK and CK-MB but without any correlation with mortality. However, high TnT levels >0.04 μg/l correlated significantly with death (days −1, +1 and +4, p = 0.003, p = 0.005 and p = 0.003, respectively). Multivariate analyses, adjusted for age, sex and ASA category, confirmed this correlation (day +4, p = 0.008). Thus, in elderly patients with comorbidities undergoing hip fracture surgery information on sex, age, ASA category and postoperative laboratory analyses on TnT provide the clinicians with useful information on patients at risk of fatal outcome.
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Roggenbach J, Böttiger BW, Teschendorf P. [Perioperative myocardial damage in non-cardiac surgery patients]. Anaesthesist 2009; 58:665-76. [PMID: 19554269 DOI: 10.1007/s00101-009-1577-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Perioperative myocardial damage occurs with a high incidence depending on the operative procedure and the patients examined and is considered to be among the most relevant risk factors for increased perioperative morbidity and mortality in patients undergoing non-cardiac surgery. The pathophysiology of myocardial damage in the perioperative period is still not well understood. Both ischemia with and without acute coronary occlusion and non-ischemic stimuli can put a substantial strain on the heart in the perioperative period. However, in many cases the clinical presentation does not allow a clear differentiation between ischemic and non-ischemic myocardial damage. In the majority of cases perioperative myocardial infarctions occur with only mild or even without any clinical symptoms. This is probably due to a considerable difference in phenotype and pathophysiology between perioperative and non-perioperative myocardial infarctions. As a result of this unexplained etiology of perioperative myocardial infarction it remains an open question whether the contemporary diagnostic and therapeutic recommendations for the acute coronary syndrome can be extrapolated to the perioperative situation. The present review reflects the current state of knowledge and presents an optional approach to the diagnosis and therapy of perioperative myocardial injury.
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Affiliation(s)
- J Roggenbach
- Klinik für Anaesthesiologie und Intensivmedizin, Klinikum der Universität Heidelberg, Im Neuenheimer Feld 110, 69115, Heidelberg.
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Chong CP, Lam QT, Ryan JE, Sinnappu RN, Lim WK. Incidence of post-operative troponin I rises and 1-year mortality after emergency orthopaedic surgery in older patients. Age Ageing 2009; 38:168-74. [PMID: 19008306 DOI: 10.1093/ageing/afn231] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES to determine the incidence of post-operative troponin I rises and its association with 1-year all-cause mortality and cardiac events after emergency orthopaedic-geriatric surgery, which has not been studied before. METHODS one hundred and two patients over the age of 60 were recruited and followed up at 1 year. All consented to serial troponin I measurements peri-operatively. RESULTS the incidence of a troponin I rise post-operatively was 52.9%. Post-operative acute myocardial infarction was diagnosed in 9.8% and at 1 year, 70% of these patients were dead. At 1 year, 32.4% (33/102) had sustained a cardiac event (myocardial infarction, congestive cardiac failure, atrial fibrillation or major arrhythmia) and using multivariate analysis, post-operative troponin rise (OR 3.9, 95% CI 1.4-10.7, P = 0.008) was an independent predictor of this. Half of the patients with a troponin rise had a cardiac event compared to 18.8% without a rise. All-cause mortality was 20.6% at 1 year; 37% with an associated post-operative troponin rise died versus 2.1% without a rise (P < 0.0001). Using multivariate analysis, only two factors were associated with 1-year all-cause mortality: post-operative troponin rise (OR 12.0, 95% CI 1.4-104.8, P = 0.025) and sustaining a post-operative in-hospital cardiac event (OR 6.6, 95% CI 1.7-25.6, P = 0.006). Furthermore, patients with higher troponin levels had significantly worse survival. CONCLUSIONS there is a high incidence of post-operative troponin I rises in older patients undergoing emergency orthopaedic surgery with 1-year mortality and cardiac events being significantly increased in these patients. Future studies are needed to determine whether any intervention can improve outcome for these patients.
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Affiliation(s)
- Carol P Chong
- Department of Aged Care, The Northern Hospital, Epping, Victoria, Australia.
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Fisher AA, Southcott EN, Goh SL, Srikusalanukul W, Hickman PE, Davis MW, Potter JM, Budge MM, Smith PN. Elevated serum cardiac troponin I in older patients with hip fracture: incidence and prognostic significance. Arch Orthop Trauma Surg 2008; 128:1073-9. [PMID: 18193436 DOI: 10.1007/s00402-007-0554-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Cardiovascular complications are the main causes of morbidity and mortality in patients with osteoporotic hip fracture (HF). The aim of this prospective study was to evaluate the incidence and prognostic significance of elevated cardiac troponin I (cTnI) in the early peri-operative period in older patients with HF. MATERIALS AND METHODS A blind evaluation of myocardial injury as detected by cTnI elevation in 238 consecutive older patients with low-trauma HF (mean age 81.9 +/- 7.8 (SD) years; 72% females). Data on demographic and clinical characteristics, in-hospital mortality, hospital length of stay and discharge destination were collected prospectively. Serum cTnI level was analysed from blood collected routinely in the first 72 h of hospital admission. RESULTS Sixty-nine (29%) patients had elevated cTnI (>0.06 microg/l) but myocardial injury was clinically recognised in only 23 (33%) and only 24 (34.8%) had a history of coronary artery disease (CAD). Patients with elevated cTnI were significantly older, more often had American Society of Anaesthesiologist status score >or=3, a history of CAD or stroke and more often were current smokers than the patients without cTnI elevation. In multivariate regression analysis only age was an independent predictor of cTnI elevation. Patients with cTnI release were twice as likely to have a length of stay >or=20 days (P = 0.047) and 2.7 times more likely to be discharged to a long-term residential care facility (RCF) (P = 0.013). cTnI level >or=1 microg/l was a strong independent predictor of all-cause mortality with 98.3% specificity and 89.1% negative predictive value. CONCLUSION Peri-operative myocardial injury is common in older HF patients but is frequently unrecognised clinically. Elevated blood cTnI level is an independent predictor of prolonged length of hospital stay (>or=20 days), need for long-term RCF and mortality (if cTnI >or=1 microg/l).
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Affiliation(s)
- A A Fisher
- Department of Geriatric Medicine, The Canberra Hospital, Woden, ACT 2606, Australia.
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Mantha S, Foss J, Ellis JE, Roizen MF. Intense cardiac troponin surveillance for long-term benefits is cost-effective in patients undergoing open abdominal aortic surgery: a decision analysis model. Anesth Analg 2007; 105:1346-56, table of contents. [PMID: 17959965 DOI: 10.1213/01.ane.0000282768.05743.92] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Srinivas Mantha
- Department of Anesthesiology, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India.
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Lucreziotti S, Conforti S, Carletti F, Santaguida G, Meda S, Raveglia F, Tundo F, Panigalli T, Biondi ML, Mezzetti M, Fiorentini C. Elevaciones de la troponina I cardiaca tras la cirugía torácica. Incidencia y correlaciones con las características clínicas basales, la proteína C reactiva y los parámetros perioperatorios. Rev Esp Cardiol 2007. [DOI: 10.1157/13111788] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Abstract
Because of changing demographics, increasing numbers of patients with IHD are presenting for noncardiac surgery, and the risks of perioperative morbidity and mortality are significant. The Lee Cardiac Risk Index is applicable in defining perioperative cardiac risk: however, ACC/AHA guidelines may not be applicable comprehensively. The role of biomarkers in risk stratification still needs to be defined. Structured management protocols that help assess, diagnose, and treat patients with IHD preoperatively are likely to help decrease postoperative morbidity and mortality, but clearly are not applicable to all patients. Augmented hemodynamic control with beta-blockers or alpha-2 agonists and modulating inflammation by statins can play an important role in improving outcomes in many patients with IHD; preoperative coronary revascularization may be of limited value. Intraoperative anesthetic management that minimizes hemodynamic perturbations is important; however, the choice of a particular technique typically is not critical. Of critical importance is the postoperative management of the patient. Postoperative myocardial injury should be identified, evaluated, and managed aggressively. Secondary stresses such as sepsis, extubation, and anemia, which can increase demand on the heart, should be treated or minimized. Clearly, optimal care of the patient with IHD entails closely coordinated assessment and management throughout the preoperative, intraoperative, and postoperative phases, if one is to optimize short- and long-term outcomes.
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Affiliation(s)
- Shamsuddin Akhtar
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, TMP-3, New Haven, CT 06520-8051, USA.
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Lucreziotti S, Conforti S, Carletti F, Santaguida G, Meda S, Raveglia F, Tundo F, Panigalli T, Biondi ML, Mezzetti M, Fiorentini C. Cardiac Troponin-I Elevations After Thoracic Surgery. Incidence and Correlations With Baseline Clinical Characteristics, C-Reactive Protein, and Perioperative Parameters. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/s1885-5857(08)60046-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lucreziotti S, Carletti F, Santaguida G, Fiorentini C. Myocardial infarction in major noncardiac surgery: Epidemiology, pathophysiology and prevention. Heart Int 2006; 2:82. [PMID: 21977256 PMCID: PMC3184667 DOI: 10.4081/hi.2006.82] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The number of subjects undergoing major noncardiac surgery who are at risk for perioperative myocardial infarction (MI) is growing worldwide. It has been estimated that 500,000 to 900,000 patients suffer major perioperative cardiovascular complications every year, with consequent heavy, long-term prognostic implications and costs. It is well known that perioperative MIs don’t share the same pathophysiology as nonsurgical MIs but the relative role of the different, potential triggers has not been completely clarified. Many aspects of the perioperative management, including risk-stratification and prophylactic or postoperative interventions have also not been completely defined. Throughout recent years many resources have been invested to clarify these aspects and experts have developed indices and algorithm-based strategies to better assess the cardiac risk and to guide the perioperative management. The scope of the present review is to discuss the main aspects of perioperative MI in noncardiac surgery, with particular regard to epidemiology, pathophysiology, preoperative risk stratification, prophylaxis and therapy.
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Affiliation(s)
- Stefano Lucreziotti
- Unità Operativa di Cardiologia, Azienda Ospedaliera S. Paolo, Polo Universitario, Milano - Italy
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Lucreziotti S, Carletti F, Santaguida G, Fiorentini C. Myocardial Infarction in Major Noncardiac Surgery: Epidemiology, Pathophysiology and Prevention. Heart Int 2006. [DOI: 10.1177/182618680600200203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Stefano Lucreziotti
- Unità Operativa di Cardiologia, Azienda Ospedaliera S. Paolo, Polo Universitario, Milano - Italy
| | - Francesca Carletti
- Unità Operativa di Cardiologia, Azienda Ospedaliera S. Paolo, Polo Universitario, Milano - Italy
| | | | - Cesare Fiorentini
- Cattedra di Cardiologia, Università degli Studi di Milano, IRCCS Centro Cardiologico Monzino, Milano - Italy
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Park KWT, Subramaniam K, Mahmood F, Shapiro F, Long S, Napoli D. Patients with positive preoperative stress tests undergoing vascular surgery. J Cardiothorac Vasc Anesth 2005; 19:494-8. [PMID: 16085256 DOI: 10.1053/j.jvca.2005.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To examine the perioperative cardiac morbidity and mortality in patients undergoing major vascular surgery with beta-blockade after a positive stress test or cardiac catheterization. DESIGN Retrospective review of a quality assurance database. SETTING A university teaching hospital. PARTICIPANTS A consecutive series of 31 patients undergoing peripheral vascular or aortic surgery after a positive stress test or catheterization between November 2001 and September 2003. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS All 31 patients had a preoperative positive stress test and/or cardiac catheterization, with 12 having multiple areas at risk for myocardial ischemia. None had an intervening coronary revascularization. Twenty-seven had at least one of the intermediate clinical predictors as defined by the American College of Cardiology and 7 had a left ventricular ejection fraction < 40%. Twenty-three patients had been on a beta-blocker and continued on it, while the remainder started on it de novo perioperatively. None of the patients suffered from myocardial infarction, congestive heart failure, or cardiac death perioperatively. CONCLUSIONS This case series reports on the authors' experience with patients undergoing high-risk vascular surgery after a positive stress test or catheterization, but without an intervening coronary intervention. All patients received perioperative beta-blockade and had a very low adverse cardiac event rate. With reduction of adverse events by beta-blockade, the likelihood of a positive event may be reduced and the utility of the test in risk stratification may be questioned.
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Affiliation(s)
- Kyung W Tim Park
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Oscarsson A, Eintrei C, Anskär S, Engdahl O, Fagerström L, Blomqvist P, Fredriksson M, Swahn E. Troponin T-values provide long-term prognosis in elderly patients undergoing non-cardiac surgery. Acta Anaesthesiol Scand 2004; 48:1071-9. [PMID: 15352951 DOI: 10.1111/j.1399-6576.2004.00463.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the significance of elevated postoperative Troponin T (TnT) levels in an elderly population undergoing non-cardiac surgery. METHODS Five hundred and forty-six consecutive patients aged 70 years or older undergoing non-cardiac surgery of >30-min duration were enrolled in this prospective, observational study. A postoperative TnT measurement was obtained on the 5th to 7th postoperative day. Troponin T values greater than 0.02 ng ml(-1) were considered positive. Patients were followed over a 1-year period, and mortality and non-fatal cardiac events (acute myocardial infarction and coronary interventions) were recorded. RESULTS Troponin T concentrations greater than 0.02 ng ml(-1) were detected in 53 of the study subjects (9.7%). Eleven per cent of the patients with elevated TnT had electrocardiographic or clinical signs of myocardial ischemia. One year after surgery, 17 (32%) of the patients with abnormal TnT concentrations had died. In a multivariate Cox regression analysis adjusting for baseline and perioperative data, a TnT value >0.02 ng ml(-1) was an independent correlate of the mortality adjusted hazard ratio (HR): 14.9 (95% CI 3.7-60.3). Other independent predictors of death were tachycardia (HR, 14.9 95% CI 3.45-64.8), ASA 4 (HR, 8.1 95% CI 1.3-50.0), reoperation (HR, 6.4 95% CI 1.1-36.9), and use of diuretics (HR, 4.2 95% CI 1.3-13.8). CONCLUSION We conclude that elevated TnT levels in the postoperative period confer a 15-fold increase in mortality during the first year after surgery. Our findings also provide evidence that silent myocardial ischemia is common in an elderly population. Routine perioperative surveillance for TnT might therefore be of use in detecting patients at an increased risk of mortality during the first postoperative year.
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Affiliation(s)
- A Oscarsson
- Department of Anesthesia and Intensive Care, University Hospital, Linkoping, Sweden
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Abstract
PURPOSE OF THE REVIEW Elevated levels of cardiac troponins, indicative of the presence of cardiac injury, have been reported in critically ill patients. In this review, the incidence, significance, and clinical relevance of elevated troponin levels among this group of patients will be discussed. RECENT FINDINGS It has been shown that elevated cardiac troponin levels can be present among critically ill septic patients without evidence of myocardial ischemia. Recent studies show that elevated troponin levels are also present in a diverse group of critically ill patients without sepsis or septic shock. In addition, several but not all studies show that the mortality rate of troponin-positive patients is significantly higher compared with troponin-negative patients. SUMMARY Elevated troponin levels are not only present in patients suffering from acute coronary syndromes but can also be present in critically ill patients. Even minor elevations are specific for myocardial injury. However, every elevated troponin level in the critically ill patient should not be rigorously diagnosed or treated as a myocardial infarction.
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Vikenes K, Andersen KS, Farstad M, Nordrehaug JE. Temporal pattern of cardiac troponin I after thoracotomy and lung surgery. Int J Cardiol 2004; 96:403-7. [PMID: 15301894 DOI: 10.1016/j.ijcard.2003.08.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2003] [Revised: 08/08/2003] [Accepted: 08/11/2003] [Indexed: 11/17/2022]
Abstract
BACKGROUND Several studies have shown that patients with perioperative myocardial infarction (MI) are at higher risk for subsequent cardiac events and the identification of these patients is important. However, the diagnosis of perioperative MI can be difficult in many cases. The cardiac troponins are biomarkers with high cardiospecificity, and the aim of this study was to assess cTnI and cTnT among other cardiac biomarkers after thoracotomy and lung surgery. METHODS 24 consecutive patients were included in the final analysis. Venous blood samples were drawn prior to the procedure, 1-3, 4-6, 16-18 and 30-32 h after surgery. Thoracotomy was performed as a standard posterolateral incision on the left or right side under general anesthesia. RESULTS Both cTnI and cTnT were completely unaffected by the thoracotomy and the lung surgery. Furthermore, no single value of the troponins was above the 99th percentile at any time. In contrast, CK-MB was elevated in nearly half the patients, although the mean values complied well with the reference limit. CK and myoglobin were both considerably elevated and did not discriminate between acute myocardial infarction and release of the markers due to extracardiac injury. CONCLUSIONS Only the troponins were unaffected by extracardiac surgery and were, thus, reliable markers of myocardial injury in patients who underwent thoracotomy and lung surgery. If the troponins are unavailable, CK-MB mass combined with the CK-MB/CK percentage should be preferred.
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Affiliation(s)
- Kjell Vikenes
- Department of Heart Disease, Haukeland University Hospital, N-5021, Bergen, Norway.
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Abstract
OBJECTIVE Review the perioperative management of patients who are scheduled for noncardiac surgery. DATA SOURCE Review of literature (PubMed, MEDLINE). CONCLUSIONS Patients with ischemic heart disease who undergo noncardiac surgery are at significant risk of perioperative cardiac morbidity and mortality. Recent joint guidelines from the American College of Cardiology and American Heart Association have significantly streamlined the preoperative evaluation processes. Augmented hemodynamic control with intensive perioperative pharmacologic therapy with beta-blockers and possibly alpha-2 agonist has been shown to improve perioperative cardiovascular outcomes. However, translating this information to clinical practice continues to be a challenge and requires a multi- disciplinary approach. A particular intraoperative anesthetic technique is unlikely to influence perioperative cardiac morbidity and mortality. Postoperative management with goals of decreasing hemodynamic stress is important in patients with ischemic heart disease. Diagnosis and management of perioperative myocardial infarction continues to be a challenge. However, use of cardiac specific biomarkers should improve the diagnostic process.
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Affiliation(s)
- Shamsuddin Akhtar
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
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Lucreziotti S, Foroni C, Fiorentini C. Diagnostic and prognostic role of cardiac troponins--reply. J Intern Med 2003; 253:389-90. [PMID: 12603509 DOI: 10.1046/j.1365-2796.2003.01078.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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