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Navab R, Haward R, Chacko J, Haward R. Platelet-Rich Plasma for Heart Cell Regeneration Post-myocardial Infarction: A Propitious Therapeutic Approach. Cureus 2024; 16:e51951. [PMID: 38333505 PMCID: PMC10852202 DOI: 10.7759/cureus.51951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 02/10/2024] Open
Abstract
Globally, one of the primary factors leading to death is cardiovascular disorders, specifically coronary artery disease, which leads to myocardial infarction (MI). This article investigates the potential of platelet-rich plasma (PRP) therapy for regenerating cardiac cells following MI. We look into the pathophysiology of MI, current treatment methods, and the heart's limited ability to heal itself. This is done to see if PRP could help the heart heal faster, reduce the size of the infarct, and stop scar tissue from forming. We analyze the production procedure of PRP, its composition of growth factors, and its utilization in many medical domains. The ways that PRP helps the heart heal are also being looked into. This includes how it affects inflammation, oxidative stress, angiogenesis, and cell proliferation. Although we recognize the existing constraints, we meticulously take into account issues such as standardization, therapeutic variance, and potential harmful effects. This study highlights the importance of comprehensive guidelines, continuous research, and enhanced clinical applications to fully harness the potential of platelet-rich plasma in the regeneration of cardiac cells after a heart attack.
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Affiliation(s)
- Rahul Navab
- Internal Medicine, PES Institute of Medical Sciences and Research, Kuppam, IND
| | - Raymond Haward
- Internal Medicine, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, IND
| | - Joshua Chacko
- Internal Medicine, Father Muller Medical College, Mangalore, IND
| | - Rachel Haward
- Internal Medicine, KVG Medical College and Hospital, Sullia, IND
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2
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Rosero EB, Rajan N, Joshi GP. Pro-Con Debate: Are Patients With Coronary Stents Suitable for Free-Standing Ambulatory Surgery Centers? Anesth Analg 2023; 136:218-226. [PMID: 36638505 DOI: 10.1213/ane.0000000000006237] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
With increasing implantation of coronary artery stents over the past 2 decades, it is inevitable that anesthesiologists practicing in the outpatient setting will need to determine whether these patients are suitable for procedures at a free-standing ambulatory surgery center (ASC). Appropriate selection of patients with coronary artery stents for a procedure in an ASC requires consideration of factors that affect the balance between the risk of stent thrombosis due to interruption of antiplatelet therapy and the thrombogenic effects of surgery, and the risk of perioperative bleeding complications that may occur if antiplatelet therapy is continued. Thus, periprocedure care of these patients presents unique challenges, particularly for extensive surgical procedures that are increasingly scheduled for free-standing ASCs, where consultation and ancillary services, as well as access to percutaneous cardiac interventions, may not be readily available. Therefore, the suitability of the ambulatory setting for this patient population remains highly controversial. In this Pro-Con commentary, we discuss the arguments for and against scheduling patients with coronary artery stents in free-standing ASCs.
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Affiliation(s)
- Eric B Rosero
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas
| | - Niraja Rajan
- Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, Pennsylvania
| | - Girish P Joshi
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas
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3
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Harris DE. Perioperative Acute Myocardial Infarction and Ischemia After Noncardiac Surgery: Pathophysiology, Prevention, and Nursing Implications. AORN J 2022; 116:517-531. [DOI: 10.1002/aorn.13826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/10/2022] [Accepted: 05/18/2022] [Indexed: 11/30/2022]
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4
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Wang QQ, Jiang Y, Zhu JG, Zhang LW, Tong HJ, Shen P. Survival of a patient who received extracorporeal membrane oxygenation due to postoperative myocardial infarction: A case report. World J Clin Cases 2022; 10:11861-11868. [PMID: 36405297 PMCID: PMC9669837 DOI: 10.12998/wjcc.v10.i32.11861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 09/01/2022] [Accepted: 10/13/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Cardiac arrest after noncardiac surgery is a dangerous complication that may contribute to mortality. Because of the high mortality rate and many complications of cardiac arrest, it is very important to identify and correct a reversible etiology early. By reporting the treatment process of this case, we aimed to broaden the diagnosis and treatment of cardiac arrest after noncardiac surgery and describe how cardiopulmonary resuscitation using extracorporeal membrane oxygenation (ECMO) can improve a patient’s chance of survival.
CASE SUMMARY A 69-year-old man visited our hospital complaining of low back pain on July 12, 2021. Magnetic resonance imaging showed lumbar disc herniation. Two hours after lumbar disc herniation surgery, the patient developed cardiac arrest. Cardiopulmonary resuscitation was performed, and ECMO was started 60 min after the initiation of cardiopulmonary resuscitation. Regarding the etiology of early cardiac arrest after surgery, acute myocardial infarction and pulmonary embolism were considered first. Based on ultrasound evaluation, acute myocardial infarction appeared more likely. Coronary angiography confirmed occlusion of the left anterior descending branch, and coronary artery stenting was performed. Pulmonary artery angiography was performed to exclude pulmonary embolism. Due to heparinization during ECMO and coronary angiography, there was a large amount of oozing blood in the surgical incision. Therefore, heparin-free ECMO was performed in the early stage, and routine heparinized ECMO was performed after hemorrhage stabilization. Eventually, the patient was discharged and made a full neurologic recovery.
CONCLUSION For early postoperative cardiac arrest, acute myocardial infarction should be considered first, and heparin should be used with caution.
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Affiliation(s)
- Qian-Qian Wang
- Department of Intensive Care Unit, The First Hospital of Jiaxing, Jiaxing 314001, Zhejiang Province, China
| | - Yi Jiang
- Department of Osteology, The First Hospital of Jiaxing, Jiaxing 314001, Zhejiang Province, China
| | - Jian-Gang Zhu
- Department of Intensive Care Unit, The First Hospital of Jiaxing, Jiaxing 314001, Zhejiang Province, China
| | - Ling-Wei Zhang
- Department of Intensive Care Unit, The First Hospital of Jiaxing, Jiaxing 314001, Zhejiang Province, China
| | - Hong-Jie Tong
- Department of Intensive Care Unit, Affiliated Jinhua Hospital Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Peng Shen
- Department of Intensive Care Unit, The First Hospital of Jiaxing, Jiaxing 314001, Zhejiang Province, China
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Thompson A, Gregory SH. Prevention of Ischemic Injury in Noncardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00012-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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6
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Zahid JA, Orhan A, Ekeloef S, Gögenur I. Myocardial Injury After Colorectal Cancer Surgery and Postoperative 90-Day Mortality and Morbidity: A Retrospective Cohort Study. Dis Colon Rectum 2021; 64:1531-1541. [PMID: 34508013 DOI: 10.1097/dcr.0000000000002061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Myocardial injury after noncardiac surgery is a strong predictor of 30-day mortality and morbidity. OBJECTIVE The purpose of this study was to examine the incidence of myocardial injury in patients undergoing colorectal cancer surgery in an enhanced recovery after surgery protocol and its association with 90-day mortality and morbidity. DESIGN This is a retrospective cohort study. SETTING This study was conducted at Zealand University Hospital, Denmark, between June 2015 and July 2017. PATIENTS Adult patients undergoing colorectal cancer surgery were included if troponin was measured at least twice during the first 7 days after surgery. The patients were followed for 90 days. MAIN OUTCOME MEASURES Myocardial injury was defined as an elevated troponin I measurement (>45 ng/L) without evidence of a nonischemic origin causing the elevation. Ninety-day mortality and complications were assessed. RESULTS A total of 586 patients were included of which 42 were diagnosed with myocardial injury. Thirteen patients (2%) died within 90 days of surgery. There was no significant difference in 90-day mortality between patients with and without myocardial injury (5% (2/42) versus 2% (11/544); p = 0.24). We found a higher incidence of postoperative complications within 90 days of surgery in the myocardial injury group than in the nonmyocardial injury group (43% (18/42) versus 20% (107/544); p < 0.01). We found a significant difference between the myocardial injury group and nonmyocardial injury group in terms of medical complications (33% (14/42) versus 9% (50/544); p < 0.01) but not surgical complications (19% (8/42) versus 16% (85/544); p = 0.56). Myocardial injury was an independent predictor of postoperative complications within 90 days of surgery (adjusted OR, 2.69; 95% CI, 1.31-5.55). LIMITATIONS This study was limited by its retrospective design. CONCLUSION Myocardial injury occurs frequently in patients undergoing colorectal cancer surgery in an enhanced recovery after surgery protocol. Patients with myocardial injury did not have a significantly higher 90-day mortality but had higher risk of 90-day postoperative complications than patients without myocardial injury. Future research should examine the prevention and treatment of myocardial injury. See Video Abstract at http://links.lww.com/DCR/B692. LESIN MIOCRDICA DESPUS DE LA CIRUGA DE CNCER COLORRECTAL Y MORTALIDAD Y MORBILIDAD POSOPERATORIAS A LOS DAS UN ESTUDIO DE COHORTE RETROSPECTIVE ANTECEDENTES:La lesión del miocardio después de una cirugía no cardíaca es un fuerte predictor de mortalidad y morbilidad a los 30 días.OBJETIVO:El propósito fue examinar la incidencia de lesión miocárdica en pacientes sometidos a cirugía de cáncer colorrectal en un protocolo de recuperación mejorada después de la cirugía y su asociación con la mortalidad y morbilidad a los 90 días.DISEÑO:Estudio de cohorte retrospectivo.AJUSTE:Realizado en el Hospital Universitario de Zelanda, Dinamarca, entre junio de 2015 y julio de 2017.PACIENTES:Se incluyeron pacientes adultos sometidos a cirugía de cáncer colorrectal, si la troponina se midió al menos dos veces durante los primeros siete días después de la cirugía. Los pacientes fueron seguidos durante 90 días.PRINCIPALES MEDIDAS DE RESULTADO:La lesión miocárdica se definió como una medición de troponina I elevada (> 45 ng / l) sin evidencia de una etiología no isquémica que causara la elevación. Se evaluaron la mortalidad y las complicaciones a los noventa días.RESULTADOS:Se incluyeron un total de 586 pacientes, de los cuales 42 fueron diagnosticados de lesión miocárdica. Trece pacientes (2%) murieron dentro de los 90 días posteriores a la cirugía. No hubo diferencias significativas en la mortalidad a 90 días entre los pacientes con y sin lesión del miocardio, 5% [2/42] versus 2% [11/544], p = 0,24. Encontramos una mayor incidencia de complicaciones posoperatorias dentro de los 90 días de la cirugía en el grupo de lesión miocárdica en comparación con el grupo de lesión no miocárdica, 43% [18/42] versus 20% [107/544], p <0,01. Encontramos una diferencia significativa entre el grupo de lesión miocárdica y el grupo de lesión no miocárdica en términos de complicaciones médicas (33% [14/42] versus 9% [50/544]; p <0,01) pero no complicaciones quirúrgicas (19% [8/42] versus 16% [85/544]; p = 0,56). La lesión miocárdica fue un predictor independiente de complicaciones posoperatorias dentro de los 90 días posteriores a la cirugía (razón de probabilidades ajustada: 2,69; intervalo de confianza del 95%: 1,31 - 5,55).LIMITACIONES:Limitado por su diseño retrospectivo.CONCLUSIÓN:La lesión del miocardio ocurre con frecuencia en pacientes sometidos a cirugía de cáncer colorrectal en un protocolo de recuperación mejorada después de la cirugía. Los pacientes con lesión miocárdica no tuvieron una mortalidad significativamente mayor a los 90 días, pero tuvieron un mayor riesgo de complicaciones posoperatorias a los 90 días en comparación con los pacientes sin lesión miocárdica. Las investigaciones futuras deben examinar la prevención y el tratamiento de la lesión miocárdica. Consulte Video Resumen en http://links.lww.com/DCR/B692.
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Affiliation(s)
- Jawad A Zahid
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, University of Copenhagen
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Wong ZZ, Chiong XH, Chaw SH, Hashim NHBM, Abidin MFBZ, Yunus SNB, Subramaniam T, Ng KT. The Use of Cerebral Oximetry in Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth 2021; 36:2002-2011. [PMID: 34657798 DOI: 10.1053/j.jvca.2021.09.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/11/2021] [Accepted: 09/27/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The evidence on the use of cerebral oximetry during surgery to minimize postoperative neurologic complications remains uncertain in the literature. The present authors aimed to assess the value of cerebral oximetry in the prevention of postoperative cognitive dysfunction, postoperative delirium, and postoperative stroke in adults undergoing surgery. DESIGN A systematic review and meta-analysis. SETTING The surgery room. PARTICIPANTS Adult patients (ages ≥18 years) undergoing surgery. INTERVENTIONS Cerebral oximetry monitoring. MEASUREMENTS AND MAIN RESULTS Databases of Ovid MEDLINE, Ovid EMBASE, and CENTRAL were systematically searched from their inception until December 2020 for randomized controlled trials comparing cerebral oximetry monitoring with either blinded or no cerebral oximetry monitoring in adults undergoing surgery. Observational studies, case reports, and case series were excluded. Seventeen studies (n = 2,120 patients) were included for quantitative meta-analysis. Patients who were randomized to cerebral oximetry monitoring had a lower incidence of postoperative cognitive dysfunction (studies = seven, n = 969, odds ratio [OR] 0.23, 95% confidence interval [CI] 0.11-0.48, p = 0.0001; evidence = very low). However, no significant differences were observed in the incidence of postoperative delirium (studies = five, n = 716, OR 0.81, 95% CI 0.53-1.25, p = 0.35; evidence = high), and postoperative stroke (studies = seven, n = 1,087, OR 0.72, 95% CI 0.30-1.69, p = 0.45; evidence = moderate). CONCLUSION Adult patients with cerebral oximetry monitoring were associated with a significant reduction of postoperative cognitive dysfunction. However, given the low certainty of evidence and substantial heterogeneity, more randomized controlled trials using standardized assessment tools for postoperative cognitive dysfunction and interventions of correcting cerebral desaturation are warranted to improve the certainty of evidence and homogeneity.
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Affiliation(s)
- Zhen Zhe Wong
- School of Medicine, International Medical University, Kuala Lumpur, Malaysia
| | - Xin Hui Chiong
- School of Medicine, University of Aberdeen, Aberdeen, United Kingdom
| | - Sook Hui Chaw
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | | | - Siti Nadzrah Binti Yunus
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Ka Ting Ng
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
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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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Iddagoda MT. The role of high-sensitive troponin measurement as a biomarker during the postoperative period for the detection of myocardial injury after non-cardiac surgery. J Perioper Pract 2021; 31:300-305. [PMID: 32609067 DOI: 10.1177/1750458920930993] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Myocardial injury after non-cardiac surgery is common and defined as myocardial ischaemia within 30 days after non-cardiac surgery. Diagnosis of myocardial injury after non-cardiac surgery is challenging as this could be clinically asymptomatic during the postoperative period due to many other factors. Role of high-sensitive cardiac troponin in diagnosing myocardial injury after non-cardiac surgery had been evaluated in several studies. Due to the fact that high-sensitive cardiac troponin remains positive for about two weeks in the body and is highly specific in diagnosing clinically silent myocardial injuries, it is recognised as the most useful biomarker in detecting myocardial injury after non-cardiac surgery. However, high-sensitive cardiac troponin is not well incorporated as a biomarker in current major perioperative guidelines or in clinical practice. The aim of this review is to discuss evidence and guidelines in this area in view of the use of high-sensitive cardiac troponin in early identification of myocardial injury after non-cardiac surgery.
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Affiliation(s)
- Mayura T Iddagoda
- Perioperative Service, 6508Royal Perth Hospital, Perth, Western Australia
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10
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Vogelsang RP, Søby JH, Tolstrup MB, Burcharth J, Ekeløf S, Gögenur I. Associations between malignancy and cardiovascular complications following emergency laparotomy - A retrospective cohort study. Surg Oncol 2021; 38:101591. [PMID: 33991941 DOI: 10.1016/j.suronc.2021.101591] [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: 12/18/2020] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Systemic inflammation in patients with malignant disease has been associated with increased risk of cardiovascular events. The pro-inflammatory perturbations following surgical trauma may further promote adverse perioperative cardiovascular events and increase the risk of patients with cancer undergoing major surgery. Our objective was to estimate the association between malignant disease and postoperative cardiovascular complications. Secondarily, we aimed to identify risk factors for postoperative cardiovascular complications. METHODS We conducted a retrospective cohort study of all patients ≥18 years undergoing emergency laparotomy between 2010 and 2016 at Department of Surgery, Zealand University Hospital, Denmark. Complications were graded according to Clavien-Dindo classification of surgical complications. Multivariate logistic regression analysis was performed to estimate association between malignant disease and cardiovascular complications within 30 days of emergency laparotomy and to identify other risk factors for postoperative cardiovascular complications after emergency laparotomy. RESULTS We identified 1188 patients ≥18 years undergoing emergency laparotomy between 2010 and 2016, in which 254 (21%) had malignant disease. Within 30 days of emergency laparotomy, 89 (9.5%) of patients without malignancy died, as compared with 45 (18%) of patients with malignancy (p < 0.001). Cardiovascular death occurred in 17 (1.8%) and 5 (2.0%) patients in the non-malignant and malignant group, respectively. Severe cardiovascular complication graded CD 3-5 occurred in 93 (8%) of all patients within 30 days of emergency laparotomy. We found no association between malignancy and postoperative cardiovascular complications in patients undergoing emergency surgery (OR 0.8, 95% CI; 0.4, 1.5). Increasing age and ASA physical status classification system (ASA) score ≥ III were the only independent risk factors of cardiovascular complications graded CD 3-5. CONCLUSIONS Malignancy was not associated with postoperative cardiovascular complications after emergency laparotomy. Risk factors for major cardiovascular complications after emergency abdominal surgery were age and ASA score ≥ III.
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Affiliation(s)
- Rasmus Peuliche Vogelsang
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Denmark. https://twitter.com/RasmusVogelsang
| | - Jacob Hartmann Søby
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Denmark
| | - Mai-Britt Tolstrup
- Department of Abdominal, Bowel, and Liver Diseases, Herlev University Hospital, Denmark
| | - Jakob Burcharth
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Denmark
| | - Sarah Ekeløf
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark
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11
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Cao D, Chandiramani R, Capodanno D, Berger JS, Levin MA, Hawn MT, Angiolillo DJ, Mehran R. Non-cardiac surgery in patients with coronary artery disease: risk evaluation and periprocedural management. Nat Rev Cardiol 2020; 18:37-57. [PMID: 32759962 DOI: 10.1038/s41569-020-0410-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2020] [Indexed: 12/18/2022]
Abstract
Perioperative cardiovascular complications are important causes of morbidity and mortality associated with non-cardiac surgery, particularly in patients with coronary artery disease (CAD). Although preoperative cardiac risk assessment can facilitate the identification of vulnerable patients and implementation of adequate preventive measures, excessive evaluation might lead to undue resource utilization and surgical delay. Owing to conflicting data, there remains some uncertainty regarding the most beneficial perioperative strategy for patients with CAD. Antithrombotic agents are the cornerstone of secondary prevention of ischaemic events but substantially increase the risk of bleeding. Given that 5-25% of patients undergoing coronary stent implantation require non-cardiac surgery within 2 years, surgery is the most common reason for premature cessation of dual antiplatelet therapy. Perioperative management of antiplatelet therapy, which necessitates concomitant evaluation of the individual thrombotic and bleeding risks related to both clinical and procedural factors, poses a recurring dilemma in clinical practice. Current guidelines do not provide detailed recommendations on this topic, and the optimal approach in these patients is yet to be determined. This Review summarizes the current data guiding preoperative risk stratification as well as periprocedural management of patients with CAD undergoing non-cardiac surgery, including those treated with stents.
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Affiliation(s)
- Davide Cao
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rishi Chandiramani
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Davide Capodanno
- Division of Cardiology, C.A.S.T., P.O. "G. Rodolico", Azienda Ospedaliero-Universitaria "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Jeffrey S Berger
- Center for the Prevention of Cardiovascular Disease, New York University Langone Health, New York, NY, USA
| | - Matthew A Levin
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mary T Hawn
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Roxana Mehran
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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12
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Marcucci M, Duceppe E, Le Manach Y, Kearon C, Eikelboom JW, Pohl K, Vincent J, Darvish-Kazem S, Srinathan SK, Neary JDD, Parlow JL, Kurz A, Gross PL, Mrkobrada M, Balasubramanian K, Sessler DI, Devereaux PJ. Tranexamic acid and rosuvastatin in patients at risk of cardiovascular events after noncardiac surgery: a pilot of the POISE-3 randomized controlled trial. Pilot Feasibility Stud 2020; 6:104. [PMID: 32699643 PMCID: PMC7372857 DOI: 10.1186/s40814-020-00643-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 07/06/2020] [Indexed: 11/10/2022] Open
Abstract
Background Surgical bleeding is associated with postoperative cardiovascular complications. The efficacy and safety of tranexamic acid (TXA) in noncardiac surgery are still uncertain. Statins may prevent perioperative cardiovascular complications. We conducted a pilot to assess the feasibility of a perioperative trial of TXA and rosuvastatin. Methods Using a factorial design, we randomized patients at cardiovascular risk undergoing noncardiac surgery to intravenous TXA (1 g at the start and end of surgery) or placebo, and oral rosuvastatin (40 mg before and 20 mg daily for 30 days after surgery) or placebo. Feasibility outcomes included recruitment rates, follow-up, and compliance to interventions. Clinical outcomes were secondarily explored. Results After 3 months, we changed the design to a partial factorial due to the difficult recruitment of statin-naive patients. Over 6 months, 100 patients were randomized in the TXA trial (49 TXA, 51 placebo), 34 in the rosuvastatin trial (18 rosuvastatin, 16 placebo). Ninety-two percent (95% CI 80–98) of TXA and 86% (95% CI 74–94) of TXA-placebo patients received the 2 study doses. Thirty-three percent (95% CI 13–59) of rosuvastatin patients and 37% (95% CI 15–65) of rosuvastatin-placebo patients discontinued the study drug. A major cardiovascular complication occurred at 30 days in 1 TXA and 6 TXA-placebo patients, and 1 rosuvastatin and no rosuvastatin-placebo patients. Conclusions Our pilot study supports the feasibility of a perioperative TXA trial in noncardiac surgery. Feasibility of a perioperative rosuvastatin trial is uncertain because of a high prevalence of statin use in the target population and concerns about compliance. Trial registration ClinicalTrials.govNCT02546648.
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Affiliation(s)
- Maura Marcucci
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON Canada.,Department of Medicine, McMaster University, Hamilton, ON Canada.,Population Health Research Institute, Hamilton, ON Canada
| | - Emmanuelle Duceppe
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON Canada.,Population Health Research Institute, Hamilton, ON Canada.,Department of Medicine, University of Montreal, Montreal, QC Canada
| | - Yannick Le Manach
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON Canada.,Population Health Research Institute, Hamilton, ON Canada.,Department of Anesthesia, McMaster University, Hamilton, ON Canada
| | - Clive Kearon
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON Canada.,Department of Medicine, McMaster University, Hamilton, ON Canada
| | - John W Eikelboom
- Department of Medicine, McMaster University, Hamilton, ON Canada
| | - Kayla Pohl
- Population Health Research Institute, Hamilton, ON Canada
| | | | - Saeed Darvish-Kazem
- Department of Medicine, McMaster University, Hamilton, ON Canada.,William Osler Health System, Brampton, ON Canada
| | | | - John D D Neary
- Department of Medicine, McMaster University, Hamilton, ON Canada
| | - Joel L Parlow
- Department of Anesthesiology and Perioperative Medicine, Kingston General Hospital and Queen's University, Kingston, ON Canada
| | - Andrea Kurz
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH USA
| | - Peter L Gross
- Department of Medicine, University of Montreal, Montreal, QC Canada
| | - Marko Mrkobrada
- Department of Medicine, University of Western Ontario, London, ON Canada
| | | | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH USA
| | - P J Devereaux
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON Canada.,Department of Medicine, McMaster University, Hamilton, ON Canada.,Population Health Research Institute, Hamilton, ON Canada
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13
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Briguglio M, Hrelia S, Malaguti M, De Vecchi E, Lombardi G, Banfi G, Riso P, Porrini M, Romagnoli S, Pino F, Crespi T, Perazzo P. Oral Supplementation with Sucrosomial Ferric Pyrophosphate Plus L-Ascorbic Acid to Ameliorate the Martial Status: A Randomized Controlled Trial. Nutrients 2020; 12:nu12020386. [PMID: 32024027 PMCID: PMC7071340 DOI: 10.3390/nu12020386] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 01/25/2020] [Accepted: 01/30/2020] [Indexed: 12/13/2022] Open
Abstract
Altered martial indices before orthopedic surgery are associated with higher rates of complications and greatly affect the patient’s functional ability. Oral supplements can optimize the preoperative martial status, with clinical efficacy and the patient’s tolerability being highly dependent on the pharmaceutical formula. Patients undergoing elective hip/knee arthroplasty were randomized to be supplemented with a 30-day oral therapy of sucrosomial ferric pyrophosphate plus L-ascorbic acid. The tolerability was 2.7% among treated patients. Adjustments for confounding factors, such as iron absorption influencers, showed a relevant response limited to older patients (≥ 65 years old), whose uncharacterized Hb loss was averted upon treatment with iron formula. Older patients with no support lost −2.8 ± 5.1%, while the intervention group gained +0.7 ± 4.6% of circulating hemoglobin from baseline (p = 0.019). Gastrointestinal diseases, medications, and possible dietary factors could affect the efficacy of iron supplements. Future opportunities may consider to couple ferric pyrophosphate with other nutrients, to pay attention in avoiding absorption disruptors, or to implement interventions to obtain an earlier martial status optimization at the population level.
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Affiliation(s)
- Matteo Briguglio
- Scientific Direction, IRCCS Orthopedic Institute Galeazzi, Via Riccardo Galeazzi 4, 20161 Milan, Italy;
- Correspondence:
| | - Silvana Hrelia
- Department for Life Quality Studies, University of Bologna, Corso d’Augusto 237, 47921 Rimini, Italy; (S.H.); (M.M.)
| | - Marco Malaguti
- Department for Life Quality Studies, University of Bologna, Corso d’Augusto 237, 47921 Rimini, Italy; (S.H.); (M.M.)
| | - Elena De Vecchi
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Orthopedic Institute Galeazzi, Via Riccardo Galeazzi 4, 20161 Milan, Italy;
| | - Giovanni Lombardi
- Laboratory of Experimental Biochemistry and Molecular Biology, IRCCS Orthopedic Institute Galeazzi, Via Riccardo Galeazzi 4, 20161 Milan, Italy;
- Department of Athletics, Strength and Conditioning, Poznań University of Physical Education, Królowej Jadwigi 27/39, 61-871 Poznań, Poland
| | - Giuseppe Banfi
- Scientific Direction, IRCCS Orthopedic Institute Galeazzi, Via Riccardo Galeazzi 4, 20161 Milan, Italy;
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 58, 20132 Milan, Italy
| | - Patrizia Riso
- Division of Human Nutrition, Department of Food, Environmental and Nutritional Sciences (DeFENS), University of Milan, Via Mangiagalli 25, 20133 Milan, Italy; (P.R.); (M.P.)
| | - Marisa Porrini
- Division of Human Nutrition, Department of Food, Environmental and Nutritional Sciences (DeFENS), University of Milan, Via Mangiagalli 25, 20133 Milan, Italy; (P.R.); (M.P.)
| | - Sergio Romagnoli
- Joint Replacement Department, IRCCS Orthopedic Institute Galeazzi, Via Riccardo Galeazzi 4, 20161 Milan, Italy;
| | - Fabio Pino
- Post-operative Intensive Care Unit & Anesthesia, IRCCS Orthopedic Institute Galeazzi, Via Riccardo Galeazzi 4, 20161 Milan, Italy; (F.P.); (T.C.); (P.P.)
| | - Tiziano Crespi
- Post-operative Intensive Care Unit & Anesthesia, IRCCS Orthopedic Institute Galeazzi, Via Riccardo Galeazzi 4, 20161 Milan, Italy; (F.P.); (T.C.); (P.P.)
| | - Paolo Perazzo
- Post-operative Intensive Care Unit & Anesthesia, IRCCS Orthopedic Institute Galeazzi, Via Riccardo Galeazzi 4, 20161 Milan, Italy; (F.P.); (T.C.); (P.P.)
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14
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Ollila A, Vikatmaa L, Virolainen J, Nisula S, Lakkisto P, Vikatmaa P, Tikkanen I, Venermo M, Pettilä V. The association of endothelial injury and systemic inflammation with perioperative myocardial infarction. Ann Clin Biochem 2019; 56:674-683. [DOI: 10.1177/0004563219873357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Major surgery predisposes to endothelial glycocalyx injury. Endothelial glycocalyx injury associates with cardiac morbidity, including spontaneous myocardial infarction. However, the relation between endothelial glycocalyx injury and the development of perioperative myocardial infarction remains unknown. Methods Fifteen perioperative myocardial infarction patients and 60 propensity-matched controls were investigated in this prospective study. The diagnosis of perioperative myocardial infarction was based on repeated cardiac troponin T measurements, electrocardiographs and recordings of ischaemic signs and symptoms. We measured endothelial glycocalyx markers – soluble thrombomodulin, syndecan-1 and vascular adhesion protein 1 – and an inflammatory marker, namely interleukin-6, preoperatively and 6 h and 24 h postoperatively. We calculated the areas under the receiver operating characteristics curves (AUCs) to compare the performances of the different markers in predicting perioperative myocardial infarction. The highest value of each marker was used in the analysis. Results The interleukin-6 concentrations of perioperative myocardial infarction patients were significantly higher preoperatively and 6 and 24 h postoperatively ( P = 0.002, P = 0.002 and P = 0.001, respectively). The AUCs (95% confidence intervals) for the detection of perioperative myocardial infarction were 0.51 (0.34–0.69) for soluble thrombomodulin, 0.63 (0.47–0.79) for syndecan-1, 0.54 (0.37–0.70) for vascular adhesion protein 1 and 0.69 (0.54–0.85) for interleukin-6. Conclusions Systemic inflammation, reflected by interleukin-6, associates with cardiac troponin T release and perioperative myocardial infarction. Circulating interleukin-6 demonstrated some potential to predict perioperative myocardial infarction, whereas endothelial glycocalyx markers did not.
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Affiliation(s)
- Aino Ollila
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Leena Vikatmaa
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juha Virolainen
- Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Sara Nisula
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Päivi Lakkisto
- Department of Clinical Chemistry and Hematology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Minerva Foundation Institute for Medical Research, Helsinki, Finland
| | - Pirkka Vikatmaa
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ilkka Tikkanen
- Minerva Foundation Institute for Medical Research, Helsinki, Finland
- Helsinki Hypertension Centre of Excellence, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Abdominal Center Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville Pettilä
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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15
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Lykov YV, Dyatlov NV, Morozova TE, Dvoretsky LI. [In-hospital Myocardial Infarction: Scale of the Problem]. KARDIOLOGIIA 2019; 59:52-60. [PMID: 31322090 DOI: 10.18087/cardio.2019.7.2645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 07/19/2019] [Indexed: 06/10/2023]
Abstract
All cases of acute myocardial infarction (AMI) can be divided into outpatient-onset AMI and in-hospital-onset AMI depending on the place and circumstances of their development. In this review we consider the problem of in-hospital AMI. Special attention is paid to specific features of its clinical manifestations and the scale of the clinical problem. Possible causes of difficulties in the diagnosis and treatment of this condition are presented in comparison with those in patients with outpatient-onset AMI.
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Affiliation(s)
- Yu V Lykov
- Sechenov First Moscow State Medical University (Sechenov University)
| | - N V Dyatlov
- Sechenov First Moscow State Medical University (Sechenov University)
| | - T E Morozova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - L I Dvoretsky
- Sechenov First Moscow State Medical University (Sechenov University)
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16
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Peri-operative endothelial dysfunction in patients undergoing minor abdominal surgery. Eur J Anaesthesiol 2019; 36:130-134. [DOI: 10.1097/eja.0000000000000935] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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17
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Revised Cardiac Risk Index as a Predictor for Myocardial Infarction and Cardiac Arrest Following Posterior Lumbar Decompression. Spine (Phila Pa 1976) 2019; 44:E187-E193. [PMID: 30005044 DOI: 10.1097/brs.0000000000002783] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective analysis of prospectively collected data. OBJECTIVE The aim of this study was to determine the ability of Revised Cardiac Risk Index (RCRI) to predict adverse cardiac events following posterior lumbar decompression (PLD). SUMMARY OF BACKGROUND DATA PLD is an increasingly common procedure used to treat a variety of degenerative spinal conditions. The RCRI is used to predict risk for cardiac events following noncardiac surgery. There is a paucity of literature that directly addresses the relationship between RCRI and outcomes following PLD, specifically, the discriminative ability of the RCRI to predict adverse postoperative cardiac events. METHODS ACS-NSQIP was utilized to identify patients undergoing PLD from 2006 to 2014. Fifty-two thousand sixty-six patients met inclusion criteria. Multivariate and ROC analysis was utilized to identify associations between RCRI and postoperative complications. RESULTS Membership in the RCRI=1 cohort was a predictor for myocardial infarction (MI) [odds ratio (OR) = 3.3, P = 0.002] and cardiac arrest requiring cardiopulmonary resuscitation (CPR) (OR = 3.4, P = 0.013). Membership in the RCRI = 2 cohort was a predictor for MI (OR = 5.9, P = 0.001) and cardiac arrest requiring CPR (OR = 12.5), Membership in the RCRI = 3 cohort was a predictor for MI (OR = 24.9) and cardiac arrest requiring CPR (OR = 26.9, P = 0.006). RCRI had a good discriminative ability to predict both MI [area under the curve (AUC) = 0.876] and cardiac arrest requiring CPR (AUC = 0.855). The RCRI had a better discriminative ability to predict these outcomes that did ASA status, which had discriminative abilities of "fair" (AUC = 0.799) and "poor" (AUC = 0.674), respectively. P < 0.001 unless otherwise specified. CONCLUSION RCRI was predictive of cardiac events following PLD, and RCRI had a better discriminative ability to predict MI and cardiac arrest requiring CPR than did ASA status. Consideration of the RCRI as a component of preoperative surgical risk stratification can minimize patient morbidity and mortality. Studies such as this can allow for implementation of guidelines that better estimate the preoperative risk profile of surgical patients. LEVEL OF EVIDENCE 3.
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18
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Ekeloef S, Alamili M, Devereaux PJ, Gögenur I. Troponin elevations after non-cardiac, non-vascular surgery are predictive of major adverse cardiac events and mortality: a systematic review and meta-analysis. Br J Anaesth 2018; 117:559-568. [PMID: 27799170 DOI: 10.1093/bja/aew321] [Citation(s) in RCA: 161] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients undergoing non-cardiac, non-vascular surgery are at risk of major cardiovascular complications. In non-cardiac surgery, troponin elevation has previously been shown to be an independent predictor of major adverse cardiac events and postoperative mortality; however, a majority of studies have focused on vascular surgery patients. The aim of this meta-analysis was to determine whether troponin elevation is a predictor of major adverse cardiac events and mortality within 30 days and 1 yr after non-cardiac, non-vascular surgery. METHODS A systematic review and meta-analysis was conducted in January 2016 according to the Meta-analysis Of Observational Studies in Epidemiology guidelines. Both interventional and observational studies measuring troponin within the first 4 days after surgery were eligible. A systematic search was performed in PubMed, EMBASE, Scopus, and the Cochrane Central Register of Controlled Trials. RESULTS Eleven eligible clinical studies (n=2193) were identified. A postoperative troponin elevation was a predictor of 30 day mortality, odds ratio (OR) 3.52 [95% confidence interval (CI) 2.21-5.62; I2=0%], and an independent predictor of 1 yr mortality, adjusted OR 2.53 (95% CI 1.20-5.36; I2=26%). A postoperative troponin elevation was associated with major adverse cardiac events at 30 days, OR 5.92 (95% CI 1.67-20.96; I2=86%), and 1 yr after surgery, adjusted OR 3.00 (95% CI 1.43-6.29; I2=21%). CONCLUSIONS Postoperative myocardial injury is an independent predictor of major adverse cardiac events and mortality within 30 days and 1 yr after non-cardiac, non-vascular surgery. The meta-analysis provides evidence that supports troponin monitoring as a cardiovascular risk stratification tool.
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Affiliation(s)
- S Ekeloef
- Department of Surgery, Center for Surgical Science, Zealand University Hospital, Koege and Roskilde, Denmark
| | - M Alamili
- Department of Surgery, Center for Surgical Science, Zealand University Hospital, Koege and Roskilde, Denmark
| | - P J Devereaux
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - I Gögenur
- Department of Surgery, Center for Surgical Science, Zealand University Hospital, Koege and Roskilde, Denmark
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19
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Small GR, Ernst J, Gauthier N, Chow BJW. Coronary CTA for Preoperative Risk Assessment in Noncardiac Surgery. CURRENT CARDIOVASCULAR IMAGING REPORTS 2018. [DOI: 10.1007/s12410-018-9461-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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20
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Helwani MA, Amin A, Lavigne P, Rao S, Oesterreich S, Samaha E, Brown JC, Nagele P. Etiology of Acute Coronary Syndrome after Noncardiac Surgery. Anesthesiology 2018; 128:1084-1091. [PMID: 29481375 PMCID: PMC5953771 DOI: 10.1097/aln.0000000000002107] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The objective of this investigation was to determine the etiology of perioperative acute coronary syndrome with a particular emphasis on thrombosis versus demand ischemia. METHODS In this retrospective cohort study, adult patients were identified who underwent coronary angiography for acute coronary syndrome within 30 days of noncardiac surgery at a major tertiary hospital between January 2008 and July 2015. Angiograms were independently reviewed by two interventional cardiologists who were blinded to clinical data and outcomes. Acute coronary syndrome was classified as ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, or unstable angina; myocardial infarctions were adjudicated as type 1 (plaque rupture), type 2 (demand ischemia), or type 4b (stent thrombosis). RESULTS Among 215,077 patients screened, 146 patients were identified who developed acute coronary syndrome: 117 were classified as non-ST-elevation myocardial infarction (80.1%); 21 (14.4%) were classified as ST-elevation myocardial infarction, and 8 (5.5%) were classified as unstable angina. After coronary angiography, most events were adjudicated as demand ischemia (type 2 myocardial infarction, n = 106, 72.6%) compared to acute coronary thrombosis (type 1 myocardial infarction, n = 37, 25.3%) and stent thrombosis (type 4B, n = 3, 2.1%). Absent or only mild, nonobstructive coronary artery disease was found in 39 patients (26.7%). In 14 patients (9.6%), acute coronary syndrome was likely due to stress-induced cardiomyopathy. Aggregate 30-day and 1-yr mortality rates were 7 and 14%, respectively. CONCLUSIONS The dominant mechanism of perioperative acute coronary syndrome in our cohort was demand ischemia. A subset of patients had no evidence of obstructive coronary artery disease, but findings were consistent with stress-induced cardiomyopathy.
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Affiliation(s)
- Mohammad A Helwani
- From the Division of Clinical and Translational Research, Department of Anesthesiology (M.A.H., S.R., S.O., E.S., J.C.B., P.N.) the Division of Cardiology, Department of Internal Medicine (A.A., P.L.), Washington University School of Medicine, St. Louis, Missouri
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21
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Biccard BM. Postoperative Troponin Elevation, Myocardial Injury, and Pulmonary Embolism. Anesth Analg 2018; 126:1435-1437. [PMID: 29672379 DOI: 10.1213/ane.0000000000002793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Bruce McClure Biccard
- From the Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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22
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Miccichè V, Baldi C, De Robertis E, Piazza O. Myocardial injury after non-cardiac surgery: a perioperative affair? Minerva Anestesiol 2018; 84:1209-1218. [PMID: 29589418 DOI: 10.23736/s0375-9393.18.12537-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Myocardial injury after non-cardiac surgery (MINS) is a rather new nosological entity and an unfortunately common perioperative complication. The diagnostic criteria for MINS, also indicated as isolated myocardial injury (IMI), are an elevated postoperative high sensitivity troponin T (hsTnT level ranging between 20 and 65 ng/L with an absolute change of at least 5 ng/L or hsTnT level >65 ng/L), in absence of symptoms and/or EKG findings suggestive of ischemia and without a non-ischemic etiology causing troponin elevation. MINS does not fulfill the universal definition of myocardial infarction even if it is related to ischemic causes and it is independently associated with 30-day postoperative mortality and complications. Nevertheless, mortality at 30 days in MINS patients has been calculated up to 10% and it increases exponentially as a function of peak postoperative troponin concentration. Physician and researchers should discriminate MINS from perioperative myocardial infarction and from not ischemic troponin increases. In the postoperative period, the possibility of missing the diagnosis of an acute coronary syndrome for the paucity of clinical symptoms or because physician failed to evaluate a postoperative EKG recording should always be considered. Physiopathology of MINS is not yet well defined: current hypotheses are surrogated from perioperative myocardial infarction studies. Up to now there are not specific treatments for MINS, even if antithrombotic therapy is under evaluation. Treatment decisions should be tailored to the individual case; potential benefits of troponin screening include a cardiology consultation and consequently, improved patients' information to promote lifestyle changes and enhanced therapy.
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Affiliation(s)
- Viviana Miccichè
- Department of Critical Care, San Giovanni di Dio e Ruggi d'Aragona University Hospital, Salerno, Italy
| | - Cesare Baldi
- Cardio-Thoracic-Vascular Department, San Giovanni di Dio e Ruggi d'Aragona University Hospital, Salerno, Italy -
| | - Edoardo De Robertis
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Ornella Piazza
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
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23
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Brown JC, Samaha E, Rao S, Helwani MA, Duma A, Brown F, Gage BF, Miller JP, Jaffe AS, Apple FS, Scott MG, Nagele P. High-Sensitivity Cardiac Troponin T Improves the Diagnosis of Perioperative MI. Anesth Analg 2017; 125:1455-1462. [PMID: 28719430 DOI: 10.1213/ane.0000000000002240] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The diagnosis of myocardial infarction (MI) after noncardiac surgery has traditionally relied on using relatively insensitive contemporary cardiac troponin (cTn) assays. We hypothesized that using a recently introduced novel high-sensitivity cTnT (hscTnT) assay would increase the detection rate of perioperative MI. METHODS In this ancillary study of the Vitamins in Nitrous Oxide trial, readjudicated incidence rates of myocardial injury (new isolated cTn elevation) and MI were compared when diagnosed by contemporary cTnI versus hscTnT. We probed various relative (eg, >50%) or absolute (eg, +5 ng/L) hscTnT change metrics. Inclusion criteria for this ancillary study were the presence of a baseline and at least 1 postoperative hscTnT value. RESULTS Among 605 patients, 70 patients (12%) had electrocardiogram changes consistent with myocardial ischemia; 82 patients (14%) had myocardial injury diagnosed by contemporary cTnI, 31 (5.1%) of which had an adjudicated MI. After readjudication, 67 patients (11%) were diagnosed with MI when using hscTnT, a 2-fold increase. Incidence rates of postoperative myocardial injury ranged from 12% (n = 73) to 65% (n = 393) depending on the hscTnT metric used. Incidence rates of MI using various hscTnT change metrics and the presence of ischemic electrocardiogram changes, but without event adjudication, ranged from 3.6% (n = 22) to 12% (n = 74), a >3-fold difference. New postoperative hscTnT elevation, either by absolute or relative hscTnT change metric, was associated with an up to 5-fold increase in 6-month mortality. CONCLUSIONS The use of hscTnT compared to contemporary cTnI increases the detection rate of perioperative MI by a factor of 2. Using different absolute or relative hscTnT change metrics may lead to under- or overdiagnosis of perioperative MI.
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Affiliation(s)
- Jamie C Brown
- From the *Division of Clinical and Translational Research, Department of Anesthesiology, †Department of Internal Medicine, and ‡Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri; §Cardiovascular Division, Department of Internal Medicine and Division of Core Clinical Laboratory Services, Department of Laboratory Medicine and Pathology, Mayo Clinic and Medical School, Rochester, Minnesota; ‖Department of Laboratory Medicine & Pathology, Hennepin County Medical Center and University of Minnesota School of Medicine, Minneapolis, Minnesota; and ¶Department of Pathology & Immunology, Washington University School of Medicine, St Louis, Missouri
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24
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Urban MK, Wolfe SW, Sanghavi NM, Fields K, Magid SK. The Incidence of Perioperative Cardiac Events after Orthopedic Surgery: A Single Institutional Experience of Cases Performed over One Year. HSS J 2017; 13:248-254. [PMID: 28983217 PMCID: PMC5617821 DOI: 10.1007/s11420-017-9561-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 04/19/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Orthopedic patients with ischemic heart disease are at risk for postoperative cardiac complications. QUESTIONS/PURPOSES Using information from two medical information retrieval systems which insured the capture of all events for the period of study, our goals were to determine the incidence of myocardial injury in at-risk patients after orthopedic surgery and to delineate the type and incidence of cardiac complications in this population. METHODS For one year, at an orthopedic hospital, we identified all postoperative patients with a measured cTnI level using an electronic ordering system. Preoperative cardiac risk factors and postoperative cardiac complications were identified in patients undergoing a total hip arthroplasty (THA), total knee arthroplasty (TKA), and posterior spinal fusion (PSF). A postoperative myocardial infarction was defined by a cTnI > 0.1 ng/mL, ECG changes, new echocardiographic regional wall motion abnormalities, and evaluation by a cardiologist. Categorical variables were compared among groups with a Fisher's exact or Chi-square test. Continuous variables were compared among groups with ANOVA or the Kruskal-Wallis test. The associations of cardiac risk factors with myocardial injury are expressed as odds ratios from logistic regression models. RESULTS During a one-year period, from 10,627 inpatient orthopedic procedures, 805 patients were identified as at risk for postoperative myocardial ischemia. A total of 20.6% (166/805) of these patients had elevated serum cTnI levels (cTnI > 0.02 ng/mL), and there were ten documented postoperative MIs (10/805; 1.2%). For the at-risk TKA, THA, or PSF patients, 19% (102/532) had elevated cTnI levels and 31% (32/102) had postoperative cardiac complications, including arrhythmias (56%), congestive heart failure (2%), and MI (1%). Adjusting for sex, age, BMI, cardiac risk factors, and medications (statins and β-blockers), PSF patients had 3.9 times the risk of myocardial injury (p = 0.003) compared to TKA patients and 4.2 times that of THA patients. CONCLUSIONS The incidence of postoperative myocardial ischemia after major orthopedic surgery in patients with cardiac risk factors is high (8.7%), but the incidence of documented myocardial infarctions and serious cardiac complications remains low (1.2-2%). Patients with higher postoperative cTnI releases were more likely to have cardiac complications, and some procedures (spinal fusions) placed the patients at a higher risk.
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Affiliation(s)
- Michael K. Urban
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Steffan W. Wolfe
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Neil M. Sanghavi
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Kara Fields
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Steven K. Magid
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
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25
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Ollila A, Virolainen J, Vanhatalo J, Vikatmaa P, Tikkanen I, Venermo M, Salmenperä M, Pettilä V, Vikatmaa L. Postoperative Cardiac Ischemia Detection by Continuous 12-Lead Electrocardiographic Monitoring in Vascular Surgery Patients: A Prospective, Observational Study. J Cardiothorac Vasc Anesth 2016; 31:950-956. [PMID: 27919716 DOI: 10.1053/j.jvca.2016.09.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Elderly patients undergoing vascular surgery are at major risk for perioperative cardiac complications. The authors investigated continuous electrocardiographic Holter monitoring in a postoperative setting to determine the degree of postoperative ischemic load and its possible associations with perioperative myocardial infarction. DESIGN A prospective, observational study. SETTING One university hospital. PARTICIPANTS The study comprised 51 patients aged 65 years or older undergoing peripheral arterial surgery. INTERVENTIONS Continuous electrocardiographic monitoring with a Holter device was started postoperatively and continued for 72 hours or until discharge. Postural changes were recorded using a 3-axis accelerometer. Standard 12-lead electrocardiography, high-sensitive troponin T measurements, and an inquiry of ischemic symptoms were performed 4 times perioperatively. MEASUREMENTS AND MAIN RESULTS The primary outcomes were ischemic load (area under the function of ischemic ST-segment deviation and ischemic time) and perioperative myocardial infarction. During 3,262.7 patient-hours of monitoring, 17 patients (33.3%) experienced 608 transient ischemic events, all denoted by ST-segment depression. Of these 17 patients, 5 experienced perioperative myocardial infarction. The mean ischemic load in all patients was 913.2±2,797.3 µV×minute. Ischemic load predicted perioperative myocardial infarction, with an area under receiver operating characteristics curve (95% confidence interval) of 0.87 (0.75-0.99). Ischemic changes occurred most frequently during hours 24 to 60 of monitoring. Ischemia was asymptomatic in 14 of 17 patients (82.4%). CONCLUSION Postoperative myocardial ischemia was common in peripheral vascular surgery patients and may progress to perioperative myocardial infarction. Ischemic load was a good predictor of perioperative myocardial infarction. Ambulatory electrocardiographic monitoring solutions for continuous postoperative ischemia detection are warranted in the surgical ward.
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Affiliation(s)
- Aino Ollila
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juha Virolainen
- Heart and Lung Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Pirkka Vikatmaa
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ilkka Tikkanen
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Minerva Foundation Institute for Medical Research, Helsinki, Finland
| | - Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Markku Salmenperä
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville Pettilä
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Leena Vikatmaa
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
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Hollis RH, Holcomb CN, Valle JA, Smith BP, DeRussy AJ, Graham LA, Richman JS, Itani KM, Maddox TM, Hawn MT. Coronary angiography and failure to rescue after postoperative myocardial infarction in patients with coronary stents undergoing noncardiac surgery. Am J Surg 2016; 212:814-822.e1. [DOI: 10.1016/j.amjsurg.2016.07.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 07/22/2016] [Accepted: 07/25/2016] [Indexed: 10/21/2022]
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Dobson GP. Addressing the Global Burden of Trauma in Major Surgery. Front Surg 2015; 2:43. [PMID: 26389122 PMCID: PMC4558465 DOI: 10.3389/fsurg.2015.00043] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 08/17/2015] [Indexed: 12/18/2022] Open
Abstract
Despite a technically perfect procedure, surgical stress can determine the success or failure of an operation. Surgical trauma is often referred to as the "neglected step-child" of global health in terms of patient numbers, mortality, morbidity, and costs. A staggering 234 million major surgeries are performed every year, and depending upon country and institution, up to 4% of patients will die before leaving hospital, up to 15% will have serious post-operative morbidity, and 5-15% will be readmitted within 30 days. These percentages equate to around 1000 deaths and 4000 major complications every hour, and it has been estimated that 50% may be preventable. New frontline drugs are urgently required to make major surgery safer for the patient and more predictable for the surgeon. We review the basic physiology of the stress response from neuroendocrine to genomic systems, and discuss the paucity of clinical data supporting the use of statins, beta-adrenergic blockers and calcium-channel blockers. Since cardiac-related complications are the most common, particularly in the elderly, a key strategy would be to improve ventricular-arterial coupling to safeguard the endothelium and maintain tissue oxygenation. Reduced O2 supply is associated with glycocalyx shedding, decreased endothelial barrier function, fluid leakage, inflammation, and coagulopathy. A healthy endothelium may prevent these "secondary hit" complications, including possibly immunosuppression. Thus, the four pillars of whole body resynchronization during surgical trauma, and targets for new therapies, are: (1) the CNS, (2) the heart, (3) arterial supply and venous return functions, and (4) the endothelium. This is termed the Central-Cardio-Vascular-Endothelium (CCVE) coupling hypothesis. Since similar sterile injury cascades exist in critical illness, accidental trauma, hemorrhage, cardiac arrest, infection and burns, new drugs that improve CCVE coupling may find wide utility in civilian and military medicine.
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Affiliation(s)
- Geoffrey P Dobson
- Heart, Trauma and Sepsis Research Laboratory, Australian Institute of Tropical Health and Medicine, College of Medicine and Dentistry, James Cook University , Townsville, QLD , Australia
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28
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Perioperative Levels and Changes of High-Sensitivity Troponin T Are Associated With Cardiovascular Events in Vascular Surgery Patients*. Crit Care Med 2014; 42:1498-506. [DOI: 10.1097/ccm.0000000000000249] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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29
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Riedel B, Rafat N, Browne K, Burbury K, Schier R. Perioperative Implications of Vascular Endothelial Dysfunction: Current Understanding of this Critical Sensor-Effector Organ. CURRENT ANESTHESIOLOGY REPORTS 2013. [DOI: 10.1007/s40140-013-0024-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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30
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van Waes JA, Nathoe HM, de Graaff JC, Kemperman H, de Borst GJ, Peelen LM, van Klei WA, Buhre WF, de Graaff JC, Kalkman CJ, van Klei WA, van Waes JA, van Wolfswinkel L, Doevendans PA, Nathoe HM, Grobben RG, Grobbee DE, Peelen LM, Kemperman H, van Solinge WW, Leiner T, de Borst GJ, Leenen LP, Moll FL. Myocardial Injury After Noncardiac Surgery and its Association With Short-Term Mortality. Circulation 2013; 127:2264-71. [DOI: 10.1161/circulationaha.113.002128] [Citation(s) in RCA: 216] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background—
To identify patients at risk for postoperative myocardial injury and death, measuring cardiac troponin routinely after noncardiac surgery has been suggested. Such monitoring was implemented in our hospital. The aim of this study was to determine the predictive value of postoperative myocardial injury, as measured by troponin elevation, on 30-day mortality after noncardiac surgery.
Methods and Results—
This observational, single-center cohort study included 2232 consecutive intermediate- to high-risk noncardiac surgery patients aged ≥60 years who underwent surgery in 2011. Troponin was measured on the first 3 postoperative days. Log binomial regression analysis was used to estimate the association between postoperative myocardial injury (troponin I level >0.06 μg/L) and all-cause 30-day mortality. Myocardial injury was found in 315 of 1627 patients in whom troponin I was measured (19%). All-cause death occurred in 56 patients (3%). The relative risk of a minor increase in troponin (0.07–0.59 μg/L) was 2.4 (95% confidence interval, 1.3–4.2;
P
<0.01), and the relative risk of a 10- to 100-fold increase in troponin (≥0.60 μg/L) was 4.2 (95% confidence interval, 2.1–8.6;
P
<0.01). A myocardial infarction according to the universal definition was diagnosed in 10 patients (0.6%), of whom 1 (0.06%) had ST-segment elevation myocardial infarction.
Conclusions—
Postoperative myocardial injury is an independent predictor of 30-day mortality after noncardiac surgery. Implementation of postoperative troponin monitoring as standard of care is feasible and may be helpful in improving the prognosis of patients undergoing noncardiac surgery.
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Affiliation(s)
- Judith A.R. van Waes
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hendrik M. Nathoe
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jurgen C. de Graaff
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hans Kemperman
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert Jan de Borst
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Linda M. Peelen
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wilton A. van Klei
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
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Singh P, Shah D, Trikha A. Recurrent intraoperative silent ST depression responding to phenylephrine. J Anaesthesiol Clin Pharmacol 2012; 28:510-3. [PMID: 23225936 PMCID: PMC3511953 DOI: 10.4103/0970-9185.101944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Intraoperative myocardial ischemia is attributed to decreased myocardial oxygen supply. We present an unusual case of recurrent, symptomless inferior wall ischemia in an apparently healthy male with no history of coronary artery disease after a spinal block. The recurring episodes were linked to tachycardia and presented with significant ST depression in Lead II with reciprocal elevation in lead aVL. The episodes responded to phenylephrine and subsided without residual sequelae.
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Affiliation(s)
- Pm Singh
- Department of Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
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32
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The role of biomarkers and B-type natriuretic peptide in diagnosis and perioperative risk prediction. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2012. [DOI: 10.1080/22201173.2012.10872870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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33
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Ryan L, Rodseth RN, Biccard BM. The treatment of perioperative myocardial infarctions following noncardiac surgery. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2012. [DOI: 10.1080/22201173.2012.10872832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- L Ryan
- Perioperative Research Unit, Department of Anaesthetics, Nelson R Mandela School of Medicine, University of KwaZulu-Natal
| | - RN Rodseth
- Perioperative Research Unit, Department of Anaesthetics, Nelson R Mandela School of Medicine, University of KwaZulu-Natal
- Inkosi Albert Luthuli Central Hospital, Mayville
| | - BM Biccard
- Perioperative Research Unit, Department of Anaesthetics, Nelson R Mandela School of Medicine, University of KwaZulu-Natal
- Inkosi Albert Luthuli Central Hospital, Mayville
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34
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Biccard BM, Naidoo P, de Vasconcellos K. What is the best pre-operative risk stratification tool for major adverse cardiac events following elective vascular surgery? A prospective observational cohort study evaluating pre-operative myocardial ischaemia monitoring and biomarker analysis. Anaesthesia 2012; 67:389-95. [DOI: 10.1111/j.1365-2044.2011.07020.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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35
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Biccard BM. Postoperative risk stratification for cardiovascular complications. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2012. [DOI: 10.1080/22201173.2012.10872825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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36
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Biccard BM. Predicting outcome. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2012. [DOI: 10.1080/22201173.2012.10872824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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37
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Shaikh N, Mazhar R, Samy H, Sadiq MO, Ibrahim HA. Perioperative myocardial infraction following video-assisted thoracic surgery: A case report and review. Anesth Essays Res 2012; 6:87-90. [PMID: 25885511 PMCID: PMC4173422 DOI: 10.4103/0259-1162.103384] [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] [Indexed: 11/08/2022] Open
Abstract
Perioperative myocardial infarction (PMI) during video-assisted thoracoscopy (VAT) surgery is rarely reported in the literature. ST-segment-elevated myocardial infarction (STEMI) is rare in the perioperative period. We report a case of STEMI, following VAT surgery, complicated by acute coronary syndrome. A 53-year male, admitted with recurrent left-sided pneumothorax, an intercostal chest drain was inserted and planned for VAT and lung resection. The intra-operative period was stable, minimal lung resection, and excision of bullae was done. Just before extubation, patient had acute myocardial infarction and cardiogenic shock. An immediate percutaneous coronary intervention (PCI) angiogram showed 90% blockage of the right coronary artery with thrombus. Export thrombectomy and balloon angioplasty was done. Weaned off from inotropes and ventilator. He was transferred to ward from there by day 12, discharged home on double antiplatelet therapy. The PMI can occur earlier than it is commonly thought, and in our patient, it was STEMI, which is rare and occurred during VAT Surgery. In our patient early detection and earlier PCI may have resulted in better outcome.
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Affiliation(s)
- Nissar Shaikh
- Department of Anesthesia/ICU, Hamad Medical Corporation, Doha, Qatar
| | - Rashid Mazhar
- Department of Cardiology and Cardiovascular Surgery, Hamad Medical Corporation, Doha, Qatar
| | - H Samy
- Department of Cardiology and Cardiovascular Surgery, Hamad Medical Corporation, Doha, Qatar
| | - M Omer Sadiq
- Department of Cardiology and Cardiovascular Surgery, Hamad Medical Corporation, Doha, Qatar
| | - H Ali Ibrahim
- Department of Cardiology and Cardiovascular Surgery, Hamad Medical Corporation, Doha, Qatar
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38
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Ryan L, Rodseth R, Biccard B. Peri-operative myocardial infarction: time for therapeutic trials. Anaesthesia 2011; 66:1083-7. [DOI: 10.1111/j.1365-2044.2011.06984.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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39
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Schlitt A, Reindl I, Ebelt H, Buerke M, Werdan K. [Cardiac biomarkers in perioperative medicine : significance for noncardiac surgery patients]. Anaesthesist 2011; 60:709-16. [PMID: 21842250 DOI: 10.1007/s00101-011-1928-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Perioperative detection of cardiac biomarkers may help to identify patients at risk. Whether detection of these markers will be recommended in the preoperative setting for patients with cardiac diseases in the future has to be discussed as large prospective trials on this topic are missing. For preoperative evaluation of cardiac insufficiency quantification of brain natriuretic peptide (BNP) and amino-terminal pro-brain natriuretic peptide (NT-proBNP) are useful markers. Troponin is the marker of choice for detection of myocardial ischemia/infarction in the postoperative setting. In unstable patients coronary angiography and/or percutaneous coronary intervention (PCI) are indicated. However, in stable patients the decision for coronary angiography and/or PCI has to be made in each patient individually after interdisciplinary discussion between anesthesiologists, cardiologists and surgeons.
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Affiliation(s)
- A Schlitt
- Klinik und Poliklinik für Innere Medizin III, Universitätsklinikum, Martin Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland.
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40
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Biccard B, Rodseth R. Utility of clinical risk predictors for preoperative cardiovascular risk prediction. Br J Anaesth 2011; 107:133-43. [DOI: 10.1093/bja/aer194] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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41
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Bock M, Wiedermann CJ, Motsch J, Fritsch G, Paulmichl M. Minimizing cardiac risk in perioperative practice – interdisciplinary pharmacological approaches. Wien Klin Wochenschr 2011; 123:393-407. [DOI: 10.1007/s00508-011-1595-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2010] [Accepted: 03/02/2011] [Indexed: 10/18/2022]
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