Myocardial injury after noncardiac surgery-incidence and predictors from a prospective observational cohort study at an Indian tertiary care centre

ESAIC focused guideline for the use of cardiac biomarkers in perioperative risk evaluation

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.

Postoperative elevated cardiac troponin levels predict all-cause mortality and major adverse cardiovascular events following noncardiac surgery: A dose-response meta-analysis of prospective studies

STUDY OBJECTIVE

To perform a dose-response meta-analysis for the association between postoperative myocardial injury (PMI) in noncardiac surgery and the risk of all-cause mortality or major adverse cardiovascular event (MACE).

DESIGN

Dose-response meta-analysis of prospective studies with weighted (WL) or generalized (GL) linear and restricted cubic spline (RCS) regression.

SETTING

Teaching hospitals.

PATIENTS

Adult patients undergoing noncardiac surgery.

INTERVENTIONS

No.

MEASUREMENTS

The primary outcome was all-cause mortality. The secondary outcome was MACE.

MAIN RESULTS

29 studies (53,518 patients) were included. The overall incidence of PMI was 26.0% (95% CI 21.0% to 32.0%). Compared to those without PMI, patients with PMI had an increased risk of all-cause mortality at short- (<12 months) (cardiac troponin[cTn]I: unadj OR 1.71,95%CI 1.22 to 2.41, P < 0.001; cTnT: unadj OR 2.33,95%CI 2.07 to 2.63, P < 0.001), and long-term (≥ 12 months) (cTnI: unadj OR 1.80, 95%CI 1.63 to 1.99; cTnT: unadj OR 1.47,95%CI 1.33 to 1.62) (All P < 0.001) follow-up. For MACE, the group with elevated values was associated with an increased risk (cTnI: unadj OR 1.98, 95% CI 1.13 to 3.47, P = 0.018; cTnT: unadj OR 2.29, 95% CI 1.88 to 2.79, P < 0.001). Dose-response analysis showed positive associations between PMI (per 1× upper reference limit[URL] increment) and all-cause mortality both at short- (unadj OR) (WL, OR 1.09, 95% CI 1.09 to 1.10; GL, OR 1.06, 95% CI 1.06 to 1.07; RCS in the range of 1-2× URL, OR = 2.43, 95%CI 2.25 to 2.62) and long-term follow-up (unadj HR) (WL, OR 1.16, 95% CI 1.14 to 1.17; GL, OR 1.15, 95% CI 1.13 to 1.16; RCS in the range of 1-2.75× URL, OR = 1.23, 95%CI 1.13 to 1.33), and MACE at longest follow-up (unadj OR) (WL: OR 1.53, 95% CI 1.49 to 1.57; GL: OR 1.46, 95% CI 1.42 to 1.50; RCS in the range of 1-2 x URL, OR = 3.10, 95%CI 2.51 to 3.81) (All P < 0.001). For mild cTn increase below URL, the risk of mortality increased with every increment of 0.25xURL (WL, OR 1.03, 95% CI 1.02 to 1.03; GL, OR 1.05, 95% CI 1.03 to 1.07; RCS in the range of 0-0.5 URL, OR = 9.41, 95% CI 7.41 to 11.95) (All P < 0.001).

CONCLUSIONS

This study shows positive WL or GL and RCS dose-response relationships between PMI and all-cause mortality at short (< 12 mons)- and long-term (≥ 12 mons) follow-up, and MACE at longest follow-up. For mild cTn increase below URL, the risk of mortality also increases even with every increment of 0.25× URL.

Perioperative strategies to reduce risk of myocardial injury after non-cardiac surgery (MINS): A narrative review

Myocardial injury is a frequent complication of surgical patients after having non-cardiac surgery that is strongly associated with perioperative mortality. While intraoperative anesthesia-related deaths are exceedingly rare, about 1% of patients undergoing non-cardiac surgery die within the first 30 postoperative days. Given the number of surgeries performed annually, death following surgery is the second leading cause of death in the United States. Myocardial injury after non-cardiac surgery (MINS) is defined as an elevation in troponin concentrations within 30 days postoperatively. Although typically asymptomatic, patients with MINS suffer myocardial damage and have a 10% risk of death within 30 days after surgery and excess risks of mortality that persist during the first postoperative year. Many factors for the development of MINS are non-modifiable, such as preexistent coronary artery disease. Preventive measures, systematic approaches to surveillance and treatment standards are still lacking, however many factors are modifiable and should be considered in clinical practice: the importance of hemodynamic control, adequate oxygen supply, metabolic homeostasis, the use of perioperative medications such as statins, anti-thrombotic agents, beta-blockers, or anti-inflammatory agents, as well as some evidence regarding the choice of sedative and analgesic for anesthesia are discussed. Also, as age and complexity in comorbidities of the surgical patient population increase, there is an urgent need to identify patients at risk for MINS and develop prevention and treatment strategies. In this review, we provide an overview of current screening standards and promising preventive options in the perioperative setting and address knowledge gaps requiring further investigation.

Long-term major adverse cardiovascular events following myocardial injury after non-cardiac surgery: meta-analysis

BACKGROUND

Myocardial injury after non-cardiac surgery is diagnosed following asymptomatic troponin elevation in the perioperative interval. Myocardial injury after non-cardiac surgery is associated with high mortality rates and significant rates of major adverse cardiac events within the first 30 days following surgery. However, less is known regarding its impact on mortality and morbidity beyond this time. This systematic review and meta-analysis aimed to establish the rates of long-term morbidity and mortality associated with myocardial injury after non-cardiac surgery.

METHODS

MEDLINE, Embase and Cochrane CENTRAL were searched, and abstracts screened by two reviewers. Observational studies and control arms of trials, reporting mortality and cardiovascular outcomes beyond 30 days in adult patients diagnosed with myocardial injury after non-cardiac surgery, were included. Risk of bias was assessed using the Quality in Prognostic Studies tool. A random-effects model was used for the meta-analysis of outcome subgroups.

RESULTS

Searches identified 40 studies. The meta-analysis of 37 cohort studies found a rate of major adverse cardiac events-associated myocardial injury after non-cardiac surgery of 21 per cent and mortality following myocardial injury after non-cardiac surgery was 25 per cent at 1-year follow-up. A non-linear increase in mortality rate was observed up to 1 year after surgery. Major adverse cardiac event rates were also lower in elective surgery compared with a subgroup including emergency cases. The analysis demonstrated a wide variety of accepted myocardial injury after non-cardiac surgery and major adverse cardiac events diagnostic criteria within the included studies.

CONCLUSION

A diagnosis of myocardial injury after non-cardiac surgery is associated with high rates of poor cardiovascular outcomes up to 1 year after surgery. Work is needed to standardize diagnostic criteria and reporting of myocardial injury after non-cardiac surgery-related outcomes.

REGISTRATION

This review was prospectively registered with PROSPERO in October 2021 (CRD42021283995).

Impact of the period of the day on all-cause mortality and major cardiovascular complications after arterial vascular surgeries

BACKGROUND

Conflicting results are reported about daytime variation on mortality and cardiac outcomes after non-cardiac surgeries. In this cohort study, we evaluate whether the period of the day in which surgeries are performed may influence all-cause mortality and cardiovascular outcomes in patients undergoing non-cardiac arterial vascular procedures.

METHODS

1,267 patients who underwent non-cardiac arterial vascular surgeries between 2012 and 2018 were prospectively included in our cohort and categorized into two groups: morning (7 a.m. to 12 a.m., 79%) and afternoon/night (12:01 p.m. to 6:59 a.m. in the next day, 21%) surgeries. Primary endpoint was all-cause mortality within 30 days and one year. Secondary endpoints were the incidence of perioperative myocardial injury/infarction (PMI), and the incidence of major adverse cardiac events (MACE, including acute myocardial infarction, acute heart failure, arrhythmias, cardiovascular death) at hospital discharge.

RESULTS

After adjusting for confounders in the multivariable Cox proportional regression, all-cause mortality rates at 30 days and one year were higher among those who underwent surgery in the afternoon/night (aHR 1.6 [95%CI 1.1-2.3], P = 0.015 and aHR 1.7 [95%CI 1.3-2.2], P < 0.001, respectively). Afternoon/night patients had higher incidence of PMI (aHR 1.4 [95%CI 1.1-1.7], P < 0.001). There was no significant difference in the incidence of MACE (aHR 1.3 [95%CI 0.9-1.7], P = 0.074).

CONCLUSIONS

In patients undergoing arterial vascular surgery, being operated in the afternoon/night was independently associated with increased all-cause mortality rates and incidence of perioperative myocardial injury/infarction.

Effect of high-risk factors on postoperative major adverse cardiovascular and cerebrovascular events trends following bariatric surgery in the United States from 2012 to 2019

BACKGROUND

Recent examination of trends in postoperative major adverse cardiovascular and cerebrovascular events (MACE) following bariatric surgery, including accredited and nonaccredited centers, and the factors affecting those trends, is lacking.

OBJECTIVES

The objective of this study was to evaluate current trends for postoperative MACE after bariatric surgery in both accredited and nonaccredited centers and the factors affecting these trends.

SETTING

This retrospective study was conducted using National Inpatient Sample database from 2012 to 2019.

METHODS

All patients who underwent inpatient laparoscopic sleeve gastrectomy (LSG), open sleeve gastrectomy (SG), laparoscopic Roux-en-Y gastric bypass (LRYGB), and open Roux-en-Y gastric bypass (RYGB) were examined. Composite MACE (acute myocardial infarction, cardiac arrest, acute stroke, and in-hospital death during bariatric surgery hospitalization) was calculated and analyzed over time along with patient demographic and co-morbid diseases using survey-weighted logistic regression.

RESULTS

MACE incidence was lowest for LSG (0.07%), followed by LRYGB (0.16%), SG (3.47%), and RYBG (3.51%). Open procedure, increasing age, male sex, body mass index ≥50, coronary artery disease, congestive heart failure, and chronic kidney disease were independent predictors for increased MACE risk. MACE incidence increased over time for SG (odds ratio [OR] 1.25 [1.16, 1.34]; P < .0001) and RYGB (OR 1.14 [1.06, 1.22]; P = .0004) but decreased for LRYGB (OR 0.93 [0.87, 1] P = .06). After adjustment for high-risk covariates, increased MACE trend seen over time was attenuated in SG (OR 1.13 [1.04-1.22]; P = .005) and RYGB (OR 1.04 [0.96-1.12]; P = .36), while there was minimal effect of these high-risk covariates on MACE trend over time in LSG and LRYGB.

CONCLUSIONS

MACE following LSG and LRYGB is rare, occurring in 0.1% of patients. Persistently increasing high-risk conditions and demographics has had minimal effect on MACE over time for LSG and LRYGB but has had significant effect on MACE trend over time in SG and RYGB.

The Predictive Role of Cardiac Troponin in Non-cardiac Surgery: A Study in the Greek Population

Introduction

The incidence of postoperative myocardial ischemia (POMI) remains uncertain and underdiagnosed despite significant morbidity and mortality rates.

Methods

This study included patients who underwent non-cardiac surgery. Troponin T (TnT) was measured on the first three postoperative days. The revised cardiac risk index, HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio (INR), elderly, drugs/alcohol concomitantly) bleeding score, and CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke or transient ischemic attack (TIA), vascular disease, age 65 to 74 years, sex category) score were combined. The receiver operating characteristic (ROC) curve was used to estimate the discriminative ability of preoperative troponin for myocardial ischemia (MI).

Results

Of 105 patients with a mean age of 69.1 years, 32.4% had MI. Hypertension, diabetes mellitus, and dyslipidemia were the main risk factors. A ROC analysis indicated that a preoperative value of 17.2 pg/ml or higher of troponin was significantly associated with MI. Moreover, a higher CHA2DS2-VASc score was associated with POMI.

Conclusions

POMI is associated with high mortality and a long stay in the intensive care unit. Routine use of different scores before surgery can be very useful.

Perioperative myocardial injury after elective neurosurgery: incidence, risk factors, and effects on mortality

Perioperative myocardial injury is an important reason of mortality and morbidity after neurosurgery. It usually is missed due to its asymptomatic character. In the present study, we investigated myocardial injury after noncardiac surgery (MINS) incidence, the risk factor for MINS, and association of MINS with 30-day mortality in neurosurgery patients. Patients with cardiac risk who underwent elective neurosurgery were enrolled to present prospective cohort study. The patients' demographics, comorbidities, medications used, medical history, and type of operation were recorded. The high-sensitivity cardiac troponin (hs-cTn) levels of the patients were measured 12, 24, and 48 h after surgery. The patients were considered MINS-positive if at least one of their postoperative hs-cTn measurement values was ≥ 14 ng/l. All the patients were followed up for 30 days after surgery for evaluation of their outcomes, including total mortality, mortality due to cardiovascular cause, and major cardiac events. A total of 312 patients completed the study and 64 (20.5%) of them was MINS-positive. Long antiplatelet or anticoagulant drug cessation time (OR: 4.9, 95% CI: 2.1-9.4) was found the most prominent risk factor for MINS occurrence. The total mortality rate was 2.4% and 6.2% in patients MINS-negative and MINS-positive, respectively (p = 0.112). The mortality rate due to cardiovascular reasons (0.8% for without MINS, 4.7 for with MINS, and p = 0.026) and incidence of the major cardiac events (4% for without MINS, 10.9 for with MINS, and p = 0.026) were significantly higher in patients with MINS. MINS is a common problem after neurosurgery, and high postoperative hs-cTn level is associated with mortality and morbidity.

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

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

Relative contribution of vitamin D deficiency to subclinical atherosclerosis in Indian context: Preliminary findings

Asian Indians have a genetic predisposition to atherothrombotic risk. common carotid intima-media thickness (CCIMT) measured by ultrasound is a quantitative marker for atherosclerotic burden and a derived variable, that is, "CCIMT statistical Z-score (Z-score)" is useful for better quantification. The association between vitamin D deficiency and atherosclerosis is inconclusive. Since, vitamin D deficiency is highly prevalent in India, there is a need to study its relative contribution to subclinical atherosclerotic burden.This prospective cross-sectional study (n = 117) in apparently healthy individuals aged 20 to 60 years sought to identify the determinants of CCIMT Z score with CCIMT measured by "echo-tracking" method. A multivariable linear regression analysis was done with CCIMT Z score as dependent variable and the following as independent variables: age, body mass index, waist-to-height ratio, total cholesterol to HDL ratio (TC-HDL ratio), serum vitamin D3 levels (ng/mL), sex, diabetes mellitus, current cigarette smoking status. A diagnostic prediction model was also developed with a threshold value of 1.96 for CCIMT Z score.The mean (SD) for calendar age (y) was 40 (8). There were 26 (22.22%) individuals in sample with CCIMT Z score ≥1.96 (advanced stage) of whom 14 (23.33%) were <40 y (n = 60). The mean score was 1.28 (90th percentile) in the entire sample. Vitamin D3 deficiency with a mean (SD) blood level (ng/mL) of 14.3 (6.4) was noted and prevalence of deficiency was 81%. The final model wasCCIMT Z-score = 0.80 +  (0.841 × current smoking = 1) + (0.156 × TC-HDL ratio) - (0.0263 × vitamin D3 blood level in ng/mL).The decreasing order of association is smoking, TC-HDL ratio, and vitamin D3. With the model, likelihood ratio (95% CIs) was better for positive test 3.5 (1.23-9.94) than that for a negative test 0.83 (0.66-1.02).Internal validation with Bootstrap resampling revealed stability of baseline diagnostic variables.There is substantial subclinical atherosclerotic burden in Indian setting with independent contribution by vitamin D deficiency. The model is valuable in "ruling-in" of the underlying advanced atherosclerosis. The study is limited by convenient sampling and lack of external validation of the model.

Intraoperative factors contributory to myocardial injury in high-risk patients undergoing abdominal surgery in a South Indian population

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.

Pre and postoperative risk management: the role of scores and biomarkers

PURPOSE OF REVIEW

The goal of risk prediction is to identify high-risk patients who will benefit from further preoperative evaluation. Clinical scores and biomarkers are very well established tools for risk prediction but their accuracy remains a controversial issue.

RECENT FINDINGS

Current guidelines recommend one of the risk tools for preoperative cardiac risk assessment: American College of Surgeons National Surgical Quality Improvement Program (NSQIP) calculator or Revised Cardiac Risk Index. Although not as easy to use as risk scores, risk models are more accurate and can predict individual patient risk more precisely. A step forward in risk estimation was performed by introducing new risk models developed from the American College of Surgeons NSQIP database - NSQIP surgical risk calculator and Myocardial Infarction or Cardiac Arrest index. Although biomarkers, especially in cardiac risk assessment, are already present in current European and American guidelines, this use is still controversial. Novel biomarkers: microRNAs, heart-type fatty acid-binding protein and mid-regional proadrenomedullin, can be used as new potential biomarkers in clinical practice. Also some of the experimental biomarkers have not yet been introduced into clinical practice, preliminary results are encouraging.

SUMMARY

Different risk indices and biomarkers might lead to varying risk estimates. However, the importance of clinical judgment in risk assessment should not be underestimated.

Statins in the perioperative period

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

Systematic review of the use of big data to improve surgery in low- and middle-income countries

Background

Technological advances have led to the generation of large amounts of data, both in surgical research and practice. Despite this, it is unclear how much originates in low‐ and middle‐income countries (LMICs) and what barriers exist to the use of such data in improving surgical care. The aim of this review was to capture the extent and impact of programmes that use large volumes of patient data on surgical care in LMICs.

Methods

A PRISMA‐compliant systematic literature review of PubMed, Embase and Google Scholar was performed in August 2018. Prospective studies collecting large volumes of patient‐level data within LMIC settings were included and evaluated qualitatively.

Results

A total of 68 studies were included from 71 LMICs, involving 708 032 patients. The number of patients in included studies varied widely (from 335 to 428 346), with 25 reporting data on 3000 or more LMIC patients. Patient inclusion in large‐data studies in LMICs has increased dramatically since 2015. Studies predominantly involved Brazil, China, India and Thailand, with low patient numbers from Africa and Latin America. Outcomes after surgery were commonly the focus (33 studies); very few large studies looked at access to surgical care or patient expenditure. The use of large data sets specifically to improve surgical outcomes in LMICs is currently limited.

Conclusion

Large volumes of data are becoming more common and provide a strong foundation for continuing investigation. Future studies should address questions more specific to surgery.

Perioperative myocardial infarction: diagnostic clues and prevention

The diagnosis of perioperative myocardial infarction can be missed if the pain is masked by postoperative analgesia and the possibility is not considered. This report is the case of a patient with a missed diagnosis of perioperative myocardial infarction. Myocardial injury and infarction from noncardiac surgery is currently the subject of intense interest and research. This report illustrates the importance of the diagnosis and suggests clues that can be used to make the diagnosis.