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Bi Z, Kong L, Zhao J, Song D, Duan F. Positive effects of low-dose S-ketamine on preventing myocardial injury after thoracoscopic lobectomy in patients aged 70 to 85. BMC Anesthesiol 2024; 24:103. [PMID: 38500033 PMCID: PMC10949622 DOI: 10.1186/s12871-024-02491-z] [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: 09/05/2023] [Accepted: 03/11/2024] [Indexed: 03/20/2024] Open
Abstract
OBJECTIVE To investigate the effects of low-dose S-ketamine on marker of myocardial injury (BNP, hs-cTnT and HFABP) after thoracoscopic lobectomy in patients aged 70 to 85. METHODS One hundred patients (four cases excluded) aged 70-85 years, with body mass index 18-24 kg·m-2 and American Society of Anesthesiologists physical status II-III, scheduled for elective lobectomy from April 2022 to April 2023, were selected. The patients were divided into two groups by a random number table method, namely, the low-dose S-ketamine combined with GDFT group (group S) and the control group (group C), with 48 cases in each group. In group S, a low dose of S-ketamine (0.2 mg/kg) was given 1 min before intubation, and the maintenance dose was 0.12 mg·kg-1·h-1. Fluid therapy, guided by cardiac index (CI), changes in stroke volume (△SV), and other dynamic indicators, was used for rehydration during the operation. Group C was given the same amount of normal saline (0.2 mg/kg) 1 min before intubation, and the same rehydration therapy was adopted during the operation. The mean arterial pressure (MAP) and heart rate (HR) of the two groups were observed and recorded immediately after entering the operating room (T0), immediately after intubation (T1), immediately after the beginning of one-lung ventilation (OLV) (T2), immediately after the beginning of surgery (T3), immediately after the end of OLV (T4), and at the end of surgery (T5). The intraoperative fluid intake and output and the use of vasoactive drugs were recorded. The plasma levels of heart-type fatty acid-binding protein (HFABP), high-sensitivity troponin T (hs-cTnT), brain natriuretic peptide (BNP), interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor-α (TNF-α) were recorded 24 h before operation and 24 and 48 h after operation. Visual analogue scale (VAS) pain scores at rest were recorded at 2 (V1), 6 (V2), 12 (V3), 24 (V4), and 48 h (V5) after operation, and the occurrence of myocardial ischemia during hospitalization was noted. RESULTS Compared with group C, MAP was significantly higher at T1-T5 in group S (P < 0.05), and the plasma concentrations of IL-6, IL-8, TNF-α, BNP, hs-cTnT, and HFABP were significantly lower at 24 and 48 h after operation (P < 0.05). The VAS pain scores at 2, 6, 12, 24, and 48 h after operation, the number of effective patient-controlled intravenous analgesia (PCIA) compressions, and the total number of PCIA compressions within 48 h after operation were significantly decreased (P < 0.05). Compared with group C, The hospitalization days, and the incidence of postoperative myocardial ischemia in group S were lower (P < 0.05). There were no significant intergroup differences in urine volume, extubation time, the incidence of postoperative atrial fibrillation, bleeding volume, colloid infusion volume, total fluid infusion volume, and the incidence of rescue analgesia. CONCLUSIONS Low-dose S-ketamine can reduce the levels of hs-cTnT, HFABP, and BNP in older patients after pulmonary lobectomy, which has a positive effect on preventing myocardial injury. TRIAL REGISTRATION This study was registered on CHICTR (registration No. ChiCTR2300074475). Date of registration: 08/08/2023.
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Affiliation(s)
- Ziqiang Bi
- Department of Anesthesiology, Affiliated Hospital of Chengde Medical College, 36 Nanyingzi Street, Chengde, 067020, Hebei Province, China
| | - Lijuan Kong
- Department of Anesthesiology, Affiliated Hospital of Chengde Medical College, 36 Nanyingzi Street, Chengde, 067020, Hebei Province, China
| | - Jiahui Zhao
- Department of Anesthesiology, Affiliated Hospital of Chengde Medical College, 36 Nanyingzi Street, Chengde, 067020, Hebei Province, China
| | - Dongdong Song
- Department of Anesthesiology, Affiliated Hospital of Chengde Medical College, 36 Nanyingzi Street, Chengde, 067020, Hebei Province, China
| | - Fengmei Duan
- Department of Anesthesiology, Affiliated Hospital of Chengde Medical College, 36 Nanyingzi Street, Chengde, 067020, Hebei Province, China.
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Sivarajah J, Toolis M, Seminoff S, Smith J, Bhalla V, Paul E, Tiruvoipati R. Prognostic value of high-sensitivity cardiac troponin in non-cardiac surgical patients in intensive care units. Intern Emerg Med 2024; 19:201-209. [PMID: 38194002 PMCID: PMC10827830 DOI: 10.1007/s11739-023-03509-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 12/06/2023] [Indexed: 01/10/2024]
Abstract
Type II myocardial injury following surgical procedures is associated with adverse outcomes. The prognostic value of high-sensitivity cardiac troponin (hs-cTn) due to type II myocardial injury in surgical patients admitted to intensive care unit (ICU) remains unclear. The aim of this study was to assess prognostic value of hs-cTn in type II acute myocardial injury in non-cardiac surgical patients requiring post-operative ICU admission. Retrospective analysis of patients admitted to two level III ICUs following surgery and had hs-cTn measured on the day of ICU admission. Patients who had type I acute myocardial infarction (AMI) during their admission were excluded from the study. The primary outcome was hospital mortality. Secondary outcomes included ICU mortality, ICU length of stay (LOS) and hospital LOS. A total of 420 patients were included. On univariable analysis, higher hs-cTn was associated with increased hospital mortality (14.6% vs 6.3%, p = 0.008), ICU LOS (41.1 h, vs 25 h, p = 0.004) and hospital LOS (253 h vs 193 h, p = 0.02). On multivariable analysis, hs-cTn was not independently associated with increased risk of hospital mortality. However, in patients who had elective surgery, hs-cTn was associated with increased risk (OR 1.048; 95% CI 1.004-1.094; p = 0.031) of hospital mortality with area under the receiver operating characteristic curve of 0.753 (95% CI 0.598-0.908). In elective surgical patients, hs-cTn was associated with increased risk of mortality. Larger multicentre studies are required to confirm this association that may assist in risk stratification of elective surgical patients requiring ICU admission.
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Affiliation(s)
- Jitain Sivarajah
- Department of Intensive Care Medicine, Frankston Hospital, 2 Hastings Road, Frankston, VIC, 3199, Australia
| | - Michael Toolis
- Department of Intensive Care Medicine, Dandenong Hospital, 135 David Street, Dandenong, VIC, 3175, Australia
| | - Samantha Seminoff
- Department of Intensive Care Medicine, Frankston Hospital, 2 Hastings Road, Frankston, VIC, 3199, Australia
| | - Jesse Smith
- Department of Intensive Care Medicine, Frankston Hospital, 2 Hastings Road, Frankston, VIC, 3199, Australia
| | - Vikram Bhalla
- Department of Intensive Care Medicine, Frankston Hospital, 2 Hastings Road, Frankston, VIC, 3199, Australia
| | - Eldho Paul
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- ANZIC-RC, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, 2 Hastings Road, Frankston, VIC, 3199, Australia.
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia.
- ANZIC-RC, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia.
- Peninsula Clinical School, Monash University, Faculty of Medicine, Nursing and Health Sciences, Frankston, Australia.
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Mases A, Beltrán de Heredia S, Gallart L, Román L, Bosch L, Núñez M, Rueda M, Recasens L, Sabaté S. Prediction of Acute Myocardial Injury in Noncardiac Surgery in Patients at Risk for Major Adverse Cardiovascular and Cerebrovascular Events: A Multivariable Risk Model. Anesth Analg 2023; 137:1116-1126. [PMID: 37043386 DOI: 10.1213/ane.0000000000006469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
BACKGROUND The best use of perioperative cardiac biomarkers assessment is still under discussion. Massive postoperative troponin surveillance can result in untenably high workloads and costs for health care systems and potentially harmful interventions for patients. In a cohort of patients at risk for major adverse cardiovascular and cerebrovascular events (MACCEs), we aimed to (1) determine whether preoperative biomarkers can identify patients at major risk for acute myocardial injury in noncardiac surgery, (2) develop a risk model for acute myocardial injury prediction, and (3) propose an algorithm to optimize postoperative troponin surveillance. METHODS Prospective, single-center cohort study enrolling consecutive adult patients (≥45 years) at risk for MACCE scheduled for intermediate-to-high-risk noncardiac surgery. Baseline high-sensitivity troponin T (hsTnT) and N-terminal fragment of pro-B-type natriuretic peptide (NT-proBNP), as well as hsTnT on the first 3 postoperative days were obtained. The main outcome was the occurrence of acute myocardial injury. Candidate predictors of acute myocardial injury were baseline concentrations of hsTnT ≥14 ng/L and NT-proBNP ≥300 pg/mL and preoperative and intraoperative variables. A multivariable risk model and a decision curve were constructed. RESULTS Of 732 patients, 42.1% had elevated hsTnT and 37.3% had elevated NT-proBNP levels at baseline. Acute myocardial injury occurred in 161 patients (22%). Elevated baseline hsTnT, found in 84% of patients with acute myocardial injury, was strongly associated with this outcome: odds ratio (OR), 12.08 (95% confidence interval [CI], 7.78-19.42). Logistic regression identified 6 other independent predictors for acute myocardial injury: age, sex, estimated glomerular filtration rate (eGFR) <45 mL·min -1 ·1.73 m -2 , functional capacity <4 METs or unknown, NT-proBNP ≥300 pg/mL, and estimated intraoperative blood loss. The c -statistic for the risk model was 77% (95% CI, 0.73-0.81). The net benefit of the model began at a risk threshold of 7%. CONCLUSIONS Baseline determination of cardiac biomarkers in patients at risk for MACCE shortly before intermediate- or high-risk noncardiac surgery helps identify those with the highest risk for acute myocardial injury. A baseline hsTnT ≥14 ng/L indicates the need for postoperative troponin surveillance. In patients with baseline hsTnT <14 ng/L, our 6-predictor model will identify additional patients at risk for acute myocardial injury who may also benefit from postoperative surveillance.
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Affiliation(s)
- Anna Mases
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Sandra Beltrán de Heredia
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Lluís Gallart
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Bellaterra, Barcelona, Spain
| | - Lorena Román
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
| | - Laia Bosch
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
| | - Maria Núñez
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
| | - Mireia Rueda
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
| | - Lluís Recasens
- Department of Cardiology, Hospital del Mar, Barcelona, Spain
| | - Sergi Sabaté
- Department of Anesthesiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Haidar S, Vazquez R, Medic G. Impact of surgical complications on hospital costs and revenues: retrospective database study of Medicare claims. J Comp Eff Res 2023; 12:e230080. [PMID: 37350467 PMCID: PMC10508298 DOI: 10.57264/cer-2023-0080] [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: 01/26/2023] [Accepted: 05/16/2023] [Indexed: 06/24/2023] Open
Abstract
Aim: To compare the length of stay, hospital costs and hospital revenues for Medicare patients with and without a subset of potentially preventable postoperative complications after major noncardiac surgery. Materials & methods: Retrospective data analysis using the Medicare Standard Analytical Files, Limited Data Set, 5% inpatient claims files for years 2016-2020. Results: In 74,103 claims selected for analysis, 71,467 claims had no complications and 2636 had one or more complications of interest. Claims with complications had significantly longer length of hospital stay (12.41 vs 3.95 days, p < 0.01), increased payments to the provider ($34,664 vs $16,641, p < 0.01) and substantially higher estimates of provider cost ($39,357 vs $16,158, p < 0.01) compared with claims without complications. This results on average in a negative difference between payments and costs for patients with complications compared with a positive difference for claims without complications (-$4693 vs $483, p < 0.01). Results were consistent across three different cost estimation methods used in the study. Conclusion: Compared with patients without postoperative complications, patients developing complications stay longer in the hospital and incur increased costs that outpace the increase in received payments. Complications are therefore costly to providers and payers, may negatively impact hospital profitability, and decrease the quality of life of patients. Quality initiatives aimed at reducing complications can be immensely valuable for both improving patient outcomes and hospital finances.
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Affiliation(s)
- Samer Haidar
- Advanced Algorithm Research Center, Philips, Cambridge, MA 02141, USA
| | - Reynaldo Vazquez
- Chief Medical Office, Philips, Eindhoven, 5656AG, The Netherlands
| | - Goran Medic
- Chief Medical Office, Philips, Eindhoven, 5656AG, The Netherlands
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Chang Y, Zhou M, Huang J, Wang Y, Shao J. Incidence and risk factors of postoperative acute myocardial injury in noncardiac patients: A systematic review and meta-analysis. PLoS One 2023; 18:e0286431. [PMID: 37319136 PMCID: PMC10270363 DOI: 10.1371/journal.pone.0286431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/16/2023] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION Postoperative myocardial injury after noncardiac surgery is common and is associated with short- and long-term morbidity and mortality. However, the incidence and risk factors for postoperative acute myocardial injury (POAMI) are currently unknown due to inconsistent definitions. METHODS We systematically searched PubMed and Web of Science to identify studies that applied the change value of preoperative and postoperative cardiac troponins to define cardiac injury. We estimated the pooled incidence, risk factors, and 30-day and long-term mortality of POAMI in noncardiac patients. The study protocol was registered with PROSPERO, CRD42023401607. RESULTS Ten cohorts containing 11,494 patients were included for analysis. The pooled incidence of POAMI was 20% (95% CI: 16% to 23%). Preoperative hypertension (OR: 1.47; 95% CI: 1.30 to 1.66), cardiac failure (OR: 2.63; 95% CI: 2.01 to 3.44), renal impairment (OR: 1.66; 95% CI: 1.48 to 1.86), diabetes (OR: 1.43; 95% CI: 1.27 to 1.61), and preoperative beta-blocker intake (OR: 1.65; 95% CI: 1.10 to 2.49) were the risk factors for POAMI. Age (mean difference: 2.08 years; 95% CI: -0.47 to 4.62), sex (male, OR: 1.16; 95% CI: 0.77 to 1.76), body mass index (mean difference: 0.35; 95% CI: -0.86 to 1.57), preoperative coronary artery disease (OR: 2.10; 95% CI: 0.85 to 5.21), stroke (OR: 0.90; 95% CI: 0.50 to 1.59) and preoperative statins intake (OR: 0.65; 95% CI: 0.21 to 2.02) were not associated with POAMI. Patients with POAMI had higher preoperative hsTnT levels (mean difference: 5.92 ng/L; 95% CI: 4.17 to 7.67) and lower preoperative hemoglobin levels (mean difference: -1.29 g/dL; 95% CI: -1.43 to -1.15) than patients without. CONCLUSION Based on this meta-analysis, approximately 1 in 5 of noncardiac patients develop POAMI. However, the lack of a universally recognized definition for POAMI, which incorporates diverse cardiac biomarkers and patient groups, poses a challenge in accurately characterizing its incidence, risk factors, and clinical outcomes.
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Affiliation(s)
- Yuan Chang
- Department of Anesthesiology, the First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Mengjiao Zhou
- Department of Anesthesiology, the First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jing Huang
- Department of Anesthesiology, the First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yanqiong Wang
- Department of Anesthesiology, the First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jianlin Shao
- Department of Anesthesiology, the First Affiliated Hospital of Kunming Medical University, Kunming, China
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Li X, Guo L, Wang J, Yang X. Pro-fibrotic and apoptotic activities of circARAP1 in myocardial ischemia-reperfusion injury. Eur J Med Res 2023; 28:84. [PMID: 36803446 PMCID: PMC9940434 DOI: 10.1186/s40001-023-01001-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 01/08/2023] [Indexed: 02/22/2023] Open
Abstract
Reperfusion modality can cause damage to cardiomyocytes, known as myocardial ischemia-reperfusion injury (MI/RI). Circular RNAs (circRNAs) are fundamental regulators associated with many cardiac diseases, including MI/RI. However, their functional impact on cardiomyocyte fibrosis and apoptosis remains elusive. Therefore, this study aimed to explore possible molecular mechanisms of circARPA1 in animal models and in hypoxia/reoxygenation (H/R)-treated cardiomyocytes. GEO dataset analysis showed that has_circ_0023461 (circARPA1) was differentially expressed in myocardial infarction samples. Real-time quantitative PCR further supported that circARPA1 was expressed at high levels in animal models and in H/R-triggered cardiomyocytes. Then, loss-of-function assays were performed to show that circARAP1 suppression effectively ameliorated cardiomyocyte fibrosis and apoptosis in MI/RI mice. Mechanistic experiments showed that miR-379-5p, KLF9 and Wnt signaling pathways were associated with circARPA1. circARPA1 can sponge miR-379-5p to regulate KLF9 expression, thereby activating the wnt/β-catenin pathway. Finally, gain-of-function assays revealed that circARAP1 aggravated MI/RI in mice and H/R-induced cardiomyocyte injury by regulating the miR-379-5p/KLF9 axis to activate Wnt/β-catenin signaling.
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Affiliation(s)
- Xi Li
- Department of Cardiology, General Hospital of Ningxia Medical University, No. 804, Shengli South Street, Xingqing District, Yinchuan, 750003, Ningxia Hui Autonomous Region, China.
| | - Lei Guo
- grid.440747.40000 0001 0473 0092Department of Cardiology, Yan’an University Xianyang Hospital, Xianyang, 716099 Shaanxi China
| | - Jingjing Wang
- grid.413385.80000 0004 1799 1445Department of Cardiology, General Hospital of Ningxia Medical University, No. 804, Shengli South Street, Xingqing District, Yinchuan, 750003 Ningxia Hui Autonomous Region China
| | - Xing Yang
- grid.440747.40000 0001 0473 0092Department of Cardiology, Yan’an University Xianyang Hospital, Xianyang, 716099 Shaanxi China
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Predicting Postoperative Troponin in Patients Undergoing Elective Hip or Knee Arthroplasty: A Comparison of Five Cardiac Risk Prediction Tools. Cardiol Res Pract 2022; 2022:8244047. [PMID: 36275928 PMCID: PMC9586832 DOI: 10.1155/2022/8244047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/06/2022] [Indexed: 11/18/2022] Open
Abstract
Background Elderly patients undergoing hip or knee arthroplasty are at a risk for myocardial injury after noncardiac surgery (MINS). We evaluated the ability of five common cardiac risk scores, alone or combined with baseline high-sensitivity cardiac troponin I (hs-cTnI), in predicting MINS and postoperative day 2 (POD2) hs-cTnI levels in patients undergoing elective total hip or knee arthroplasty. Methods This study is ancillary to the Genetics-InFormatics Trial (GIFT) of Warfarin Therapy to Prevent Deep Venous Thrombosis, which enrolled patients 65 years and older undergoing elective total hip or knee arthroplasty. The five cardiac risk scores evaluated were the atherosclerotic cardiovascular disease calculator (ASCVD), the Framingham risk score (FRS), the American College of Surgeon's National Surgical Quality Improvement Program (ACS-NSQIP) calculator, the revised cardiac risk index (RCRI), and the reconstructed RCRI (R-RCRI). Results None of the scores predicted MINS in women. Among men, the ASCVD (C-statistic of 0.66; p=0.04), ACS-NSQIP (C-statistic of 0.69; p=0.01), and RCRI (C-statistic of 0.64; p=0.04) predicted MINS. Among all patients, spearman correlations (rs) of the risk scores with the POD2 hs-cTnI levels were 0.24, 0.20, 0.11, 0.11, and 0.08 for the ASCVD, Framingham, ACS-NSQIP, RCRI, and R-RCRI scores, respectively, with p values of <0.001, <0.001, <0.001, 0.006, and 0.025. Baseline hs-cTnI predicted MINS (C-statistics: 0.63 in women and 0.72 in men) and postoperative hs-cTnI (rs = 0.51, p=0.001). Conclusion In elderly patients undergoing elective hip or knee arthroplasty, several of the scores modestly predicted MINS in men and correlated with POD2 hs-cTnI.
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Loft FC, Rasmussen SM, Elvekjaer M, Haahr‐Raunkjaer C, Sørensen HBD, Aasvang EK, Meyhoff CS. Continuously monitored vital signs for detection of myocardial injury in high-risk patients - An observational study. Acta Anaesthesiol Scand 2022; 66:674-683. [PMID: 35247272 PMCID: PMC9314636 DOI: 10.1111/aas.14056] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 02/22/2022] [Accepted: 02/25/2022] [Indexed: 12/21/2022]
Abstract
Background Patients are at risk of myocardial injury after major non‐cardiac surgery and during acute illness. Myocardial injury is associated with mortality, but often asymptomatic and currently detected through intermittent cardiac biomarker screening. This delays diagnosis, where vital signs deviations may serve as a proxy for early signs of myocardial injury. This study aimed to assess the association between continuous monitored vital sign deviations and subsequent myocardial injury following major abdominal cancer surgery and during acute exacerbation of chronic obstructive pulmonary disease. Methods Patients undergoing major abdominal cancer surgery or admitted with acute exacerbation of chronic obstructive pulmonary disease had daily troponin measurements. Continuous wireless monitoring of several vital signs was performed for up to 96 h after admission or surgery. The primary exposure was cumulative duration of peripheral oxygen saturation (SpO2) below 85% in the 24 h before the primary outcome of myocardial injury, defined as a new onset ischaemic troponin elevation assessed daily. If no myocardial injury occurred, the primary exposure was based on the first 24 h of measurement. Results A total of 662 patients were continuously monitored and 113 (17%) had a myocardial injury. Cumulative duration of SpO2 < 85% was significantly associated with myocardial injury (mean difference 14.2 min [95% confidence interval −4.7 to 33.1 min]; p = .005). Durations of hypoxaemia (SpO2 < 88% and SpO2 < 80%), tachycardia (HR > 110 bpm and HR > 130 bpm) and tachypnoea (RR > 24 min−1 and RR > 30 min−1) were also significantly associated with myocardial injury (p < .04, for all). Conclusion Duration of severely low SpO2 detected by continuous wireless monitoring is significantly associated with myocardial injury in high‐risk patients admitted to hospital wards. The effect of early detection and interventions should be assessed next.
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Affiliation(s)
- Frederik C. Loft
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital University of Copenhagen Copenhagen Denmark
- Copenhagen Center for Translational Research Copenhagen University Hospital Bispebjerg and Frederiksberg Copenhagen Denmark
| | - Søren M. Rasmussen
- Digital Health Section Department of Health Technology Technical University of Denmark Kongens Lyngby Denmark
| | - Mikkel Elvekjaer
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital University of Copenhagen Copenhagen Denmark
- Copenhagen Center for Translational Research Copenhagen University Hospital Bispebjerg and Frederiksberg Copenhagen Denmark
- Department of Anaesthesiology Centre for Cancer and Organ Diseases Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Camilla Haahr‐Raunkjaer
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital University of Copenhagen Copenhagen Denmark
- Copenhagen Center for Translational Research Copenhagen University Hospital Bispebjerg and Frederiksberg Copenhagen Denmark
- Department of Anaesthesiology Centre for Cancer and Organ Diseases Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Helge B. D. Sørensen
- Digital Health Section Department of Health Technology Technical University of Denmark Kongens Lyngby Denmark
| | - Eske K. Aasvang
- Department of Anaesthesiology Centre for Cancer and Organ Diseases Rigshospitalet University of Copenhagen Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Christian S. Meyhoff
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital University of Copenhagen Copenhagen Denmark
- Copenhagen Center for Translational Research Copenhagen University Hospital Bispebjerg and Frederiksberg Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
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Rafiudeen R, Barlis P, White HD, van Gaal W. Type 2 MI and Myocardial Injury in the Era of High-sensitivity Troponin. Eur Cardiol 2022; 17:e03. [PMID: 35284006 PMCID: PMC8900132 DOI: 10.15420/ecr.2021.42] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/21/2021] [Indexed: 11/21/2022] Open
Abstract
Troponin has been the cornerstone of the definition of MI since its introduction to clinical practice. High-sensitivity troponin has allowed clinicians to detect degrees of myocardial damage at orders of magnitude smaller than previously and is challenging the definitions of MI, with implications for patient management and prognosis. Detection and diagnosis are no doubt enhanced by the greater sensitivity afforded by these markers, but perhaps at the expense of specificity and clarity. This review focuses on the definitions, pathophysiology, prognosis, prevention and management of type 2 MI and myocardial injury. The five types of MI were first defined in 2007 and were recently updated in 2018 in the fourth universal definition of MI. The authors explore how this pathophysiological classification is used in clinical practice, and discuss some of the unanswered questions in this era of availability of high-sensitivity troponin.
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Affiliation(s)
- Rifly Rafiudeen
- Department of Cardiology, The Northern Hospital, Melbourne, Australia; Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Peter Barlis
- Department of Cardiology, The Northern Hospital, Melbourne, Australia; Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - William van Gaal
- Department of Cardiology, The Northern Hospital, Melbourne, Australia; Department of Medicine, The University of Melbourne, Melbourne, Australia
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Jorge AJL, Mesquita ET, Martins WDA. Myocardial Injury after Non-cardiac Surgery - State of the Art. Arq Bras Cardiol 2021; 117:544-553. [PMID: 34550241 PMCID: PMC8462967 DOI: 10.36660/abc.20200317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 11/04/2020] [Indexed: 11/18/2022] Open
Abstract
Aproximadamente 300 milhões de cirurgias não cardíacas são realizadas anualmente no mundo, e eventos cardiovasculares adversos são as principais causas de morbimortalidade no período perioperatório e pós-operatório. A lesão miocárdica após cirurgia não cardíaca (MINS, do inglês myocardial injury after non-cardiac surgery) é uma nova entidade clínica associada com desfechos cardiovasculares adversos. MINS é definida como uma lesão miocárdica que pode resultar em necrose secundária à isquemia, com elevação dos biomarcadores. A lesão tem importância prognóstica e ocorre em até 30 dias após a cirurgia não cardíaca. Os critérios diagnósticos para MINS são: níveis elevados de troponina durante ou em até 30 dias após a cirurgia não cardíaca, sem evidência de etiologia não isquêmica, sem que haja necessariamente sintomas isquêmicos ou achados eletrocardiográficos de isquemia. Recentemente, pacientes com maior risco para MINS têm sido identificados por variáveis clínicas e biomarcadores, bem como por protocolos de vigilância quanto ao monitoramento eletrocardiográfico e dosagem de troponina cardíaca. Pacientes idosos com doença aterosclerótica prévia necessitam medir troponina diariamente no período pós-operatório. O objetivo deste trabalho é descrever este novo problema de saúde pública, seu impacto clínico e a abordagem terapêutica contemporânea.
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Affiliation(s)
| | - Evandro Tinoco Mesquita
- Centro de Ensino e Treinamento Edson de Godoy Bueno / UHG, Rio de Janeiro, RJ - Brasil.,UNIALFA / Colégio Brasileiro de Executivos em Saúde CBEXs, São Paulo, SP - Brasil.,Sociedad Interamericana de Cardiología (SIAC), Cidade do México - México.,DASA Complexo Hospitalar de Niterói, Niterói, RJ - Brasil
| | - Wolney de Andrade Martins
- Universidade Federal Fluminense (UFF), Niterói, RJ - Brasil.,DASA Complexo Hospitalar de Niterói, Niterói, RJ - Brasil
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11
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Serrano AB, Gomez-Rojo M, Ureta E, Nuñez M, Fernández Félix B, Velasco E, Burgos J, Popova E, Urrutia G, Gomez V, Del Rey JM, Sanjuanbenito A, Zamora J, Monteagudo JM, Pestaña D, de la Torre B, Candela-Toha Á. Preoperative clinical model to predict myocardial injury after non-cardiac surgery: a retrospective analysis from the MANAGE cohort in a Spanish hospital. BMJ Open 2021; 11:e045052. [PMID: 34348944 PMCID: PMC8340283 DOI: 10.1136/bmjopen-2020-045052] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
- Ana Belen Serrano
- Department of Anesthesiology and Surgical Critical Care, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Maria Gomez-Rojo
- Department of Anesthesiology and Surgical Critical Care, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Eva Ureta
- Department of Anesthesiology and Surgical Critical Care, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Monica Nuñez
- Department of Anesthesiology and Surgical Critical Care, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Borja Fernández Félix
- Clinical Biostatistics Unit, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Elisa Velasco
- Department of Cardiology, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Javier Burgos
- Department of Urology, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Ekaterine Popova
- Biomedical Research Institute, Iberoamerican Cochrane Center, (IIB Sant Pau), Barcelona, Catalunya, Spain
| | - Gerard Urrutia
- CIBER Epidemiología y Salud Pública (CIBERESP), Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Cataluña, Spain
| | - Victoria Gomez
- Department of Urology, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Jose Manuel Del Rey
- Department of Biochemistry, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Alfonso Sanjuanbenito
- Department of General Surgery, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Javier Zamora
- Clinical Biostatistics Unit, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Comunidad de Madrid, Spain
- Institute of metabolism and systems researchs, University of Birmingham, Birmingham, UK
| | | | - David Pestaña
- Department of Anesthesiology and Surgical Critical Care, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
- Universidad Alcalá de Henares, Madrid, Spain
| | - Basilio de la Torre
- Department of Traumatology, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Ángel Candela-Toha
- Department of Anesthesiology and Surgical Critical Care, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
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12
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Weersink CSA, van Waes JAR, Grobben RB, Nathoe HM, van Klei WA. Patient Selection for Routine Troponin Monitoring After Noncardiac Surgery. J Am Heart Assoc 2021; 10:e019912. [PMID: 34219462 PMCID: PMC8483467 DOI: 10.1161/jaha.120.019912] [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]
Abstract
Background Myocardial infarction is an important complication after noncardiac surgery. Therefore, perioperative troponin surveillance is recommended for patients at risk. The aim of this study was to identify patients at high risk of perioperative myocardial infarction (POMI), in order to aid appropriate selection and to omit redundant laboratory measurements in patients at low risk. Methods and Results This observational cohort study included patients ≥60 years of age who underwent intermediate to high risk noncardiac surgery. Routine postoperative troponin I monitoring was performed. The primary outcome was POMI. Classification and regression tree analysis was used to identify patient groups with varying risks of POMI. In each subgroup, the number needed to screen to identify 1 patient with POMI was calculated. POMI occurred in 216 (4%) patients and other myocardial injury in 842 (15%) of the 5590 included patients. Classification and regression tree analysis divided patients into 14 subgroups in which the risk of POMI ranged from 1.7% to 42%. Using a risk of POMI ≥2% to select patients for routine troponin I monitoring, this monitoring would be advocated in patients ≥60 years of age undergoing emergency surgery, or those undergoing elective surgery with a Revised Cardiac Risk Index class >2 (ie >1 risk factor). The number needed to screen to detect a patient with POMI would be 14 (95% CI 14–14) and 26% of patients with POMI would be missed. Conclusions To improve selection of high‐risk patients ≥60 years of age, routine postoperative troponin I monitoring could be considered in patients undergoing emergency surgery, or in patients undergoing elective surgery classified as having a revised cardiac risk index class >2.
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Affiliation(s)
- Corien S A Weersink
- Department of Anesthesiology University Medical Center Utrecht Utrecht The Netherlands
| | - Judith A R van Waes
- Department of Anesthesiology University Medical Center Utrecht Utrecht The Netherlands
| | - Remco B Grobben
- Department of Cardiology University Medical Center Utrecht Utrecht The Netherlands
| | - Hendrik M Nathoe
- Department of Cardiology University Medical Center Utrecht Utrecht The Netherlands
| | - Wilton A van Klei
- Department of Anesthesiology University Medical Center Utrecht Utrecht The Netherlands
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13
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Azizi PM, Wijeysundera DN, Wijeysundera HC, Austin PC, Jerath A, Han L, Koh M, Ko DT. Troponin Testing After Noncardiac Surgery in Ontario: An Observational Study. CJC Open 2021; 3:904-912. [PMID: 34401697 PMCID: PMC8348325 DOI: 10.1016/j.cjco.2021.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 03/08/2021] [Indexed: 11/25/2022] Open
Abstract
Background In 2017, the Canadian Cardiovascular Society (CCS) published guidelines recommending postoperative troponin surveillance in higher-risk patients having major noncardiac surgery. The objective of this study was to evaluate the proportion of major noncardiac surgery patients that would meet recommendations for troponin testing and to assess the rates of troponin testing before guideline adoption. Methods We conducted a retrospective observational study of patients age 40 to 105 undergoing a subset of major noncardiac surgeries that included orthopedics, gynecology, general, urology, vascular, and thoracic surgeries in Ontario, Canada from January 1, 2010 to December 31, 2017. The primary outcomes were the proportion of patients recommended for testing based on the guidelines and rates of troponin testing within 2 days of surgery. Results We identified 257,704 patients who underwent noncardiac surgery. Mean age was 66.4 ± 11.9 years, and 12.4% underwent urgent surgery. Applying the CCS guidelines, 71.2% of elective surgery patients and 81.0% of urgent surgery patients would have met recommendations for postoperative troponin screening, whereas 10.8% and 27.1% received postoperative troponin testing, respectively. Most elective surgery patients met recommendations for testing based on the age criterion (54.9%), followed by diabetes (24.6%) and high-risk surgery (22.7%) criteria. Troponin testing varied substantially by types of surgery: highest for open abdominal aortic aneurisms and lowest for hysterectomies. Conclusions Based on the CCS guidelines, most patients undergoing the subset of surgeries assessed would have met recommendations for routine troponin testing. In contrast, routine troponin testing before guideline adoption was done infrequently in Ontario, with substantial variations based on the surgery type.
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Affiliation(s)
- Paymon M Azizi
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Duminda N Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia, St Michael's Hospital, Toronto, Ontario, Canada
| | - Harindra C Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Peter C Austin
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | | | - Lu Han
- ICES, Toronto, Ontario, Canada
| | | | - Dennis T Ko
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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14
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Fang J, Zheng W, Hu P, Wu J. Investigating the effect of lncRNA HOTAIR on apoptosis induced by myocardial ischemia-reperfusion injury. Mol Med Rep 2021; 23:169. [PMID: 33398378 PMCID: PMC7821281 DOI: 10.3892/mmr.2020.11808] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 10/30/2020] [Indexed: 11/05/2022] Open
Abstract
The present study aimed to investigate the effect of the long non‑coding ribonucleic acid (lncRNA) HOX transcript antisense intergenic RNA (HOTAIR) on apoptosis induced by ischemia‑reperfusion injury. Differential lncRNAs in myocardial ischemia rats were screened by a lncRNA microarray and the expression levels of lncRNA HOTAIR and microRNA (miR)‑130a‑3p were analyzed using reverse transcription‑quantitative polymerase chain reaction in hypoxia‑induced cardiomyocytes. The mechanism of lncRNA HOTAIR in cardiotoxicity was investigated using cell transfection, lncRNA knockdown, Cell Counting Kit‑8, flow cytometry, western blotting, dual luciferase reporter assays and RNA immunoprecipitation. The expression level of lncRNA HOTAIR was significantly downregulated in the ischemic myocardium of rats. Overexpression of HOTAIR in H9c2 (rat cardiomyocyte line) cells could inhibit the apoptosis induced by H2O2. A direct interaction was found between HOTAIR and miR‑130a‑3p, and mouse double minute 4 (MDM4) was also found to be a potential target of miR‑130a‑3p. The overexpression of MDM4 in H9c2 cells transfected with miR‑130a‑3p mimics increased apoptosis, and miR‑130a‑3p targeted inhibition of MDM4 promoted H2O2‑induced apoptosis of H9c2 cells. Overall, HOTAIR was found to inhibit the apoptosis of H9c2 cells induced by H2O2 through the miR‑130a‑3p/MDM4 axis.
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Affiliation(s)
- Jijing Fang
- Department of Rehabilitation Medicine, The First People's Hospital of Tonglu, Tonglu County, Hangzhou, Zhejiang 311500, P.R. China
| | - Weihong Zheng
- School of Life Science, Huzhou University, Huzhou, Zhejiang 313000, P.R. China
| | - Pengfei Hu
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang 310005, P.R. China
| | - Jiale Wu
- Department of Geratology, Hangzhou Hospital of Traditional Chinese Medicine, Hangzhou, Zhejiang 310007, P.R. China
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15
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Gopan G, Kumar L, Babu AR, Sudhakar A, George R, Menon VP. Intraoperative factors contributory to myocardial injury in high-risk patients undergoing abdominal surgery in a South Indian population. Indian J Anaesth 2020; 64:743-749. [PMID: 33162567 PMCID: PMC7641085 DOI: 10.4103/ija.ija_436_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/16/2020] [Accepted: 05/28/2020] [Indexed: 12/15/2022] Open
Abstract
Background and Aims: Myocardial injury after non-cardiac surgery (MINS) is associated with high postoperative mortality. We sought to examine the intraoperative variables associated with MINS among high-risk patients undergoing abdominal surgery at a South Indian Centre. Methods: A retrospective analysis of patients who underwent abdominal surgery, aged >45 years with one of five factors: hypertension, diabetes mellitus, previous coronary artery disease (CAD), stroke, or peripheral vascular disease or all patients >65 years of age was undertaken. Forty-six patients with raised troponin Group P (Trop I > 0.03 ng/d) were compared with 125 troponin-negative patients Group N (Trop I < 0.012 ng/dL) as well as 51 with intermediate levels Group I (Trop I > 0.012 and < 0.03 ng/dL). We evaluated the association of pre and intraoperative factors on MINS using logistic regression to identify the explanatory variables. Results: Demographics were similar among the three groups. In-hospital mortality was significantly higher in group P (P = 0.005).The use of vasopressors (OR 2.6; 95% CI 1.2–5.5), female gender, (OR 2.3; 95%CI 1.1–4.7), associated CAD (OR 2.8;95% CI 1.1–7.4), and fresh frozen plasma (FFP) transfusion (OR 12.1;95% CI 1.3–11.7) were associated with MINS in regression analysis between group P versus group N. Female gender (OR2.3; 95% CI 1.2–4.5), postoperative mechanical ventilation (OR 3.5; 95% CI 1.2–10.4), and perioperative hypothermia (OR 4.5; 95% CI 1.3–14.9) were significant between Group P and Group I with Group N. Conclusions: Female patients with CAD undergoing abdominal surgery, needing vasopressors and transfusion of plasma are at high risk for MINS with higher hospital mortality and merit vigilant monitoring postoperatively.
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Affiliation(s)
- G Gopan
- Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Lakshmi Kumar
- Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Anjana Rajan Babu
- Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Abish Sudhakar
- Department of Paediatric Cardiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Rubin George
- Department of Internal Medicine, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Vidya P Menon
- Department of Internal Medicine, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
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16
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Conti D, Ballo P, Ruggiano P, Boccalini R, Pavoni V, Sarti A. Very early postoperative troponin increase and clinical outcome in patients admitted to the recovery room after noncardiac surgery with suspected cardiac events. Indian Heart J 2020; 72:197-199. [PMID: 32768022 PMCID: PMC7411100 DOI: 10.1016/j.ihj.2020.05.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 04/12/2020] [Accepted: 05/19/2020] [Indexed: 12/13/2022] Open
Abstract
We assessed the prognostic meaning of very early (<6 h) troponin increase after noncardiac surgery in a population of patients admitted to the recovery room, for whom troponin measurements were taken because of a suspected cardiac event. Among a total of 296 patients, abnormal troponin was found in 24 (8.1%). Ten patients in this group (41.7%) and 27 among those with normal troponin (9.9%) experienced cardiovascular death, myocardial infarction, or decompensated heart failure at one month (p < 0.0001). Troponin was independently associated with a two-fold risk of events (p < 0.0001). In these patients, very early troponin measurement in the recovery room may help to identify patients at risk of cardiovascular events.
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Affiliation(s)
- Duccio Conti
- Anaesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Florence, Italy.
| | - Piercarlo Ballo
- Cardiology Unit, Santa Maria Annunziata Hospital, Florence, Italy
| | - Peggy Ruggiano
- Anaesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Florence, Italy
| | - Rossana Boccalini
- Anaesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Florence, Italy
| | - Vittorio Pavoni
- Anaesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Florence, Italy
| | - Armando Sarti
- Anaesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Florence, Italy
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17
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Agrimi J, Baroni C, Anakor E, Lionetti V. Perioperative Heart-Brain Axis Protection in Obese Surgical Patients: The Nutrigenomic Approach. Curr Med Chem 2020; 27:258-281. [PMID: 30324875 DOI: 10.2174/0929867325666181015145225] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 08/01/2018] [Accepted: 09/25/2018] [Indexed: 02/06/2023]
Abstract
The number of obese patients undergoing cardiac and noncardiac surgery is rapidly increasing because they are more prone to concomitant diseases, such as diabetes, thrombosis, sleep-disordered breathing, cardiovascular and cerebrovascular disorders. Even if guidelines are already available to manage anesthesia and surgery of obese patients, the assessment of the perioperative morbidity and mortality from heart and brain disorders in morbidly obese surgical patients will be challenging in the next years. The present review will recapitulate the new mechanisms underlying the Heart-brain Axis (HBA) vulnerability during the perioperative period in healthy and morbidly obese patients. Finally, we will describe the nutrigenomics approach, an emerging noninvasive dietary tool, to maintain a healthy body weight and to minimize the HBA propensity to injury in obese individuals undergoing all types of surgery by personalized intake of plant compounds that may regulate the switch from health to disease in an epigenetic manner. Our review provides current insights into the mechanisms underlying HBA response in obese surgical patients and how they are modulated by epigenetically active food constituents.
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Affiliation(s)
- Jacopo Agrimi
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Carlotta Baroni
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Ekene Anakor
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Vincenzo Lionetti
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,UOS Anesthesiology, Fondazione Toscana G. Monasterio, Pisa, Italy
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18
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González-Tallada A, Borrell-Vega J, Coronado C, Morales P, de Miguel M, Ferreira-González I, de Nadal M. Myocardial Injury After Noncardiac Surgery: Incidence, Predictive Factors, and Outcome in High-Risk Patients Undergoing Thoracic Surgery: An Observational Study. J Cardiothorac Vasc Anesth 2020; 34:426-432. [DOI: 10.1053/j.jvca.2019.08.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 08/04/2019] [Accepted: 08/07/2019] [Indexed: 11/11/2022]
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19
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Lowe MJ, Lightfoot NJ. The prognostic implication of perioperative cardiac enzyme elevation in patients with fractured neck of femur: A systematic review and meta-analysis. Injury 2020; 51:164-173. [PMID: 31879176 DOI: 10.1016/j.injury.2019.12.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/11/2019] [Accepted: 12/09/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Neck of Femur (NOF) fractures are a common injury in comorbid elderly patients which are associated with increased rates of morbidity and mortality following fracture. Because of their injury, patients can experience reductions in quality of life and independent living leading to transfer to nursing home or dependent levels of care. Numerous factors are associated with either complications or reductions in survival following fractured NOF. From the VISION cohort there is evidence that troponin elevation in the post-operative period following a diverse range of non-cardiac surgical procedures may lead to an increased risk of mortality in the absence of classical ischaemic or cardiac symptoms. The aim of this systematic review and meta-analysis is to validate the utility of perioperative troponin elevation as a prognostic indicator for mortality and cardiac morbidity in those with fractured NOF. METHODS The PRISMA guidelines for the conduct of meta-analyses were followed. An electronic search was conducted of the EMBASE, MEDLINE (Ovid) and Biosis databases. Studies were included for analysis if they stratified outcomes by perioperative troponin elevation in surgically managed fractured NOF and reported sufficient data on troponin elevation and mortality following surgery. Primary and secondary outcomes assessed were all-cause post-operative mortality and a composite measure of cardiac complications (myocardial infarction, cardiac failure and arrhythmia) respectively. RESULTS Eleven studies met inclusion criteria giving a total of 1363 patients. Overall, 497 patients (36.5%) experienced an elevation in troponin levels following surgery. Perioperative troponin elevation was significantly associated with all-cause mortality (OR 2.6; 95% CI 1.5 - 4.6; p <0.001) and cardiac complications (OR 7.4; 95% CI 3.5 - 15.8; p <0.001). Patient factors significantly associated with troponin elevation included pre-existing coronary artery disease, cardiac failure, hypertension, previous stroke and previous myocardial infarction. CONCLUSION Perioperative troponin elevation is significantly associated with increased mortality and post-operative cardiac complications following fractured NOF and may be a useful prognostic indicator in these patients. Future research should further stratify patients by the magnitude of troponin elevation and further refine the risk factors.
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Affiliation(s)
- Matthew J Lowe
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand.
| | - Nicholas J Lightfoot
- Department of Anaesthesia and Pain Medicine, Middlemore Hospital, Auckland, New Zealand
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20
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Meershoek AJA, Leunissen TC, van Waes JAR, Klei WA, Huisman A, de Groot MCH, Hoefer IE, van Solinge WW, Moll FL, de Borst GJ. Reticulated Platelets as Predictor of Myocardial Injury and 30 Day Mortality After Non-cardiac Surgery. Eur J Vasc Endovasc Surg 2019; 59:309-318. [PMID: 31812606 DOI: 10.1016/j.ejvs.2019.06.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 04/09/2019] [Accepted: 06/22/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE A pre-operative marker for identification of patients at risk of peri-operative adverse events and 30 day mortality might be the percentage of young, reticulated platelets (pRP). This study aimed to determine the predictive value of pre-operative pRP on post-operative myocardial injury (PMI) and 30 day mortality, in patients aged ≥ 60 years undergoing moderate to high risk non-cardiac surgery. METHODS The incidence of PMI (troponin I > 0.06 μg/L) and 30 day mortality was compared for patients with normal and high pRP (≥2.82%) obtained from The Utrecht Patient Orientated Database. The predictive pRP value was assessed using logistic regression. A prediction model for PMI or 30 day mortality with known risk factors was compared with a model including increased pRP using the area under the receiving operator characteristics curve (AUROC). RESULTS In total, 26.5% (607/2289) patients showed pre-operative increased pRP. Increased pRP was associated with more PMI and 30 day mortality compared with normal pRP (36.1% vs. 28.3%, p < .001 and 8.6% vs. 3.6%, p < .001). The median pRP was higher in patients suffering PMI and 30 day mortality compared with not (2.21 [IQR: 1.57-3.11] vs. 2.07 [IQR: 1.52-1.78], p = .002, and 2.63 [IQR: 1.76-4.15] vs. 2.09 [IQR: 1.52-3.98], p < .001). pRP was independently related to PMI (OR: 1.28 [95% CI: 1.04-1.59], p = .02) and 30 day mortality (OR: 2.35 [95% CI: 1.56-3.55], p < .001). Adding increased pRP to the predictive model of PMI or 30 day mortality did not increase the AUROC 0.71 vs. 0.72, and 0.80 vs. 0.81. CONCLUSION In patients undergoing major non-cardiac surgery, increased pre-operative pRP is related to 30 day mortality and PMI.
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Affiliation(s)
- Armelle J A Meershoek
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Tesse C Leunissen
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands; Department of Clinical Chemistry and Haematology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Judith A R van Waes
- Department of Anaesthesiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Wilton A Klei
- Department of Anaesthesiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Albert Huisman
- Department of Clinical Chemistry and Haematology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Mark C H de Groot
- Department of Clinical Chemistry and Haematology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Imo E Hoefer
- Department of Clinical Chemistry and Haematology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Wouter W van Solinge
- Department of Clinical Chemistry and Haematology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Frans L Moll
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands.
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Moon YJ, Kwon HM, Jung KW, Jeong HW, Park YS, Jun IG, Song JG, Hwang GS. Risk stratification of myocardial injury after liver transplantation in patients with computed tomographic coronary angiography-diagnosed coronary artery disease. Am J Transplant 2019; 19:2053-2066. [PMID: 30653845 DOI: 10.1111/ajt.15263] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 11/28/2018] [Accepted: 01/06/2019] [Indexed: 02/06/2023]
Abstract
We aimed to determine if the severity of computed tomographic coronary angiography (CTCA)-diagnosed coronary artery disease (CAD) is associated with postliver transplantation (LT) myocardial infarction (MI) within 30 days and early mortality. We retrospectively evaluated 2118 consecutive patients who underwent CAD screening using CTCA. Post-LT type-2 MI, elicited by oxygen supply-and-demand mismatch within a month after LT, was assessed according to the severity of CTCA-diagnosed CAD. Obstructive CAD (>50% narrowing, 9.2% prevalence) was identified in 21.7% of patients with 3 or more known CAD risk factors of the American Heart Association. Post-LT MI occurred in 60 (2.8%) of total patients in whom 90-day mortality rate was 16.7%. Rates of post-LT MI were 2.1%, 3.1%, 3.4%, 4.3%, and 21.4% for normal, nonobstructive CAD, and 1-, 2-, and 3-vessel obstructive CAD, respectively. Two-vessel or 3-vessel obstructive CAD showed a 4.9-fold higher post-LT MI risk compared to normal coronary vessels. The sensitivity and negative predictive value of obstructive CAD in detecting post-LT MI were, respectively, 20% and 97.5%. In conclusion, negative CTCA finding in suspected patients can successfully exclude post-LT MI, whereas proceeding with invasive angiography is needed to further risk-stratify in patients with significant CTCA-diagnosed CAD. Prognostic role of CTCA in predicting post-LT MI needs further research.
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Affiliation(s)
- Young-Jin Moon
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Mee Kwon
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyeo-Woon Jung
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Won Jeong
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong-Seok Park
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In-Gu Jun
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun-Gol Song
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Peri-operative copeptin concentrations and their association with myocardial injury after vascular surgery: A prospective observational cohort study. Eur J Anaesthesiol 2019; 35:682-690. [PMID: 29750698 DOI: 10.1097/eja.0000000000000815] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Copeptin levels in conjunction with cardiac troponin may be used to rule out early myocardial infarction in patients presenting with chest pain. Raised pre-operative copeptin has been shown to be associated with postoperative cardiac events. However, very little is known about the peri-operative time course of copeptin or the feasibility of very early postoperative copeptin measurement to diagnose or rule-out myocardial injury. OBJECTIVES In this preparatory analysis for a larger trial, we sought to examine the time course of peri-operative copeptin and identify the time at which concentrations returned to pre-operative levels. Second, in an explorative analysis, we sought to examine the association of copeptin in general and at various time points with myocardial injury occurring within the first 48 h. DESIGN Preparatory analysis of a prospective, observational cohort study. SETTING Single university centre from February to July 2016. PATIENTS A total of 30 consecutive adults undergoing vascular surgery. INTERVENTION Serial peri-operative copeptin measurements. MAIN OUTCOME MEASURE We measured copeptin concentrations before and immediately after surgery (0 h), then at 2, 4, 6 and 8 h after surgery and on the first and second postoperative day. Postoperative concentrations were compared with pre-operative levels with a Wilcoxon signed-rank test. Second, we explored an association between postoperative copeptin concentrations and myocardial injury by the second postoperative day. Myocardial injury was defined as a 5 ng l increase between pre-operative and postoperative high-sensitivity cardiac troponin T with an absolute peak of at least 20 ng l. RESULTS Immediate postoperative copeptin concentrations (median [interquartile range]) increased nearly eight-fold from pre-operative values (8.5 [3.6 to 13.8] to 64.75 pmol l [29.6 to 258.7]; P < 0.001). Copeptin concentrations remained elevated until returning to baseline on the second postoperative day. Postoperative copeptin was significantly higher in patients experiencing myocardial injury than in those who did not (P = 0.02). The earliest most promising single time point for diagnosis may be immediately after surgery (0 h). The receiver-operating characteristics curve for immediate postoperative copeptin and myocardial injury by the second postoperative day was 0.743 (95% confidence interval 0.560 to 0.926). CONCLUSION Copeptin concentrations are greatly increased after vascular surgery and remain so until the 2nd postoperative day. Postoperative copeptin concentrations appear to be higher in patients who go on to exhibit myocardial injury. Immediate postoperative copeptin concentrations show promise for eliminating or identifying those at risk of myocardial injury. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02687776, Mauermann/Lurati Buse.
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Myocardial injury in noncardiac surgery in Sweden: Study protocol for a multicentre, observational cohort study of patients undergoing elective, major abdominal surgery. Eur J Anaesthesiol 2019; 36:383-385. [PMID: 30946177 DOI: 10.1097/eja.0000000000000976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ollila A, Vikatmaa L, Sund R, Pettilä V, Wilkman E. Efficacy and safety of intravenous esmolol for cardiac protection in non-cardiac surgery. A systematic review and meta-analysis. Ann Med 2019; 51:17-27. [PMID: 30346213 PMCID: PMC7856921 DOI: 10.1080/07853890.2018.1538565] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Haemodynamic instability predisposes patients to cardiac complications in non-cardiac surgery. Esmolol, a short-acting cardioselective beta-adrenergic blocker might be efficient in perioperative cardiac protection, but could affect other vital organs, such as the kidneys, and post-discharge survival. We performed a systematic review on the use of esmolol for perioperative cardiac protection. We searched PubMed, Ovid Medline and Cochrane Central Register for Controlled trials. Eligible randomized controlled studies (RCTs) reported a perioperative esmolol intervention with at least one of the primary (major cardiac or renal complications during the first 30 postoperative days) or secondary (postoperative adverse effects and all-cause mortality) outcomes. We included 196 adult patients from three RCTs. Esmolol significantly reduced postoperative myocardial ischaemia, RR =0.43 [95% confidence interval, CI: 0.21-0.88], p = .02. No association with clinically significant bradycardia and hypotension compared to patients receiving control treatment could be confirmed (RR =7.4 [95% CI: 0.29-139.81], p = .18 and RR =2.21 [95% CI: 0.34-14.36], p = .41, respectively). No differences regarding other outcomes were observed. No study reported postoperative renal outcomes. Esmolol seems promising for the prevention of perioperative myocardial ischaemia. However, the association with bradycardia and hypotension remains unclear. Randomized trials investigating the effect of β1-selective blockade on clinically relevant outcomes and non-cardiac vital organs are warranted. Key messages Short-acting cardioselective esmolol seems efficient in the prevention of perioperative myocardial ischaemia. The possibly increased risk of bradycardia and hypotension with short-acting intravenous beta blockade could not be confirmed or refuted by available data. Future adequately powered trials investigating the effect of β1-selective blockade on clinically relevant outcomes and non-cardiac vital organs are warranted.
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Affiliation(s)
- Aino Ollila
- a Department of Perioperative, Intensive Care and Pain Medicine , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Leena Vikatmaa
- a Department of Perioperative, Intensive Care and Pain Medicine , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Reijo Sund
- b Institute of Clinical Medicine, University of Eastern Finland , Kuopio , Finland.,c Faculty of Social Sciences , Centre for Research Methods, University of Helsinki , Helsinki , Finland
| | - Ville Pettilä
- a Department of Perioperative, Intensive Care and Pain Medicine , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Erika Wilkman
- a Department of Perioperative, Intensive Care and Pain Medicine , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
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Verbree-Willemsen L, Grobben RB, van Waes JAR, Peelen LM, Nathoe HM, van Klei WA, Grobbee DE. Causes and prevention of postoperative myocardial injury. Eur J Prev Cardiol 2019; 26:59-67. [PMID: 30207484 PMCID: PMC6287250 DOI: 10.1177/2047487318798925] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 08/14/2018] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Laura Verbree-Willemsen
- Department of Epidemiology, Julius
Center for Health Sciences and Primary Care, University Medical Center Utrecht,
Utrecht University, The Netherlands
| | - Remco B Grobben
- Department of Cardiology, University
Medical Center Utrecht, Utrecht University, The Netherlands
| | - Judith AR van Waes
- Department of Anaesthesiology,
University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Linda M Peelen
- Department of Epidemiology, Julius
Center for Health Sciences and Primary Care, University Medical Center Utrecht,
Utrecht University, The Netherlands
- Department of Anaesthesiology,
University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Hendrik M Nathoe
- Department of Cardiology, University
Medical Center Utrecht, Utrecht University, The Netherlands
| | - Wilton A van Klei
- Department of Anaesthesiology,
University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Diederick E Grobbee
- Department of Epidemiology, Julius
Center for Health Sciences and Primary Care, University Medical Center Utrecht,
Utrecht University, The Netherlands
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Ladha K, Beattie W, Tait G, Wijeysundera D. Association between preoperative ambulatory heart rate and postoperative myocardial injury: a retrospective cohort study. Br J Anaesth 2018; 121:722-729. [DOI: 10.1016/j.bja.2018.06.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/28/2018] [Accepted: 06/17/2018] [Indexed: 11/30/2022] Open
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Nyame YA, Abelson B, Khanna A, Menon V, Klein EA, Goldman HB. Perioperative Troponin is a Predictor of Both Short- and Intermediate-term Mortality Among Patients Undergoing Major Urologic Surgery. Urology 2018; 123:108-113. [PMID: 30201299 DOI: 10.1016/j.urology.2018.06.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 06/12/2018] [Accepted: 06/17/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To determine whether a positive troponin is a predictor of intermediate- and long-term mortality in patients undergoing major urologic surgeries at our institution. METHODS This is a retrospective analysis of patients undergoing major urologic surgery at the Cleveland Clinic from 2010-2015. Patients were stratified by the presence and maximum value of troponin blood-draw, if performed within 30 days of surgery. Survival analysis was performed using Kaplan-Meier function (univariate) and Cox regression analysis (continuous) to assess mortality risk. RESULTS Within 30 days of surgery, 1305 (15.5%) patients a troponin drawn, and 304 (3.6%) of them had an abnormal troponin level (>0.01 ng/mL). Patients with positive troponin drawn for cause within 30 days of surgery had a significantly decreased overall survival at 5 years of 70.6% (95% CI 62.6, 77.2) when compared to patients with negative troponin (81.7% [95% CI 77.4, 85.3]) and no troponin drawn (90.4% [95% CI 89.0, 91.6]). CONCLUSION For cause serum troponin blood draw and peak levels demonstrated a positive correlation with all-cause mortality in patients undergoing major urologic surgeries Prospective studies are needed to better understand the utility of postoperative troponin as predictive marker of mortality.
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Affiliation(s)
- Yaw A Nyame
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH.
| | - Benjamin Abelson
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Abhinav Khanna
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Venu Menon
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Eric A Klein
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Howard B Goldman
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
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Yang HS, Hur M, Yi A, Kim H, Kim J. Prognostic Role of High-sensitivity Cardiac Troponin I and Soluble Suppression of Tumorigenicity-2 in Surgical Intensive Care Unit Patients Undergoing Non-cardiac Surgery. Ann Lab Med 2018; 38:204-211. [PMID: 29401554 PMCID: PMC5820064 DOI: 10.3343/alm.2018.38.3.204] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 11/29/2017] [Accepted: 12/26/2017] [Indexed: 12/22/2022] Open
Abstract
Background The prognostic utility of cardiac biomarkers, high-sensitivity cardiac troponin I (hs-cTnI) and soluble suppression of tumorigenicity-2 (sST2), in non-cardiac surgery is not well-defined. We evaluated hs-cTnI and sST2 as predictors of 30-day major adverse cardiac events (MACE) in patients admitted to the surgical intensive care unit (SICU) following major non-cardiac surgery. Methods hs-cTnI and sST2 concentrations were measured in 175 SICU patients immediately following surgery and for three days postoperatively. The results were analyzed in relation to 30-day MACE and were compared with the revised Goldman cardiac risk index (RCRI) score. Results Overall, 30-day MACE was observed in 16 (9.1%) patients. hs-cTnI and sST2 concentrations differed significantly between the two groups with and without 30-day MACE (P<0.05). The maximum concentration of sST2 was an independent predictor of 30-day MACE (odds ratio=1.016, P=0.008). The optimal cut-off values of hs-cTnI and sST2 for predicting 30-day MACE were 53.0 ng/L and 182.5 ng/mL, respectively. A combination of hs-cTnI and sST2 predicted 30-day MACE better than the RCRI score. Moreover, 30-day MACE was observed more frequently with increasing numbers of above-optimal cut-off hs-cTnI and sST2 values (P<0.0001). Reclassification analyses indicated that the addition of biomarkers to RCRI scores improved the prediction of 30-day MACE. Conclusions This study demonstrates the utility of hs-cTnI and sST2 in predicting 30-day MACE following non-cardiac surgery. Cardiac biomarkers would provide enhanced risk stratification in addition to clinical RCRI scores for patients undergoing major non-cardiac surgery.
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Affiliation(s)
- Hyun Suk Yang
- Department of Cardiovascular Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Mina Hur
- Department of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Korea.
| | - Ahram Yi
- Department of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Hanah Kim
- Department of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Jayoun Kim
- Research Coordinating Center, Konkuk University Medical Center, Seoul, Korea
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Abstract
To successfully deliver greater perioperative value-based care and to effectively contribute to sustained and meaningful perioperative population health management, the scope of existing preoperative management and its associated services and care provider skills must be expanded. New models of preoperative management are needed, which rely extensively on continuously evolving evidence-based best practice, as well as telemedicine and telehealth, including mobile technologies and connectivity. Along with conventional comorbidity optimization, prehabilitation can effectively promote enhanced postoperative recovery. This article focuses on the opportunities and mechanisms for delivering value-based, comprehensive preoperative assessment and global optimization of the surgical patient.
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Affiliation(s)
- Neil N Shah
- Department of Medicine, Dell Medical School, The University of Texas at Austin, Health Discovery Building, 1701 Trinity Street, Austin, TX 78712-1875, USA
| | - Thomas R Vetter
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Health Discovery Building, Room 6.812, 1701 Trinity Street, Austin, TX 78712-1875, USA; Department of Population Health, Dell Medical School, The University of Texas at Austin, Health Discovery Building, Room 6.812, 1701 Trinity Street, Austin, TX 78712-1875, USA.
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Ischemia and perioperative infarction. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2018. [DOI: 10.1097/cj9.0000000000000044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] Open
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Abstract
Purpose of Review The central question of preoperative assessment is not “What can be done?” but “What should be done and how?” Predicting a patient’s risk of unwanted outcomes is vital to answering this question. This review discusses risk prediction tools currently available and anticipates future developments. Recent Findings Simple, parsimonious risk scales and scores are being replaced by complex risk prediction models as high-capacity information systems become ubiquitous. The accuracy of risk estimation will be further increased by improved assessment of physical fitness, frailty, and incorporation of existing and novel biomarkers. However, the limitations of risk prediction for individual patient care must be recognized. Summary Risk prediction is transforming from clinical estimation to statistical science. Predictions should be used within the context of a patient’s baseline risk (life expectancy independent of surgery), personal circumstances, quality of life, their expectations and values, and consideration of outcomes that are meaningful for the patient.
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Affiliation(s)
- Pragya Ajitsaria
- 1Department of Anaesthesia & Perioperative Medicine, John Hunter Hospital, Locked Bag 1 HRMC, Newcastle, NSW 2310 Australia.,2University of Newcastle, Newcastle, NSW Australia
| | - Sabry Z Eissa
- 1Department of Anaesthesia & Perioperative Medicine, John Hunter Hospital, Locked Bag 1 HRMC, Newcastle, NSW 2310 Australia.,2University of Newcastle, Newcastle, NSW Australia
| | - Ross K Kerridge
- 1Department of Anaesthesia & Perioperative Medicine, John Hunter Hospital, Locked Bag 1 HRMC, Newcastle, NSW 2310 Australia.,2University of Newcastle, Newcastle, NSW Australia
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Activation of Endocannabinoid Receptor 2 as a Mechanism of Propofol Pretreatment-Induced Cardioprotection against Ischemia-Reperfusion Injury in Rats. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2017; 2017:2186383. [PMID: 28814985 PMCID: PMC5549482 DOI: 10.1155/2017/2186383] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 04/20/2017] [Accepted: 04/30/2017] [Indexed: 01/16/2023]
Abstract
Propofol pretreatment before reperfusion, or propofol conditioning, has been shown to be cardioprotective, while its mechanism is unclear. The current study investigated the roles of endocannabinoid signaling in propofol cardioprotection in an in vivo model of myocardial ischemia/reperfusion (I/R) injury and in in vitro primary cardiomyocyte hypoxia/reoxygenation (H/R) injury. The results showed that propofol conditioning increased both serum and cell culture media concentrations of endocannabinoids including anandamide (AEA) and 2-arachidonoylglycerol (2-AG) detected by LC-MS/MS. The reductions of myocardial infarct size in vivo and cardiomyocyte apoptosis and death in vitro were accompanied with attenuations of oxidative injuries manifested as decreased reactive oxygen species (ROS), malonaldehyde (MDA), and MPO (myeloperoxidase) and increased superoxide dismutase (SOD) production. These effects were mimicked by either URB597, a selective endocannabinoids degradation inhibitor, or VDM11, a selective endocannabinoids reuptake inhibitor. In vivo study further validated that the cardioprotective and antioxidative effects of propofol were reversed by selective CB2 receptor antagonist AM630 but not CB1 receptor antagonist AM251. We concluded that enhancing endogenous endocannabinoid release and subsequent activation of CB2 receptor signaling represent a major mechanism whereby propofol conditioning confers antioxidative and cardioprotective effects against myocardial I/R injury.
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Liu YY, Xue FS, Li HX, Yang GZ. Is acute kidney injury really a detrimental factor of myocardial injury after noncardiac surgery in critical patients? J Crit Care 2017; 42:116. [PMID: 28711862 DOI: 10.1016/j.jcrc.2017.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 07/08/2017] [Indexed: 11/24/2022]
Affiliation(s)
- Ya-Yang Liu
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fu-Shan Xue
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Hui-Xian Li
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Gui-Zhen Yang
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Optimizing patients undergoing surgery (OPUS): Part II - still a matter of 'eminence-based medicine'? Curr Opin Anaesthesiol 2017; 30:390-391. [PMID: 28346231 DOI: 10.1097/aco.0000000000000474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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