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Loosen G, Taboada D, Ortmann E, Martinez G. How Would I Treat My Own Chronic Thromboembolic Pulmonary Hypertension in the Perioperative Period? J Cardiothorac Vasc Anesth 2024; 38:884-894. [PMID: 37716891 DOI: 10.1053/j.jvca.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 07/04/2023] [Accepted: 07/14/2023] [Indexed: 09/18/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) results from an incomplete resolution of acute pulmonary embolism, leading to occlusive organized thrombi, vascular remodeling, and associated microvasculopathy with pulmonary hypertension (PH). A definitive CTEPH diagnosis requires PH confirmation by right-heart catheterization and evidence of chronic thromboembolic pulmonary disease on imaging studies. Surgical removal of the organized fibrotic material by pulmonary endarterectomy (PEA) under deep hypothermic circulatory arrest represents the treatment of choice. One-third of patients with CTEPH are not deemed suitable for surgical treatment, and medical therapy or interventional balloon pulmonary angioplasty presents alternative treatment options. Pulmonary endarterectomy in patients with technically operable disease significantly improves symptoms, functional capacity, hemodynamics, and quality of life. Perioperative mortality is <2.5% in expert centers where a CTEPH multidisciplinary team optimizes patient selection and ensures the best preoperative optimization according to individualized risk assessment. Despite adequate pulmonary artery clearance, patients might be prone to perioperative complications, such as right ventricular maladaptation, airway bleeding, or pulmonary reperfusion injury. These complications can be treated conventionally, but extracorporeal membrane oxygenation has been included in their management recently. Patients with residual PH post-PEA should be considered for medical or percutaneous interventional therapy.
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Affiliation(s)
- Gregor Loosen
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Dolores Taboada
- Pulmonary Vascular Diseases Unit, Cambridge National Pulmonary Hypertension Service, Royal Papworth Hospital NHS, Department of Cardiothoracic Anesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Erik Ortmann
- Department of Anesthesiology, Schuechtermann-Heart-Centre, Bad Rothenfelde, Germany
| | - Guillermo Martinez
- Pulmonary Vascular Diseases Unit, Cambridge National Pulmonary Hypertension Service, Royal Papworth Hospital NHS, Department of Cardiothoracic Anesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom.
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F. Mostafa M, Ahmad Ibrahim Elmorabaa H, Mahmoud Mostafa M, Mostafa Abd El Gawad R, Ismail Seddik M, Herdan R, Hassanien Bakr M, Zarief Kamel E. Effects of preoperative intravenous glutamine administration on cardiac and renal functions in patients undergoing mitral valve replacement surgeries: A randomized double-blind controlled trial. EGYPTIAN JOURNAL OF ANAESTHESIA 2023. [DOI: 10.1080/11101849.2023.2180571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Affiliation(s)
- Mohamed F. Mostafa
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
| | | | | | | | - Mohamed Ismail Seddik
- Department of Clinical Pathology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ragaa Herdan
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mostafa Hassanien Bakr
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Emad Zarief Kamel
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
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Lurati Buse G, Bollen Pinto B, Abelha F, Abbott TEF, Ackland G, Afshari A, De Hert S, Fellahi JL, Giossi L, Kavsak P, Longrois D, M'Pembele R, Nucaro A, Popova E, Puelacher C, Richards T, Roth S, Sheka M, Szczeklik W, van Waes J, Walder B, Chew MS. ESAIC focused guideline for the use of cardiac biomarkers in perioperative risk evaluation. Eur J Anaesthesiol 2023; 40:888-927. [PMID: 37265332 DOI: 10.1097/eja.0000000000001865] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND In recent years, there has been increasing focus on the use of cardiac biomarkers in patients undergoing noncardiac surgery. AIMS The aim of this focused guideline was to provide updated guidance regarding the pre-, post- and combined pre-and postoperative use of cardiac troponin and B-type natriuretic peptides in adult patients undergoing noncardiac surgery. METHODS The guidelines were prepared using Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology. This included the definition of critical outcomes, a systematic literature search, appraisal of certainty of evidence, evaluation of biomarker measurement in terms of the balance of desirable and undesirable effects including clinical outcomes, resource use, health inequality, stakeholder acceptance, and implementation. The panel differentiated between three different scopes of applications: cardiac biomarkers as prognostic factors, as tools for risk prediction, and for biomarker-enhanced management strategies. RESULTS In a modified Delphi process, the task force defined 12 critical outcomes. The systematic literature search resulted in over 25,000 hits, of which 115 full-text articles formed the body of evidence for recommendations. The evidence appraisal indicated heterogeneity in the certainty of evidence across critical outcomes. Further, there was relevant gradient in the certainty of evidence across the three scopes of application. Recommendations were issued and if this was not possible due to limited evidence, clinical practice statements were produced. CONCLUSION The ESAIC focused guidelines provide guidance on the perioperative use of cardiac troponin and B-type natriuretic peptides in patients undergoing noncardiac surgery, for three different scopes of application.
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Affiliation(s)
- Giovanna Lurati Buse
- From the Department of Anaesthesiology, University Hospital Dusseldorf, Dusseldorf, Germany (GLB, RMP, AN, SR), Division of Anaesthesiology, Geneva University Hospitals (HUG), Geneva, Switzerland (BBP, MS, BW), Department of Anesthesiology, Centro Hospitalar Universitário de São João, Porto, Portugal (FA), Cardiovascular Research and Development Center (UnIC@RISE), Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal (FA), William Harvey Research Institute, Queen Mary University of London, London, UK (TEA, GA), Department of Anaesthesia and Perioperative Medicine, Royal London Hospital, Barts Health NHS Trust, London, UK (GA), Department of Paediatric and Obstetric Anaesthesia, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Denmark (AA), Department of Anaesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium (SDH), Service d'Anesthésie-Réanimation, Hôpital Universitaire Louis Pradel, Hospices Civils de Lyon, 59 boulevard Pinel, 69500 Lyon, France (J-LF), "Patients as Partners" program, Geneva University Hospitals (HUG), Geneva, Switzerland (LG), Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada (PK), Department of Anesthesiology and Intensive Care, Bichat Claude-Bernard Hospital, Assistance Publique-Hopitaux de Paris - Nord, University of Paris, INSERM U1148, Paris, France (DL), Institut d'Investigació Biomèdica Sant Pau (IIB SANT PAU), Barcelona, Spain (EP), Centro Cochrane Iberoamericano, Barcelona, Spain (EP), Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel-Stadt, Switzerland (CP), Department of Internal Medicine, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Basel-Stadt, Switzerland (CP), Division of Surgery, University of Western Australia, Perkins South Building, Fiona Stanley Hospital, Murdoch, Perth, WA, Australia (TR), Institute of Clinical Trials and Methodology and Division of Surgery, University College London, UK (TR), Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland (WS), Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (JvW), Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University Hospital, Sweden (MSC)
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Ramasco Rueda F, Planas Roca A, Méndez Hernández R, Figuerola Tejerina A, Tamayo Gómez E, Garcia Bernedo C, Maseda Garrido E, Pascual Gómez NF, de la Varga-Martínez O. Usefulness of Preoperative Determination of Serum MR-ProAdrenomedullin Levels to Predict the Need for Postoperative Organ Support in Abdominal Oncological Surgery. J Pers Med 2023; 13:1151. [PMID: 37511765 PMCID: PMC10381245 DOI: 10.3390/jpm13071151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/10/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
The need for postoperative organic support is associated with patient outcomes. Biomarkers may be useful for detecting patients at risk. MR-ProADM is a novel biomarker with an interesting profile that can be used in this context. The main objective of this study was to verify whether there was an association between the preoperative serum levels of MR-ProADM and the need for organic support after elective abdominal cancer surgery, and to determine the preoperative MR-ProADM value that predicts the need for postoperative organic support. This was a multicenter prospective observational study conducted by four tertiary hospitals in Spain between 2017 and 2018. Plasma samples were collected for the quantification of MR-ProADM from adults who underwent major abdominal surgery during 2017-2018. The primary outcome was the need for organic support in the first seven postoperative days and its association with the preoperative levels of MR-ProADM, and the secondary outcome was the preoperative levels of MR-ProADM in the study population. This study included 370 patients with a mean age of 67.4 ± 12.9 years. Seventeen percent (63 patients) required some postoperative organic support measures in the first week. The mean preoperative value of MR-ProADM in patients who required organic support was 1.16 ± 1.15 nmol/L. The AUC-ROC of the preoperative MR-ProADM values associated with the need for organic support was 0.67 (95% CI: 0.59-0.75). The preoperative MR-ProADM value, which showed the best compromise in sensitivity and specificity for predicting the need for organic support, was 0.70 nmol/L. The negative predictive value was 91%. A multivariate analysis confirmed that a preoperative level of MR-ProADM ≥ 0.70 nmol/L is an independent factor associated with risk of postoperative organic support (OR 2, 6). Elevated preoperative MR-ProADM levels are associated with the need for postoperative organic support. Therefore, MR-ProADM may be a useful biomarker for perioperative risk assessment.
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Affiliation(s)
- Fernando Ramasco Rueda
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de la Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Antonio Planas Roca
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de la Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Rosa Méndez Hernández
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de la Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Angels Figuerola Tejerina
- Departament of Preventive Medicine and Public Health, Hospital Universitario de la Princesa, Diego de Leon 62, 28006 Madrid, Spain
| | - Eduardo Tamayo Gómez
- Teaching Unit of Anesthesiology and Critical Pathology, Faculty of Medicine, University of Valladolid, 47003 Valladolid, Spain
- Departament Anesthesiology and Surgical Intensive Care, Valladolid University Clinical Hospital, 47003 Valladolid, Spain
| | - Carlos Garcia Bernedo
- Department of Anaesthesiology and Surgical Intensive Care, Hospital del Mar, Passeig Marítim 25-29, 08003 Barcelona, Spain
| | - Emilio Maseda Garrido
- Department of Anaesthesiology and Surgical Intensive Care, Hospital QuirónSalud Valle del Henares, Constitution Avenue, 249, Torrejon de Ardoz, 28850 Madrid, Spain
| | - Natalia F Pascual Gómez
- Departament of Clinical Analysis, Hospital Universitario de la Princesa, Diego de Leon 62, 28006 Madrid, Spain
| | - Olga de la Varga-Martínez
- Department of Anaesthesiology, Infanta Leonor University Hospital, Gran Via del Este 80, 28031 Madrid, Spain
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Méndez Hernández R, Ramasco Rueda F. Biomarkers as Prognostic Predictors and Therapeutic Guide in Critically Ill Patients: Clinical Evidence. J Pers Med 2023; 13:jpm13020333. [PMID: 36836567 PMCID: PMC9965041 DOI: 10.3390/jpm13020333] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/13/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023] Open
Abstract
A biomarker is a molecule that can be measured in a biological sample in an objective, systematic, and precise way, whose levels indicate whether a process is normal or pathological. Knowing the most important biomarkers and their characteristics is the key to precision medicine in intensive and perioperative care. Biomarkers can be used to diagnose, in assessment of disease severity, to stratify risk, to predict and guide clinical decisions, and to guide treatments and response to them. In this review, we will analyze what characteristics a biomarker should have and how to ensure its usefulness, and we will review the biomarkers that in our opinion can make their knowledge more useful to the reader in their clinical practice, with a future perspective. These biomarkers, in our opinion, are lactate, C-Reactive Protein, Troponins T and I, Brain Natriuretic Peptides, Procalcitonin, MR-ProAdrenomedullin and BioAdrenomedullin, Neutrophil/lymphocyte ratio and lymphopenia, Proenkephalin, NefroCheck, Neutrophil gelatinase-associated lipocalin (NGAL), Interleukin 6, Urokinase-type soluble plasminogen activator receptor (suPAR), Presepsin, Pancreatic Stone Protein (PSP), and Dipeptidyl peptidase 3 (DPP3). Finally, we propose an approach to the perioperative evaluation of high-risk patients and critically ill patients in the Intensive Care Unit (ICU) based on biomarkers.
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Vernooij LM, van Klei WA, Moons KG, Takada T, van Waes J, Damen JA. The comparative and added prognostic value of biomarkers to the Revised Cardiac Risk Index for preoperative prediction of major adverse cardiac events and all-cause mortality in patients who undergo noncardiac surgery. Cochrane Database Syst Rev 2021; 12:CD013139. [PMID: 34931303 PMCID: PMC8689147 DOI: 10.1002/14651858.cd013139.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The Revised Cardiac Risk Index (RCRI) is a widely acknowledged prognostic model to estimate preoperatively the probability of developing in-hospital major adverse cardiac events (MACE) in patients undergoing noncardiac surgery. However, the RCRI does not always make accurate predictions, so various studies have investigated whether biomarkers added to or compared with the RCRI could improve this. OBJECTIVES Primary: To investigate the added predictive value of biomarkers to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery. Secondary: To investigate the prognostic value of biomarkers compared to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery. Tertiary: To investigate the prognostic value of other prediction models compared to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery. SEARCH METHODS We searched MEDLINE and Embase from 1 January 1999 (the year that the RCRI was published) until 25 June 2020. We also searched ISI Web of Science and SCOPUS for articles referring to the original RCRI development study in that period. SELECTION CRITERIA We included studies among adults who underwent noncardiac surgery, reporting on (external) validation of the RCRI and: - the addition of biomarker(s) to the RCRI; or - the comparison of the predictive accuracy of biomarker(s) to the RCRI; or - the comparison of the predictive accuracy of the RCRI to other models. Besides MACE, all other adverse outcomes were considered for inclusion. DATA COLLECTION AND ANALYSIS We developed a data extraction form based on the CHARMS checklist. Independent pairs of authors screened references, extracted data and assessed risk of bias and concerns regarding applicability according to PROBAST. For biomarkers and prediction models that were added or compared to the RCRI in ≥ 3 different articles, we described study characteristics and findings in further detail. We did not apply GRADE as no guidance is available for prognostic model reviews. MAIN RESULTS We screened 3960 records and included 107 articles. Over all objectives we rated risk of bias as high in ≥ 1 domain in 90% of included studies, particularly in the analysis domain. Statistical pooling or meta-analysis of reported results was impossible due to heterogeneity in various aspects: outcomes used, scale by which the biomarker was added/compared to the RCRI, prediction horizons and studied populations. Added predictive value of biomarkers to the RCRI Fifty-one studies reported on the added value of biomarkers to the RCRI. Sixty-nine different predictors were identified derived from blood (29%), imaging (33%) or other sources (38%). Addition of NT-proBNP, troponin or their combination improved the RCRI for predicting MACE (median delta c-statistics: 0.08, 0.14 and 0.12 for NT-proBNP, troponin and their combination, respectively). The median total net reclassification index (NRI) was 0.16 and 0.74 after addition of troponin and NT-proBNP to the RCRI, respectively. Calibration was not reported. To predict myocardial infarction, the median delta c-statistic when NT-proBNP was added to the RCRI was 0.09, and 0.06 for prediction of all-cause mortality and MACE combined. For BNP and copeptin, data were not sufficient to provide results on their added predictive performance, for any of the outcomes. Comparison of the predictive value of biomarkers to the RCRI Fifty-one studies assessed the predictive performance of biomarkers alone compared to the RCRI. We identified 60 unique predictors derived from blood (38%), imaging (30%) or other sources, such as the American Society of Anesthesiologists (ASA) classification (32%). Predictions were similar between the ASA classification and the RCRI for all studied outcomes. In studies different from those identified in objective 1, the median delta c-statistic was 0.15 and 0.12 in favour of BNP and NT-proBNP alone, respectively, when compared to the RCRI, for the prediction of MACE. For C-reactive protein, the predictive performance was similar to the RCRI. For other biomarkers and outcomes, data were insufficient to provide summary results. One study reported on calibration and none on reclassification. Comparison of the predictive value of other prognostic models to the RCRI Fifty-two articles compared the predictive ability of the RCRI to other prognostic models. Of these, 42% developed a new prediction model, 22% updated the RCRI, or another prediction model, and 37% validated an existing prediction model. None of the other prediction models showed better performance in predicting MACE than the RCRI. To predict myocardial infarction and cardiac arrest, ACS-NSQIP-MICA had a higher median delta c-statistic of 0.11 compared to the RCRI. To predict all-cause mortality, the median delta c-statistic was 0.15 higher in favour of ACS-NSQIP-SRS compared to the RCRI. Predictive performance was not better for CHADS2, CHA2DS2-VASc, R2CHADS2, Goldman index, Detsky index or VSG-CRI compared to the RCRI for any of the outcomes. Calibration and reclassification were reported in only one and three studies, respectively. AUTHORS' CONCLUSIONS Studies included in this review suggest that the predictive performance of the RCRI in predicting MACE is improved when NT-proBNP, troponin or their combination are added. Other studies indicate that BNP and NT-proBNP, when used in isolation, may even have a higher discriminative performance than the RCRI. There was insufficient evidence of a difference between the predictive accuracy of the RCRI and other prediction models in predicting MACE. However, ACS-NSQIP-MICA and ACS-NSQIP-SRS outperformed the RCRI in predicting myocardial infarction and cardiac arrest combined, and all-cause mortality, respectively. Nevertheless, the results cannot be interpreted as conclusive due to high risks of bias in a majority of papers, and pooling was impossible due to heterogeneity in outcomes, prediction horizons, biomarkers and studied populations. Future research on the added prognostic value of biomarkers to existing prediction models should focus on biomarkers with good predictive accuracy in other settings (e.g. diagnosis of myocardial infarction) and identification of biomarkers from omics data. They should be compared to novel biomarkers with so far insufficient evidence compared to established ones, including NT-proBNP or troponins. Adherence to recent guidance for prediction model studies (e.g. TRIPOD; PROBAST) and use of standardised outcome definitions in primary studies is highly recommended to facilitate systematic review and meta-analyses in the future.
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Affiliation(s)
- Lisette M Vernooij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Wilton A van Klei
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Anesthesiologist and R. Fraser Elliott Chair in Cardiac Anesthesia, Department of Anesthesia and Pain Management Toronto General Hospital, University Health Network and Professor, Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Karel Gm Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Judith van Waes
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Johanna Aag Damen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Ganesh R, Kebede E, Mueller M, Gilman E, Mauck KF. Perioperative Cardiac Risk Reduction in Noncardiac Surgery. Mayo Clin Proc 2021; 96:2260-2276. [PMID: 34226028 DOI: 10.1016/j.mayocp.2021.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 02/20/2021] [Accepted: 03/04/2021] [Indexed: 11/21/2022]
Abstract
Major adverse cardiovascular events are a significant source of morbidity and mortality in the perioperative setting, estimated to occur in approximately 5% of patients undergoing nonemergent noncardiac surgery. To minimize the incidence and impact of these events, careful attention must be paid to preoperative cardiovascular assessment to identify patients at high risk of cardiovascular complications. Once identified, cardiovascular risk reduction is achieved through optimization of medical conditions, appropriate management of medication, and careful monitoring to allow for early identification of-and intervention for-any new conditions that would increase the risk of adverse cardiovascular outcomes. The major cardiovascular and anesthesiology societies in the United States, Europe, and Canada have published guidelines for perioperative management of patients undergoing noncardiac surgery. However, since publication of these guidelines, there has been a practice-changing evolution in the medical literature. In this review, we attempt to reconcile the recommendations made in these 3 comprehensive guidelines, while updating recommendations, based on new evidence, when available.
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Affiliation(s)
- Ravindra Ganesh
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN.
| | - Esayas Kebede
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Michael Mueller
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Elizabeth Gilman
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Karen F Mauck
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
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Khurshaidi MN, Waqar A, Asghar MS, Kiran A, Tariq A, Kanwal N, Jawed R, Rasheed U, Hassan M, Mazhar A. Prognostic Value of Preoperative Pro-B-Type Natriuretic Peptide: Early Predictor of Cardiovascular Complications and Mortality After Major Abdominal Surgery. Cureus 2020; 12:e11338. [PMID: 33304674 PMCID: PMC7719483 DOI: 10.7759/cureus.11338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background and objectives In surgical patients, coronary disease is the main cause of perioperative mortality. The incidence of serious cardiovascular complications is reported as 5% with a probability of 1-2% of death from the cardiac cause in major non-cardiac surgery. B-type natriuretic peptide (BNP) is a sensitive and specific predictor of left ventricular systolic dysfunction and predicts first cardiovascular event and death in the general population. The recent guidelines recommended the use of pro-BNP for independent perioperative prognosis in cardiac patients undergoing non-cardiac surgery. The aim of this study is to assess the predictive value of raised pro-BNP levels in patients who underwent major abdominal surgery and evaluate its relationship with cardiovascular complications and mortality occurring up to 30 days after surgery. Materials and methods We reviewed the medical records of patients undergone surgical procedures in the abdominal region lasting more than two hours, requiring postoperative high dependence or intensive care and an expected hospital stay of at least three days. All types of open or laparoscopic-assisted abdominal or pelvic surgeries that were evaluated for preoperative pro-BNP levels were included in the study. During the postoperative period, all patients were followed for cardiac complications and mortality for 30 days after surgery. Postoperative adverse cardiac events were predefined as angina pectoris, myocardial infarction, cardiogenic dyspnea, acute arrhythmias (atrial fibrillation/flutter, ventricular fibrillation/tachycardia), acute hypertensive event (hypertensive emergency or urgency), congestive heart failure, acute pulmonary edema, or primary cardiac death. While non-cardiac complications were also documented as either pulmonary, septic, postsurgical site infection, and other systemic complications. Subsequently, a survival analysis was done for the discretion of cardiovascular complications and mortality. Results The mean age of the study population was found to be 50.22 ± 14.28 years, mean pro-BNP levels were 909.29 ± 3950.04, and mean days of hospital stay were 7.43 ± 4.49 days. The 30-day postoperative all-cause mortality was found to be 9.8%. Hypertension and diabetes were frequent comorbidities amongst the study population. The mean preoperative pro-BNP levels were found higher in the male gender (p=0.071), also found higher in those with cardiovascular complications (p=0.006) and mortality (p=0.057). Receiver operating characteristic (ROC) analysis showed cardiovascular outcomes with a cut-off value of pro-BNP at 143 pg/ml, AUC of 0.891, at a sensitivity of 91%, positive predictive value (PPV) of 96%, a specificity of 75%, and negative predictive value (NPV) of 58%, while the same for mortality at a cut-off value of 164 pg/ml was found with AUC of 0.815, at a sensitivity of 84%, a specificity of 66%, PPV of 97%, and NPV of 21%. The unadjusted odds ratio for cardiovascular complications was found to be 17.857 (95% CI: 6.56-48.60) while that for mortality was 10.863 (95% Cl: 2.29-51.37). The Kaplan-Meier survival curves showing elevated pro-BNP levels were significantly associated with cardiovascular events, with 30 days mortality at a cut-off value of 164 pg/ml. Conclusion Pro-BNP is a useful marker in postoperative patients for not only predicting cardiovascular outcomes as cited by many previous studies but also mortality.
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Affiliation(s)
| | - Asad Waqar
- General Surgery, Liaquat National Hospital, Karachi, PAK
| | | | - Afshan Kiran
- Internal Medicine, Shaheed Mohtarma Benazir Bhutto Medical College, Lyari General Hospital, Karachi, PAK
| | - Asma Tariq
- General Surgery, Liaquat National Hospital, Karachi, PAK
| | - Noureen Kanwal
- General Surgery, Liaquat National Hospital, Karachi, PAK
| | - Rumael Jawed
- Internal Medicine, Liaquat National Hospital, Karachi, PAK
| | - Uzma Rasheed
- Internal Medicine, Liaquat National Hospital, Karachi, PAK
| | - Maira Hassan
- Internal Medicine, Liaquat National Hospital, Karachi, PAK
| | - Anees Mazhar
- Orthopaedics, Liaquat National Hospital, Karachi, PAK
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Usefulness of computer-assisted ECG analysis in the pre-operative evaluation of noncardiac surgery. Eur J Anaesthesiol 2020; 37:1075-1077. [PMID: 33027228 DOI: 10.1097/eja.0000000000001256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Smith NA, Batterham M, Peoples GE, Shulman MA. The clinical, functional and disability characteristics of patients with severe obesity presenting for non-bariatric surgery. Anaesth Intensive Care 2019; 47:522-531. [PMID: 31779477 DOI: 10.1177/0310057x19887976] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The clinical and functional characteristics of patients with severe obesity who present for non-bariatric surgery have rarely been described. For this study, 293 such patients (mean body mass index 42 kg/m2) were investigated using their medical records, a 6-minute walk test, N-terminal pro B-type natriuretic peptide measurement, and the World Health Organization Disability Assessment Schedule 2.0 measure of disability. Cardiorespiratory disease and diabetes were common, with blood tests revealing a high probability of additional unexpected and undiagnosed renal and cardiac disease in a significant proportion of patients. One-third of patients had natriuretic peptide values that identify early left ventricular dysfunction in the community, with 16% above a value described as useful in predicting adverse outcomes for elective surgical patients. Only 10% of patients walked a distance within 10% of that predicted in six minutes, and 22% did not complete the test. Over one-third of patients (34%) had a clinically significant level of disability, with those unable to walk for six minutes describing higher levels of disability. Functional capacity as measured by the 6-minute walk test was significantly lower than would be expected from age, gender, and weight alone, and was related to age and degree of disability but not body mass index. We describe a severely obese population presenting for non-bariatric surgery who had significant levels of comorbid disease, functional impairment, and disability that were not apparent on routine preoperative assessment.
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Affiliation(s)
- Natalie A Smith
- School of Medicine, University of Wollongong, Wollongong, Australia
| | - Marijka Batterham
- Statistical Consulting Centre, School of Mathematics and Applied Statistics, University of Wollongong, Wollongong, Australia
| | | | - Mark A Shulman
- Department of Anaesthesiology and Perioperative Medicine, The Alfred Hospital and Monash University, Melbourne, Australia
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Pre-Operative pro-adrenomedullin as a predictor of postoperative requirement of organ support in patients scheduled for major abdominal surgery. A prospective observational pilot study. ACTA ACUST UNITED AC 2019; 67:8-14. [PMID: 31757431 DOI: 10.1016/j.redar.2019.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 09/05/2019] [Accepted: 10/02/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Mid-Regional-Pro-Adrenomedullin (MR-Pro-ADM) is a marker of severity in a wide spectrum of pathological conditions such as sepsis, and cardiovascular dysfunction. Its usefulness as a predictor of morbidity and mortality in surgical patients has yet to be elucidated. We examined the ability of preoperative MR-Pro-ADM in predicting Postoperative Requirement of Organ Support (PROS). METHODS One centre, pilot, prospective observational cohort study, enrolling adult patients scheduled for major abdominal surgery. The accuracy of the MR-Pro-ADM to predict PROS was determined by area under the receiver operating characteristic curve (AUROC) analysis. An univariate analysis was performed to identify the association of PROS and the MR-Pro-ADM value with the best combination of sensitivity and specificity. A multivariate analysis was performed to identify preoperative MR-Pro-ADM as independent risk factor for PROS. RESULTS A total of 59 patients scheduled for major abdominal surgery were enrolled. The incidence of PROS was 13.6%. The association of MR-Pro-ADM levels with the incidence of PROS, was determined by an area under the ROC curve of 0.85 (95% CI: 0.74-0.96, p=0.002). The preoperative value of MR-Pro-ADM with the best combination of sensitivity and specificity to predict PROS was 0.87 nmol/l. Patients with preoperative serum levels of MR-Pro-ADM≥0.87 nmol/l had a significantly higher incidence of PROS (33.3% vs 4.9%, p=0.007). MR-Pro-ADM≥0.87 nmol/l was shown to be an independent risk factor for PROS (p=0.001; OR 9.758; IC 1.73-54.78) in the multivariate analysis. CONCLUSION The preoperative serum level of MR-Pro-ADM may be a useful biomarker of perioperative risk and to predict postoperative requirement of organic support (PROS) in adult patients scheduled for major abdominal surgery.
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Parker DM, Everett AD, Stabler ME, Leyenaar J, Vricella L, Jacobs JP, Thiessen-Philbrook H, Parikh C, Greenberg JH, Brown JR. The Association Between Cardiac Biomarker NT-proBNP and 30-Day Readmission or Mortality After Pediatric Congenital Heart Surgery. World J Pediatr Congenit Heart Surg 2019; 10:446-453. [PMID: 31307305 DOI: 10.1177/2150135119842864] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Very little is known about clinical and biomarker predictors of readmissions following pediatric congenital heart surgery. The cardiac biomarker N-terminal pro-brain natriuretic peptide (NT-proBNP) can help predict readmission in adult populations, but the estimated utility in predicting risk of readmission or mortality after pediatric congenital heart surgery has not previously been studied. Our objective was to evaluate the association between pre- and postoperative serum biomarker levels and 30-day readmission or mortality for pediatric patients undergoing congenital heart surgery. METHODS We measured pre- and postoperative NT-proBNP levels in two prospective cohorts of 522 pediatric patients <18 years of age who underwent at least one congenital heart operation from 2010 to 2014. Blood samples were collected before and after surgery. We evaluated the association between pre- and postoperative NT-proBNP with readmission or mortality within 30 days of discharge, using multivariate logistic regression, adjusting for covariates based on the Society of Thoracic Surgeons (STS) Congenital Heart Surgery Mortality Risk Model. RESULTS The Johns Hopkins Children's Center cohort and the Translational Research Investigating Biomarker Endpoints in Acute Kidney Injury (TRIBE-AKI) cohort demonstrate event rates of 12.9% and 9.4%, respectively, for the composite end point. After adjustment for covariates in the STS congenital risk model, we did not find an association between elevated levels of NT-proBNP and increased risk of readmission or mortality following congenital heart surgery for either cohort. CONCLUSIONS In our two cohorts, preoperative and postoperative values of NT-proBNP were not significantly associated with readmission or mortality following pediatric congenital heart surgery. These findings will inform future studies evaluating multimarker risk assessment models in the pediatric population.
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Affiliation(s)
- Devin M Parker
- 1 The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
| | - Allen D Everett
- 2 Division of Pediatric Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Meagan E Stabler
- 3 Department of Epidemiology, Geisel School of Medicine, Lebanon, NH, USA
| | - JoAnna Leyenaar
- 1 The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA.,4 Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Luca Vricella
- 2 Division of Pediatric Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeffrey P Jacobs
- 5 Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,6 Division of Cardiovascular Surgery, Department of Surgery Johns Hopkins All Children's Heart Institute, Johns Hopkins All Children's Hospital and Florida Hospital for Children, Saint Petersburg, Tampa, Orlando, FL, USA
| | | | - Chirag Parikh
- 7 Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jason H Greenberg
- 8 Section of Nephrology, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Jeremiah R Brown
- 1 The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA.,3 Department of Epidemiology, Geisel School of Medicine, Lebanon, NH, USA.,9 Department of Biomedical Data Science, Geisel School of Medicine, Lebanon, NH, USA
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Polineni S, Parker DM, Alam SS, Thiessen-Philbrook H, McArthur E, DiScipio AW, Malenka DJ, Parikh CR, Garg AX, Brown JR. Predictive Ability of Novel Cardiac Biomarkers ST2, Galectin-3, and NT-ProBNP Before Cardiac Surgery. J Am Heart Assoc 2018; 7:JAHA.117.008371. [PMID: 29982227 PMCID: PMC6064859 DOI: 10.1161/jaha.117.008371] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Current preoperative models use clinical risk factors alone in estimating risk of in-hospital mortality following cardiac surgery. However, novel biomarkers now exist to potentially improve preoperative prediction models. An assessment of Galectin-3, N-terminal pro b-type natriuretic peptide (NT-ProBNP), and soluble ST2 to improve the predictive ability of an existing prediction model of in-hospital mortality may improve our capacity to risk-stratify patients before surgery. METHODS AND RESULTS We measured preoperative biomarkers in the NNECDSG (Northern New England Cardiovascular Disease Study Group), a prospective cohort of 1554 patients undergoing coronary artery bypass graft surgery. Exposures of interest were preoperative levels of galectin-3, NT-ProBNP, and ST2. In-hospital mortality and adverse events occurring after coronary artery bypass graft were the outcomes. After adjustment, NT-ProBNP and ST2 showed a statistically significant association with both their median and third tercile categories with NT-ProBNP odds ratios of 2.89 (95% confidence interval [CI]: 1.04-8.05) and 5.43 (95% CI: 1.21-24.44) and ST2 odds ratios of 3.96 (95% CI: 1.60-9.82) and 3.21 (95% CI: 1.17-8.80), respectively. The model receiver operating characteristic score of the base prediction model (0.80 [95% CI: 0.72-0.89]) varied significantly from the new multi-marker model (0.85 [95% CI: 0.79-0.91]). Compared with the Northern New England (NNE) model alone, the full prediction model with biomarkers NT-proBNP and ST2 shows significant improvement in model classification of in-hospital mortality. CONCLUSIONS This study demonstrates a significant improvement of preoperative prediction of in-hospital mortality in patients undergoing coronary artery bypass graft and suggests that biomarkers can be used to identify patients at higher risk.
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Affiliation(s)
- Sai Polineni
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine, Lebanon, NH
| | - Devin M Parker
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine, Lebanon, NH
| | - Shama S Alam
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine, Lebanon, NH
| | | | - Eric McArthur
- Institute for Clinical Evaluative Sciences, Ontario, Canada
| | | | | | - Chirag R Parikh
- Program of Applied Translational Research, Yale School of Medicine, New Haven, CT
| | - Amit X Garg
- Institute for Clinical Evaluative Sciences, Ontario, Canada
| | - Jeremiah R Brown
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine, Lebanon, NH
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Reply to: association of increased N terminal B-type natriuretic propeptide levels with short-term adverse outcomes after noncardiac surgery. Eur J Anaesthesiol 2018; 34:107-108. [PMID: 28027208 DOI: 10.1097/eja.0000000000000554] [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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Can nonstandardised, simplified autonomic function tests be used for risk profiling in the anaesthesia population? Eur J Anaesthesiol 2017; 34:845-846. [PMID: 29087994 DOI: 10.1097/eja.0000000000000696] [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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Association of increased N terminal B-type natriuretic propeptide levels with short-term adverse outcomes after noncardiac surgery. Eur J Anaesthesiol 2017; 34:105-107. [DOI: 10.1097/eja.0000000000000562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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