Association between pre-operative statin use and major cardiovascular complications among patients undergoing non-cardiac surgery: the VISION study

Differences between patients in whom physicians agree versus disagree about the preoperative diagnosis of heart failure

STUDY OBJECTIVE

To quantify preoperative heart failure (HF) diagnostic agreement and identify characteristics of patients in whom physicians agreed versus disagreed about the diagnosis.

DESIGN

Observational cohort study.

SETTING

Patients undergoing major non-cardiac surgery at an academic center between 2015 and 2019.

PATIENTS

40,659 patients undergoing major non-cardiac surgery, among which a stratified subsample of 1018 patients with and without documented HF was reviewed.

INTERVENTIONS

Via a panel of physicians frequently managing patients with HF (cardiologists, cardiac anesthesiologists, intensivists), detailed chart reviews were performed (two per patient; median review time 32 min per reviewer per patient) to render adjudicated HF diagnoses.

MEASUREMENTS

Adjudicated diagnostic agreement measures (percent agreement, Krippendorf's alpha) and univariate comparisons (standardized differences) between patients in whom physicians agreed versus disagreed about the preoperative HF diagnosis.

MAIN RESULTS

Among patients with documented HF, physicians agreed about the diagnosis in 80.0% of cases (consensus positive), disagreed in 13.8% (disagreement), and refuted the diagnosis in 6.3% (consensus negative). Conversely, among patients without documented HF, physicians agreed about the diagnosis in 88.0% (consensus negative), disagreed in 8.4% (disagreement), and refuted the diagnosis in 3.6% (consensus positive). The estimated agreement for the 40,659 cases was 91.1% (95% CI 88.3%-93.9%); Krippendorff's alpha was 0.77 (0.75-0.80). Compared to patients in whom physicians agreed about a HF diagnosis, patients in whom physicians disagreed exhibited fewer guideline-defined HF diagnostic criteria.

CONCLUSIONS

Physicians usually agree about HF diagnoses adjudicated via chart review, although disagreement is not uncommon and may be partly explained by heterogeneous clinical presentations. Our findings inform preoperative screening processes by identifying patients whose characteristics contribute to physician disagreement via chart review. Clinical Trial Number / Registry URL: Not applicable.

Guideline adherence to statin therapy and association with short-term and long-term cardiac complications following noncardiac surgery: A cohort study

BACKGROUND

Peri-operative complications are common and associated with high morbidity and mortality. Optimising the use of statins might be of important benefit in peri-operative care and reduce morbidity and mortality.

OBJECTIVE

To evaluate adherence to current guideline recommendations regarding statin therapy and its association with peri-operative and long-term cardiac complications.

DESIGN

Prospective cohort study.

SETTING

Multicentre study with enrolment from October 2014 to February 2018.

PATIENTS

Eight thousand one hundred and sixteen high-risk inpatients undergoing major noncardiac surgery who were eligible for the institutional peri-operative myocardial injury/infarction (PMI) active surveillance and response program.

MAIN OUTCOME MEASURES

Class I indications for statin therapy were derived from the current ESC Clinical Practice Guidelines during the time of enrolment. PMI was prospectively defined as an absolute increase in cTn concentration of the 99th percentile in healthy individuals above the preoperative concentration within the first three postoperative days. Long-term cardiac complications included cardiovascular death and spontaneous myocardial infarction (MI) within 120 days.

RESULTS

The mean age was 73.7 years; 45.2% were women. Four thousand two hundred and twenty-seven of 8116 patients (52.1%) had a class I indication for statin therapy. Of these, 2440 of 4227 patients (57.7%) were on statins preoperatively. Adherence to statins was lower in women than in men (46.9 versus 63.9%, P  < 0.001). PMI due to type 1 myocardial infarction/injury (T1MI; n  = 42), or likely type 2 MI (lT2MI; n  = 466) occurred in 508 of 4170 (12.2%) patients. The weighted odds ratio in patients on statin therapy was 1.15 [95% confidence interval (CI) 1.01 to 1.31, P  = 0.036]. During the 120-day follow-up, 192 patients (4.6%) suffered cardiovascular death and spontaneous MI. After multivariable adjustment, preoperative use of statins was associated with reduced risk; weighted hazard ratio 0.59 (95% CI 0.41 to 0.86, P  = 0.006).

CONCLUSION

Adherence to guideline-recommended statin therapy was suboptimal, particularly in women. Statin use was associated with an increased risk of PMI due to T1MI and lT2MI but reduced risk of cardiovascular death and spontaneous MI within 120 days.

TRIAL REGISTRATION

Clinicaltrials.gov identifier NCT02573532.

Cost-effectiveness of a high-sensitivity cardiac troponin T systematic screening strategy compared with usual care to identify patients with peri-operative myocardial injury after major noncardiac surgery

BACKGROUND

About 300 million surgeries are performed worldwide annually and this figure is increasing constantly. Peri-operative myocardial injury (PMI), detected by cardiac troponin (cTn) elevation, is a common cardiac complication of noncardiac surgery, strongly associated with short- and long-term mortality. Without systematic peri-operative cTn screening, most cases of PMI may go undetected. However, little is known about cost effectiveness of a systematic PMI screening strategy with high-sensitivity cardiac troponin T (hs-cTnT) after noncardiac surgery.

OBJECTIVE

To assess, in patients with high cardiovascular risk, the cost-effectiveness of a systematic screening strategy using a hs-cTnT assay, to identify patients with PMI after major noncardiac surgery, compared with usual care.

DESIGN

Cost-effectiveness analysis; single centre prospective cohort study.

SETTING

Spanish University Hospital.

PATIENTS

From July 2016 to March 2019, we included 1477 consecutive surgical patients aged ≥65 or if <65, with documented history of cardiovascular disease or impaired renal function, who underwent major noncardiac surgery and required at least an overnight hospital stay. We excluded patients aged <65 years without cardiovascular disease, undergoing minor surgery, or with an expected <24 h hospital stays.

INTERVENTIONS

We conducted a decision-tree analysis, comparing a systematic screening strategy measuring hs-cTnT before surgery, and at the 2nd and 3rd days after surgery vs. a usual care strategy. We considered a third-party payer perspective and the outcomes of both strategies in the short-term (30 days follow-up). Information about costs was expressed in Euros-2021. We calculated the incremental cost-effectiveness ratio (ICER) of the systematic hs-cTnT strategy, defined as the expected cost per any additional PMI detected, and explored the robustness of the model using deterministic and probabilistic sensitivity analysis.

MAIN OUTCOME MEASURES

ICER of the systematic hs-cTnT screening strategy.

RESULTS

The ICER was €425 per any additionally detected PMI. The deterministic sensitivity analysis showed that a 15% variation in costs, and a 1% variation in the predictive values, had a minor impact over the ICER, except in case of the negative predictive value of the systematic hs-cTnT screening strategy. Monte Carlo simulations (probabilistic sensitivity analysis) showed that systematic hs-cTnT screening would be cost-effective in 100% of cases with a 'willingness to pay' of €780.

CONCLUSIONS

Our results suggest that systematic peri-operative PMI screening with hs-cTnT may be cost-effective in the short-term in patients undergoing major noncardiac surgery. Economic evaluations, with a long-term horizon, are still needed.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT03438448.

Prevalence and trends of perioperative major adverse cardiovascular and cerebrovascular events during cancer surgeries

Major adverse cardiovascular and cerebrovascular events (MACCE) is an important cause of morbidity and mortality during perioperative period. In this study, we looked for national trends in perioperative MACCE and its components as well as cancer types associated with high rates of perioperative MACCE during major cancer surgeries. This study was a retrospective analysis of the National Inpatient Sample, 2005-2014. Hospitalizations for surgeries of prostate, bladder, esophagus, pancreas, lung, liver, colorectal, and breast among patients 40 years and greater were included in the analysis. MACCE was defined as a composite measure that included in-hospital all-cause mortality, acute myocardial infarction (AMI), and ischemic stroke. A total of 2,854,810 hospitalizations for major surgeries were included in this study. Of these, 67,316 (2.4%) had perioperative MACCE. Trends of perioperative MACCE showed that it decreased significantly for AMI, death and any MACCE, while stroke did not significantly change during the study period. Logistic regression analysis for perioperative MACCE by cancer types showed that surgeries for esophagus, pancreas, lung, liver, and colorectal cancers had significantly greater odds for perioperative MACCE. The surgeries identified to have greater risks for MACCE in this study could be risk stratified for better informed decision-making and management.

Perioperative Medication Management in Elective Plastic Surgery Procedures

BACKGROUND

Perioperative medication management is vital to maintain patient safety while under anesthesia, as well as to avoid postoperative complications. Plastic surgeons make daily decisions on whether to ask a patient to stop taking medication before their surgery. These important decisions can affect bleeding risk, wound healing, and interactions with anesthetics, which can range from minor to life-threatening. Current plastic surgery literature lacks a comprehensive review of perioperative medication management, with existing reports focusing on specific procedures and specific medication classes.

METHODS

A PubMed database search was conducted for articles through July 2021. The bibliographies of included studies were also examined for articles not acquired in the initial search queries. The authors included studies on medication usage and perioperative guidance in patients undergoing elective plastic surgery procedures. The authors excluded studies unrelated to plastic surgery and studies where the medications were used as an intervention. Abstracts, animal studies, studies involving the pediatric population, and book chapters were also excluded, as well as articles not published in English.

RESULTS

A total of 801 papers were identified by our search terms. After title and abstract screening, 35 papers were selected for full-text review. After full-text review, 20 papers were selected for inclusion, with an additional 6 papers from cited references added. Of the 26 papers, 6 papers discussed psychotropic drugs, 6 papers discussed medications affecting hemostasis, 4 papers discussed hormone-containing medications, 3 papers discussed antilipid medications, 2 papers discussed antihypertensive medications, 2 papers discussed herbal supplements, 1 paper discussed both psychotropic and herbal supplements, 1 paper discussed medications affecting wound healing, and 1 paper discussed rheumatologic medications. A summary of those recommendations was then compiled together.

CONCLUSIONS

The perioperative medication management in elective plastic surgery procedures remains a complex and multidisciplinary process. It is important to manage these patients in a case-by-case manner and to consult a specialist when necessary. Careful medication reconciliation is essential to decrease the likelihood of adverse outcomes and interactions with perioperative anesthetics.

Can Ultrasound-Guided Femoral Vein Measurements Predict Spinal Anesthesia-Induced Hypotension in Non-Obstetric Surgery? A Prospective Observational Study

Background and objectives: To investigate whether ultrasound (US)-guided femoral vein (FV) and inferior vena cava (IVC) measurements obtained before spinal anesthesia (SA) can be utilized to predict SA-induced hypotension (SAIH) and to identify risk factors associated with SAIH in patients undergoing non-obstetric surgery under SA. Methods: This was a prospective observational study conducted between November 2021 and April 2022. The study included 95 patients over the age of 18 with an American Society of Anesthesiologists (ASA) physical status score of 1 or 2. The maximum and minimum diameters of FV and IVC were measured under US guidance before SA initiation, and the collapsibility index values of FV and IVC were calculated. Patients with and without SAIH were compared. Results: SAIH was observed in 12 patients (12.6%). Patients with and without SAIH were similar in terms of age [58 (IQR: 19-70) vs. 48 (IQR: 21-71; p = 0.081) and sex (males comprised 63.9% of the SAIH and 75.0% of the non-SAIH groups) (p = 0.533). According to univariate analysis, no significant relationship was found between SAIH and any of the FV or IVC measurements. Multiple logistic regression analysis revealed that having an ASA class of 2 was the only independent risk factor for SAIH development (p = 0.014), after adjusting for age, sex, and all other relevant parameters. Conclusions: There is not enough evidence to accept the feasibility of utilizing US-guided FV or IVC measurements to screen for SAIH development in patients undergoing non-obstetric surgery under SA. For this, multicenter studies with more participants are needed.

Perioperative statin medication impairs pulmonary outcome after abdomino-thoracic esophagectomy

Background

Although surgery is the curative option of choice for patients with locally advanced esophageal cancer, morbidity, especially the rate of pulmonary complications, and consequently mortality of patients undergoing abdomino-thoracic esophagectomy remain unacceptably high. Causes for developing post-esophagectomy pulmonary complications are trauma to the lung and thoracic cavity as well as systemic inflammatory response. Statins are known to influence inflammatory pathways, but whether perioperative statin medication impacts on inflammatory response and pulmonary complication development after esophagectomy had not been investigated, yet.

Methods

Retrospective analysis and propensity score matching of patients, who either received perioperative statin medication [statin( +)] or not [statin( −)], with regard to respiratory impairment (PaO₂/FiO₂ < 300 mmHg), pneumonia development, and inflammatory serum markers after abdomino-thoracic esophagectomy.

Results

Seventy-eight patients who underwent abdomino-thoracic esophagectomy for cancer were included into propensity score pair-matched analysis [statin( +): n = 26 and statin( −): n = 52]. Although no differences were seen in postoperative inflammatory serum markers, C-reactive protein values correlated significantly with the development of pneumonia beyond postoperative day 3 in statin( −) patients. This effect was attenuated under statin medication. No difference was seen in cumulative incidences of respiratory impairment; however, significantly higher rate (65.4% versus 38.5%, p = 0.0317, OR 3.022, 95% CI 1.165–7.892) and higher cumulative incidence (p = 0.0468) of postoperative pneumonia were seen in statin( +) patients, resulting in slightly longer postoperative stay on intensive care unit (p = 0.0612) as well as significantly prolonged postoperative in-hospital stay (p = 0.0185).

Conclusions

Development of pulmonary complications after abdomino-thoracic esophagectomy is multifactorial but frequent. The establishment of preventive measures into the perioperative clinical routine is mandatory for an improved patient outcome. Perioperative medication with statins might influence pneumonia development in the highly vulnerable lung after abdomino-thoracic esophagectomy. Perioperative interruption of statin medication might be beneficial in appropriate patients; however, further clinical trials and translational studies are needed to prove this hypothesis.

Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update

Background

This is the second updated Enhanced Recovery After Surgery (ERAS®) Society guideline, presenting a consensus for optimal perioperative care in bariatric surgery and providing recommendations for each ERAS item within the ERAS® protocol.

Methods

A principal literature search was performed utilizing the Pubmed, EMBASE, Cochrane databases and ClinicalTrials.gov through December 2020, with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. After critical appraisal of these studies, the group of authors reached consensus regarding recommendations.

Results

The quality of evidence for many ERAS interventions remains relatively low in a bariatric setting and evidence-based practices may need to be extrapolated from other surgeries.

Conclusion

A comprehensive, updated evidence-based consensus was reached and is presented in this review by the ERAS® Society.

Diagnosis and Management of Patients With Myocardial Injury After Noncardiac Surgery: A Scientific Statement From the American Heart Association

Myocardial injury after noncardiac surgery is defined by elevated postoperative cardiac troponin concentrations that exceed the 99th percentile of the upper reference limit of the assay and are attributable to a presumed ischemic mechanism, with or without concomitant symptoms or signs. Myocardial injury after noncardiac surgery occurs in ≈20% of patients who have major inpatient surgery, and most are asymptomatic. Myocardial injury after noncardiac surgery is independently and strongly associated with both short-term and long-term mortality, even in the absence of clinical symptoms, electrocardiographic changes, or imaging evidence of myocardial ischemia consistent with myocardial infarction. Consequently, surveillance of myocardial injury after noncardiac surgery is warranted in patients at high risk for perioperative cardiovascular complications. This scientific statement provides diagnostic criteria and reviews the epidemiology, pathophysiology, and prognosis of myocardial injury after noncardiac surgery. This scientific statement also presents surveillance strategies and treatment approaches.

Trends in early postoperative major adverse cardiovascular and cerebrovascular events associated with bariatric surgery: an analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry

BACKGROUND

The population undergoing bariatric surgery (BaS) has many cardiovascular risk factors that can lead to significant perioperative cardiovascular morbidity.

OBJECTIVES

We aimed to examine trends in the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) after BaS.

SETTING

Academic Hospital, United States METHODS: We performed a retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry for patients aged ≥18 years undergoing laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2015 to 2019. Data on demographics, co-morbidities, and type of procedure were collected. MACCE was defined as a composite variable including perioperative acute myocardial infarction (AMI), cardiac arrest requiring cardiopulmonary resuscitation, acute stroke, and all-cause mortality. We utilized the Cochrane-Armitage and Jonckheere-Terpstra tests to assess for significant trend changes throughout the years.

RESULTS

A total of 752,722 patients were included in our analysis (LSG = 73.2%, LRYGB = 26.8%). Postoperative MACCE occurred in 1058 patients (.14%), and was more frequent in patients undergoing LRYGB (.20%). The frequency of MACCE declined from .17% to .14% (P = .053), driven by a decline in the frequency of AMI (.04% to .02%, P = .002), cardiac arrest (.05% to .04%, P = .897), and all-cause death (.11% to .08%, P = .040), but with an increase in perioperative stroke (.01% to .02%, P = .057).

CONCLUSION

The overall risk of MACCE after BaS is .14% and has been declining in the last 5 years. This trend is likely multifactorial and further analysis is necessary to provide a detailed explanation.

Variation in preoperative stress testing by patient, physician and surgical type: a cohort study

OBJECTIVES

To describe variation in and drivers of contemporary preoperative cardiac stress testing.

SETTING

A dedicated preoperative risk assessment and optimisation clinic at a large integrated medical centre from 2008 through 2018.

PARTICIPANTS

A cohort of 118 552 adult patients seen by 104 physicians across 159 795 visits to a preoperative risk assessment and optimisation clinic.

MAIN OUTCOME

Referral for stress testing before major surgery, including nuclear, echocardiographic or electrocardiographic-only stress testing, within 30 days after a clinic visit.

RESULTS

A total of 8303 visits (5.2%) resulted in referral for preoperative stress testing. Key patient factors associated with preoperative stress testing included predicted surgical risk, patient functional status, a previous diagnosis of ischaemic heart disease, tobacco use and body mass index. Patients living in either the most-deprived or least-deprived census block groups were more likely to be tested. Patients were tested more frequently before aortic, peripheral vascular or urologic interventions than before other surgical subcategories. Even after fully adjusting for patient and surgical factors, provider effects remained important: marginal testing rates differed by a factor-of-three in relative terms and around 2.5% in absolute terms between the 5th and 95th percentile physicians. Stress testing frequency decreased over the time period; controlling for patient and physician predictors, a visit in 2008 would have resulted in stress testing approximately 3.5% of the time, while a visit in 2018 would have resulted in stress testing approximately 1.3% of the time.

CONCLUSIONS

In this large cohort of patients seen for preoperative risk assessment at a single health system, decisions to refer patients for preoperative stress testing are influenced by various factors other than estimated perioperative risk and functional status, the key considerations in current guidelines. The frequency of preoperative stress testing has decreased over time, but remains highly provider-dependent.

Preoperative clinical model to predict myocardial injury after non-cardiac surgery: a retrospective analysis from the MANAGE cohort in a Spanish hospital

OBJECTIVES

To determine preoperative factors associated to myocardial injury after non-cardiac surgery (MINS) and to develop a prediction model of MINS.

DESIGN

Retrospective analysis.

SETTING

Tertiary hospital in Spain.

PARTICIPANTS

Patients aged ≥45 years undergoing major non-cardiac surgery and with at least two measures of troponin levels within the first 3 days of the postoperative period. All patients were screened for the MANAGE trial.

PRIMARY AND SECONDARY OUTCOME MEASURES

We used multivariable logistic regression analysis to study risk factors associated with MINS and created a score predicting the preoperative risk for MINS and a nomogram to facilitate bed-side use. We used Least Absolute Shrinkage and Selection Operator method to choose the factors included in the predictive model with MINS as dependent variable. The predictive ability of the model was evaluated. Discrimination was assessed with the area under the receiver operating characteristic curve (AUC) and calibration was visually assessed using calibration plots representing deciles of predicted probability of MINS against the observed rate in each risk group and the calibration-in-the-large (CITL) and the calibration slope. We created a nomogram to facilitate obtaining risk estimates for patients at pre-anaesthesia evaluation.

RESULTS

Our cohort included 3633 patients recruited from 9 September 2014 to 17 July 2017. The incidence of MINS was 9%. Preoperative risk factors that increased the risk of MINS were age, American Status Anaesthesiology classification and vascular surgery. The predictive model showed good performance in terms of discrimination (AUC=0.720; 95% CI: 0.69 to 0.75) and calibration slope=1.043 (95% CI: 0.90 to 1.18) and CITL=0.00 (95% CI: -0.12 to 0.12).

CONCLUSIONS

Our predictive model based on routinely preoperative information is highly affordable and might be a useful tool to identify moderate-high risk patients before surgery. However, external validation is needed before implementation.

Association Between Preoperative Statin Use and Respiratory Complications After Noncardiac Surgery: A Retrospective Cohort Analysis

BACKGROUND

Statins possess pleiotropic effects, which potentially benefit noncardiovascular conditions. Previous work suggests that statins reduce inflammation and prevent acute respiratory distress syndrome and infections. However, there is a paucity of data regarding potential benefits of statins on respiratory and infectious complications, particularly after noncardiac surgery. We therefore evaluated respiratory and other complications in noncardiac surgery patients taking or not taking statins preoperatively.

METHODS

We obtained data from the Cleveland Clinic Perioperative Health Documentation System and evaluated medical records of 92,139 inpatients who had noncardiac surgery. Among these, 31,719 patients took statins preoperatively. Statin patients were compared to nonstatin patients on incidence of intraoperative use of albuterol and postoperative respiratory complications for primary analysis. Infectious complications, cardiovascular complications, in-hospital mortality, and duration of hospitalization were compared for secondary analyses, using inverse probability of treatment weighting to control for potential confounding.

RESULTS

Statin use was associated with lower odds of intraoperative albuterol treatment (odds ratio [OR] = 0.89; 97.5% confidence interval [CI], 0.82-0.97; P = .001; number needed to treat [NNT] = 216). Postoperative respiratory complications were also less common (OR = 0.82; 98.75% CI, 0.78-0.87; P < .001). Secondarily, statin use was associated with lower odds of infections, cardiovascular complications, in-hospital mortality, and shorter duration of hospitalization. The interaction between statin use and sex was significant (with significance criteria P < .10) for all primary and secondary outcomes except intraoperative use of albuterol.

CONCLUSIONS

Preoperative statin use in noncardiac surgical patients was associated with slightly reduced odds of postoperative respiratory, infectious, and cardiovascular complications. However, the NNTs were high. Thus, despite the fact that statins appeared to be associated with lower odds of various complications, especially cardiovascular complications, our results do not support using statins specifically to reduce noncardiovascular complications after noncardiac surgery.

Mid-Term Survival and Risk Factors Associated With Myocardial Injury After Fenestrated and/or Branched Endovascular Aortic Aneurysm Repair

OBJECTIVE

Myocardial injury after non-cardiac surgery (MINS) is an independent predictor of post-operative mortality in non-cardiac surgery patients and may increase health costs. Few data are available for MINS in vascular surgery patients, in general, and those undergoing fenestrated/branched endovascular aortic repairs (F/BEVAR), in particular. The incidence of MINS after F/BEVAR, the associated risk factors, and prognosis have not been determined. The aim of the present study was to help fill these knowledge gaps.

METHODS

A single centre, retrospective study was carried out at a high volume F/BEVAR centre in a university hospital. Adult patients who underwent F/BEVAR between October 2010 and December 2018 were included. A high sensitivity troponin T (HsTnT) assay was performed daily in the first few post-operative days. MINS was defined as a HsTnT level ≥ 14 ng/L (MINS₁₄) or ≥ 20 ng/L (MINS₂₀). After assessment of the incidence of MINS, survival up to two years was estimated in a Kaplan-Meier analysis and the groups were compared according to MINS status. A secondary aim was to identify predictors of MINS.

RESULTS

Of the 387 included patients, 240 (62.0%) had MINS₁₄ and 166 (42.9%) had MINS₂₀. In multivariable Cox models, both conditions were significantly associated with poor two year survival (MINS14: adjusted hazard ratio [aHR] 2.15, 95% confidence interval [CI] 1.10 - 4.19; MINS₂₀: aHR 2.43, 95% CI 1.36 - 4.34). In a multivariable logistic regression, age, revised cardiac risk index, duration of surgery, pre-operative estimated glomerular filtration rate (eGFR), and haemoglobin level were independent predictors of MINS.

CONCLUSION

After F/BEVAR surgery, the incidence of MINS was particularly high, regardless of the definition considered (MINS₁₄ or MINS₂₀). MINS was significantly associated with poor two year survival. The modifiable predictors identified were duration of surgery, eGFR, and haemoglobin level.

Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery: A Scientific Statement From the American Heart Association/American Stroke Association

Perioperative stroke is a potentially devastating complication in patients undergoing noncardiac, nonneurological surgery. This scientific statement summarizes established risk factors for perioperative stroke, preoperative and intraoperative strategies to mitigate the risk of stroke, suggestions for postoperative assessments, and treatment approaches for minimizing permanent neurological dysfunction in patients who experience a perioperative stroke. The first section focuses on preoperative optimization, including the role of preoperative carotid revascularization in patients with high-grade carotid stenosis and delaying surgery in patients with recent strokes. The second section reviews intraoperative strategies to reduce the risk of stroke, focusing on blood pressure control, perioperative goal-directed therapy, blood transfusion, and anesthetic technique. Finally, this statement presents strategies for the evaluation and treatment of patients with suspected postoperative strokes and, in particular, highlights the value of rapid recognition of strokes and the early use of intravenous thrombolysis and mechanical embolectomy in appropriate patients.

Actual Issues of the Cardiac Complications Risk Assessment and Correction in Non-Cardiac Surgery

Worldwide, more than 200 million non-cardiac surgeries are performed annually, and this number is constantly increasing; cardiac complications are the leading cause of death in such surgeries. So, in a multicenter study conducted in 27 countries, cardiovascular complications were present in 68% of cases of death in the postoperative period. Registers of recent years have shown that the number of such complications remains high, for example, with a dynamic assessment of troponins, perioperative myocardial damage was detected in 13-18% of cases. This review provides a critical analysis of the step-by-step algorithm for assessing cardiac risk of non-cardiac operations considering the emergence of new publications on this topic. The review discusses new data on risk assessment scales, functional state assessment, the use of non-invasive tests, biomarkers, the role of preventive myocardial revascularization in the preoperative period, and drug therapy. The issues of non-cardiac operations after percutaneous coronary intervention, perioperative myocardial damage are considered separately. The review emphasizes the difficulties in obtaining evidence, conducting randomized clinical trials in this section of medicine, which do not allow obtaining unambiguous conclusions in most cases and lead to inconsistencies and ambiguities in the recommendations of various expert groups. This review will help practitioners navigate this issue and help to use the optimal diagnostic and treatment strategy before performing non-cardiac surgery.

Accountability, research transparency and data reporting

More than one published paper are often derived from analyzing the same cohort of individuals to make full use of the collected information. Preplanned study outcomes are generally mentioned in open databases while exhaustive information on methodological aspects are provided in submitted articles.

Non-cardiac surgery in patients with coronary artery disease: risk evaluation and periprocedural management

Perioperative cardiovascular complications are important causes of morbidity and mortality associated with non-cardiac surgery, particularly in patients with coronary artery disease (CAD). Although preoperative cardiac risk assessment can facilitate the identification of vulnerable patients and implementation of adequate preventive measures, excessive evaluation might lead to undue resource utilization and surgical delay. Owing to conflicting data, there remains some uncertainty regarding the most beneficial perioperative strategy for patients with CAD. Antithrombotic agents are the cornerstone of secondary prevention of ischaemic events but substantially increase the risk of bleeding. Given that 5-25% of patients undergoing coronary stent implantation require non-cardiac surgery within 2 years, surgery is the most common reason for premature cessation of dual antiplatelet therapy. Perioperative management of antiplatelet therapy, which necessitates concomitant evaluation of the individual thrombotic and bleeding risks related to both clinical and procedural factors, poses a recurring dilemma in clinical practice. Current guidelines do not provide detailed recommendations on this topic, and the optimal approach in these patients is yet to be determined. This Review summarizes the current data guiding preoperative risk stratification as well as periprocedural management of patients with CAD undergoing non-cardiac surgery, including those treated with stents.

Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS): an international prospective cohort study establishing diagnostic criteria and prognostic importance

BACKGROUND

We aimed to establish diagnostic criteria for bleeding independently associated with mortality after noncardiac surgery (BIMS) defined as bleeding during or within 30 days after noncardiac surgery that is independently associated with mortality within 30 days of surgery, and to estimate the proportion of 30-day postoperative mortality potentially attributable to BIMS.

METHODS

This was a prospective cohort study of participants ≥45 yr old having inpatient noncardiac surgery at 12 academic hospitals in eight countries between 2007 and 2011. Cox proportional hazards models evaluated the adjusted relationship between candidate diagnostic criteria for BIMS and all-cause mortality within 30 days of surgery.

RESULTS

Of 16 079 participants, 2.0% (315) died and 36.1% (5810) met predefined screening criteria for bleeding. Based on independent association with 30-day mortality, BIMS was identified as bleeding leading to a postoperative haemoglobin <70 g L^-1, transfusion of ≥1 unit of red blood cells, or that was judged to be the cause of death. Bleeding independently associated with mortality after noncardiac surgery occurred in 17.3% of patients (2782). Death occurred in 5.8% of patients with BIMS (161/2782), 1.3% (39/3028) who met bleeding screening criteria but not BIMS criteria, and 1.1% (115/10 269) without bleeding. BIMS was associated with mortality (adjusted hazard ratio: 1.87; 95% confidence interval: 1.42-2.47). We estimated the proportion of 30-day postoperative deaths potentially attributable to BIMS to be 20.1-31.9%.

CONCLUSIONS

Bleeding independently associated with mortality after noncardiac surgery (BIMS), defined as bleeding that leads to a postoperative haemoglobin <70 g L^-1, blood transfusion, or that is judged to be the cause of death, is common and may account for a quarter of deaths after noncardiac surgery.

CLINICAL TRIAL REGISTRATION

NCT00512109.

Preoperative prediction of Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS): an international prospective cohort study

BACKGROUND

Diagnostic criteria for Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS) have been defined as bleeding that leads to a postoperative haemoglobin <70 g L^-1, leads to blood transfusion, or is judged to be the direct cause of death. Preoperative prediction guides for BIMS can facilitate informed consent and planning of perioperative care.

METHODS

In a prospective cohort study of 16 079 participants aged ≥45 yr having inpatient noncardiac surgery at 12 academic hospitals in eight countries between 2007 and 2011, 17.3% (2782) experienced BIMS. An electronic risk calculator for BIMS was developed and internally validated by logistic regression with bootstrapping, and further simplified to a risk index. Decision curve analysis assessed the potential utility of each prediction guide compared with a strategy of identifying risk of BIMS based on preoperative haemoglobin <120 g L^-1.

RESULTS

With information about the type of surgery, preoperative haemoglobin, age, sex, functional status, kidney function, history of high-risk coronary artery disease, and active cancer, the risk calculator accurately predicted BIMS (bias-corrected C-statistic, 0.84; 95% confidence interval, 0.837-0.852). A simplified index based on preoperative haemoglobin <120 g L^-1, open surgery, and high-risk surgery also predicted BIMS, but less accurately (C-statistic, 0.787; 95% confidence interval, 0.779-0.796). Both prediction guides could improve decision making compared with knowledge of haemoglobin <120 g L^-1 alone.

CONCLUSIONS

BIMS, defined as bleeding that leads to a postoperative haemoglobin <70 g L^-1, leads to blood transfusion, or that is judged to be the direct cause of death, can be predicted by a simple risk index before surgery.

CLINICAL TRIAL REGISTRATION

NCT00512109.

Perioperative Cardiovascular Risk Assessment and Management for Noncardiac Surgery: A Review

IMPORTANCE

Perioperative cardiovascular complications occur in 3% of hospitalizations for noncardiac surgery in the US. This review summarizes evidence regarding cardiovascular risk assessment prior to noncardiac surgery.

OBSERVATIONS

Preoperative cardiovascular risk assessment requires a focused history and physical examination to identify signs and symptoms of ischemic heart disease, heart failure, and severe valvular disease. Risk calculators, such as the Revised Cardiac Risk Index, identify individuals with low risk (<1%) and higher risk (≥1%) for perioperative major adverse cardiovascular events during the surgical hospital admission or within 30 days of surgery. Cardiovascular testing is rarely indicated in patients at low risk for major adverse cardiovascular events. Stress testing may be considered in patients at higher risk (determined by the inability to climb ≥2 flights of stairs, which is <4 metabolic equivalent tasks) if the results from the testing would change the perioperative medical, anesthesia, or surgical approaches. Routine coronary revascularization does not reduce perioperative risk and should not be performed without specific indications independent of planned surgery. Routine perioperative use of low-dose aspirin (100 mg/d) does not decrease cardiovascular events but does increase surgical bleeding. Statins are associated with fewer postoperative cardiovascular complications and lower mortality (1.8% vs 2.3% without statin use; P < .001) in observational studies, and should be considered preoperatively in patients with atherosclerotic cardiovascular disease undergoing vascular surgery. High-dose β-blockers (eg, 100 mg of metoprolol succinate) administered 2 to 4 hours prior to surgery are associated with a higher risk of stroke (1.0% vs 0.5% without β-blocker use; P = .005) and mortality (3.1% vs 2.3% without β-blocker use; P = .03) and should not be routinely used. There is a greater risk of perioperative myocardial infarction and major adverse cardiovascular events in adults aged 75 years or older (9.5% vs 4.8% for younger adults; P < .001) and in patients with coronary stents (8.9% vs 1.5% for those without stents; P < .001) and these patients warrant careful preoperative consideration.

CONCLUSIONS AND RELEVANCE

Comprehensive history, physical examination, and assessment of functional capacity during daily life should be performed prior to noncardiac surgery to assess cardiovascular risk. Cardiovascular testing is rarely indicated in patients with a low risk of major adverse cardiovascular events, but may be useful in patients with poor functional capacity (<4 metabolic equivalent tasks) undergoing high-risk surgery if test results would change therapy independent of the planned surgery. Perioperative medical therapy should be prescribed based on patient-specific risk.

[Diagnostic and Therapeutic Management of Carotid Artery Disease]

Diagnostic and Therapeutic Management of Carotid Artery Disease Abstract. A quarter of all ischemic strokes is caused by atherosclerotic obliterations of the extra- and intracranial brain-supplying vessels. The prevalence of atherosclerotic extracranial carotid stenosis rises up to 6-15 % from the age of 65. The risk of stroke in symptomatic carotid stenosis, i.e. after stroke or transient ischemic attack (TIA), is very high at 25 % within 14 days. Conservative therapy is the cornerstone of treatment by controlling the risk factors, treatment with platelet aggregation inhibitors and antihypertensive and lipid-lowering medication. Carotid endarterectomy (CEA) is the first line treatment for symptomatic patients with a >50 % and asymptomatic patients with a >60 % carotid stenosis. In order to ensure the best possible treatment of patients with asymptomatic and symptomatic carotid stenosis, interdisciplinary cooperation in diagnostics, therapy and aftercare in a neuromedical centre of maximum care is necessary.

Relationship between Perioperative Hypotension and Perioperative Cardiovascular Events in Patients with Coronary Artery Disease Undergoing Major Noncardiac Surgery

BACKGROUND

Perioperative hypotension is associated with cardiovascular events in patients having noncardiac surgery. It is unknown if the severity of preexisting coronary artery disease determines susceptibility to the cardiovascular risks of perioperative hypotension.

METHODS

In this retrospective exploratory analysis of a substudy of an international prospective blinded cohort study, 955 patients 45 yr of age or older with history or risk factors for coronary artery disease underwent coronary computed tomographic angiography before elective inpatient noncardiac surgery. The authors evaluated the potential interaction between angiographic findings and perioperative hypotension (defined as systolic blood pressure less than 90 mmHg for a total of 10 min or more during surgery or for any duration after surgery and for which intervention was initiated) on the composite outcome of time to myocardial infarction or cardiovascular death up to 30 days after surgery. Angiography assessors were blinded to study outcomes; patients, treating clinicians, and outcome assessors were blinded to angiography findings.

RESULTS

Cardiovascular events (myocardial infarction or cardiovascular death within 30 days after surgery) occurred in 7.7% of patients (74/955), including in 2.7% (8/293) without obstructive coronary disease or hypotension compared to 6.7% (21/314) with obstructive coronary disease but no hypotension (hazard ratio, 2.51; 95% CI, 1.11 to 5.66; P = 0.027), 8.8% (14/159) in patients with hypotension but without obstructive coronary disease (hazard ratio, 3.85; 95% CI, 1.62 to 9.19; P = 0.002), and 16.4% (31/189) with obstructive coronary disease and hypotension (hazard ratio, 7.34; 95% CI, 3.37 to 15.96; P < 0.001). Hypotension was independently associated with cardiovascular events (hazard ratio, 3.17; 95% CI, 1.99 to 5.06; P < 0.001). This association remained in patients without obstructive disease and did not differ significantly across degrees of coronary disease (P value for interaction, 0.599).

CONCLUSIONS

In patients having noncardiac surgery, perioperative hypotension was associated with cardiovascular events regardless of the degree of coronary artery disease on preoperative coronary computed tomographic angiography.

High-Sensitivity Troponin T Testing: Consequences on Daily Clinical Practice and Effects on Diagnosis of Myocardial Infarction

It remains unclear how introduction of high-sensitivity troponin T testing, as opposed to conventional troponin testing, has affected the diagnosis of acute myocardial infarction (AMI) and resource utilization in unselected hospitalized patients. In this retrospective analysis, we include all consecutive cases from our center during two corresponding time frames (10/2016–04/2017 and 10/2017–04/2018) for which different troponin tests were performed: conventional troponin I (cTnI) and high-sensitivity troponin T (hs-TnT) assays. Testing was performed in 18,025 cases. The incidence of troponin levels above the 99th percentile was significantly higher in cases tested using hs-TnT. This was not associated with increased utilization of echocardiography, coronary angiography, or percutaneous coronary intervention. Although there were no changes in local standard operating procedures, study site personnel, or national coding guidelines, the number of coded AMI significantly decreased after introduction of hs-TnT. In this single-center retrospective study comprising 18,025 mixed medical and surgical cases with troponin testing, the introduction of hs-TnT was not associated with changes in resource utilization among the general cohort, but instead, led to a decrease in the international classification of diseases (ICD)-10 coded diagnosis of AMI.

The case for statin use to reduce perioperative adverse cardiovascular and cerebrovascular events

Ischaemic heart disease and stroke are the leading causes of death worldwide at 119 per 100,000 and 85 per 100,000 population. For the USA, heart disease is leading cause of death at 165 per 100,000 population. In developed countries, strokes and acute myocardial infarction in the general population have fallen from smoking reduction, lifestyle modifications and therapeutic interventions including statins. In a population-based stroke study in the UK involving primary care practices, of in-hospital strokes 90% were ischaemic, and 37% occurred within 1 week of an operation. Approximately 50% of the patients were not on a statin. In the UK, there is a national screening initiative for the prevention of atherosclerotic cardiovascular disease (ASCVD) offered to people aged 40-74 yr old. The QRISK3 tool calculates the risk of developing heart disease or stroke over 10 yr, from which recommendations are made on interventions for the prevention of ASCVD up to age 84 yr, with similar screening and assessment tools in Europe and the US. If the QRISK3 score tool for calculating cardiovascular risk is considered sufficiently robust for population screening in primary care, should anaesthetists not use the same screening for secondary care? We present a case for statin use over the perioperative period, to reduce early vascular adverse events based on statins' early pleiotropic actions, using the primary care QRISK tool for screening of ASCVD risk.

Myocardial Injury After Noncardiac Surgery: A Systematic Review and Meta-Analysis

Myocardial injury after noncardiac surgery (MINS) is a common postoperative complication associated with adverse cardiovascular outcomes. The purpose of this systematic review was to determine the incidence, clinical features, pathogenesis, management, and outcomes of MINS. We searched PubMed, Embase, Central and Web of Science databases for studies reporting the incidence, clinical features, and prognosis of MINS. Data analysis was performed with a mixed-methods approach, with quantitative analysis of meta-analytic methods for incidence, management, and outcomes, and a qualitative synthesis of the literature to determine associated preoperative factors and MINS pathogenesis. A total of 195 studies met study inclusion criteria. Among 169 studies reporting outcomes of 530,867 surgeries, the pooled incidence of MINS was 17.9% [95% confidence interval (CI), 16.2-19.6%]. Patients with MINS were older, more frequently men, and more likely to have cardiovascular risk factors and known coronary artery disease. Postoperative mortality was higher among patients with MINS than those without MINS, both in-hospital (8.1%, 95% CI, 4.4-12.7% vs 0.4%, 95% CI, 0.2-0.7%; relative risk 8.3, 95% CI, 4.2-16.6, P < 0.001) and at 1-year after surgery (20.6%, 95% CI, 15.9-25.7% vs 5.1%, 95% CI, 3.2-7.4%; relative risk 4.1, 95% CI, 3.0-5.6, P < 0.001). Few studies reported mechanisms of MINS or the medical treatment provided. In conclusion, MINS occurs frequently in clinical practice, is most common in patients with cardiovascular disease and its risk factors, and is associated with increased short- and long-term mortality. Additional investigation is needed to define strategies to prevent MINS and treat patients with this diagnosis.

Preoperative Statin Use and 90-Day Mortality after Noncardiac Surgery: A Hospital Registry Study

OBJECTIVE

The aim of this study was to investigate the association between preadmission statin use and 90-day mortality after planned elective noncardiac surgery in adult patients.

SUMMARY BACKGROUND DATA

Statin therapy is known to have pleiotropic effects, which improve the outcomes of various diseases. However, the effect of perioperative statin therapy on postoperative mortality remains controversial.

METHODS

This retrospective cohort study analyzed the medical records of adult patients who were admitted to a single tertiary academic hospital for elective noncardiac surgery between January 2012 and December 2018. The primary endpoint was 90-day mortality, which was defined as any mortality within 90 days after surgery. The secondary endpoint was overall survival.

RESULTS

After propensity score matching, a total of 33,514 patients (16,757 patients in each group) were included in the analysis. The logistic regression analysis of the propensity score-matched cohort indicated that the odds ratio (OR) of 90-day mortality in the statin group was 26% lower than that of the nonstatin group [OR: 0.74; 95% confidence interval (CI): 0.59 to 0.92; P = 0.009]. The sensitivity analysis indicated that the high-dose intensity statin group had a 61% lower 90-day mortality rate than the nonstatin group (OR: 0.39; 95% CI: 0.18-0.84; P = 0.016). The overall survival time was significantly longer in the statin group than in the nonstatin group after propensity score matching (P < 0.001 by log-rank test).

CONCLUSIONS

Preoperative statin use was associated with lower 90-day mortality and longer overall survival for adult patients who underwent elective noncardiac surgery. This association was more evident for high-intensity statin users.

Perioperative Major Adverse Cardiovascular and Cerebrovascular Events Associated With Noncardiac Surgery

Importance

Major adverse cardiovascular and cerebrovascular events (MACCE) are a significant source of perioperative morbidity and mortality following noncardiac surgery.

Objective

To evaluate national trends in perioperative cardiovascular outcomes and mortality after major noncardiac surgery and to identify surgical subtypes associated with cardiovascular events using a large administrative database of United States hospital admissions.

Design, Setting, Participants

Patients who underwent major noncardiac surgery from January 2004 to December 2013 were identified using the National Inpatient Sample.

Main Outcomes and Measures

Perioperative MACCE (primary outcome), defined as in-hospital, all-cause death, acute myocardial infarction (AMI), or acute ischemic stroke, were evaluated over time.

Results

Among 10 581 621 hospitalizations (mean [SD] patient age, 65.74 [12.32] years; 5 975 798 female patients 56.60%]) for major noncardiac surgery, perioperative MACCE occurred in 317 479 hospitalizations (3.0%), corresponding to an annual incidence of approximately 150 000 events after applying sample weights. Major adverse cardiovascular and cerebrovascular events occurred most frequently in patients undergoing vascular (7.7%), thoracic (6.5%), and transplant surgery (6.3%). Between 2004 and 2013, the frequency of MACCE declined from 3.1% to 2.6% (P for trend <.001; adjusted odds ratio [aOR], 0.95; 95% CI, 0.94-0.97) driven by a decline in frequency of perioperative death (aOR, 0.79; 95% CI, 0.77-0.81) and AMI (aOR, 0.87; 95% CI, 0.84-0.89) but an increase in perioperative ischemic stroke from 0.52% in 2004 to 0.77% in 2013 (P for trend <.001; aOR 1.79; CI 1.73-1.86).

Conclusions and Relevance

Perioperative MACCE occurs in 1 of every 33 hospitalizations for noncardiac surgery. Despite reductions in the rate of death and AMI among patients undergoing major noncardiac surgery in the United States, perioperative ischemic stroke increased over time. Additional efforts are necessary to improve cardiovascular care in the perioperative period of patients undergoing noncardiac surgery.

Statins in the perioperative period

In this review, we discuss clinical evidence-based data regarding the potential benefit of statin therapy in the perioperative period of non-cardiac surgery. Results from meta-analyses of prospective observational studies have provided conflicting evidence. Moreover, comparison among studies is complicated by varying data sources, outcome definitions, types of surgery, and preoperative versus perioperative statin therapy. However, results of two recent large prospective cohort studies showed that statin use on the day of or the day after non-cardiac surgery (or both) is associated with lower 30-day all-cause mortality and reduction in a variety of postoperative complications, predominantly cardiac, compared with non-use during this period. There is a paucity of data from randomized controlled trials assessing the benefit of statin therapy in non-cardiac surgery. No randomized controlled trials have shown that initiating a statin in statin-naïve patients may reduce the risk of cardiovascular complications in non-cardiac surgeries. One randomized clinical trial demonstrated that the use of a preoperative statin in patients with stable coronary heart disease treated with long-term statin therapy had a significant reduction in the incidence of myocardial necrosis and major adverse cardiovascular events after non-cardiac surgery. In conclusion, it is important that all health-care professionals involved in the care of the surgical patient emphasize the need to resume statin therapy, particularly in patients with established atherosclerotic cardiovascular disease. However, initiating a statin in statin-naïve patients undergoing non-cardiac surgery needs more evidence-based data.

Medical therapy for atherosclerotic cardiovascular disease in patients with myocardial injury after non-cardiac surgery

BACKGROUND

Myocardial injury after non-cardiac surgery (MINS) is a common post-operative cardiovascular complication and is associated with short and long-term mortality. The objective of this study was to describe the contemporary management of patients with and without MINS after total joint and spine orthopedic surgery at a large urban health system in the United States.

METHODS

Adults admitted for total joint and major spine surgery from January 2013 through December 2015 with ≥1 cardiac troponin (cTn) measurement during their hospitalization were identified. MINS was defined by a peak cTn above the 99th percentile of the upper reference limit. Demographics, medical comorbidities, and admission and discharge medications were reviewed for all patients.

RESULTS

A total of 2561 patients underwent 2798 orthopedic surgeries, and 236 cases of MINS were identified. Patients with MINS were older (71.9 ± 10.9 vs. 67.0 ± 10.0, p < 0.001) and more likely to have cardiovascular risk factors, including hypertension, chronic kidney disease, prior stroke, coronary artery disease, prior MI, and a history of heart failure. Among patients with MINS, only 112 (47.5%) were discharged on a combination of aspirin and statin. Patients with MINS were more likely to be prescribed a statin (154 [65.3%] vs. 1463 [57.1%], p = 0.018), beta-blocker (147 [62.3%] vs. 1194 [46.6%], p < 0.001), and oral anticoagulation (65 [27.5%] vs. 436 [17.0%], p < 0.001) than patients without MINS.

CONCLUSIONS

The proportion of patients with MINS who were prescribed medical therapy for atherosclerotic cardiovascular disease was low. Additional efforts to determine optimal management of MINS are warranted.

Perioperative care of cardiac patient's candidate for non-cardiac surgery: a critical appraisal of emergent evidence and international guidelines

The perioperative management of a cardiac-patient candidate to non-cardiac surgery (NCS) remains a topic of considerable debate. In recent years, the overall tendency from professional societies has been to delineate how to identify and manage high-risk patients following the best evidence. However, significant concerns persist, especially in the care of intermediate-risk patients (also labeled at "acceptable" risk), who may not fit into the categories of "completely healthy" or "critically ill", but that might still encounter dramatic (and unexpected) perioperative events. The specific interest and main goal of this expert viewpoint pertains to the care of cardiac patients scheduled for NCS, addressing central questions of real-life clinical care that practicing anesthesiologists and cardiologists face daily, discussing recent American College of Cardiology/American Heart Association (ACC/AHA), European Society of Cardiology/European Society of Anaesthesiology (ESC/ESA), and Canadian Cardiovascular Society (CCS) guidelines. The viewpoint aims to discuss few of the important topics pertaining perioperative assessment and management: type of NCS and perioperative cardiac events, risk prediction including testing, and perioperative management of cardiac therapy. The fact that cardiac adverse events have reduced in number mostly due to better preoperative management and prevention should not prompt a reduction in clinical evaluations. While debate remains pertaining the most appropriate way to evaluate patients for NCS within international societies, a comprehensive approach-evaluation best recognized to assess functional and heart status, should be maintained, keeping into consideration the surgical procedure and global health management.

Causes and prevention of postoperative myocardial injury

Over the past few years non-cardiac surgery has been recognised as a serious circulatory stress test which may trigger cardiovascular events such as myocardial infarction, in particular in patients at high risk. Detection of these postoperative cardiovascular events is difficult as clinical symptoms often go unnoticed. To improve detection, guidelines advise to perform routine postoperative assessment of cardiac troponin. Troponin elevation - or postoperative myocardial injury - can be caused by myocardial infarction. However, also non-coronary causes, such as cardiac arrhythmias, sepsis and pulmonary embolism, may play a role in a considerable number of patients with postoperative myocardial injury. It is crucial to acquire more knowledge about the underlying mechanisms of postoperative myocardial injury because effective prevention and treatment options are lacking. Preoperative administration of beta-blockers, aspirin, statins, clonidine, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, and preoperative revascularisation have all been investigated as preventive options. Of these, only statins should be considered as the initiation or reload of statins may reduce the risk of postoperative myocardial injury. There is also not enough evidence for intraoperative measures such blood pressure optimisation or intensified medical therapy once patients have developed postoperative myocardial injury. Given the impact, better preoperative identification of patients at risk of postoperative myocardial injury, for example using preoperatively measured biomarkers, would be helpful to improve cardiac optimisation.

Statin therapy improved long-term prognosis in patients with major non-cardiac vascular surgeries: a systematic review and meta-analysis

OBJECTIVE

To investigate whether statin intervention will improve the long-term prognosis of patients undergoing major non-cardiac vascular surgeries.

METHODS

Major database searches for clinical trials enrolling patients undergoing major non-cardiac vascular surgeries, including lower limb revascularization, carotid artery surgeries, arteriovenous fistula, and aortic surgeries, were performed. Subgroup analyses, stratified by surgical types or study types, were employed to obtain statistical results regarding survival, patency rates, amputation, and cardiovascular and stroke events. Odds ratio (ORs) and 95% confidence intervals (CIs) were calculated by Review Manager 5.3. Sensitivity analysis, publication bias and meta-regression were conducted by Stata 14.0.

RESULTS

In total, 34 observational studies, 8 prospective cohort studies and 4 randomized controlled clinical trials (RCTs) were enrolled in the present analysis. It was demonstrated that statin usage improved all-cause mortality in lower limb, carotid, aortic and mixed types of vascular surgery subgroups compared with those in which statins were not used. Additionally, the employment of statins efficiently enhanced the primary and secondary patency rates and significantly decreased the amputation rates in the lower limb revascularization subgroup. Furthermore, for other complications, statin intervention decreased cardiovascular events in mixed types of vascular surgeries and stroke incidence in the carotid surgery subgroup. No significant publication bias was observed. The meta-regression results showed that the morbidity of cardiovascular disease or the use of aspirin might affect the overall estimates in several subgroups.

CONCLUSIONS

This meta-analysis demonstrated that statin therapy was associated with improved survival rates and patency rates and with reduced cardiovascular or stroke morbidities in patients who underwent non-cardiac vascular surgeries.

Perioperative acute myocardial infarction associated with non-cardiac surgery

Aims

Acute myocardial infarction (AMI) is a significant cardiovascular complication following non-cardiac surgery. We sought to evaluate national trends in perioperative AMI, its management, and outcomes.

Methods and results

Patients who underwent non-cardiac surgery from 2005 to 2013 were identified using the United States National Inpatient Sample. Perioperative AMI was evaluated over time. Propensity score matching was used to compile a cohort of AMI patients managed invasively (defined as cardiac catheterization or coronary revascularization) vs. conservatively. The primary outcome was in-hospital all-cause mortality. Among 9 566 277 hospitalizations for major non-cardiac surgery, perioperative AMI occurred in 84 093 (0.88%). Over time, the rate of perioperative AMI per 100 000 surgeries declined by 170 [95% confidence intervals (95% CI) 158-181], from 898 in 2005 to 729 in 2013 (P for trend <0.0001). Perioperative AMI occurred most frequently in patients undergoing vascular (2.0%), transplant (1.6%), and thoracic (1.5%) surgery. In-hospital mortality was higher in patients with perioperative AMI than those without AMI [18.0% vs. 1.5%, P < 0.0001; adjusted odds ratio (OR) 5.76, 95% CI 5.65-5.88]. Mortality associated with perioperative AMI declined over time (adjusted OR 0.86, 95% CI 0.84-0.88). In a propensity-matched cohort of 34 650 patients with perioperative AMI, invasive management was associated with lower mortality than conservative management (8.9% vs. 18.1%, P < 0.001; OR 0.44, 95% CI 0.41-0.47).

Conclusion

In an observational cohort study from the USA, perioperative AMI occurs in 0.9% of patients undergoing major non-cardiac surgery and is strongly associated with in-hospital mortality. Invasive management of such patients may mitigate some of this excess risk, and further research on the management of perioperative AMI is warranted.

Perioperative management of patients with coronary artery disease undergoing non-cardiac surgery: Summary from the French Society of Anaesthesia and Intensive Care Medicine 2017 convention

This review summarises the specific stakes of preoperative, intraoperative, and postoperative periods of patients with coronary artery disease undergoing non-cardiac surgery. All practitioners involved in the perioperative management of such high cardiac risk patients should be aware of the modern concepts expected to decrease major adverse cardiac events and improve short- and long-term outcomes. A multidisciplinary approach via a functional heart team including anaesthesiologists, cardiologists and surgeons must be encouraged. Rational and algorithm-guided management of those patients should be known and implemented from preoperative to postoperative period.

Postoperative Myocardial Injury and Inflammation Is Not Blunted by a Trial of Atorvastatin in Orthopedic Surgery Patients

BACKGROUND

Orthopedic patients are at risk for adverse postoperative cardiovascular outcomes.

QUESTIONS/PURPOSES

This pilot randomized controlled trial (RCT) of atorvastatin vs. placebo in orthopedic surgery patients was performed in order to assess: (1) the prevalence of perioperative myocardial injury; (2) the effect of atorvastatin on perioperative inflammation; and (3) the feasibility of performing a large RCT of statin therapy in orthopedic patients.

METHODS

Hip fracture (hip Fx) and total hip and knee replacement (THR and TKR) patients were randomized 1:1 to atorvastatin 40 mg daily vs. placebo, starting preoperatively and continuing until postoperative day (POD) 45. High-sensitivity cardiac troponin I (hs-cTnI), high-sensitivity C-reactive protein (hs-CRP), and interleukin-6 (IL-6) were measured preoperatively and on POD 2. Patients were monitored for adverse events until POD 90.

RESULTS

Five hundred fifty-six patients were screened, 22 were recruited (4 hip Fx, 11 THR, 7 TKR), and 2 withdrew. Most (80%) had detectable hs-cTnI (> 1.1 pg/mL) preoperatively. Twenty percent had a perioperative rise in hs-cTnI (≥ 10 pg/mL), which was not blunted by atorvastatin. Hs-CRP rose in 19/20 patients, and IL-6 rose in all patients. However, atorvastatin did not blunt the rise in these inflammatory biomarkers. On POD 2, IL-6 and hs-cTnI levels correlated (ρ = 0.59, p = 0.02). Recruitment was limited by the high prevalence of statin use in the screened population and a high prevalence of exclusions among hip fracture patients.

CONCLUSION

Perioperative myocardial injury and inflammation are common in orthopedic patients and do not appear to be reduced in those randomized to atorvastatin.

TRIAL REGISTRATION

NCT02197065.

Recommendations for perioperative management of lung cancer patients with comorbidities

Objectives

To improve surgical outcomes, clinicians must provide optimal perioperative care for comorbidities identified as significant factors in risk models for patients undergoing lung cancer surgery.

Methods

We reviewed trends in perioperative care for idiopathic pulmonary fibrosis, cardiovascular diseases, and end-stage renal diseases in patients undergoing lung cancer surgery, as large clinical databases indicate that these comorbidities are significant risk factors for lung cancer surgery. Articles identified by keyword searches were included in the analysis.

Results

Significant predictive factors for acute exacerbation of idiopathic pulmonary fibrosis were identified. However, no effective perioperative care was identified for prevention of acute exacerbation of interstitial pneumonia. The timing of coronary revascularization and antithrombotic management for cardiovascular diseases are subjects of ongoing research, and acid–base balance is essential in the management of hemodialysis patients with end-stage renal diseases.

Conclusions

To improve surgical outcomes for lung cancer patients, future studies should continue to study optimal perioperative management of comorbidities.