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An Y, Wang T, Li L, Li Z, Liang C, Wang P, Jia X, Song H, Zhao L. Impact of neuromuscular block on myocardial injury after non-cardiac surgery (MINS) incidence in the early postoperative stage of older patients undergoing laparoscopic colorectal cancer resection: a randomized controlled study. BMC Geriatr 2024; 24:509. [PMID: 38862916 PMCID: PMC11167868 DOI: 10.1186/s12877-024-05125-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 05/31/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Myocardial injury after non-cardiac surgery (MINS) is a common and serious complication in older patients. This study investigates the impact of neuromuscular block on the MINS incidence and other cardiovascular complications in the early postoperative stage of older patients undergoing laparoscopic colorectal cancer resection. METHODS 70 older patients who underwent laparoscopic colorectal cancer resection were separated into the deep neuromuscular block group and moderate neuromuscular block group for 35 cases in each group (n = 1:1). The deep neuromuscular block group maintained train of four (TOF) = 0, post-tetanic count (PTC) 1-2, and the moderate neuromuscular block group maintained TOF = 1-2 during the operation. Sugammadex sodium was used at 2 mg/kg or 4 mg/kg for muscle relaxation antagonism at the end of surgery. The MINS incidence was the primary outcome and compared with Fisher's exact test. About the secondary outcomes, the postoperative pain was analyzed with Man-Whitney U test, the postoperative nausea and vomiting (PONV) and the incidence of cardiovascular complications were analyzed with Chi-square test, intraoperative mean artery pressure (MAP) and cardiac output (CO) ratio to baseline, length of stay and dosage of anesthetics were compared by two independent samples t-test. RESULTS MINS was not observed in both groups. The highest incidence of postoperative cardiovascular complications was lower limbs deep vein thrombosis (14.3% in deep neuromuscular block group and 8.6% in moderate neuromuscular group). The numeric rating scale (NRS) score in the deep neuromuscular block group was lower than the moderate neuromuscular block group 72 h after surgery (0(1,2) vs 0(1,2), P = 0.018). The operation time in the deep neuromuscular block group was longer (356.7(107.6) vs 294.8 (80.0), min, P = 0.008), the dosage of propofol and remifentanil was less (3.4 (0.7) vs 3.8 (1.0), mg·kg-1·h-1, P = 0.043; 0.2 (0.06) vs 0.3 (0.07), μg·kg-1·min-1, P < 0.001), and the length of hospital stay was shorter than the moderate neuromuscular block group (18.4 (4.9) vs 22.0 (8.3), day, P = 0.028). The differences of other outcomes were not statistically significant. CONCLUSIONS Maintaining different degrees of the neuromuscular block under TOF guidance did not change the MINS incidence within 7 days after surgery in older patients who underwent laparoscopic colorectal cancer resection. TRIAL REGISTRATION The present study was registered in the Chinese Clinical Trial Registry (10/02/2021, ChiCTR2100043323).
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Affiliation(s)
- Yi An
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Lixia Li
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Zhongjia Li
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Chuanyu Liang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Pei Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Xuefei Jia
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Hongyi Song
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Lei Zhao
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China.
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Venishetty N, Jose J, Purudappa PPA, Mounasamy V, Sambandam S. Factors that influence the mortality of patients following hip hemiarthroplasty. ARTHROPLASTY 2024; 6:36. [PMID: 38844977 PMCID: PMC11157840 DOI: 10.1186/s42836-024-00247-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 03/07/2024] [Indexed: 06/09/2024] Open
Abstract
INTRODUCTION Hip hemiarthroplasty (HHA) is one of the most common types of orthopedic surgery. With the prevalence and utilization of the surgery increasing year after year, this procedure is found to be associated with severe postoperative complications and eventually mortality. Thus, it is crucial to understand the factors that increase the risk of mortality following HHA. METHODS Using the Nationwide Inpatient Sample (NIS) database, patients undergoing HHA from 2016 to 2019 were identified. This sample was stratified into a mortality group and a control group. The data regarding patients' demographics, co-morbidities, and associated complications were compared between the groups. RESULTS Of the 84,067 patients who underwent the HHA procedures, 1,327 (1.6%) patients died. Additionally, the mortality group had a higher percentage of patients who were non-electively admitted (P < 0.001) and diabetic patients with complications (P < 0.001), but lower incidences of tobacco-related disorders (P < 0.001). Significant differences were also seen in age (P < 0.001), length of stay (P < 0.001), and total charges (P < 0.001) between the two groups. Preoperatively, those aged > 70 years (OR: 2.11, 95% CI [1.74, 2.56], P < 0.001) had diabetes without complications (OR: 0.32, 95% CI [0.23, 0.44], P < 0.001), tobacco-related disorders (OR: 0.24, 95% CI [0.17, 0.34], P < 0.001) and increased rates of mortality after HHA. Postoperatively, conditions, such as pulmonary embolisms (OR: 6.62, 95% CI [5.07, 8.65], P < 0.001), acute renal failure (OR: 4.58 95% CI [4.09, 5.13], P < 0.001), pneumonia (95% CI [2.72, 3.83], P < 0.001), and myocardial infarctions (OR: 2.65, 95% CI [1.80, 3.92], P < 0.001) increased likelihood of death after undergoing HHA. Patients who were electively admitted (OR: 0.46 95% CI [0.35, 0.61], P < 0.001) had preoperative obesity (OR: 0.67, 95% CI [0.44, 0.84], P = 0.002), and a periprosthetic dislocation (OR: 0.51, 95% CI [0.31, 0.83], P = 0.007) and were found to have a decreased risk of mortality following THA. CONCLUSIONS Analysis of pre- and postoperative complications relating to HHA revealed that several comorbidities and postoperative complications increased the odds of mortality. Old age, pulmonary embolisms, acute renal failure, pneumonia, and myocardial infraction enhanced the odds of post-HHA mortality.
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Affiliation(s)
- Nikit Venishetty
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, 79905, USA.
| | | | | | - Varatharaj Mounasamy
- Department of Orthopedics, University of Texas Southwestern, Dallas VAMC, Dallas, TX, 75390, USA
| | - Senthil Sambandam
- Department of Orthopedics, University of Texas Southwestern, Dallas VAMC, Dallas, TX, 75390, USA.
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Ran S, Yu Q, Fu M, Hou Z, Wang Z. Risk factors and prognosis of postoperative acute myocardial infarction in elderly hip fracture patients combined with coronary heart disease. J Orthop Surg Res 2024; 19:306. [PMID: 38773536 PMCID: PMC11106927 DOI: 10.1186/s13018-024-04757-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 04/21/2024] [Indexed: 05/24/2024] Open
Abstract
INTRODUCTION This article mainly studies the risk factors for postoperative acute myocardial infarction (AMI) in elderly hip fracture patients combined with coronary heart disease (CHD), constructs a prediction model, and evaluates the prognosis of all the patients. METHODS This article retrospectively collected elderly patients with hip fracture and CHD who underwent hip fracture surgery at the Third Hospital of Hebei Medical University from January 2019 to December 2021. Demographic data, laboratory indicators, and imaging examination results were collected from the medical case system. The risk factors of postoperative AMI were determined by univariate and multivariate logistic regression, and a nomogram prediction model was established. The ROC curve, calibration curve and DCA decision curve were plotted by R language software. The patients in the training set were followed up for 2 years to evaluate their survival situation. RESULTS 1094 eligible patients were divided into a training set (n = 824 from January 1, 2019 to September 31, 2021) and a validation set (n = 270 from October 1, 2021 to December 31, 2022). In the training set, women accounted for 58.6%; The average age of the patients was 79.45 years old; The main type of fracture was intertrochanteric fracture. There were 64.7% patients taken B receptor blockers; A total of 166 (20.1%) patients underwent percutaneous coronary intervention (PCI); Hypertension accounted for 55.5%; 520 (63.1%) patients had a preoperative waiting time greater than 3 days; The average hemoglobin value upon admission was 101.36 g/L; The average intraoperative bleeding volume was 212.42 ml; The average surgical time was 2.5 ± 0.3 h; Reginal anesthesia accounted for 29.7%; 63 (68.5%) AMI patients had no obvious clinical symptoms; 68 (73.9%) AMI patients did not show ST-segment elevation in ECG; The risk factors of postoperative AMI were age, hemoglobin at admission, diabetes, chronic kidney disease, intraoperative bleeding, and reginal anesthesia. The AUC of the nomogram prediction model was 0.729. The AUC in the validation set was 0.783. Survival analysis showed a significant statistical difference in 2-year mortality between patients with AMI and without AMI, among all the patients with AMI, patients with ECG ST-segment elevation has higher mortality than patients without ECG ST-segment elevation. CONCLUSION Our research results found that the incidence of postoperative AMI in elderly patients with hip fractures and CHD was 11.1%. Age, diabetes, hemoglobin at admission, regional anesthesia, chronic kidney disease, and intraoperative bleeding are risk factors. The AUC of the nomogram in training set is 0.729. The 2-year mortality rate of the patients with AMI is higher than that of patients without AMI.
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Affiliation(s)
- Saidi Ran
- Department of Geriatric Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Qili Yu
- Department of Geriatric Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - MingMing Fu
- Department of Geriatric Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Zhiyong Hou
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, People's Republic of China.
| | - Zhiqian Wang
- Department of Geriatric Orthopedics, The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, People's Republic of China.
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Lurati Buse G, Bollen Pinto B, Abelha F, Abbott TEF, Ackland G, Afshari A, De Hert S, Fellahi JL, Giossi L, Kavsak P, Longrois D, M'Pembele R, Nucaro A, Popova E, Puelacher C, Richards T, Roth S, Sheka M, Szczeklik W, van Waes J, Walder B, Chew MS. ESAIC focused guideline for the use of cardiac biomarkers in perioperative risk evaluation. Eur J Anaesthesiol 2023; 40:888-927. [PMID: 37265332 DOI: 10.1097/eja.0000000000001865] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND In recent years, there has been increasing focus on the use of cardiac biomarkers in patients undergoing noncardiac surgery. AIMS The aim of this focused guideline was to provide updated guidance regarding the pre-, post- and combined pre-and postoperative use of cardiac troponin and B-type natriuretic peptides in adult patients undergoing noncardiac surgery. METHODS The guidelines were prepared using Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology. This included the definition of critical outcomes, a systematic literature search, appraisal of certainty of evidence, evaluation of biomarker measurement in terms of the balance of desirable and undesirable effects including clinical outcomes, resource use, health inequality, stakeholder acceptance, and implementation. The panel differentiated between three different scopes of applications: cardiac biomarkers as prognostic factors, as tools for risk prediction, and for biomarker-enhanced management strategies. RESULTS In a modified Delphi process, the task force defined 12 critical outcomes. The systematic literature search resulted in over 25,000 hits, of which 115 full-text articles formed the body of evidence for recommendations. The evidence appraisal indicated heterogeneity in the certainty of evidence across critical outcomes. Further, there was relevant gradient in the certainty of evidence across the three scopes of application. Recommendations were issued and if this was not possible due to limited evidence, clinical practice statements were produced. CONCLUSION The ESAIC focused guidelines provide guidance on the perioperative use of cardiac troponin and B-type natriuretic peptides in patients undergoing noncardiac surgery, for three different scopes of application.
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Affiliation(s)
- Giovanna Lurati Buse
- From the Department of Anaesthesiology, University Hospital Dusseldorf, Dusseldorf, Germany (GLB, RMP, AN, SR), Division of Anaesthesiology, Geneva University Hospitals (HUG), Geneva, Switzerland (BBP, MS, BW), Department of Anesthesiology, Centro Hospitalar Universitário de São João, Porto, Portugal (FA), Cardiovascular Research and Development Center (UnIC@RISE), Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal (FA), William Harvey Research Institute, Queen Mary University of London, London, UK (TEA, GA), Department of Anaesthesia and Perioperative Medicine, Royal London Hospital, Barts Health NHS Trust, London, UK (GA), Department of Paediatric and Obstetric Anaesthesia, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Denmark (AA), Department of Anaesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium (SDH), Service d'Anesthésie-Réanimation, Hôpital Universitaire Louis Pradel, Hospices Civils de Lyon, 59 boulevard Pinel, 69500 Lyon, France (J-LF), "Patients as Partners" program, Geneva University Hospitals (HUG), Geneva, Switzerland (LG), Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada (PK), Department of Anesthesiology and Intensive Care, Bichat Claude-Bernard Hospital, Assistance Publique-Hopitaux de Paris - Nord, University of Paris, INSERM U1148, Paris, France (DL), Institut d'Investigació Biomèdica Sant Pau (IIB SANT PAU), Barcelona, Spain (EP), Centro Cochrane Iberoamericano, Barcelona, Spain (EP), Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel-Stadt, Switzerland (CP), Department of Internal Medicine, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Basel-Stadt, Switzerland (CP), Division of Surgery, University of Western Australia, Perkins South Building, Fiona Stanley Hospital, Murdoch, Perth, WA, Australia (TR), Institute of Clinical Trials and Methodology and Division of Surgery, University College London, UK (TR), Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland (WS), Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (JvW), Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University Hospital, Sweden (MSC)
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Atar D, Rosseland LA, Jammer I, Aakre KM, Wiseth R, Molund M, Gualandro DM, Omland T. Implementing screening for myocardial injury in non-cardiac surgery: perspectives of an ad-hoc interdisciplinary expert group. SCAND CARDIOVASC J 2023; 57:31-39. [PMID: 37141087 DOI: 10.1080/14017431.2022.2112071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Objectives. Perioperative myocardial injury (PMI) is increasingly recognised as an important complication of non-cardiac surgery, with often clinically silent presentation, but detrimental prognosis. Active screening for PMI, involving the detection of dynamic and elevated levels of cardiac troponin, has recently been advocated by an increasing number of guidelines; however, active PMI screening has not been reflected in clinical practice. Design. As consensus on a common screening and management pathway is lacking, we synthesise the current evidence to provide suggestions on the selection of patients for screening, organisation of a screening program, and a potential management pathway, building upon a recently published perioperative screening algorithm. Results. Screening should be performed using high-sensitivity assays both preoperatively and postoperatively (postoperative Days 1 and 2) in patients at high-risk of experiencing perioperative complications. Conclusion. This expert opinion piece by an interdisciplinary group of predominantly Norwegian clinicians aims to assist healthcare professionals planning to implement guideline-recommended PMI screening at a local level in order to improve patient outcomes following non-cardiac surgery.
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Affiliation(s)
- Dan Atar
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Leiv Arne Rosseland
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Ib Jammer
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kristin Moberg Aakre
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Rune Wiseth
- Clinic of Cardiology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Marius Molund
- Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway
| | - Danielle M Gualandro
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
| | - Torbjørn Omland
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
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Yang L, Shi S, Li J, Fang Z, Guo J, Kang W, Shi J, Yuan S, Yan F, Zhou C. Postoperative elevated cardiac troponin levels predict all-cause mortality and major adverse cardiovascular events following noncardiac surgery: A dose-response meta-analysis of prospective studies. J Clin Anesth 2023; 90:111229. [PMID: 37573706 DOI: 10.1016/j.jclinane.2023.111229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/24/2023] [Accepted: 08/08/2023] [Indexed: 08/15/2023]
Abstract
STUDY OBJECTIVE To perform a dose-response meta-analysis for the association between postoperative myocardial injury (PMI) in noncardiac surgery and the risk of all-cause mortality or major adverse cardiovascular event (MACE). DESIGN Dose-response meta-analysis of prospective studies with weighted (WL) or generalized (GL) linear and restricted cubic spline (RCS) regression. SETTING Teaching hospitals. PATIENTS Adult patients undergoing noncardiac surgery. INTERVENTIONS No. MEASUREMENTS The primary outcome was all-cause mortality. The secondary outcome was MACE. MAIN RESULTS 29 studies (53,518 patients) were included. The overall incidence of PMI was 26.0% (95% CI 21.0% to 32.0%). Compared to those without PMI, patients with PMI had an increased risk of all-cause mortality at short- (<12 months) (cardiac troponin[cTn]I: unadj OR 1.71,95%CI 1.22 to 2.41, P < 0.001; cTnT: unadj OR 2.33,95%CI 2.07 to 2.63, P < 0.001), and long-term (≥ 12 months) (cTnI: unadj OR 1.80, 95%CI 1.63 to 1.99; cTnT: unadj OR 1.47,95%CI 1.33 to 1.62) (All P < 0.001) follow-up. For MACE, the group with elevated values was associated with an increased risk (cTnI: unadj OR 1.98, 95% CI 1.13 to 3.47, P = 0.018; cTnT: unadj OR 2.29, 95% CI 1.88 to 2.79, P < 0.001). Dose-response analysis showed positive associations between PMI (per 1× upper reference limit[URL] increment) and all-cause mortality both at short- (unadj OR) (WL, OR 1.09, 95% CI 1.09 to 1.10; GL, OR 1.06, 95% CI 1.06 to 1.07; RCS in the range of 1-2× URL, OR = 2.43, 95%CI 2.25 to 2.62) and long-term follow-up (unadj HR) (WL, OR 1.16, 95% CI 1.14 to 1.17; GL, OR 1.15, 95% CI 1.13 to 1.16; RCS in the range of 1-2.75× URL, OR = 1.23, 95%CI 1.13 to 1.33), and MACE at longest follow-up (unadj OR) (WL: OR 1.53, 95% CI 1.49 to 1.57; GL: OR 1.46, 95% CI 1.42 to 1.50; RCS in the range of 1-2 x URL, OR = 3.10, 95%CI 2.51 to 3.81) (All P < 0.001). For mild cTn increase below URL, the risk of mortality increased with every increment of 0.25xURL (WL, OR 1.03, 95% CI 1.02 to 1.03; GL, OR 1.05, 95% CI 1.03 to 1.07; RCS in the range of 0-0.5 URL, OR = 9.41, 95% CI 7.41 to 11.95) (All P < 0.001). CONCLUSIONS This study shows positive WL or GL and RCS dose-response relationships between PMI and all-cause mortality at short (< 12 mons)- and long-term (≥ 12 mons) follow-up, and MACE at longest follow-up. For mild cTn increase below URL, the risk of mortality also increases even with every increment of 0.25× URL.
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Affiliation(s)
- Lijing Yang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Sheng Shi
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Jun Li
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Zhongrong Fang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Jingfei Guo
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Wenying Kang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Jia Shi
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Su Yuan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Fuxia Yan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Chenghui Zhou
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China; Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China.
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Strickland SS, Quintela EM, Wilson MJ, Lee MJ. Long-term major adverse cardiovascular events following myocardial injury after non-cardiac surgery: meta-analysis. BJS Open 2023; 7:7142743. [PMID: 37104754 PMCID: PMC10129390 DOI: 10.1093/bjsopen/zrad021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/12/2022] [Accepted: 01/27/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Myocardial injury after non-cardiac surgery is diagnosed following asymptomatic troponin elevation in the perioperative interval. Myocardial injury after non-cardiac surgery is associated with high mortality rates and significant rates of major adverse cardiac events within the first 30 days following surgery. However, less is known regarding its impact on mortality and morbidity beyond this time. This systematic review and meta-analysis aimed to establish the rates of long-term morbidity and mortality associated with myocardial injury after non-cardiac surgery. METHODS MEDLINE, Embase and Cochrane CENTRAL were searched, and abstracts screened by two reviewers. Observational studies and control arms of trials, reporting mortality and cardiovascular outcomes beyond 30 days in adult patients diagnosed with myocardial injury after non-cardiac surgery, were included. Risk of bias was assessed using the Quality in Prognostic Studies tool. A random-effects model was used for the meta-analysis of outcome subgroups. RESULTS Searches identified 40 studies. The meta-analysis of 37 cohort studies found a rate of major adverse cardiac events-associated myocardial injury after non-cardiac surgery of 21 per cent and mortality following myocardial injury after non-cardiac surgery was 25 per cent at 1-year follow-up. A non-linear increase in mortality rate was observed up to 1 year after surgery. Major adverse cardiac event rates were also lower in elective surgery compared with a subgroup including emergency cases. The analysis demonstrated a wide variety of accepted myocardial injury after non-cardiac surgery and major adverse cardiac events diagnostic criteria within the included studies. CONCLUSION A diagnosis of myocardial injury after non-cardiac surgery is associated with high rates of poor cardiovascular outcomes up to 1 year after surgery. Work is needed to standardize diagnostic criteria and reporting of myocardial injury after non-cardiac surgery-related outcomes. REGISTRATION This review was prospectively registered with PROSPERO in October 2021 (CRD42021283995).
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Affiliation(s)
- Scarlett S Strickland
- Academic Directorate of General Surgery, Sheffield Teaching Hospitals, Sheffield, UK
| | - Ella M Quintela
- Department of Anaesthesia, Sheffield Teaching Hospitals, Sheffield, UK
- Centre for Urgent and Emergency Care Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Matthew J Wilson
- Department of Anaesthesia, Sheffield Teaching Hospitals, Sheffield, UK
- Centre for Urgent and Emergency Care Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Matthew J Lee
- Academic Directorate of General Surgery, Sheffield Teaching Hospitals, Sheffield, UK
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, UK
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8
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Duan X, Miao Z, Chen J. LncRNA KCNQ1OT1 attenuates myocardial injury induced by hip fracture via regulating of miR-224-3p/GATA4 axis. Int Immunopharmacol 2022; 107:108627. [PMID: 35217336 DOI: 10.1016/j.intimp.2022.108627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/03/2022] [Accepted: 02/12/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE This article aims to discuss the role of l KCNQ1 opposite strand/antisense transcript 1 (KCNQ1OT1) in myocardial injury caused by a hip fracture and further investigate its potential molecular mechanisms. METHODS X-Ray and H&E staining are used to observe hip fracture and pathological changes of myocardial tissue. ELISA and kits are used to detect inflammatory cytokines, lactate dehydrogenase (LDH), and creatine kinase (CK) in serum. The proliferation and apoptosis of H9c2 are determined by CCK-8 and flow cytometry. RT-qPCR and Western blot are applied to quantitatively assess the expression of related genes. Bioinformatics analysis is performed to search the downstream target of KCNQ1OT1 and miR-224-3p. Furthermore, the interaction is verified by a luciferase reporter assay. RESULTS A hip fracture model was successfully established. The high expression of inflammatory cytokines and cardiac injury markers indicated that hip fracture successfully induced myocardial injury. In TNF-ɑ treated cardiomyocyte model, high expression of KCNQ1OT1 promoted H9c2 cell proliferation and inhibited apoptosis. Furthermore, in the myocardial injury model rats induced by hip fracture, a high expression of KCNQ1OT1 reduced pathological damage in the myocardial tissue. Further research illustrated that miR-224-3p was the direct target of KCNQ1OT1, and GATA4 was the direct target of miR-224-3p. Importantly, functional research findings indicated that KCNQ1OT1 regulated myocardial injury caused by hip fracture via targeting the miR-224-3p/GATA4 axis. CONCLUSION Our study demonstrates that the KCNQ1OT1 suppresses myocardial injury via mediating miR-224-3p/GATA4, which provides a latent target for myocardial injury treatment.
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Affiliation(s)
- Xuzhou Duan
- Department of Orthopedics, Changhai Hospital Affiliated to the Navy Military Medical University, 168 Changhai Road, Yangpu District 200433, Shanghai, China
| | - Zhijing Miao
- Department of Cardiology, Shanghai Baoshan Hospital of Integrated Traditional Chinese and Western Medicine, 181 Friendship Road, Baoshan District 201901, Shanghai, China
| | - Jia Chen
- Department of Cardiology, Shanghai Baoshan Hospital of Integrated Traditional Chinese and Western Medicine, 181 Friendship Road, Baoshan District 201901, Shanghai, China.
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9
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Wang L, Cai M, Li X, Deng X, Xue Q, Zhou L, Yang M. Association of Acute Perioperative Myocardial Injury With All-Cause Mortality Within 90 Days After Hip Fracture Repair in the Elderly: A Prospective Study. Geriatr Orthop Surg Rehabil 2022; 13:21514593211070129. [PMID: 35047229 PMCID: PMC8761883 DOI: 10.1177/21514593211070129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction It remains unclear whether acute perioperative myocardial injury (APMI) increases mortality in the elderly. This study aimed to investigate APMI’s association with mortality within 90 days after hip fracture repair in elderly patients. Materials and Methods This prospective study enrolled elderly patients admitted to the department of Traumatology and Orthopaedics in XXX Hospital, who underwent surgery in 2018–2019 with a 90-day follow-up. According to survival status within 90 days, survival and death groups were constituted. Clinical, demographic, and laboratory indicators and 90-day mortality post-surgery were recorded. APMI’s association with 90-day mortality post-surgery was analyzed by logistic regression. Results Totally 248 participants were enrolled, including 224 and 24 in the survival and death groups, respectively, for a mortality rate of 9.7%. Compared with surviving individuals, the death group was older [81 (75–86) vs 87 (82–89) years], and had higher incidence rates of APMI (24.6% vs 58.3%), intertrochanteric fractures (41.1% vs 62.5%), preoperative atrial fibrillation (8.9% vs 29.2%), and dementia (73.7% vs 95.8%) (all P<.05). They also showed higher pre-injury frail scale scores [1 (0–2) vs 3 (1–4)] and Nottingham hip fracture scores (NHFSs) [4 (4–5) vs 6.5 (5–7)], lower Glomerular filtration [62 (46.1–78.6) vs 44.37 (35–61.92) ml/min], and reduced odds of glomerular filtration rate <60 mL/min (75.0% vs 46.9%) (all P < .05). APMI (OR = 3.294, 95% CI: 1.217–8.913) and NHFS (OR = 2.089, 95% CI: 1.353–3.225) independently predicted 90-day mortality post-surgery (all P<.05). Conclusions APMI is associated with increased mortality risk within 90 days after hip fracture repair in elderly patients.
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Affiliation(s)
- Lei Wang
- Department of Geratology, Beijing Jishuitan Hospital, Beijing, China
| | - Meng Cai
- Department of Geratology, Beijing Jishuitan Hospital, Beijing, China
| | - Xiaoying Li
- Department of Geratology, Beijing Jishuitan Hospital, Beijing, China
| | - Xiaohui Deng
- Department of Geratology, Beijing Jishuitan Hospital, Beijing, China
| | - Qiang Xue
- Department of Geratology, Beijing Jishuitan Hospital, Beijing, China
| | - Li Zhou
- Department of Geratology, Beijing Jishuitan Hospital, Beijing, China
| | - Minghui Yang
- Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital, Beijing, China
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10
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A bibliometric analysis of orthogeriatric care: top 50 articles. Eur J Trauma Emerg Surg 2021; 48:1673-1682. [PMID: 34114053 PMCID: PMC9192394 DOI: 10.1007/s00068-021-01715-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 05/26/2021] [Indexed: 11/22/2022]
Abstract
Background Population is ageing and orthogeriatric care is an emerging research topic. Purpose This bibliometric review aims to provide an overview, to investigate the status and trends in research in the field of orthogeriatric care of the most influential literature. Methods From the Core Collection databases in the Thomson Reuters Web of Knowledge, the most influential original articles with reference to orthogeriatric care were identified in December 2020 using a multistep approach. A total of 50 articles were included and analysed in this bibliometric review. Results The 50 most cited articles were published between 1983 and 2017. The number of total citations per article ranged from 34 to 704 citations (mean citations per article: n = 93). Articles were published in 34 different journals between 1983 and 2017. In the majority of publications, geriatricians (62%) accounted for the first authorship, followed by others (20%) and (orthopaedic) surgeons (18%). Articles mostly originated from Europe (76%), followed by Asia–pacific (16%) and Northern America (8%). Key countries (UK, Sweden, and Spain) and key topic (hip fracture) are key drivers in the orthogeriatric research. The majority of articles reported about therapeutic studies (62%). Conclusion This bibliometric review acknowledges recent research. Orthogeriatric care is an emerging research topic in which surgeons have a potential to contribute and other topics such as intraoperative procedures, fractures other than hip fractures or elective surgery are related topics with the potential for widening the field to research.
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11
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Puelacher C, Bollen Pinto B, Mills NL, Duceppe E, Popova E, Duma A, Nagele P, Omland T, Hammerer-Lercher A, Lurati Buse G. Expert consensus on peri-operative myocardial injury screening in noncardiac surgery: A literature review. Eur J Anaesthesiol 2021; 38:600-608. [PMID: 33653981 DOI: 10.1097/eja.0000000000001486] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Peri-operative myocardial injury, detected by dynamic and elevated cardiac troponin (cTn) concentrations, is a common complication of noncardiac surgery that is strongly associated with 30-day mortality. Although active screening for peri-operative myocardial injury has been suggested in recent guidelines, clinical implementation remains tentative due to a lack of examples on how to tackle such an interdisciplinary project at a local level. Moreover, consensus on which assay and cTn cut-off values should be used has not yet been reached, and guidance on whom to screen is lacking. In this article, we aim to summarise local examples of successfully implemented cTn screening practices and review the current literature in order to provide information and suggestions for patient selection, organisation of a screening programme, caveats and a potential management pathway.
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Affiliation(s)
- Christian Puelacher
- From the Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital of Basel, University of Basel; Department of Internal Medicine, University Hospital Basel, University Basel, Basel (CP), Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland (CP, BBP), Geneva Perioperative Basic, Translational and Clinical Research Group (BB-P), BHF Centre for Cardiovascular Science and Usher Institute, University of Edinburgh, Edinburgh, UK (NLM), Department of Medicine, Centre Hospitalier de l'Universite de Montreal, Montreal, Quebec, Canada (ED), Iberoamerican Cochrane Centre, Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain (EP), Department of Anaesthesiology and Intensive Care, Medical University of Vienna, Vienna, Austria (AD), Departments of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois, USA (PN), Department of Cardiology, Division of Medicine, Akershus University Hospital and University of Oslo, Oslo, Norway (TO), Institute of Laboratory Medicine, County Hospital Aarau, Aarau, Switzerland (A-HL), Department of Anaesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany (GLB)
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12
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Norring-Agerskov D, Madsen CM, Bathum L, Pedersen OB, Lauritzen JB, Jørgensen NR, Jørgensen HL. History of cardiovascular disease and cardiovascular biomarkers are associated with 30-day mortality in patients with hip fracture. Osteoporos Int 2019; 30:1767-1778. [PMID: 31278472 DOI: 10.1007/s00198-019-05056-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 06/12/2019] [Indexed: 11/30/2022]
Abstract
UNLABELLED Hip fractures are associated with increased mortality and it is important to identify risk factors. This study demonstrates that preexisting cardiovascular disease as well as cardiovascular biomarkers that are associated with increased 30-day mortality. These findings can be used to identify high-risk patients who might benefit from specialized care. INTRODUCTION This study investigates the association between cardiovascular disease (CVD), cardiovascular biomarkers, and 30-day mortality following a hip fracture. METHODS The Danish National Patient Registry was used to investigate the association between CVD and mortality following hip fracture in a nationwide population-based cohort study. In a subset of the included patients (n = 355), blood samples were available from a local biobank. These samples were used for analyzing the association between specific biochemical markers and mortality. The primary outcome was 30-day mortality. RESULTS A total of 113,211 patients were included in the population-based cohort study. Among these, heart failure was present in 9.4%, ischemic heart disease in 15.9%, and ischemic stroke in 12.0%. Within 30 days after the hip fracture, 11,488 patients died, resulting in an overall 30-day mortality of 10.1%. The 30-day mortality was significantly increased in individuals with preexisting CVD with multivariably adjusted odds ratios of 1.69 (95% confidence interval, 1.60-1.78) for heart failure, 1.23 (1.17-1.29) for ischemic heart disease, and 1.06 (1.00-1.12) for ischemic stroke. In the local database including 355 patients, 41 (11.5%) died within 30 days. The multivariably adjusted odds ratio for 30-day mortality increased with increasing NT-proBNP (2.36 [1.53-3.64] per quartile) and decreased with increasing HDL cholesterol (0.58 [0.41-0.82] per quartile). On this basis, we established a model for predicting the probability of death based on the biochemical markers. CONCLUSION Preexisting CVD was associated with increased 30-day mortality after a hip fracture. Furthermore, high levels of NT-proBNP and low levels of HDL cholesterol were associated with increased 30-day mortality.
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Affiliation(s)
- D Norring-Agerskov
- Department of Clinical Biochemistry, Hvidovre Hospital, Kettegård Alle 30, 2650, Hvidovre, Denmark.
- Open Patient Data Explorative Network, University of Southern Denmark and Odense University Hospital, J.B. Winsløws Vej 9A, 5000, Odense C, Denmark.
| | - C M Madsen
- Department of Clinical Biochemistry, Herlev og Gentofte Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark
| | - L Bathum
- Department of Clinical Biochemistry, Hvidovre Hospital, Kettegård Alle 30, 2650, Hvidovre, Denmark
| | - O B Pedersen
- Department of Clinical Immunology, Næstved Sygehus, Ringstedgade 61, 4700, Næstved, Denmark
| | - J B Lauritzen
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen N, Denmark
- Department of Orthopedic Surgery, Bispebjerg Hospital, Bispebjerg Bakke 23, 2400, Copenhagen NV, Denmark
| | - N R Jørgensen
- Open Patient Data Explorative Network, University of Southern Denmark and Odense University Hospital, J.B. Winsløws Vej 9A, 5000, Odense C, Denmark
- Department of Clinical Biochemistry, Rigshospitalet, Valdemar Hansens Vej 13, 2600, Glostrup, Denmark
| | - H L Jørgensen
- Department of Clinical Biochemistry, Hvidovre Hospital, Kettegård Alle 30, 2650, Hvidovre, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen N, Denmark
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13
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Mol K, Hoeks S, Liem V, Stolker R, van Lier F. Postoperative troponin release is associated with major adverse cardiovascular events in the first year after noncardiac surgery. Int J Cardiol 2019; 280:8-13. [DOI: 10.1016/j.ijcard.2019.01.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 12/19/2018] [Accepted: 01/09/2019] [Indexed: 11/16/2022]
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14
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Zhang LJ, Li N, Li Y, Zeng XT, Liu MY. Cardiac Biomarkers Predicting MACE in Patients Undergoing Noncardiac Surgery: A Meta-Analysis. Front Physiol 2019; 9:1923. [PMID: 30713501 PMCID: PMC6346145 DOI: 10.3389/fphys.2018.01923] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 12/20/2018] [Indexed: 12/25/2022] Open
Abstract
Objective: The present meta-analysis was aimed to systematically evaluate the effectiveness and accuracy of brain natriuretic peptide (BNP), cardiac troponin (cTn), high sensitive C reactive protein (hs-CRP) and CRP for predicting postoperative major adverse cardiovascular events (MACE) in patients undergoing noncardiac surgery. Methods: A total of 26 relevant studies with 7,877 participants were collected from five databases, namely PubMed, Embase, China National Knowledge Infrastructure (CNKI), CQVIP and the Wanfang Database until August 10, 2018. And the Review Manager Version 5.3 and Stata/SE 12 software were used for data syntheses in the meta-analysis. Results: Strong relationships of BNP/NT-proBNP, cTnI/cTnT and hs-CRP with MACE were detected in patients undergoing noncardiac surgery, and the five biomarkers all increased the risk of MACE. Compared to normal levels, elevated BNP/NT-proBNP could increase the MACE risk by almost 4-fold [RR:3.92, 95%CI: 3.23–4.75, P < 0.001]; elevated BNP corresponded to a 4.5-fold risk [RR:4.57, 95%CI: 3.37–6.20, P < 0.001]; elevated NT-proBNP led to a 3-fold higher risk [RR:3.48, 95%CI: 2.71–4.46, P < 0.001]. Comparing with normal levels of cTnI/cTnT, increased cTnI/cTnT was associated with nearly 5-fold more higher risk of MACE [RR:5.52, 95%CI: 4.62–6.58, P < 0.001]; elevated cTnI faced a 5-fold risk [RR:5.21, 95%CI: 3.96–6.86, P < 0.001]; elevated cTnT resulted in nearly 6-fold higher risk [RR:5.73, 95%CI: 4.55–7.22, P < 0.001]. The elevation of hs-CRP was associated with nearly 4-fold higher risk of MACE in comparison with normal concentration [RR:3.73, 95%CI: 2.63–5.30, P < 0.001]. Conclusion: According to the results of our meta-analysis, the elevations of BNP/NT-proBNP, cTnI/cTnT, and hs-CRP, pre-operation or post-operation immediately, can predict much higher risk of postoperative MACE in patients undergoing noncardiac surgery.
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Affiliation(s)
- Li-Jun Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Na Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yang Li
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Center for Evidence-Based and Translational Medicine, Wuhan University, Wuhan, China
| | - Xian-Tao Zeng
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Center for Evidence-Based and Translational Medicine, Wuhan University, Wuhan, China
| | - Mei-Yan Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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15
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Mortazavi MMT, Ganjpour Sales J, Nouri-Vaskeh M, Parish M, Abdolhosseynzadeh S. Perioperative Cardiac Troponin I Levels in Patients Undergoing Total Hip and Total Knee Arthroplasty: A Single Center Study. Anesth Pain Med 2018; 8:e84228. [PMID: 30719421 PMCID: PMC6347731 DOI: 10.5812/aapm.84228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 10/20/2018] [Accepted: 11/10/2018] [Indexed: 11/16/2022] Open
Abstract
Background Cardiac injury is one of the significant perioperative complications in major orthopedic surgeries and its early diagnosis is useful in the reduction of postoperative comorbidity. The cardiac troponin is a sensitive and specific biomarker for detecting this damage. Objectives The aim of this study was to evaluate the levels of perioperative cardiac troponin I (cTnI) before and after arthroplasty in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). The effects of related variables and probable major cardiac complications were evaluated in this study. Methods For one year, in a prospective, cross-sectional study, the serum levels of cTnI before and 48 hours after arthroplasty were evaluated in 52 patients. Possible contributing factors including age, gender, body mass index (BMI), daily activity, history of hospitalization due to cardiovascular diseases, underlying illness, and medications were recorded. The Chi-square test, Pearson correlation, and Spearman test were used to examine the relationship between variables. Results The mean cTnI increased significantly after arthroplasty (P < 0.001). There was no significant relationship between age (P = 0.708), gender (P = 0.225), BMI (P = 0.195), daily activity (0.441), underlying illness (P = 0.244), and cTnI levels after arthroplasty. Linear regression showed BMI was significantly correlated with troponin changes (P = 0.006). Five patients had heart palpitations and one had chest pain, but none of the patients had any findings in favor of cardiac injury. Conclusions cTnI levels after THA and TKA increased significantly, but this elevation was in the normal range. In addition, none of them had a new cardiac complication after arthroplasty.
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Affiliation(s)
- Mir Mohammad Taghi Mortazavi
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Jafar Ganjpour Sales
- Department of Orthopedics Surgery, Shohada Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Masoud Nouri-Vaskeh
- Connective Tissue Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Corresponding Author: Connective Tissue Diseases Research Center, Tabriz University of Medical Sciences, Postal Code: 5166614756, Tabriz, Iran.
| | - Masoud Parish
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
- Corresponding Author: Department of Anesthesiology and Critical Care, Faculty of Medicine, Tabriz University of Medical Sciences, Postal Code: 5166614756, Tabriz, Iran.
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16
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Ekeloef S, Alamili M, Devereaux PJ, Gögenur I. Troponin elevations after non-cardiac, non-vascular surgery are predictive of major adverse cardiac events and mortality: a systematic review and meta-analysis. Br J Anaesth 2018; 117:559-568. [PMID: 27799170 DOI: 10.1093/bja/aew321] [Citation(s) in RCA: 161] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients undergoing non-cardiac, non-vascular surgery are at risk of major cardiovascular complications. In non-cardiac surgery, troponin elevation has previously been shown to be an independent predictor of major adverse cardiac events and postoperative mortality; however, a majority of studies have focused on vascular surgery patients. The aim of this meta-analysis was to determine whether troponin elevation is a predictor of major adverse cardiac events and mortality within 30 days and 1 yr after non-cardiac, non-vascular surgery. METHODS A systematic review and meta-analysis was conducted in January 2016 according to the Meta-analysis Of Observational Studies in Epidemiology guidelines. Both interventional and observational studies measuring troponin within the first 4 days after surgery were eligible. A systematic search was performed in PubMed, EMBASE, Scopus, and the Cochrane Central Register of Controlled Trials. RESULTS Eleven eligible clinical studies (n=2193) were identified. A postoperative troponin elevation was a predictor of 30 day mortality, odds ratio (OR) 3.52 [95% confidence interval (CI) 2.21-5.62; I2=0%], and an independent predictor of 1 yr mortality, adjusted OR 2.53 (95% CI 1.20-5.36; I2=26%). A postoperative troponin elevation was associated with major adverse cardiac events at 30 days, OR 5.92 (95% CI 1.67-20.96; I2=86%), and 1 yr after surgery, adjusted OR 3.00 (95% CI 1.43-6.29; I2=21%). CONCLUSIONS Postoperative myocardial injury is an independent predictor of major adverse cardiac events and mortality within 30 days and 1 yr after non-cardiac, non-vascular surgery. The meta-analysis provides evidence that supports troponin monitoring as a cardiovascular risk stratification tool.
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Affiliation(s)
- S Ekeloef
- Department of Surgery, Center for Surgical Science, Zealand University Hospital, Koege and Roskilde, Denmark
| | - M Alamili
- Department of Surgery, Center for Surgical Science, Zealand University Hospital, Koege and Roskilde, Denmark
| | - P J Devereaux
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - I Gögenur
- Department of Surgery, Center for Surgical Science, Zealand University Hospital, Koege and Roskilde, Denmark
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17
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Perioperative Elevation of Troponin I Predicts Survival After Orthopaedic Surgery in Older Patients With Fracture. INT J GERONTOL 2018. [DOI: 10.1016/j.ijge.2018.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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18
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Miccichè V, Baldi C, De Robertis E, Piazza O. Myocardial injury after non-cardiac surgery: a perioperative affair? Minerva Anestesiol 2018; 84:1209-1218. [PMID: 29589418 DOI: 10.23736/s0375-9393.18.12537-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Myocardial injury after non-cardiac surgery (MINS) is a rather new nosological entity and an unfortunately common perioperative complication. The diagnostic criteria for MINS, also indicated as isolated myocardial injury (IMI), are an elevated postoperative high sensitivity troponin T (hsTnT level ranging between 20 and 65 ng/L with an absolute change of at least 5 ng/L or hsTnT level >65 ng/L), in absence of symptoms and/or EKG findings suggestive of ischemia and without a non-ischemic etiology causing troponin elevation. MINS does not fulfill the universal definition of myocardial infarction even if it is related to ischemic causes and it is independently associated with 30-day postoperative mortality and complications. Nevertheless, mortality at 30 days in MINS patients has been calculated up to 10% and it increases exponentially as a function of peak postoperative troponin concentration. Physician and researchers should discriminate MINS from perioperative myocardial infarction and from not ischemic troponin increases. In the postoperative period, the possibility of missing the diagnosis of an acute coronary syndrome for the paucity of clinical symptoms or because physician failed to evaluate a postoperative EKG recording should always be considered. Physiopathology of MINS is not yet well defined: current hypotheses are surrogated from perioperative myocardial infarction studies. Up to now there are not specific treatments for MINS, even if antithrombotic therapy is under evaluation. Treatment decisions should be tailored to the individual case; potential benefits of troponin screening include a cardiology consultation and consequently, improved patients' information to promote lifestyle changes and enhanced therapy.
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Affiliation(s)
- Viviana Miccichè
- Department of Critical Care, San Giovanni di Dio e Ruggi d'Aragona University Hospital, Salerno, Italy
| | - Cesare Baldi
- Cardio-Thoracic-Vascular Department, San Giovanni di Dio e Ruggi d'Aragona University Hospital, Salerno, Italy -
| | - Edoardo De Robertis
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Ornella Piazza
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
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Olechowski B, Khanna V, Mariathas M, Ashby A, Dalton RT, Nordon I, Englyst N, Harris S, Nicholas Z, Thayalasamy K, Mahmoudi M, Curzen N. Changes in platelet function with inflammation in patients undergoing vascular surgery. Platelets 2017; 30:190-198. [DOI: 10.1080/09537104.2017.1392498] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Bartosz Olechowski
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Vikram Khanna
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mark Mariathas
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Alexander Ashby
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Richard T Dalton
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ian Nordon
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nicola Englyst
- Institute of Developmental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Scott Harris
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Zoe Nicholas
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Kala Thayalasamy
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Michael Mahmoudi
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nick Curzen
- Wessex Cardiothoracic Centre University, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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20
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Pedersen AB, Ehrenstein V, Szépligeti SK, Sørensen HT. Hip Fracture, Comorbidity, and the Risk of Myocardial Infarction and Stroke: A Danish Nationwide Cohort Study, 1995-2015. J Bone Miner Res 2017; 32:2339-2346. [PMID: 28833527 DOI: 10.1002/jbmr.3242] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 08/16/2017] [Accepted: 08/18/2017] [Indexed: 11/06/2022]
Abstract
We evaluated risks of MI and stroke in elderly patients with hip fracture compared with the general population. We also examined the interaction between hip fracture and comorbidity with respect to risks of MI or stroke, defined as excess of risk explained by combining risks of hip fracture and comorbidity. We conducted a population-based cohort study using Danish health registries, in 1995 to 2015 including 110,563 hip fracture patients and 552,774 members of the comparison cohort from the general population. Thirty-day cumulative incidences of MI were 1.15% among patients with hip fracture and 0.09% in the general population (adjusted hazard ratio [aHR] = 12.97; 95% confidence interval [CI], 11.56 to 14.55). Thirty-day cumulative incidences of stroke were 2.16% for hip fracture patients and 0.21% in the general population (aHR = 9.42; 95% CI, 8.71 to 10.19). During the 31 to 365 days following hip fracture, the aHR for MI was 1.05 (95% CI, 0.97 to 1.14) and remained at this level during the remainder of follow-up (maximum of 20 years). The aHR for stroke was 1.29 (95% CI, 1.22 to 1.35) during the 31 to 365 days following hip fracture, remained elevated for up to 10 years, and then decreased to the general population level. The aHRs for MI and stroke were increased for both men and women, and in all age and comorbidity groups. During the first 30 days, up to 76% of MI and stroke risk was attributable to interaction between hip fracture and comorbidity. Patients with hip fracture are at increased risk of both MI and stroke up to 1 year following the fracture. Risk of stroke, but not of MI, was elevated during up to 10 years postfracture. Although the absolute risks were low, our finding underscores the importance of targeting multimorbidity, including prevention and adequate treatment, to improve the prognosis of hip fracture patients. © 2017 American Society for Bone and Mineral Research.
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Affiliation(s)
- Alma B Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Vera Ehrenstein
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Health Research & Policy (Epidemiology), Stanford University, Stanford, CA, USA
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21
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Larsen M, Bayard C, Lepetitcorps H, Cohen-Bittan J, Appay V, Boddaert J, Sauce D. Elevated Neopterin Levels Predict Early Death in Older Hip-fracture Patients. EBioMedicine 2017; 26:157-164. [PMID: 29157836 PMCID: PMC5832560 DOI: 10.1016/j.ebiom.2017.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 11/03/2017] [Accepted: 11/03/2017] [Indexed: 12/11/2022] Open
Abstract
Our society faces a major challenge concerning management of the health and socio-economic burden caused by acute physical stress in the older population (+ 75 years). In particular, hip-fracture surgery (HFS) represents a major health care preoccupation, affecting 1.6 million patients worldwide, resulting in a significant drop in life quality and autonomy. The trauma is associated with 20–30% one-year mortality in the elderly. In the present study, we aim to identify factors, which influence and/or predict the outcome of elderly hip- fracture patients (HFP) post-surgery. Our objective was to identify biomarkers with a prognostic capacity of one-year mortality. We employed an observational cohort of HFP (n = 60) followed-up longitudinally during the first year post fracture. Clinical and biological data (n = 136), collected at arrival to hospital, were then compared to healthy controls (n = 42) and analyzed using a regularized logistic regression model with lasso penalty followed by 10-fold cross-validation of variables. We show that plasmatic neopterin levels, a molecule released by IFN-γ-activated macrophages, is predictive of mortality in HFP (ROC-AUC = 0.859). Moreover, neopterin measured at arrival to the hospital correlated negatively with the time of survival after HFS. Neopterin therefore represents a biomarker, which enables better follow-up of patients at risk of early death. Neopterin level, measured at arrival to hospital, is a robust predictive marker of one-year mortality in HFPs. Neopterin concentration correlated negatively with the time of survival after hip fracture surgery.
The growing incidence of hip fractures, due to demographically aging populations, represent an important burden for health care systems and for injured patients in terms of hospitalization, rehabilitation, needs for long-term care, change in autonomy and mortality. Hip fractures are associated with high rates of adverse outcome, but previous studies have not discovered methods to identify patients at high risk of pernicious clinical outcome or death. Here, we show that innate immune activation post hip fracture in older adults is associated with pernicious clinical outcome.
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Affiliation(s)
- Martin Larsen
- INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), F-75013 Paris, France
| | - Charles Bayard
- INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), F-75013 Paris, France
| | - Hélène Lepetitcorps
- INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), F-75013 Paris, France
| | - Judith Cohen-Bittan
- AP-HP, Service de gériatrie, Hôpital Pitié-Salpêtrière, F-75013 Paris, France
| | - Victor Appay
- INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), F-75013 Paris, France; Sorbonne Universités, UPMC Univ Paris 06, DHU FAST, CR7, F-75013 Paris, France
| | - Jacques Boddaert
- AP-HP, Service de gériatrie, Hôpital Pitié-Salpêtrière, F-75013 Paris, France; Sorbonne Universités, UPMC Univ Paris 06, DHU FAST, CR7, F-75013 Paris, France
| | - Delphine Sauce
- INSERM, U1135, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), F-75013 Paris, France; Sorbonne Universités, UPMC Univ Paris 06, DHU FAST, CR7, F-75013 Paris, France.
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22
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Vallet H, Chenevier-Gobeaux C, Villain C, Cohen-Bittan J, Ray P, Epelboin L, Verny M, Riou B, Khiami F, Boddaert J. Prognostic Value of Serum Procalcitonin After Orthopedic Surgery in the Elderly Population. J Gerontol A Biol Sci Med Sci 2017; 72:438-443. [PMID: 27231388 DOI: 10.1093/gerona/glw097] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 05/10/2016] [Indexed: 12/21/2022] Open
Abstract
Background Orthopedic surgery is more and more frequent in the older patients and is associated with a high mortality rate. Although serum procalcitonin levels are associated with prognosis in young adults, data are still lacking in the elderly population, and especially after surgery. The main objective of this study was to determine the prognostic value of procalcitonin levels in a large geriatric orthopedic population, and we compared it with clinical variables and biomarkers. Methods This is a prospective study including patients admitted in our dedicated geriatric postoperative unit, after orthopedic surgery with immediate postoperative measured procalcitonin levels. Collected data included age, sex, medical history, functional status (activities of daily living [ADL]), fracture type, Cumulative Illness Rating scale (CIRS), postoperative complications, and biological data. The primary endpoint was the 30-day mortality. Results 436 patients (age 85±6 years) were included. Hip fracture surgery was the most frequent (n = 310; 71%), and the 30-day mortality rate was 6.9%. Compared with C-reactive protein (CRP), albumin, CIRS, and ADL, procalcitonin had the highest area under the receiver operating characteristic curve for predicting 30-day mortality (0.74; 95% CI: 0.70-0.78). Using a cutoff at 1 µg/L, procalcitonin was more specific than CIRS to predict 30-day mortality (92 vs 77%; p < .001). In a multivariable analysis, procalcitonin level higher than 0.39 µg/L is a significant predictor of mortality within 30 days (odds ratio 3.84; 95% CI: 1.61-9.14, p = .002). Conclusion Elevated procalcitonin values were strongly and significantly associated with mortality within 30 days in older patients after orthopedic surgery.
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Affiliation(s)
- Hélène Vallet
- Unit of Peri-Operative Geriatric Care, Department of Geriatrics, Hôpitaux Universitaires Pitié-Salpêtrière-Charles Foix. DHU FAST, Assistance Publique Hôpitaux de Paris (APHP), Paris, France.,Sorbonne Universités, UPMC Paris 6, Paris, France
| | | | - Cédric Villain
- Unit of Peri-Operative Geriatric Care, Department of Geriatrics, Hôpitaux Universitaires Pitié-Salpêtrière-Charles Foix. DHU FAST, Assistance Publique Hôpitaux de Paris (APHP), Paris, France
| | - Judith Cohen-Bittan
- Unit of Peri-Operative Geriatric Care, Department of Geriatrics, Hôpitaux Universitaires Pitié-Salpêtrière-Charles Foix. DHU FAST, Assistance Publique Hôpitaux de Paris (APHP), Paris, France
| | - Patrick Ray
- Sorbonne Universités, UPMC Paris 6, Paris, France.,Department of Emergency Medicine, Groupe Hospitalo-Universitaire de l'Est parisien, site Tenon, APHP, Paris, France
| | - Loïc Epelboin
- Department of Infectious and Tropical Diseases, Centre Hospitalier Andrée Rosemon, Université de la Guyane, Institut Pasteur de La Guyane et Centre d'Investigation Clinique CIC Antilles-Guyane Inserm 1424, Guyane Française, France
| | - Marc Verny
- Unit of Peri-Operative Geriatric Care, Department of Geriatrics, Hôpitaux Universitaires Pitié-Salpêtrière-Charles Foix. DHU FAST, Assistance Publique Hôpitaux de Paris (APHP), Paris, France.,Sorbonne Universités, UPMC Paris 6, Paris, France.,UMR CNRS 8256, Paris, France
| | - Bruno Riou
- Sorbonne Universités, UPMC Paris 6, Paris, France.,Department of Emergency Medicine and Surgery, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, APHP, Paris, France.,UMR INSERM 1166, IHU ICAN, Paris, France
| | - Frédéric Khiami
- Sorbonne Universités, UPMC Paris 6, Paris, France.,Department of Orthopedic Surgery and Trauma, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, APHP, Paris, France
| | - Jacques Boddaert
- Unit of Peri-Operative Geriatric Care, Department of Geriatrics, Hôpitaux Universitaires Pitié-Salpêtrière-Charles Foix. DHU FAST, Assistance Publique Hôpitaux de Paris (APHP), Paris, France.,Sorbonne Universités, UPMC Paris 6, Paris, France.,UMR CNRS 8256, Paris, France
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23
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Wongrakpanich S, Kallis C, Prasad P, Kanjanahattakij N, Sirinvaravong N, Rangaswami J, Rosenzweig A. Prevalence of false positive troponin I in elderly patients with rhabdomyolysis. Geriatr Gerontol Int 2017; 17:1137-1140. [DOI: 10.1111/ggi.13021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 01/17/2017] [Indexed: 11/30/2022]
Affiliation(s)
| | - Christos Kallis
- Department of Medicine; Einstein Medical Center; Philadelphia Pennsylvania USA
| | - Prithiv Prasad
- Department of Medicine; Einstein Medical Center; Philadelphia Pennsylvania USA
| | | | - Natee Sirinvaravong
- Department of Medicine; Einstein Medical Center; Philadelphia Pennsylvania USA
| | - Janani Rangaswami
- Department of Medicine; Einstein Medical Center; Philadelphia Pennsylvania USA
| | - Andrew Rosenzweig
- Department of Medicine; Einstein Medical Center; Philadelphia Pennsylvania USA
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24
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van Waes JAR, Grobben RB, Nathoe HM, Kemperman H, de Borst GJ, Peelen LM, van Klei WA. One-Year Mortality, Causes of Death, and Cardiac Interventions in Patients with Postoperative Myocardial Injury. Anesth Analg 2017; 123:29-37. [PMID: 27111647 DOI: 10.1213/ane.0000000000001313] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND To evaluate the role of routine troponin surveillance in patients undergoing major noncardiac surgery, unblinded screening with cardiac consultation per protocol was implemented at a tertiary care center. In this study, we evaluated 1-year mortality, causes of death, and consequences of cardiac consultation of this protocol. METHODS This observational cohort included 3224 patients ≥60 years old undergoing major noncardiac surgery. Troponin I was measured routinely on the first 3 postoperative days. Myocardial injury was defined as troponin I >0.06 μg/L. Regression analysis was used to determine the association between myocardial injury and 1-year mortality. The causes of death, the diagnoses of the cardiologists, and interventions were determined for different levels of troponin elevation. RESULTS Postoperative myocardial injury was detected in 715 patients (22%) and was associated with 1-year all-cause mortality (relative risk [RR] 1.4, P = 0.004; RR 1.6, P < 0.001; and RR 2.2, P < 0.001 for minor, moderate, and major troponin elevation, respectively). Cardiac death within 1 year occurred in 3%, 5%, and 11% of patients, respectively, in comparison with 3% of the patients without myocardial injury (P = 0.059). A cardiac consultation was obtained in 290 of the 715 patients (41%). In 119 (41%) of these patients, the myocardial injury was considered to be attributable to a predisposing cardiac condition, and in 111 patients (38%), an intervention was initiated. CONCLUSIONS Postoperative myocardial injury was associated with an increased risk of 1-year all-cause but not cardiac mortality. A cardiac consultation with intervention was performed in less than half of these patients. The small number of interventions may be explained by a low suspicion of a cardiac etiology in most patients and lack of consensus for standardized treatment in these patients.
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Affiliation(s)
- Judith A R van Waes
- From the *Department of Anesthesiology; †Department of Cardiology; ‡Department of Clinical Chemistry and Haematology; §Department of Surgery; and ‖Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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25
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Vallet H, Breining A, Le Manach Y, Cohen-Bittan J, Mézière A, Raux M, Verny M, Riou B, Khiami F, Boddaert J. Isolated cardiac troponin rise does not modify the prognosis in elderly patients with hip fracture. Medicine (Baltimore) 2017; 96:e6169. [PMID: 28207554 PMCID: PMC5319543 DOI: 10.1097/md.0000000000006169] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Perioperative myocardial infarction remains a life-threatening complication in noncardiac surgery and even an isolated troponin rise (ITR) is associated with significant mortality. Our aim was to assess the prognostic value of ITR in elderly patients with hip fracture.In this cohort study, all patients admitted between 2009 and 2013 in our dedicated geriatric postoperative unit after hip fracture surgery with a cardiac troponin I determination were included and divided into Control, ITR, and acute coronary syndrome (ACS) groups. The primary end point was a composite criteria defined as 6-month mortality and/or re-hospitalization. Secondary end points included 30-day mortality, 6-month mortality, and 6-month functional outcome.Three hundred twelve patients were (age 85 ± 7 years) divided into Control (n = 217), ITR (n = 50), and ACS (n = 45) groups. There was no significant difference for any postoperative complications between ITR and Control groups. In contrast, atrial fibrillation, acute heart failure, hemorrhage, and ICU admission were significantly more frequent in the ACS group. Compared to the Control group, 6-month mortality and/or rehospitalization was not significantly modified in the ITR group (26% vs. 28%, P = 0.84, 95% confidence interval [CI] of the difference -13%-14%), whereas it was increased in the ACS group (44% vs. 28%, P = 0.02, 95% CI of the difference 2%-32%). ITR was not associated with a higher risk of new institutionalization or impaired walking ability at 6 months, in contrast to ACS group.In elderly patients with hip fracture, ITR was not associated with a significant increase in death and/or rehospitalization within 6 months.
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Affiliation(s)
- Hélène Vallet
- Sorbonne Universités UPMC Univ Paris 06, DHU FAST
- Department of Geriatry
| | - Alice Breining
- Sorbonne Universités UPMC Univ Paris 06, DHU FAST
- Department of Geriatry
| | - Yannick Le Manach
- Departments of Anesthesia & Clinical Epidemiology and Biostatistics, Michael DeGroote School of Medicine, Population Health Research Institute, Perioperative Medicine and Surgical Research Unit, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | | | - Anthony Mézière
- Department of Rehabilitation, GH Charles Foix, APHP, Ivry sur Seine
| | - Mathieu Raux
- UMRS INSERM 1158
- Department of Anesthesiology and Critical Care
| | - Marc Verny
- Sorbonne Universités UPMC Univ Paris 06, DHU FAST
- Department of Geriatry
- Centre National de la Recherche Scientifique (CNRS), Paris, France
| | - Bruno Riou
- UMRS INSERM 1166, IHU ICAN
- Department of Emergency Medicine and Surgery
| | - Frédéric Khiami
- Department of Orthopedic Surgery and Trauma Groupe Hospitalier (GH) Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Jacques Boddaert
- Sorbonne Universités UPMC Univ Paris 06, DHU FAST
- UMRS INSERM 1166, IHU ICAN
- Department of Geriatry
- Centre National de la Recherche Scientifique (CNRS), Paris, France
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26
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Lyons MM, Bhatt NY, Kneeland-Szanto E, Keenan BT, Pechar J, Stearns B, Elkassabany NM, Memtsoudis SG, Pack AI, Gurubhagavatula I. Sleep apnea in total joint arthroplasty patients and the role for cardiac biomarkers for risk stratification: an exploration of feasibility. Biomark Med 2016; 10:265-300. [PMID: 26925513 DOI: 10.2217/bmm.16.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Obstructive sleep apnea (OSA) is highly prevalent in patients undergoing total joint arthroplasty (TJA) and is a major risk factor for postoperative cardiovascular complications and death. Recognizing this, the American Society of Anesthesiologists urges clinicians to implement special considerations in the perioperative care of OSA patients. However, as the volume of patients presenting for TJA increases, resources to implement these recommendations are limited. This necessitates mechanisms to efficiently risk stratify patients having OSA who may be susceptible to post-TJA cardiovascular complications. We explore the role of perioperative measurement of cardiac troponins (cTns) and brain natriuretic peptides (BNPs) in helping determine which OSA patients are at increased risk for post-TJA cardiovascular-related morbidity.
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Affiliation(s)
- M Melanie Lyons
- Division of Sleep Medicine, Center for Sleep & Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Biobehavioral Research, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Nitin Y Bhatt
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, The Ohio State University, Columbus, OH, USA
| | - Elizabeth Kneeland-Szanto
- Division of Sleep Medicine, Center for Sleep & Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brendan T Keenan
- Division of Sleep Medicine, Center for Sleep & Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joanne Pechar
- Department of Penn Orthopaedics, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Branden Stearns
- Division of Sleep Medicine, Center for Sleep & Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nabil M Elkassabany
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology & Public Health, Weill Cornell Medical College & Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA
| | - Allan I Pack
- Division of Sleep Medicine, Center for Sleep & Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Indira Gurubhagavatula
- Division of Sleep Medicine, Center for Sleep & Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Sleep Medicine, CMC VA Medical Center, Philadelphia, PA, USA
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27
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Smilowitz NR, Oberweis BS, Nukala S, Rosenberg A, Stuchin S, Iorio R, Errico T, Radford MJ, Berger JS. Perioperative antiplatelet therapy and cardiovascular outcomes in patients undergoing joint and spine surgery. J Clin Anesth 2016; 35:163-169. [PMID: 27871515 DOI: 10.1016/j.jclinane.2016.07.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 05/13/2016] [Accepted: 07/11/2016] [Indexed: 01/01/2023]
Abstract
STUDY OBJECTIVE Perioperative thrombotic complications after orthopedic surgery are associated with significant morbidity and mortality. The use of aspirin to reduce perioperative cardiovascular complications in certain high-risk cohorts remains controversial. Few studies have addressed aspirin use, bleeding, and cardiovascular outcomes among high-risk patients undergoing joint and spine surgery. DESIGN/SETTING/PATIENTS We performed a retrospective comparison of adults undergoing knee, hip, or spine surgery at a tertiary care center during 2 periods between November 2008 and December 2009 (reference period) and between April 2013 and December 2013 (contemporary period). MEASUREMENTS Patient demographics, comorbidities, management, and outcomes were ascertained using hospital datasets. MAIN RESULTS A total of 5690 participants underwent 3075 joint and spine surgeries in the reference period and 2791 surgeries in the contemporary period. Mean age was 61±13 years, and 59% were female. In the overall population, incidence of myocardial injury (3.1% vs 5.8%, P<.0001), hemorrhage (0.2% vs 0.8%, P=.0009), and red blood cell transfusion (17.2% vs 24.8%, P<.001) were lower in the contemporary period. Among 614 participants with a preoperative diagnosis of coronary artery disease (CAD), in-hospital aspirin use was significantly higher in the contemporary period (66% vs 30.7%, P<.0001); numerically, fewer participants developed myocardial injury (13.5% vs 19.3%, P=.05), had hemorrhage (0.3% vs 2.1%, P=.0009), and had red blood cell transfusion (37.2% vs 44.2%, P<.001) in the contemporary vs reference period. CONCLUSIONS In a large tertiary care center, the incidence of perioperative bleeding and cardiovascular events decreased over time. In participants with CAD, perioperative aspirin use increased and appears to be safe.
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Affiliation(s)
- Nathaniel R Smilowitz
- Department of Medicine, Division of Cardiology, New York University School of Medicine, New York, New York, USA
| | - Brandon S Oberweis
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Swetha Nukala
- Department of Clinical Quality and Clinical Effectiveness, New York University School of Medicine, New York, New York, USA
| | - Andrew Rosenberg
- Department of Anesthesiology, New York University School of Medicine, New York, New York, USA
| | - Steven Stuchin
- Department of Orthopedic Surgery, New York University School of Medicine, New York, New York, USA
| | - Richard Iorio
- Department of Orthopedic Surgery, New York University School of Medicine, New York, New York, USA
| | - Thomas Errico
- Department of Orthopedic Surgery, New York University School of Medicine, New York, New York, USA
| | - Martha J Radford
- Department of Medicine, Division of Cardiology, New York University School of Medicine, New York, New York, USA; Department of Population Health, New York University School of Medicine, New York, New York, USA
| | - Jeffrey S Berger
- Department of Medicine, Division of Cardiology, New York University School of Medicine, New York, New York, USA; Department of Surgery, Division of Vascular Surgery, New York University School of Medicine, New York, New York, USA.
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28
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Hye RJ, Voeks JH, Malas MB, Tom M, Longson S, Blackshear JL, Brott TG. Anesthetic type and risk of myocardial infarction after carotid endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). J Vasc Surg 2016; 64:3-8.e1. [PMID: 26994949 DOI: 10.1016/j.jvs.2016.01.047] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 01/26/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) is usually performed under general anesthesia (GA), although some advocate regional anesthesia (RA) to reduce hemodynamic instability and allow neurologic monitoring and selective shunting. RA does not reduce risk of periprocedural stroke or death, although some series show a reduction in myocardial infarction (MI). We investigated the association of anesthesia type and periprocedural MI among patients receiving GA or RA for CEA and patients undergoing carotid artery stenting (CAS) in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). METHODS Between 2000 and 2008, 1151 patients underwent CEA (anesthetic type available for 1149 patients), and 1123 patients underwent CAS ≤30 days of randomization in CREST. CEA patients were categorized by anesthetic type (GA vs RA). CREST defined protocol MI as chest pain or electrocardiogram change plus biomarker evidence of MI, and total MI was defined as protocol MI plus biomarker-positive (+)-only MI. The incidence of protocol MI and total MI in patients undergoing CEA under GA and RA were compared with those undergoing CAS. Other study end points were similarly compared. Differences in baseline characteristics and periprocedural events were evaluated among the three groups. Logistic regression, adjusting for age and symptomatic status, was used to assess group differences. RESULTS The three groups had similar demographic risk factors, except for prevalence of symptomatic carotid stenosis, which was lowest in the CEA-RA group (P = .03). Of the 111 patients in the CEA-RA group, no protocol MIs occurred and only two biomarker+-only MIs, for an overall incidence of 1.8%, similar to the 1.7% overall incidence in patients undergoing CAS. In contrast, the combined incidence of protocol and biomarker+-only MIs in the 1038 patients in the CEA-GA group was significantly higher at 3.4% (P = .04), twice the risk of protocol MI and biomarker+-only MI compared with those undergoing CAS (odds ratio [OR], 2.01; 95% confidence interval [CI], 1.14-3.54). Direct comparison of the MI incidence between CEA-RA and CEA-GA showed no statistical difference. Patients undergoing CEA-GA had lower odds of a periprocedural stroke (OR, 0.48; 95% CI, 0.28-0.79) and stroke or death (OR, 0.46; 95% CI, 0.27-0.76) compared with those undergoing CAS but were not significantly different from those undergoing CEA-RA. CONCLUSIONS Patients in CREST undergoing CEA-RA had a similar risk of periprocedural MI as those undergoing CAS, whereas the risk for CEA-GA was twice that compared with patients undergoing CAS. Nevertheless, because periprocedural MI is one of the few variables favoring CAS over CEA and has been associated with decreased long-term survival, RA should be seriously considered for patients undergoing CEA.
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Affiliation(s)
- Robert J Hye
- Department of Vascular Surgery, Kaiser Permanente, San Diego, Calif
| | - Jenifer H Voeks
- Department of Neurology, Medical University of South Carolina, Charleston, SC
| | - Mahmoud B Malas
- Department of Vascular and Endovascular Surgery, Johns Hopkins University, Baltimore, Md
| | - MeeLee Tom
- Department of Surgery, New Jersey Medical School, Rutgers/The State University of New Jersey, Newark, NJ
| | - Sonni Longson
- Department of Vascular Surgery, Kaiser Permanente, San Diego, Calif
| | | | - Thomas G Brott
- Department of Surgery, New Jersey Medical School, Rutgers/The State University of New Jersey, Newark, NJ; Department of Neurology, Mayo Clinic, Jacksonville, Fla.
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29
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Relation of perioperative elevation of troponin to long-term mortality after orthopedic surgery. Am J Cardiol 2015; 115:1643-8. [PMID: 25890628 DOI: 10.1016/j.amjcard.2015.03.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 03/13/2015] [Accepted: 03/13/2015] [Indexed: 11/21/2022]
Abstract
Myocardial necrosis in the perioperative period of noncardiac surgery is associated with short-term mortality, but long-term outcomes have not been characterized. We investigated the association between perioperative troponin elevation and long-term mortality in a retrospective study of consecutive subjects who underwent hip, knee, and spine surgery. Perioperative myocardial necrosis and International Classification of Disease, Ninth Revision-coded myocardial infarction (MI) were recorded. Long-term survival was assessed using the Social Security Death Index database. Logistic regression models were used to identify independent predictors of long-term mortality. A total of 3,050 subjects underwent surgery. Mean age was 60.8 years, and 59% were women. Postoperative troponin was measured in 1,055 subjects (34.6%). Myocardial necrosis occurred in 179 cases (5.9%), and MI was coded in 20 (0.7%). Over 9,015 patient-years of follow-up, 111 deaths (3.6%) occurred. Long-term mortality was 16.8% in subjects with myocardial necrosis and 5.8% with a troponin in the normal range. Perioperative troponin elevation (hazard ratio 2.33, 95% confidence interval 1.33 to 4.10) and coded postoperative MI (adjusted hazard ratio 3.51, 95% confidence interval 1.44 to 8.53) were significantly associated with long-term mortality after multivariable adjustment. After excluding patients with coronary artery disease and renal dysfunction, myocardial necrosis remained associated with long-term mortality. In conclusion, postoperative myocardial necrosis is common after orthopedic surgery. Myocardial necrosis is independently associated with long-term mortality at 3 years and may be used to identify patients at higher risk for events who may benefit from aggressive management of cardiovascular risk factors.
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Ma J, Xin Q, Wang X, Gao M, Wang Y, Liu J. Prediction of perioperative cardiac events through preoperative NT-pro-BNP and cTnI after emergent non-cardiac surgery in elderly patients. PLoS One 2015; 10:e0121306. [PMID: 25799524 PMCID: PMC4370461 DOI: 10.1371/journal.pone.0121306] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 01/29/2015] [Indexed: 01/26/2023] Open
Abstract
Objectives Clinical risk stratification has an important function in preoperative evaluation of patients at risk for cardiac events prior to non-cardiac surgery. The aim of this study was to determine whether the combined measurement of pre-operative N-terminal pro-brain natriuretic peptide (NT-pro-BNP) and cardiac troponin I (cTnI) could provide useful prognostic information about postoperative major adverse cardiac events (MACE) within 30 days in patients aged over 60 years undergoing emergent non-cardiac surgery. Methods The study group comprised 2519 patients aged over 60 years that were undergoing emergent non-cardiac surgery between December 2007 and December 2013. NT-pro-BNP and cTnI were measured during hospital admission. The patients were monitored for MACE (cardiac death, non-fatal myocardial infarction, or cardiac arrest) during the 30-day postoperative follow-up period. Results MACE occurred in 251 patients (10.0%). Preoperative NT-pro-BNP and cTNI level were significantly higher in the individuals that experienced MACE than in those who did not (P < 0.001). The confounding factors of age, sex, co-morbidities and preoperative medications were adjusted in a multivariate logistic regression analysis. This analysis showed that preoperative NT-proBNP level > 917 pg/mL (OR 4.81, 95% CI 3.446–6.722, P < 0.001) and cTnI ≥ 0.07 ng/mL (OR 8.74, 95% CI 5.881–12.987, P < 0.001) remained significantly and independently associated with MACE after the adjustment of the confounding factors. Kaplan-Meier event-free survival curves demonstrated that patients with preoperative simultaneous NT-proBNP level > 917 pg/mL and cTnT ≥0.07 ng/mL had worse event-free survival than individual assessments of either biomarker. Conclusion Preoperative plasma NT-proBNP and cTnI are both independently associated with an increased risk of MACE in elderly patients after emergent non-cardiac surgery. The combination of these biomarkers provides better prognostic information than using either biomarker separately.
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Affiliation(s)
- Jinling Ma
- Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China
- * E-mail:
| | - Qian Xin
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Xiujie Wang
- Department of Radiology, Zhaoyuan People's Hospital, Shandong, China
| | - Meng Gao
- Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Yutang Wang
- Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Jie Liu
- Emergency Department, Chinese PLA General Hospital, Beijing, China
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Rudd N, Subiakto I, Asrar Ul Haq M, Mutha V, Van Gaal WJ. Use of ivabradine and atorvastatin in emergent orthopedic lower limb surgery and computed tomography coronary plaque imaging and novel biomarkers of cardiovascular stress and lipid metabolism for the study and prevention of perioperative myocardial infarction: study protocol for a randomized controlled trial. Trials 2014; 15:352. [PMID: 25195125 PMCID: PMC4162914 DOI: 10.1186/1745-6215-15-352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 08/22/2014] [Indexed: 11/23/2022] Open
Abstract
Background The incidence of perioperative myocardial infarction (PMI) globally is known to be around 2 to 3% and can prolong hospitalization, increased morbidity and mortality. Little is known about the pathophysiology and risk factors for PMI. We investigate the presence of elevated novel cardiac markers and preoperative coronary artery plaque through contemporary laboratory techniques to determine the correlation with PMI, as well as studying ivabradine and atorvastatin as protective pharmacotherapies against PMI in the context of orthopedic surgery. Methods/Design We aim to enroll 200 patients aged above 60 years who suffer from neck of femur fracture requiring surgery. Patients will be randomized to four arms (no study drugs, atorvastatin only, ivabradine only and ivabradine and atorvastatin). Our primary outcome is incidence of PMI. All patients will receive an electrocardiogram, cardiac echocardiography, measurement of novel cardiac biomarkers and computed tomography (CT) coronary angiography. A telephone interview post discharge will be conducted at 30 days, 60 days and 1 year. Discussion We postulate that ivabradine and atorvastatin will reduce the rate and magnitude of PMI following surgery by reducing heart rate and attenuating catecholamine-induced tachycardia postoperatively. Secondly, we postulate that postoperative reduction in heart rate and catecholamine-induced tachycardia with ivabradine will correlate with a reduction in cardiovascular novel biomarkers which will reduce atrial stretch and postoperative incidence of arrhythmia. We aim to demonstrate that treatment with ivabradine and atorvastatin will cause a reduction in the incidence and magnitude of PMI, the benefit of which is derived primarily in patients with greater atherosclerotic burden as measured by higher CT coronary calcium scores. Trial registration This study protocol has been listed in the Australia New Zealand Clinical Trial Registry (registration number: ACTRN12612000340831) on 23 March 2012.
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Affiliation(s)
| | | | - Muhammad Asrar Ul Haq
- Department of Cardiology, The Northern Hospital, 185 Cooper Street, Epping 3076, VIC, Australia.
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Oberweis BS, Cuff G, Rosenberg A, Pardo L, Nardi MA, Guo Y, Dweck E, Marshall M, Steiger D, Stuchin S, Berger JS. Platelet aggregation and coagulation factors in orthopedic surgery. J Thromb Thrombolysis 2014; 38:430-8. [DOI: 10.1007/s11239-014-1078-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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van Waes JA, Nathoe HM, de Graaff JC, Kemperman H, de Borst GJ, Peelen LM, van Klei WA, Buhre WF, de Graaff JC, Kalkman CJ, van Klei WA, van Waes JA, van Wolfswinkel L, Doevendans PA, Nathoe HM, Grobben RG, Grobbee DE, Peelen LM, Kemperman H, van Solinge WW, Leiner T, de Borst GJ, Leenen LP, Moll FL. Myocardial Injury After Noncardiac Surgery and its Association With Short-Term Mortality. Circulation 2013; 127:2264-71. [DOI: 10.1161/circulationaha.113.002128] [Citation(s) in RCA: 216] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background—
To identify patients at risk for postoperative myocardial injury and death, measuring cardiac troponin routinely after noncardiac surgery has been suggested. Such monitoring was implemented in our hospital. The aim of this study was to determine the predictive value of postoperative myocardial injury, as measured by troponin elevation, on 30-day mortality after noncardiac surgery.
Methods and Results—
This observational, single-center cohort study included 2232 consecutive intermediate- to high-risk noncardiac surgery patients aged ≥60 years who underwent surgery in 2011. Troponin was measured on the first 3 postoperative days. Log binomial regression analysis was used to estimate the association between postoperative myocardial injury (troponin I level >0.06 μg/L) and all-cause 30-day mortality. Myocardial injury was found in 315 of 1627 patients in whom troponin I was measured (19%). All-cause death occurred in 56 patients (3%). The relative risk of a minor increase in troponin (0.07–0.59 μg/L) was 2.4 (95% confidence interval, 1.3–4.2;
P
<0.01), and the relative risk of a 10- to 100-fold increase in troponin (≥0.60 μg/L) was 4.2 (95% confidence interval, 2.1–8.6;
P
<0.01). A myocardial infarction according to the universal definition was diagnosed in 10 patients (0.6%), of whom 1 (0.06%) had ST-segment elevation myocardial infarction.
Conclusions—
Postoperative myocardial injury is an independent predictor of 30-day mortality after noncardiac surgery. Implementation of postoperative troponin monitoring as standard of care is feasible and may be helpful in improving the prognosis of patients undergoing noncardiac surgery.
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Affiliation(s)
- Judith A.R. van Waes
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hendrik M. Nathoe
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jurgen C. de Graaff
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hans Kemperman
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert Jan de Borst
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Linda M. Peelen
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wilton A. van Klei
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
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Perioperative myocardial infarctions are common and often unrecognized in patients undergoing hip fracture surgery. J Trauma Acute Care Surg 2013; 74:1087-91. [PMID: 23511149 DOI: 10.1097/ta.0b013e3182827322] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this prospective cohort study was to assess the incidence and characteristics of acute myocardial infarction in patients undergoing surgery for acute hip fracture. METHODS A consecutive cohort of patients (n = 200, 68 men) referred to acute surgical correction of hip fracture was studied. Troponin T (TnT) measurements and electrocardiographic (ECG) recordings were performed at admission, before operation, and on the first and 2nd postoperative days, which were used for diagnosis. RESULTS The age of the patients ranged from 32 to 98 years (mean, 80.8 years), and 65 patients had a history of coronary artery disease. A significant rise in TnT as a sign of myocardial infarction was observed in 71 patients (35.5%), and 25 of them had a TnT elevation exceeding five times the upper normal limit. TnT elevation was observed in 36 patients (51%) already before surgery. Seven patients (10%) had ST elevation myocardial infarction, 23 patients (32%) had new ST depressions, and 21 patients (30%) had no new ST segment changes in the serial electrocardiographic recordings. In 40 patients (56%), the perioperative myocardial infarction was the first manifestation of coronary artery disease. Multivariate logistic regression revealed that old age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02-1.10; p = 0.002), earlier revascularization (OR, 3.29; 95% CI 1.12-9.73; p = 0.03), and heart failure (OR, 2.42; 95% CI 1.04-5.61; p = 0.04) were independent predictors of TnT elevation. Majority of myocardial infarctions were asymptomatic or unrecognized. Evidence-based medications of myocardial infarction were seldom started and cardiologist was consulted in 12 patients (16.9%). CONCLUSION Patients with hip fracture often develop asymptomatic and clinically unrecognized perioperative myocardial infarctions. Earlier diagnosis and appropriate treatment of cardiac infarction may improve survival of hip fracture patients. LEVEL OF EVIDENCE Epidemiologic study, level III.
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Blackshear JL, Brott TG. Ascertainment of any and all neurologic and myocardial damage in carotid revascularization: the key to optimization? Expert Rev Cardiovasc Ther 2013; 11:469-84. [PMID: 23570360 DOI: 10.1586/erc.13.25] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The majority of carotid revascularization procedures performed at present are in asymptomatic patients. Since such procedures convey no immediate benefit, but rather protect from future hazard, optimization of procedural safety is mandatory. The authors focus their discussion on the methodologies that assess periprocedural myocardial damage and brain injury, as used in past clinical trials, from the fields of perioperative medicine and neurovascular imaging, and discuss methodologies to reduce both events in carotid revascularization.
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Affiliation(s)
- Joseph L Blackshear
- Division of Cardiovascular Diseases, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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Oberweis BS, Nukala S, Rosenberg A, Guo Y, Stuchin S, Radford MJ, Berger JS. Thrombotic and bleeding complications after orthopedic surgery. Am Heart J 2013; 165:427-33.e1. [PMID: 23453114 DOI: 10.1016/j.ahj.2012.11.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 11/19/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Thrombotic and bleeding complications are major concerns during orthopedic surgery. Given the frequency of orthopedic surgical procedures and the limited data in the literature, we sought to investigate the incidence and risk factors for thrombotic (myocardial necrosis and infarction) and bleeding events in patients undergoing orthopedic surgery. METHODS AND RESULTS We performed a retrospective cohort analysis of 3,082 consecutive subjects ≥21 years of age undergoing hip, knee, or spine surgery between November 1, 2008, and December 31, 2009. Patient characteristics were ascertained using International Classification of Diseases, Ninth Revision, diagnosis coding and retrospective review of medical records, and laboratory/blood bank databases. In-hospital outcomes included myocardial necrosis (elevated troponin), major bleeding, coded myocardial infarction, and coded hemorrhage as defined by International Classification of Diseases, Ninth Revision, coding. Of the 3,082 subjects, mean age was 60.8 ± 13.3 years, and 59% were female. Myocardial necrosis, coded myocardial infarction, major bleeding, and coded hemorrhage occurred in 179 (5.8%), 20 (0.7%), 165 (5.4%), and 26 (0.8%) subjects, respectively. Increasing age (P < .001), coronary artery disease (P < .001), cancer (P = .004), and chronic kidney disease (P = .01) were independent predictors of myocardial necrosis, whereas procedure type (P < .001), cancer (P < .001), female sex (P < .001), coronary artery disease (P < .001), and chronic obstructive pulmonary disease (P = .01) were independent predictors of major bleeding. CONCLUSION There is a delicate balance between thrombotic and bleeding events in the perioperative period after orthopedic surgery. Perioperative risk of both thrombosis and bleeding deserves careful attention in preoperative evaluation, and future prospective studies aimed at attenuating this risk are warranted.
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Chong CP, van Gaal WJ, Profitis K, Ryan JE, Savige J, Lim WK. Electrocardiograph Changes, Troponin Levels and Cardiac Complications After Orthopaedic Surgery. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2013. [DOI: 10.47102/annals-acadmedsg.v42n1p24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Introduction: The relationship between electrocardiograph (ECG) changes and troponin levels after the emergency orthopaedic surgery are not well characterised. The aim of this study was to determine the correlation between ECG changes (ischaemia or arrhythmia), troponin elevations perioperatively and cardiac complications. Materials and Methods: One hundred and eighty-seven orthopaedic patients over 60 years of age were prospectively tested for troponin I and ECGs were performed on the first 3 postoperative mornings or until discharge. Results: The incidences of pre- and postoperative troponin elevation were 15.5% and 37.4% respectively, the majority were asymptomatically detected. Most of the patients who sustained a troponin rise did not have any concomitant ECG changes (51/70 or 72.9%). Postoperative ECG changes were noted in 18.4% (34/185) and of those with ECG changes, slightly more than half (55.9%) had a troponin elevation. Most ECG changes occurred on postoperative day 1 and were non-ST elevation in type. ECG changes occurred more frequently with higher troponin levels. Postoperative troponin elevation (P = 0.018) and not preoperative troponin level (P = 0.060) was associated with ECG changes on univariate analysis. Two premorbid factors were predictors of postoperative ECG changes using multivariate logistical regression; age [odds ratio (OR), 1.05; 95% CI, 1.005 to 1.100, P = 0.029) and sex OR, 2.4; 95% CI, 1.069 to 5.446, P = 0.034). Twenty patients sustained postoperative cardiac complications; 9 (45%) were associated with ECG changes and 16 (80%) with postoperative troponin elevation. Pre- or postoperative troponin elevation better predicted cardiac complications compared with preoperative ECG changes. Conclusion: Electrocardiograph changes do not necessarily accompany troponin elevations after the emergency orthopaedic surgery but are more likely to have higher troponin levels. The best predictor of postoperative cardiac complications is troponin elevation.
Key words: Cardiovascular, Fracture, Myocardial ischaemia, Myocardial infarction, Surgery
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Affiliation(s)
| | | | | | - Julie E Ryan
- The Northern Hospital, Epping, Victoria, Australia
| | - Judy Savige
- Northern Clinical Research Centre, Northern Health, The University of Melbourne, Victoria, Australia
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Smeets SJM, Poeze M, Verbruggen JPAM. Preoperative cardiac evaluation of geriatric patients with hip fracture. Injury 2012; 43:2146-51. [PMID: 22995981 DOI: 10.1016/j.injury.2012.08.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Accepted: 07/31/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND The American College of Cardiology (ACC) and the American Heart Association (AHA) have developed guidelines for perioperative assessment of patients in case of non-cardiac surgery. The aim of this study was to investigate if the preoperative cardiac evaluation of geriatric patients with hip fracture was in accordance with these guidelines and what the effects were on outcome. METHODS In a retrospective study 388 patients with hip fracture treated in the department of Trauma surgery of the Maastricht University Medical Centre in the Netherlands were included. All patients were treated between 2003 and 2006 and had at least two year follow-up. The preoperative cardiac screening was analysed with respect to content and to which level this followed the ACC/AHA guidelines. These guidelines were used to classify cardiac risk into low, intermediate and high risk. This was related to the outcome measurements delay to surgery, perioperative complications and mortality. RESULTS According to the ACC/AHA guidelines 82% of patients received correct preoperative cardiac screening in the low vs. 46% in the intermediate and 86% in the high risk group. The most frequent reason for incorrect preoperative cardiac screening was overscreening (>95%). The delay to surgery increased by 9.9h in the case of overscreening (p=0.03). A previous cardiac history was a significant risk factor for early mortality. Delay of >48 h was associated with more cardiovascular complications and mortality both on univariate and multivariate analysis. CONCLUSION Preoperative cardiac screening is frequently unnecessary after hip fracture, especially in patients with intermediate risk predictors and increases the delay to surgery. Delay of >48 h was associated with more cardiovascular complications and mortality postoperatively. The implementation of the ACC/AHA guidelines may prevent unnecessary cardiac consultations which reduces preoperative resources, delay to surgery and possibly decreases postoperative complications.
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Affiliation(s)
- S J M Smeets
- Department of Surgery, Maastricht University Medical Center, Postbus 5800, 6202 AZ Maastricht, The Netherlands.
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Mohan IV, Naylor AR. Carotid artery stenting: where are we up to with evidence-based practice? ANZ J Surg 2012; 82:486-8. [PMID: 22863221 DOI: 10.1111/j.1445-2197.2012.06131.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Irwin V Mohan
- Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
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Chong CP, van Gaal WJ, Ryan JE, Profitis K, Savige J, Lim WK. Does cardiology intervention improve mortality for post-operative troponin elevations after emergency orthopaedic-geriatric surgery? A randomised controlled study. Injury 2012; 43:1193-8. [PMID: 22541758 DOI: 10.1016/j.injury.2012.03.034] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Revised: 01/29/2012] [Accepted: 03/31/2012] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Troponin elevations are common after emergency orthopaedic surgery and confer a higher mortality at one year. The objective was to determine if comprehensive cardiology care after emergency orthopaedic surgery reduces mortality at one year in patients who sustain a post-operative troponin elevation versus standard care. METHODS A randomised controlled trial was conducted at a metropolitan teaching hospital in Melbourne, Australia. 187 consecutive patients were eligible with 70 patients randomised. Troponin I was tested peri-operatively and patients with a troponin elevation were randomised to cardiology care versus standard ward management. The main outcome measure was one year mortality. RESULTS The incidence of a post-operative troponin elevation was 37.4% (70/187) and these 70 patients were randomised. In-hospital cardiac complications were similar between the randomised groups: standard care (7/35 or 20.0%) versus cardiology care (8/35 or 22.9%). There was no difference in 1 year mortality between the randomised groups (6/35 or 17.1% in each group). Multivariate predictors of 1 year mortality were post-operative troponin elevation OR 4.3 (95% CI, 1.1-16.4, p=0.035), age OR 1.1 (95% CI, 1.02-1.2, p=0.016) and number of comorbidities OR 2.1 (95% CI, 1.3-3.5, p=0.004). At 1 year 35/187 (18.7%) sustained a cardiac complication and 23/35 (65.7%) had a troponin elevation. CONCLUSIONS There was no difference in mortality between patients with a post-operative troponin elevation randomised to cardiology care compared with standard care. Troponin elevation predicted one year mortality. Further research is needed to find an effective intervention to reduce mortality.
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Affiliation(s)
- Carol P Chong
- Department of Aged Care, The Northern Hospital, Epping, Victoria, Australia.
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Canary in the coal mine: cardiac troponins in noncoronary diseases. Am J Med 2012; 125:527-8. [PMID: 22325234 DOI: 10.1016/j.amjmed.2011.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2011] [Accepted: 07/11/2011] [Indexed: 11/23/2022]
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Chong CP, Lim WK, Velkoska E, van Gaal WJ, Ryan JE, Savige J, Burrell LM. N-terminal pro-brain natriuretic peptide and angiotensin-converting enzyme-2 levels and their association with postoperative cardiac complications after emergency orthopedic surgery. Am J Cardiol 2012; 109:1365-73. [PMID: 22381157 DOI: 10.1016/j.amjcard.2011.12.032] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Revised: 12/11/2011] [Accepted: 12/11/2011] [Indexed: 11/19/2022]
Abstract
The prognostic usefulness of the cardiac biomarkers N-terminal pro-brain natriuretic peptide (NT-proBNP) and angiotensin-converting enzyme 2 (ACE-2), in predicting adverse cardiac outcomes after orthopedic surgery is not well studied. The aim of our study was to determine the usefulness of perioperative NT-proBNP and ACE-2 for predicting cardiac events after emergency orthopedic surgery. The perioperative NT-proBNP and ACE-2 levels were determined in 187 consecutive patients aged >60 years who underwent orthopedic surgery with 1 year of follow-up for any cardiac complications (defined as acute myocardial infarction, congestive cardiac failure, atrial fibrillation, or major arrhythmia) and death. Of the 187 patients, 20 (10.7%) sustained an in-hospital postoperative cardiac complication. The total all-cause in-hospital and 1-year mortality rate was 1.6% (3 of 187) and 8.6% (16 of 187), respectively. The median preoperative and postoperative NT-proBNP level was greater in patients who sustained an in-hospital cardiac event than in those who had not (386 vs 2,273 pg/ml, p <0.001, and 605 vs 4,316 pg/ml, p <0.001, respectively). Similarly, the postoperative median ACE-2 levels were significantly greater in the patients with an in-hospital cardiac event than in those without (25.3 vs 39.5 pmol/ml/min, p = 0.012). A preoperative NT-proBNP level of ≥741 pg/ml (odds ratio 4.5, 95% confidence interval 1.3 to 15.2, p = 0.017), postoperative troponin elevation (odds ratio 4.9, 95% confidence interval 1.3 to 18.9, p = 0.022), and number of co-morbidities (odds ratio 1.8, 95% confidence interval 1.2 to 2.8, p = 0.009) independently predicted in-hospital cardiac complications on multivariate analysis. The pre- and postoperative NT-proBNP level independently predicted 1-year cardiovascular complications but not the ACE-2 levels. In conclusion, elevated perioperative NT-proBNP predicted in-hospital and 1-year cardiac events in an emergency orthopedic population but the ACE-2 levels did not, which requires additional study for validation.
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Affiliation(s)
- Carol P Chong
- Department of Aged Care, The Northern Hospital, Epping, Victoria, Australia.
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Troponin T in hip fracture patients: prognostic significance for mortality at one year. Hip Int 2012; 21:757-61. [PMID: 22117257 DOI: 10.5301/hip.2011.8840] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2011] [Indexed: 02/04/2023]
Abstract
Hip fractures are common injuries in the elderly, with significant mortality and morbidity from several factors. Many of these patients have cardiac disease, and some develop cardiac complications which may increase mortality. Troponin T is a marker of myocardial injury but can be raised in other conditions. Patients over 60 years admitted with hip fracture during the study period had their troponin T measured on admission and postoperatively. Assay was performed after the patient had completed their treatment. We report the results of this study one year after the last patient was admitted. 108 patients were recruited. The average age was 84 years, 86% were female. The mean hospital stay was 20 days. This study found that 27% of hip fracture patients had some increase in the troponin T levels in the peri-operative period. This increase was not associated with an increase in early mortality, but there was an increase in one-year mortality for those with an increase in troponin T (45% versus 22%, p=0.03). These findings indicate that the routine measurement of troponin T does not correlate with acute mortality and is not necessary without evidence of an acute cardiac event.
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Chong C, Lam Q, Ryan J, Sinnappu R, Lim WK. Impact of troponin 1 on long-term mortality after emergency orthopaedic surgery in older patients. Intern Med J 2011; 40:751-6. [PMID: 19811558 DOI: 10.1111/j.1445-5994.2009.02063.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine the association between post-operative troponin rises and longer term (2-year) mortality after emergency orthopaedic surgery in patients over 60 years of age. METHODS One hundred and two patients were recruited in 2006 and had inpatient troponin 1 measurements. These patients were followed up by a telephone call annually for complications. RESULTS At 2 years, 29.4% (30/102) of patients had died. Twenty-five patients (25/54 or 49.3%) with a troponin rise were dead at 2 years compared with five patients without a troponin rise (5/48 or 10.4%), which was significantly different P < 0.0001. Patients with a higher troponin level (>0.1 µg/L) were more likely to be dead at 2 years compared with those with a lower level of troponin. However, when adjusted for other comorbidities the association between troponin elevation and death at 2 years did not persist. Using Cox regression multivariate analysis, only one factor, sustaining an in-hospital cardiac event odds ratio 4.3 (95% confidence interval 1.8-10.3, P = 0.001), was associated with 2 years all-cause mortality . Furthermore, patients who sustained a symptomatic troponin rise (P < 0.0001) or asymptomatic troponin rise (P = 0.004) were more likely to have died at 2 years compared with those with no troponin rise. Three factors were significantly associated with a cardiac event during the second year: (i) post-operative troponin rise (P = 0.05); (ii) pre-morbid atrial fibrillation (P = 0.04); and (iii) post-operative renal failure (P < 0.001). CONCLUSION Elevated post-operative troponin levels are predictive of 1-year but not 2-year mortality in older patients undergoing emergency orthopaedic surgery.
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Affiliation(s)
- C Chong
- Department of Aged Care, The Northern Hospital, Epping, Victoria, Australia.
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Abstract
BACKGROUND Cardiac injury after orthopaedic surgery is an increasing problem particularly in an ageing population. The detection of cardiac injury has been aided by the use of cardiac troponins which has also raised questions about the utility of this enzyme in the post-operative setting. OBJECTIVE This review evaluates the diagnosis and pathophysiology of myocardial infarction after orthopaedic surgery and examines how myocardial injury is detected, with particular emphasis on the role of troponin testing. SUBJECTS Eight recent orthopaedic trials evaluating the use of troponin were identified in the literature and included in this review. RESULTS This review found that the diagnosis of myocardial infarction ismore difficult after surgery since classic symptoms may be atypical or absent. Therefore, there ismore reliance on the typical rise and fall in troponin to diagnose cardiac injury especially because electrocardiograph changes may be hard to detect. The pathophysiology of ischaemia after orthopaedic surgery may be different to ischaemia in the non-surgical setting. The incidence of troponin elevation is between 22 and 52.9% after emergency orthopaedic operations. Of note, patients sustaining a troponin elevation are often asymptomatic. Small studies have found troponin to be a prognostic marker of in-hospital cardiac complications, increased length of stay, increased likelihood of discharge to residential care and death at 1 year. No interventional studies have been published to date. CONCLUSION Cardiac injury is an important complication after orthopaedic surgery. Studies have found that troponin testing can detect asymptomatic cardiac injury. These patients are at risk of poorer outcomes and future research should be directed towards treatment of these patients.
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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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Ausset S, Donat N, Masson Y. [Cardiac complications following hip fracture surgery]. ACTA ACUST UNITED AC 2011; 30:e65-7. [PMID: 21820845 DOI: 10.1016/j.annfar.2011.06.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Hip fracture is a major health burden due to both its frequency and its deep impact on patient's outcome. The key issue of this poor outcome seems to be cardiac complications. The onset of these cardiac complications seems to appear early in the clinical course in the form of perioperative myocardial ischemia that are both preventable and treatable. Their clinical and electrocardiographic pattern is very poor and they can be thoroughly detected by only either a systematic electrocardiographic 12 lead monitoring or troponin dosage.
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Affiliation(s)
- S Ausset
- Service D'anesthésie-Réanimation, Hôpital D'instruction des Armées Percy, 101, avenue Henri-Barbusse, BP 406, 92141 Clamart Cedex, France.
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Blackshear JL, Cutlip DE, Roubin GS, Hill MD, Leimgruber PP, Begg RJ, Cohen DJ, Eidt JF, Narins CR, Prineas RJ, Glasser SP, Voeks JH, Brott TG. Myocardial infarction after carotid stenting and endarterectomy: results from the carotid revascularization endarterectomy versus stenting trial. Circulation 2011; 123:2571-8. [PMID: 21606394 DOI: 10.1161/circulationaha.110.008250] [Citation(s) in RCA: 163] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) found a higher risk of stroke after carotid artery stenting and a higher risk of myocardial infarction (MI) after carotid endarterectomy. METHODS AND RESULTS Cardiac biomarkers and ECGs were performed before and 6 to 8 hours after either procedure and if there was clinical evidence of ischemia. In CREST, MI was defined as biomarker elevation plus either chest pain or ECG evidence of ischemia. An additional category of biomarker elevation with neither chest pain nor ECG abnormality was prespecified (biomarker+ only). Crude mortality and risk-adjusted mortality for MI and biomarker+ only were assessed during follow-up. Among 2502 patients, 14 MIs occurred in carotid artery stenting and 28 MIs in carotid endarterectomy (hazard ratio, 0.50; 95% confidence interval, 0.26 to 0.94; P=0.032) with a median biomarker ratio of 40 times the upper limit of normal. An additional 8 carotid artery stenting and 12 carotid endarterectomy patients had biomarker+ only (hazard ratio, 0.66; 95% confidence interval, 0.27 to 1.61; P=0.36), and their median biomarker ratio was 14 times the upper limit of normal. Compared with patients without biomarker elevation, mortality was higher over 4 years for those with MI (hazard ratio, 3.40; 95% confidence interval, 1.67 to 6.92) or biomarker+ only (hazard ratio, 3.57; 95% confidence interval, 1.46 to 8.68). After adjustment for baseline risk factors, both MI and biomarker+ only remained independently associated with increased mortality. CONCLUSIONS In patients randomized to carotid endarterectomy versus carotid artery stenting, both MI and biomarker+ only were more common with carotid endarterectomy. Although the levels of biomarker elevation were modest, both events were independently associated with increased future mortality and remain an important consideration in choosing the mode of carotid revascularization or medical therapy. CLINICAL TRIAL REGISTRATION URL: http://www.ClinicalTrials.gov. Unique identifier: NCT00004732.
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Affiliation(s)
- Joseph L Blackshear
- Mayo Clinic, Griffin 3rd Floor, 4500 San Pablo Rd, Jacksonville, FL 32224, 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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Cardiac troponin T: an important predictor of late death and myocardial infarction following hip fracture: an eight-year prospective observational cohort study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2010. [DOI: 10.1007/s00590-010-0696-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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