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Xu L, Yang M, Wei A, Wei Z, Qin Y, Wang K, Li B, Chen K, Liu C, Li C, Wang T. Aerobic exercise-induced HIF-1α upregulation in heart failure: exploring potential impacts on MCT1 and MPC1 regulation. Mol Med 2024; 30:83. [PMID: 38867145 PMCID: PMC11167843 DOI: 10.1186/s10020-024-00854-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 06/05/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND The terminal stage of ischemic heart disease develops into heart failure (HF), which is characterized by hypoxia and metabolic disturbances in cardiomyocytes. The hypoxic failing heart triggers hypoxia-inducible factor-1α (HIF-1α) actions in the cells sensitized to hypoxia and induces metabolic adaptation by accumulating HIF-1α. Furthermore, soluble monocarboxylic acid transporter protein 1 (MCT1) and mitochondrial pyruvate carrier 1 (MPC1), as key nodes of metabolic adaptation, affect metabolic homeostasis in the failing rat heart. Aerobic exercise training has been reported to retard the progression of HF due to enhancing HIF-1α levels as well as MCT1 expressions, whereas the effects of exercise on MCT1 and MPC1 in HF (hypoxia) remain elusive. This research aimed to investigate the action of exercise associated with MCT1 and MPC1 on HF under hypoxia. METHODS The experimental rat models are composed of four study groups: sham stented (SHAM), HF sedentary (HF), HF short-term exercise trained (HF-E1), HF long-term exercise trained (HF-E2). HF was initiated via left anterior descending coronary artery ligation, the effects of exercise on the progression of HF were analyzed by ventricular ultrasound (ejection fraction, fractional shortening) and histological staining. The regulatory effects of HIF-1α on cell growth, MCT1 and MPC1 protein expression in hypoxic H9c2 cells were evaluated by HIF-1α activatort/inhibitor treatment and plasmid transfection. RESULTS Our results indicate the presence of severe pathological remodelling (as evidenced by deep myocardial fibrosis, increased infarct size and abnormal hypertrophy of the myocardium, etc.) and reduced cardiac function in the failing hearts of rats in the HF group compared to the SHAM group. Treadmill exercise training ameliorated myocardial infarction (MI)-induced cardiac pathological remodelling and enhanced cardiac function in HF exercise group rats, and significantly increased the expression of HIF-1α (p < 0.05), MCT1 (p < 0.01) and MPC1 (p < 0.05) proteins compared to HF group rats. Moreover, pharmacological inhibition of HIF-1α in hypoxic H9c2 cells dramatically downregulated MCT1 and MPC1 protein expression. This phenomenon is consistent with knockdown of HIF-1α at the gene level. CONCLUSION The findings propose that long-term aerobic exercise training, as a non- pharmacological treatment, is efficient enough to debilitate the disease process, improve the pathological phenotype, and reinstate cardiac function in HF rats. This benefit is most likely due to activation of myocardial HIF-1α and upregulation of MCT1 and MPC1.
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Affiliation(s)
- Longfei Xu
- Military Medical Sciences Academy, Tianjin, 300050, China
| | - Miaomiao Yang
- Military Medical Sciences Academy, Tianjin, 300050, China
| | - Aili Wei
- Military Medical Sciences Academy, Tianjin, 300050, China
| | - Zilin Wei
- Military Medical Sciences Academy, Tianjin, 300050, China
| | - Yingkai Qin
- Military Medical Sciences Academy, Tianjin, 300050, China
| | - Kun Wang
- Military Medical Sciences Academy, Tianjin, 300050, China
| | - Bin Li
- No. 950 Hospital of the Chinese People's Liberation Army, Yecheng, 844999, China
| | - Kang Chen
- Military Medical Sciences Academy, Tianjin, 300050, China
- Tianjin Key Laboratory of Exercise Physiology & Sports Medicine, Tianjin University of Sport, Tianjin, 301617, China
| | - Chen Liu
- Military Medical Sciences Academy, Tianjin, 300050, China
- Tianjin Key Laboratory of Exercise Physiology & Sports Medicine, Tianjin University of Sport, Tianjin, 301617, China
| | - Chao Li
- Military Medical Sciences Academy, Tianjin, 300050, China.
| | - Tianhui Wang
- Military Medical Sciences Academy, Tianjin, 300050, China.
- Tianjin Key Laboratory of Exercise Physiology & Sports Medicine, Tianjin University of Sport, Tianjin, 301617, China.
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2
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Law C, Bhimani N, Mitchell D, Yu MY, Chan P, Leibman S, Smith G. The Impact of Age on the Post-operative Outcomes in Patients Undergoing Resection for Oesophageal and Gastric Cancer. World J Surg 2023; 47:3270-3280. [PMID: 37851066 PMCID: PMC10694104 DOI: 10.1007/s00268-023-07223-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Within our ageing population, there is an increasing number of elderly patients presenting with oesophagogastric cancer. Resection remains the mainstay of curative treatment however it has substantial morbidity. The aim of this study was to assess whether age was an independent predictor of resection related complications in our unit. METHODS A retrospective cohort study of prospectively collated data from 2002 to 2020 of patients undergoing resection for oesophageal and gastric cancers was analysed. Patients aged over 75 and 75 and under were compared for peri-operative morbidity (via the Clavien-Dindo classification), length of stay (LOS), unplanned readmission, 30- and 90-day mortality, and use of neoadjuvant therapy. RESULTS Data for 466 consecutive patients undergoing oesophagogastric resection (277 oesophagectomy and 189 gastrectomy) were available for analysis. 22% of patients were aged over 75 (14% (39/277) of the oesophagectomy cohort, 34% (65/189) of the gastrectomy cohort). Oesophagectomy patients over 75 were more likely to develop post-operative complications, particularly cardiac or thromboembolic, (69.2%) than those in the younger cohort (50.4%, p = 0.029). There was no difference in complication rates between the younger and older patients undergoing gastrectomy (29.0% vs. 33.9% p = 0.495). The 30- and 90-day mortality rates were 1.4% (n = 4) and 2.5% (n = 7), respectively, for the oesophagectomy cohort and 1.1% (n = 2) and 1.6% (n = 3) for the gastrectomy cohort, with no difference between age groups. CONCLUSION In this series, we found that patients over the age of 75 were able to undergo oesophageal and gastric resection with curative intent with acceptable post-operative morbidity and mortality.
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Affiliation(s)
- Cameron Law
- Upper Gastrointestinal Surgical Unit, Clinical Administration 8A Office ASB, Royal North Shore Hospital, Reserve Road, St Leonards, NSW, 2065, Australia
- Northern Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Nazim Bhimani
- Upper Gastrointestinal Surgical Unit, Clinical Administration 8A Office ASB, Royal North Shore Hospital, Reserve Road, St Leonards, NSW, 2065, Australia.
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
| | - David Mitchell
- Upper Gastrointestinal Surgical Unit, Clinical Administration 8A Office ASB, Royal North Shore Hospital, Reserve Road, St Leonards, NSW, 2065, Australia
| | - Mia Yue Yu
- Upper Gastrointestinal Surgical Unit, Clinical Administration 8A Office ASB, Royal North Shore Hospital, Reserve Road, St Leonards, NSW, 2065, Australia
| | - Priscilla Chan
- Upper Gastrointestinal Surgical Unit, Clinical Administration 8A Office ASB, Royal North Shore Hospital, Reserve Road, St Leonards, NSW, 2065, Australia
| | - Steven Leibman
- Upper Gastrointestinal Surgical Unit, Clinical Administration 8A Office ASB, Royal North Shore Hospital, Reserve Road, St Leonards, NSW, 2065, Australia
- Northern Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Garett Smith
- Upper Gastrointestinal Surgical Unit, Clinical Administration 8A Office ASB, Royal North Shore Hospital, Reserve Road, St Leonards, NSW, 2065, Australia
- Northern Clinical School, University of Sydney, Sydney, NSW, Australia
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Hiraoka E, Tanabe K, Izuta S, Kubota T, Kohsaka S, Kozuki A, Satomi K, Shiomi H, Shinke T, Nagai T, Manabe S, Mochizuki Y, Inohara T, Ota M, Kawaji T, Kondo Y, Shimada Y, Sotomi Y, Takaya T, Tada A, Taniguchi T, Nagao K, Nakazono K, Nakano Y, Nakayama K, Matsuo Y, Miyamoto T, Yazaki Y, Yahagi K, Yoshida T, Wakabayashi K, Ishii H, Ono M, Kishida A, Kimura T, Sakai T, Morino Y. JCS 2022 Guideline on Perioperative Cardiovascular Assessment and Management for Non-Cardiac Surgery. Circ J 2023; 87:1253-1337. [PMID: 37558469 DOI: 10.1253/circj.cj-22-0609] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Affiliation(s)
- Eiji Hiraoka
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital
| | | | - Tadao Kubota
- Department of General Surgery, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Amane Kozuki
- Division of Cardiology, Osaka Saiseikai Nakatsu Hospital
| | | | | | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Susumu Manabe
- Department of Cardiovascular Surgery, International University of Health and Welfare Narita Hospital
| | - Yasuhide Mochizuki
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Taku Inohara
- Department of Cardiovascular Medicine, Keio University Graduate School of Medicine
| | - Mitsuhiko Ota
- Department of Cardiovascular Center, Toranomon Hospital
| | | | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital
| | - Yumiko Shimada
- JADECOM Academy NP·NDC Training Center, Japan Association for Development of Community Medicine
| | - Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Tomofumi Takaya
- Department of Cardiovascular Medicine, Hyogo Prefectural Himeji Cardiovascular Center
| | - Atsushi Tada
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Kazuya Nagao
- Department of Cardiology, Osaka Red Cross Hospital
| | - Kenichi Nakazono
- Department of Pharmacy, St. Marianna University Yokohama Seibu Hospital
| | | | | | - Yuichiro Matsuo
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | | | | | | | | | | | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
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4
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Murad MH, Kara Balla A, Khan MS, Shaikh A, Saadi S, Wang Z. Thresholds for interpreting the fragility index derived from sample of randomised controlled trials in cardiology: a meta-epidemiologic study. BMJ Evid Based Med 2023; 28:133-136. [PMID: 35264405 DOI: 10.1136/bmjebm-2021-111858] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/26/2022] [Indexed: 11/03/2022]
Abstract
The fragility index (FI) was proposed as a simplified way to communicate robustness of statistically significant results and their susceptibility to a change of a handful number of events. While this index is intuitive, it is not anchored by a cut-off or a guide for interpretation. We identified cardiovascular trials published in six high impact journals from 2007 to 2021 (500 or more participants and a dichotomous statistically significant primary outcome). We estimated area under curve (AUC) to determine FI value that best predicts whether the treatment effect was precise, defined as adequately powered for a plausible relative risk reduction (RRR) of 25% or 30% or having a CI that is sufficiently narrow to exclude a risk reduction that is too small (close to the null, <0.05). The median FI of 201 included cardiovascular trials was 13 (range 1-172). FI exceeded the number of patients lost to follow-up in 46/201 (22.89%) trials. FI values of 19 and 22 predicted that trials would be precise (powered for RRR of 30% and 25%; respectively, combined with CI that excluded risk reduction <0.05). AUC for meeting these precision criteria was 0.90 (0.86-0.94). In conclusion, FI values that range 19-22 may meet various definitions of precision and can be used as a rule of thumb to suggest that a treatment effect is likely precise and less susceptible to random error. The number of patients lost to follow-up should be presented alongside FI to better illustrate fragility.
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Affiliation(s)
- Mohammad Hassan Murad
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Muhammad Shahzeb Khan
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Asim Shaikh
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Samer Saadi
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Zhen Wang
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
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5
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Khan O, Patel M, Tomdio AN, Beall J, Jovin IS. Beta-Blockers in the Prevention and Treatment of Ischemic Heart Disease: Evidence and Clinical Practice. Heart Views 2023; 24:41-49. [PMID: 37124437 PMCID: PMC10144413 DOI: 10.4103/heartviews.heartviews_75_22] [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: 08/22/2022] [Accepted: 10/02/2022] [Indexed: 02/25/2023] Open
Abstract
Coronary artery disease (CAD) is the most prevalent cardiovascular disease characterized by atherosclerotic plaque buildup that can lead to partial or full obstruction of blood flow in the coronary arteries. Treatment for CAD involves a combination of lifestyle changes, pharmacologic therapy, and modern revascularization procedures. Beta-adrenoceptor antagonists (or beta-blockers) have been widely used for decades as a key therapy for CAD. In this review, prior studies are examined to better understand beta-adrenoceptor antagonist use in patients with acute coronary syndrome, stable coronary heart disease, and in the perioperative setting. The evidence for the benefit of beta-blocker therapy is well established for patients with acute myocardial infarction, but it diminishes as the time from the index cardiac event elapses. The evidence for benefit in the perioperative setting is not strong.
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Affiliation(s)
- Omer Khan
- Department of Medicine, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Murti Patel
- Department of Medicine, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
- Department of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Anna N. Tomdio
- Department of Medicine, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
- Department of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jeffrey Beall
- Department of Medicine, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Ion S. Jovin
- Department of Medicine, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
- Department of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
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6
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Halvorsen S, Mehilli J, Cassese S, Hall TS, Abdelhamid M, Barbato E, De Hert S, de Laval I, Geisler T, Hinterbuchner L, Ibanez B, Lenarczyk R, Mansmann UR, McGreavy P, Mueller C, Muneretto C, Niessner A, Potpara TS, Ristić A, Sade LE, Schirmer H, Schüpke S, Sillesen H, Skulstad H, Torracca L, Tutarel O, Van Der Meer P, Wojakowski W, Zacharowski K. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J 2022; 43:3826-3924. [PMID: 36017553 DOI: 10.1093/eurheartj/ehac270] [Citation(s) in RCA: 244] [Impact Index Per Article: 122.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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7
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Lee C, Columbo JA, Stone DH, Creager MA, Henkin S. Preoperative evaluation and perioperative management of patients undergoing major vascular surgery. Vasc Med 2022; 27:496-512. [PMID: 36214163 PMCID: PMC9551317 DOI: 10.1177/1358863x221122552] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients undergoing major vascular surgery have an increased risk of perioperative major adverse cardiovascular events (MACE). Accordingly, in this population, it is of particular importance to appropriately risk stratify patients' risk for these complications and optimize risk factors prior to surgical intervention. Comorbidities that portend a higher risk of perioperative MACE include coronary artery disease, heart failure, left-sided valvular heart disease, and significant arrhythmic burden. In this review, we provide a current approach to risk stratification prior to major vascular surgery and describe the strengths and weaknesses of different cardiac risk indices; discuss the role of noninvasive and invasive cardiac testing; and review perioperative pharmacotherapies.
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Affiliation(s)
| | | | | | | | - Stanislav Henkin
- Stanislav Henkin, Heart and Vascular
Center, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at
Dartmouth, Lebanon, NH 03756, USA.
Twitter: @stanhenkin
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8
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Nato CG, Tabacco L, Bilotta F. Fraud and retraction in perioperative medicine publications: what we learned and what can be implemented to prevent future recurrence. JOURNAL OF MEDICAL ETHICS 2022; 48:479-484. [PMID: 33990431 DOI: 10.1136/medethics-2021-107252] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 04/04/2021] [Accepted: 04/08/2021] [Indexed: 06/12/2023]
Abstract
Fraud in medical publications is an increasing concern. In particular, disciplines related to perioperative medicine-including anaesthesia and critical care-currently hold the highest rankings in terms of retracted papers for research misconduct. The dominance of this dubious achievement is attributable to a limited number of researchers who have repeatedly committed scientific fraud. In the last three decades, six researchers have authored 421 of the 475 papers retracted in perioperative medicine. This narrative review reports on six cases of fabricated publication in perioperative medicine that resulted in the paper's retraction. The process that led to the unveiling of the fraud, the impact on clinical practice, and changes in regulatory mechanisms of scientific companies and governmental agencies' policies are also presented. Fraud in medical publications is a growing concern that affects perioperative medicine requiring a substantial number of papers to be retracted. The continuous control elicited by readers, by local institutional review boards, scientific journal reviewers, scientific societies and government agencies can play an important role in preserving the 'pact of trust' between authors, professionals and ultimately the relationship between doctors and patients.
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Affiliation(s)
- Consolato Gianluca Nato
- Department of Anaesthesiology, Critical Care and Pain Medicine, Umberto I Policlinico di Roma, Roma, Lazio, Italy
| | - Leonardo Tabacco
- Department of Anaesthesiology, Critical Care and Pain Medicine, Umberto I Policlinico di Roma, Roma, Lazio, Italy
| | - Federico Bilotta
- Department of Anaesthesiology, Critical Care and Pain Medicine, Umberto I Policlinico di Roma, Roma, Lazio, Italy
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9
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Anderson B, Qasim M, Evison F, Gallier S, Townend JN, Ferro CJ, Sharif A. A population cohort analysis of English transplant centers indicates major adverse cardiovascular events after kidney transplantation. Kidney Int 2022; 102:876-884. [PMID: 35716956 DOI: 10.1016/j.kint.2022.05.017] [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: 07/19/2021] [Revised: 04/27/2022] [Accepted: 05/09/2022] [Indexed: 11/16/2022]
Abstract
Major adverse cardiovascular event (MACE) rates immediately after kidney transplantation remain uncertain due to heterogeneous reporting in the literature. To clarify this, we retrospectively studied every eligible kidney transplant procedure performed in England between April 1, 2002 and March 31. 2018 with follow-up through August 31, 2019. The primary outcome of interest was MACE broadly defined as any hospital admission with myocardial infarction, stroke, unstable angina, heart failure, any coronary revascularisation procedure and/or any cardiovascular death. Among 30,325 kidney transplant recipients, MACE occurred in 781 within the first year after transplantation (2.6% of all kidney transplant procedures). Of these 781 events, 201 occurred during the index admission for kidney transplantation surgery representing 25.7% of all first-year MACE and 0.7% of all kidney transplant procedures. Kidney transplant recipients who suffered a non-fatal MACE within the first year had significantly decreased 1-, 3-, 5- and 10-year patient survival of 80.5%, 70.2%, 59.5% and 38.6% respectively, compared to 97.4%, 94.4%, 90.7% and 78.4% for kidney transplant recipients not developing MACE.. In an adjusted Cox proportional hazard model, non-fatal MACE within the first-year post-transplant was associated with significant long-term mortality risk (hazard ratio 2.59; 95% confidence interval 2.34-2.88). Kidney transplant recipients experiencing MACE during the index admission compared to subsequent admissions were differentiated by age, sex and previous cardiac history but had similar patient survival. These rates are significantly lower than those reported in North America. Thus, our data confirms MACE is not a benign post-transplant event and has a strong association with long-term mortality risk.
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Affiliation(s)
- Benjamin Anderson
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Muhammad Qasim
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Felicity Evison
- Department of Health Informatics, Queen Elizabeth Hospital, Birmingham, UK
| | - Suzy Gallier
- Department of Health Informatics, Queen Elizabeth Hospital, Birmingham, UK
| | - Jonathan N Townend
- Department of Cardiology, University Hospitals Birmingham, UK; Institute of Cardiovascular Sciences, University of Birmingham, UK
| | - Charles J Ferro
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK; Institute of Cardiovascular Sciences, University of Birmingham, UK
| | - Adnan Sharif
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, UK.
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10
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McGinigle KL, Spangler EL, Pichel AC, Ayyash K, Arya S, Settembrini AM, Garg J, Thomas MM, Dell KE, Swiderski IJ, Lindo F, Davies MG, Setacci C, Urman RD, Howell SJ, Ljungqvist O, de Boer HD. Perioperative care in open aortic vascular surgery: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery. J Vasc Surg 2022; 75:1796-1820. [PMID: 35181517 DOI: 10.1016/j.jvs.2022.01.131] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/03/2022] [Indexed: 12/12/2022]
Abstract
The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS®) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based recommendations related to all of the health care received in the perioperative period for patients undergoing open abdominal aortic operations (both transabdominal and retroperitoneal approaches, including supraceliac, suprarenal, and infrarenal clamp sites, for aortic aneurysm and aortoiliac occlusive disease). Structured around the ERAS® core elements, 36 recommendations were made and organized into preadmission, preoperative, intraoperative, and postoperative recommendations.
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Affiliation(s)
- Katharine L McGinigle
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Emily L Spangler
- Department of Surgery, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Adam C Pichel
- Department of Anaesthesia, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Katie Ayyash
- Department of Perioperative Medicine (Merit), York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
| | - Shipra Arya
- Department of Surgery, School of Medicine, Stanford University, Palo Alto, CA
| | | | - Joy Garg
- Department of Vascular Surgery, Kaiser Permanente San Leandro, San Leandro, CA
| | - Merin M Thomas
- Lenox Hill Hospital, Northwell Health, New Hyde Park, NY
| | | | | | - Fae Lindo
- Stanford University Hospital, Palo Alto, CA
| | - Mark G Davies
- Department of Surgery, Joe R. & Teresa Lozano Long School of Medicine, University of Texas Health Sciences Center, San Antonio, TX
| | - Carlo Setacci
- Department of Surgery, University of Siena, Siena, Italy
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Simon J Howell
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Olle Ljungqvist
- Department of Surgery, School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Hans D de Boer
- Department of Anesthesiology, Pain Medicine and Procedure Sedation and Analgesia, Martini General Hospital Groningen, Groningen, the Netherlands
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11
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Jha S. Decision-Making Dilemma in Preoperative Cardiac Evaluation: Should We Turn the Page or Close the Book? Cureus 2022; 14:e21151. [PMID: 35165601 PMCID: PMC8831317 DOI: 10.7759/cureus.21151] [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] [Accepted: 01/12/2022] [Indexed: 11/06/2022] Open
Abstract
Coronary artery disease is one of the most dreadful and life-threatening diseases out of all cardiac diseases. The diagnosis and management of coronary artery disease comprise stepwise approaches. All these approaches are mostly guideline-driven. While the majority of the time, guidelines help us take the most appropriate care, exceptions do exist. For example, patients may have unusual risk factors and abnormal test results; however, they do not fit into the guideline algorithm to proceed further. This case report of a 68-year-old male patient depicts a true example of such a situation. He presented to the cardiologist's office for pre-operative cardiac evaluation for urological surgery. In view of associated risk factors, an exercise stress test was done, which showed critical abnormalities. As per the pre-operative cardiac assessment guidelines, the patient did not meet the criteria for further testing. However, a clinician's strong judgment and persistent negotiation superseded those barriers. Given critical abnormalities of the exercise stress test, the patient underwent cardiac catheterization. He was found to have triple vessel disease on cardiac catheterization. The scheduled surgery was withheld, and the patient underwent a coronary artery bypass graft. This life-threatening condition could have been easily missed if only the guidelines were to be followed. While guidelines cover a significant portion of the bell curve, this case report represents the importance of not missing the tail ends of the curve. It enhances the importance of thinking out of the box based on clinical training and expertise.
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12
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Balcı E, Demir ZA, Bahçecitapar M. Management of renin-angiotensin-aldosterone inhibitors and other antihypertensives and their clinical effects on pre-anesthesia blood pressure. Anesth Pain Med (Seoul) 2022; 17:112-119. [PMID: 34991190 PMCID: PMC8841255 DOI: 10.17085/apm.21050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 10/23/2021] [Indexed: 11/28/2022] Open
Abstract
Background Blood pressure fluctuations appear more significant in patients with poorly controlled hypertension and are known to be associated with adverse perioperative morbidity. In the present study, we aimed to determine the effects of antihypertensive drug treatment strategies on preanesthetic operating room blood pressure measurements. Methods A total of 717 patients participated in our study; 383 patients who were normotensive based on baseline measurements and not under antihypertensive therapy were excluded from the analysis. The remaining 334 patients were divided into six groups according to the antihypertensive drug treatment. These six groups were examined in terms of preoperative baseline and pre-anesthesia blood pressure measurements. Results As a result of the study, it was observed that 24% of patients had high blood pressure precluding surgery, and patients using renin-angiotensin-aldosterone system inhibitors (RAASI) had higher pre-anesthesia systolic blood pressure than patients using other antihypertensive drugs. Patients who received beta-blockers were also observed to have the lowest pre-anesthesia systolic blood pressure, diastolic blood pressure, and mean blood pressure, compared to others. Conclusions Recently, whether RAASI should be continued preoperatively remains controversial. Our study shows that RAASI cannot provide optimal pre-anesthesia blood pressure and lead to an increase in the number of postponed surgeries, probably due to withdrawal of medication before the operation. Therefore, the preoperative discontinuation of RAASI should be reevaluated in future studies.
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Affiliation(s)
- Eda Balcı
- Department of Anesthesiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
| | - Zeliha Aslı Demir
- Department of Anesthesiology, Ankara City Hospital, Health Sciences University, Ankara, Turkey
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Effects of short-term bisoprolol on perioperative myocardial injury in patients undergoing non-cardiac surgery: a randomized control study. Sci Rep 2021; 11:22006. [PMID: 34759287 PMCID: PMC8581026 DOI: 10.1038/s41598-021-01365-5] [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: 07/13/2021] [Accepted: 10/27/2021] [Indexed: 11/09/2022] Open
Abstract
The protective role of preoperative beta-blocker in patients undergoing non-cardiac surgery is unknown. We aimed to evaluate the effects of beta-blocker on perioperative myocardial injury in patients undergoing non-cardiac surgery. We consecutively enrolled 112 patients undergoing non-cardiac surgery. They were randomly allocated to receive bisoprolol or placebo given at least 2 days preoperatively and continued until 30 days after surgery. The primary outcome was incidence of perioperative myocardial injury defined by a rise of high-sensitive troponin-T (hs-TnT) more than 99th percentile of upper reference limit or a rise of hs-TnT more than 20% if baseline level is abnormal. Baseline characteristics were comparable between bisoprolol and placebo in randomized cohort Mean age was 62.5 ± 11.8 years and 76 (67.8%) of 112 patients were male. Among 112 patients, 49 (43.8%) underwent vascular surgery and 63 (56.2%) underwent thoracic surgery. The median duration of assigned treatment prior to surgery was 4 days (2-6 days). We did not demonstrate the significant difference in the incidence of perioperative myocardial injury [52.6% (30 of 57 patients) vs. 49.1% (27 of 55 patients), P = 0.706]. In addition, the incidence of intraoperative hypotension was higher in bisoprolol group than placebo group in patients undergoing non-cardiac surgery [70.2% (40 of 57 patients) vs. 47.3% (26 of 55 patients), P = 0.017]. We demonstrated that there was no statistically significant difference in perioperative myocardial injury observed between patients receiving bisoprolol and placebo who had undergone non-cardiac surgery.
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Gessouroun A, Flynn BC. Increasing the Perioperative Specialists Role: Comment on the 2021 American Heart Association Scientific Statement on Myocardial Injury After Noncardiac Surgery. J Cardiothorac Vasc Anesth 2021; 36:932-935. [PMID: 34876352 DOI: 10.1053/j.jvca.2021.10.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Andrew Gessouroun
- Department of Anesthesiology, Division of Critical Care, University of Kansas Medical Center, Kansas City, KS
| | - Brigid C Flynn
- Department of Anesthesiology, Division of Critical Care, University of Kansas Medical Center, Kansas City, KS.
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Guide de Pratique Clinique. Prise en charge de l’hypertension artérielle chez l’adulte en Tunisie. LA TUNISIE MÉDICALE 2021. [PMCID: PMC9003593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Ce document a été réalisé dans le cadre d'une collaboration entre l'Instance Nationale de l’Évaluation et de l'Accréditation en Santé (INEAS), la Société Tunisienne de Cardiologie et de Chirurgie Cardiovasculaire (STCCCV) et la Caisse Nationale d’Assurance Maladie (CNAM).
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Abstract
BACKGROUND Hepatorenal syndrome (HRS) is a serious complication of liver cirrhosis with poor survival in the absence of liver transplantation (LT). HRS represents a state of profound circulatory and cardiac dysfunction. Whether it increases risk of perioperative major adverse cardiovascular events (MACE) following LT remains unclear. METHODS We performed a retrospective cohort study of 560 consecutive patients undergoing cardiac workup for LT of whom 319 proceeded to LT. All patients underwent standardized assessment including dobutamine stress echocardiography. HRS was defined according to International Club of Ascites criteria. RESULTS Primary outcome of 30-day MACE occurred in 74 (23.2%) patients. A significantly higher proportion of patients with HRS experienced MACE (31 [41.9%] versus 54 [22.0%]; P = 0.001). After adjusting for age, model for end-stage liver disease score, cardiovascular risk index, history of coronary artery disease, and a positive stress test, HRS remained an independent predictor for MACE (odds ratio [OR], 2.44; 95% confidence interval [CI], 1.13-5.78). Other independent predictors included poor functional status (OR, 3.38; 95% CI, 1.41-8.13), pulmonary hypertension (OR, 3.26; 95% CI, 1.17-5.56), and beta-blocker use (OR, 2.56; 95% CI, 1.10-6.48). Occurrence of perioperative MACE was associated with a trend toward poor age-adjusted survival over 3.6-year follow-up (hazard ratio, 2.0; 95% CI, 0.98-4.10; P = 0.057). CONCLUSIONS HRS, beta-blocker use, pulmonary hypertension, and poor functional status were all associated with over a 2-fold higher risk of MACE following LT. Whether inclusion of these variables in routine preoperative assessment can facilitate cardiac risk stratification warrants further study.
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Sumin AN. Actual Issues of the Cardiac Complications Risk Assessment and Correction in Non-Cardiac Surgery. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2020. [DOI: 10.20996/1819-6446-2020-10-08] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Worldwide, more than 200 million non-cardiac surgeries are performed annually, and this number is constantly increasing; cardiac complications are the leading cause of death in such surgeries. So, in a multicenter study conducted in 27 countries, cardiovascular complications were present in 68% of cases of death in the postoperative period. Registers of recent years have shown that the number of such complications remains high, for example, with a dynamic assessment of troponins, perioperative myocardial damage was detected in 13-18% of cases. This review provides a critical analysis of the step-by-step algorithm for assessing cardiac risk of non-cardiac operations considering the emergence of new publications on this topic. The review discusses new data on risk assessment scales, functional state assessment, the use of non-invasive tests, biomarkers, the role of preventive myocardial revascularization in the preoperative period, and drug therapy. The issues of non-cardiac operations after percutaneous coronary intervention, perioperative myocardial damage are considered separately. The review emphasizes the difficulties in obtaining evidence, conducting randomized clinical trials in this section of medicine, which do not allow obtaining unambiguous conclusions in most cases and lead to inconsistencies and ambiguities in the recommendations of various expert groups. This review will help practitioners navigate this issue and help to use the optimal diagnostic and treatment strategy before performing non-cardiac surgery.
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Affiliation(s)
- A. N. Sumin
- Research Institute for Complex Issues of Cardiovascular Diseases
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Chanan EL, Kendale SM, Cuff G, Galloway AC, Nunnally ME. Adverse Outcomes Associated With Delaying or Withholding β-Blockers After Cardiac Surgery: A Retrospective Single-Center Cohort Study. Anesth Analg 2020; 131:1156-1163. [PMID: 32925336 DOI: 10.1213/ane.0000000000005051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Ideal timing of postoperative β-blockers is unclear. We hypothesized that patients who do not receive β-blockers immediately after cardiac surgery would have increased in-hospital mortality (primary outcome) and postoperative hemodynamic, pulmonary, neurologic, or respiratory complications (secondary outcomes). METHODS We performed a retrospective cohort study evaluating patients who underwent cardiac surgery at our institution from January 1, 2013 to September 30, 2017. We compared outcomes between patients who received β-blockers by postoperative day (POD) 5 with outcomes in patients who did not receive β-blockers at any time or received them after POD 5. Inverse probability of treatment weighting was used to minimize confounding. Univariate logistic regression analyses were performed on the weighted sets using absent or delayed β-blockers as the independent variable and each outcome as dependent variables in separate analyses. A secondary analysis was performed in patients prescribed preoperative β-blockers. E-values were calculated for significant outcomes. RESULTS All results were confounder adjusted. Among patients presenting for cardiac surgery, not receiving β-blockers by POD 5 or at any time was not associated with the primary outcome in-hospital mortality, estimated odds ratio (OR; 99.5% confidence interval [CI]) of 1.6 (0.49-5.1), P = .28. Not receiving β-blockers by POD 5 or at any time was associated with postoperative atrial fibrillation, estimated OR (99.5% CI) of 1.5 (1.1-2.1), P < .001, and pulmonary complications, estimated OR (99.5% CI) of 3.0 (1.8-5.2), P < .001. E-values were 2.4 for postoperative atrial fibrillation and 5.6 for pulmonary complications. Among patients presenting for cardiac surgery taking preoperative β-blockers, not receiving β-blockers by POD 5 or at any time was not associated with the primary outcome mortality, with estimated OR (99.5% CI) of 1.3 (0.43-4.1), P = .63. In this subset, not receiving β-blockers by POD 5 or at any time was associated with increased adjusted ORs of postoperative atrial fibrillation (OR = 1.6; 99.5% CI, 1.1-2.4; P < .001) and postoperative pulmonary complications (OR = 2.8; 99.5% CI, 1.6-5.2; P < .001). Here, e-values were 2.7 for postoperative atrial fibrillation and 5.1 for pulmonary complications. For the sensitivity analyses for secondary outcomes, exposure and outcome periods overlap. Outcomes may have occurred before or after postoperative β-blocker administration. CONCLUSIONS Among patients who undergo cardiac surgery, not receiving postoperative β-blockers within the first 5 days after cardiac surgery or at any time is not associated with in-hospital mortality and is associated with, but may not necessarily cause, postoperative atrial fibrillation and pulmonary complications.
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Affiliation(s)
- Emily L Chanan
- From the Departments of Anesthesiology, Perioperative Care and Pain Medicine and
| | - Samir M Kendale
- From the Departments of Anesthesiology, Perioperative Care and Pain Medicine and
| | - Germaine Cuff
- From the Departments of Anesthesiology, Perioperative Care and Pain Medicine and
| | - Aubrey C Galloway
- Cardiothoracic Surgery, New York University (NYU) Langone Health, New York, New York
| | - Mark E Nunnally
- From the Departments of Anesthesiology, Perioperative Care and Pain Medicine and
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The Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH 2019). Hypertens Res 2020; 42:1235-1481. [PMID: 31375757 DOI: 10.1038/s41440-019-0284-9] [Citation(s) in RCA: 976] [Impact Index Per Article: 244.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Algahtani R, Merenda A. Multimorbidity and Critical Care Neurosurgery: Minimizing Major Perioperative Cardiopulmonary Complications. Neurocrit Care 2020; 34:1047-1061. [PMID: 32794145 PMCID: PMC7426068 DOI: 10.1007/s12028-020-01072-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/28/2020] [Indexed: 11/19/2022]
Abstract
With increasing prevalence of chronic diseases, multimorbid patients have become commonplace in the neurosurgical intensive care unit (neuro-ICU), offering unique management challenges. By reducing physiological reserve and interacting with one another, chronic comorbidities pose a greatly enhanced risk of major postoperative medical complications, especially cardiopulmonary complications, which ultimately exert a negative impact on neurosurgical outcomes. These premises underscore the importance of perioperative optimization, in turn requiring a thorough preoperative risk stratification, a basic understanding of a multimorbid patient’s deranged physiology and a proper appreciation of the potential of surgery, anesthesia and neurocritical care interventions to exacerbate comorbid pathophysiologies. This knowledge enables neurosurgeons, neuroanesthesiologists and neurointensivists to function with a heightened level of vigilance in the care of these high-risk patients and can inform the perioperative neuro-ICU management with individualized strategies able to minimize the risk of untoward outcomes. This review highlights potential pitfalls in the intra- and postoperative neuro-ICU period, describes common preoperative risk stratification tools and discusses tailored perioperative ICU management strategies in multimorbid neurosurgical patients, with a special focus on approaches geared toward the minimization of postoperative cardiopulmonary complications and unplanned reintubation.
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Affiliation(s)
- Rami Algahtani
- Department of Neurology, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Amedeo Merenda
- Department of Neurology, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA. .,Department of Neurosurgery, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA.
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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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Ziff OJ, Samra M, Howard JP, Bromage DI, Ruschitzka F, Francis DP, Kotecha D. Beta-blocker efficacy across different cardiovascular indications: an umbrella review and meta-analytic assessment. BMC Med 2020; 18:103. [PMID: 32366251 PMCID: PMC7199339 DOI: 10.1186/s12916-020-01564-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 03/17/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Beta-blockers are widely used for many cardiovascular conditions; however, their efficacy in contemporary clinical practice remains uncertain. METHODS We performed a prospectively designed, umbrella review of meta-analyses of randomised controlled trials (RCTs) investigating the evidence of beta-blockers in the contemporary management of coronary artery disease (CAD), heart failure (HF), patients undergoing surgery or hypertension (registration: PROSPERO CRD42016038375). We searched MEDLINE, EMBASE and the Cochrane Library from inception until December 2018. Outcomes were analysed as beta-blockers versus control for all-cause mortality, myocardial infarction (MI), incident HF or stroke. Two independent investigators abstracted the data, assessed the quality of the evidence and rated the certainty of evidence. RESULTS We identified 98 meta-analyses, including 284 unique RCTs and 1,617,523 patient-years of follow-up. In CAD, 12 meta-analyses (93 RCTs, 103,481 patients) showed that beta-blockers reduced mortality in analyses before routine reperfusion, but there was a lack of benefit in contemporary studies where ≥ 50% of patients received thrombolytics or intervention. Beta-blockers reduced incident MI at the expense of increased HF. In HF with reduced ejection fraction, 34 meta-analyses (66 RCTs, 35,383 patients) demonstrated a reduction in mortality and HF hospitalisation with beta-blockers in sinus rhythm, but not in atrial fibrillation. In patients undergoing surgery, 23 meta-analyses (89 RCTs, 19,211 patients) showed no effect of beta-blockers on mortality for cardiac surgery, but increased mortality in non-cardiac surgery. In non-cardiac surgery, beta-blockers reduced MI after surgery but increased the risk of stroke. In hypertension, 27 meta-analyses (36 RCTs, 260,549 patients) identified no benefit versus placebo, but beta-blockers were inferior to other agents for preventing mortality and stroke. CONCLUSIONS Beta-blockers substantially reduce mortality in HF patients in sinus rhythm, but for other conditions, clinicians need to weigh up both benefit and potential risk.
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Affiliation(s)
- Oliver J Ziff
- University of Birmingham Institute of Cardiovascular Sciences, Medical School, Birmingham, B15 2TT, UK.,University College London, London, WC1E 6BT, UK
| | | | | | - Daniel I Bromage
- University College London, London, WC1E 6BT, UK.,Kings College London, London, WC2R 2LS, UK
| | | | | | - Dipak Kotecha
- University of Birmingham Institute of Cardiovascular Sciences, Medical School, Birmingham, B15 2TT, UK. .,Monash Centre of Cardiovascular Research & Education in Therapeutics, Monash University, Melbourne, Victoria, 3004, Australia. .,University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Institute of Translational Medicine, Birmingham, B15 2GW, UK.
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Nan Y, Jia F, Du X, Mei Z. Beta-blocker exposure for short-term outcomes following non-cardiac surgery: A meta-analysis of observational studies. Int J Surg 2020; 76:153-162. [PMID: 32169568 DOI: 10.1016/j.ijsu.2020.02.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/19/2020] [Accepted: 02/25/2020] [Indexed: 01/07/2023]
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Toda H, Nakamura K, Shimizu K, Ejiri K, Iwano T, Miyoshi T, Nakagawa K, Yoshida M, Watanabe A, Nishii N, Hikasa Y, Hayashi M, Morita H, Morimatsu H, Ito H. Effects of Bisoprolol Transdermal Patches for Prevention of Perioperative Myocardial Injury in High-Risk Patients Undergoing Non-Cardiac Surgery ― Multicenter Randomized Controlled Study ―. Circ J 2020; 84:642-649. [DOI: 10.1253/circj.cj-19-0871] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Hironobu Toda
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Kazuyoshi Shimizu
- Department of Anesthesiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Kentaro Ejiri
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Takayuki Iwano
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Toru Miyoshi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Koji Nakagawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Masashi Yoshida
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Atsuyuki Watanabe
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Nobuhiro Nishii
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Yukiko Hikasa
- Department of Anesthesiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Masao Hayashi
- Department of Anesthesiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hiroshi Morita
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hiroshi Morimatsu
- Department of Anesthesiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
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Kapadia F. Suggestions and Commentary on Creating, Interpreting and Using Clinical Practice Guidelines. Indian J Crit Care Med 2020; 24:S2-S5. [PMID: 32205953 PMCID: PMC7085815 DOI: 10.5005/jp-journals-10071-g23182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
How to cite this article: Farhad Kapadia. Suggestions and Commentary on Creating, Interpreting and Using Clinical Practice Guidelines. Indian J Crit Care Med 2020;24(Suppl 1):S2–S5.
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Affiliation(s)
- Farhad Kapadia
- Farhad Kapadia, Department of Intensive Care and Medicine, Hinduja Hospital, Veer Savarkar Marg, Mahim, Mumbai, Maharashtra, India, e-mail:
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Walter E, Heringlake M. Cost-Effectiveness Analysis of Landiolol, an Ultrashort-Acting Beta-Blocker, for Prevention of Postoperative Atrial Fibrillation for the Germany Health Care System. J Cardiothorac Vasc Anesth 2019; 34:888-897. [PMID: 31837963 DOI: 10.1053/j.jvca.2019.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/28/2019] [Accepted: 11/04/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Landiolol is an ultrashort-acting beta-blocker with high beta-1 receptor affinity and less blood pressure-lowering properties than other beta-blockers available for intravenous use in Germany. The present analysis aimed to determine whether perioperative treatment with landiolol in cardiac surgical patients is cost-effective under the conditions of the German Diagnosis-Related Groups health cost reimbursement system. DESIGN On the basis of clinical outcome data from a meta-analysis that included 622 patients from 7 randomized controlled trials, a decision-model was developed to determine the cost-effectiveness of landiolol versus standard-of-care (SoC). SETTING Hospital setting. PARTICIPANTS Hospital patients undergoing a representative mix of cardiac surgical procedures (MIX-CS) and isolated coronary artery bypass grafting (CABG). INTERVENTIONS Landiolol versus SoC in prevention of atrial fibrillation immediately after cardiac surgery. MEASUREMENTS AND MAIN RESULTS The model benefit was expressed in a reduction of postoperative atrial fibrillation (POAF) episodes and reduced complications. The model calculated total inpatient costs over the hospital length of stay. Costs from published sources were used for the German hospital perspective. SoC was associated with POAF rates of 36.0% to 39.2% and 24.4% to 30.1% in the MIX-CS and CABG populations, respectively. Patients with POAF had a higher morbidity and mortality. Estimated total costs for SoC patients in the MIX-CS and CABG groups were 28.792 € and 25.630 €, respectively. Landiolol reduced the incidence of POAF to 12.6% in the MIX-CS and 12.1% in the CABG groups. This was associated with a cost reduction of 2.209 € and 1.470 €. CONCLUSIONS This analysis suggests that preventing POAF with landiolol is highly cost-effective. Additional studies are needed to assess whether a comparable reduction in POAF and associated cost savings may be achieved using conventional intravenous beta-blockers or amiodarone.
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Affiliation(s)
- Evelyn Walter
- IPF Institute for Pharmaeconomic Research, Vienna, Austria.
| | - Matthias Heringlake
- Department of Anesthesiology and Intensive Care Medicine, University of Lübeck, Lübeck, Germany
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Abstract
ZusammenfassungErhöhter Blutdruck bleibt eine Hauptursache von kardiovaskulären Erkrankungen, Behinderung und frühzeitiger Sterblichkeit in Österreich, wobei die Raten an Diagnose, Behandlung und Kontrolle auch in rezenten Studien suboptimal sind. Das Management von Bluthochdruck ist eine häufige Herausforderung für Ärztinnen und Ärzte vieler Fachrichtungen. In einem Versuch, diagnostische und therapeutische Strategien zu standardisieren und letztendlich die Rate an gut kontrollierten Hypertoniker/innen zu erhöhen und dadurch kardiovaskuläre Erkrankungen zu verhindern, haben 13 österreichische medizinische Fachgesellschaften die vorhandene Evidenz zur Prävention, Diagnose, Abklärung, Therapie und Konsequenzen erhöhten Blutdrucks gesichtet. Das hier vorgestellte Ergebnis ist der erste Österreichische Blutdruckkonsens. Die Autoren und die beteiligten Fachgesellschaften sind davon überzeugt, daß es einer gemeinsamen nationalen Anstrengung bedarf, die Blutdruck-assoziierte Morbidität und Mortalität in unserem Land zu verringern.
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Preoperative β-blocker use correlates with worse outcomes in patients undergoing aortic valve replacement. J Thorac Cardiovasc Surg 2019; 158:1589-1597.e3. [DOI: 10.1016/j.jtcvs.2018.12.108] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 12/17/2018] [Accepted: 12/20/2018] [Indexed: 01/26/2023]
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Koutsaki M, Patoulias D, Tsinivizov P, Doumas M, Kallistratos M, Thomopoulos C, Poulimenos L, Agnelli G, Mancia G, Manolis A. Evaluation, risk stratification and management of hypertensive patients in the perioperative period. Eur J Intern Med 2019; 69:1-7. [PMID: 31606306 DOI: 10.1016/j.ejim.2019.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 08/18/2019] [Accepted: 09/15/2019] [Indexed: 12/19/2022]
Abstract
Uncontrolled hypertension represents an important cause for postponing a non-cardiac surgery. Perioperative management of hypertensive patients should focus on cardiovascular risk stratification, evaluation of blood pressure levels and hypertension control, registration of the ongoing antihypertensive regimen and counseling about clinical decisions related to the expected perioperative blood pressure fluctuations. To date, there is a lack of evidence on how hypertensive patients should be perioperatively treated, while an empirical clinical approach is usually pursued in the usual practice. The present review appraises the gaps in the evidence and illustrates the current empirical approach of perioperative management of hypertension in non-cardiac surgery.
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Affiliation(s)
- Maria Koutsaki
- Department of Cardiology, Asklepeion General Hospital, Athens, Greece
| | - Dimitrios Patoulias
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Pavlos Tsinivizov
- Department of Cardiology, Asklepeion General Hospital, Athens, Greece
| | - Michael Doumas
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Contemporary personalized β-blocker management in the perioperative setting. J Anesth 2019; 34:115-133. [PMID: 31637510 DOI: 10.1007/s00540-019-02691-9] [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: 04/30/2019] [Accepted: 09/26/2019] [Indexed: 10/25/2022]
Abstract
Beta-adrenergic blockers (β-blockers) are clearly indicated for the long-term treatment of patients with systolic heart failure and post-acute myocardial infarction. Early small-scale studies reported their potential benefits for perioperative use; subsequent randomized controlled trials, however, failed to reproduce earlier findings. Furthermore, their role in reducing major postoperative cardiac events following noncardiac and cardiac surgery remains controversial. This case-based review presents an overview of contemporary literature on perioperative β-blocker use with a focus on data available since 2008 when the PreOperative ISchemic Evaluation (POISE) trial was published. Our review suggests that studies should determine the effects of situational-based guidelines on perioperative β-blocker use on the risk of cardiac adverse events and mortality in the perioperative period.
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Blessberger H, Lewis SR, Pritchard MW, Fawcett LJ, Domanovits H, Schlager O, Wildner B, Kammler J, Steinwender C. Perioperative beta-blockers for preventing surgery-related mortality and morbidity in adults undergoing non-cardiac surgery. Cochrane Database Syst Rev 2019; 9:CD013438. [PMID: 31556094 PMCID: PMC6761481 DOI: 10.1002/14651858.cd013438] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Randomized controlled trials (RCTs) have yielded conflicting results regarding the ability of beta-blockers to influence perioperative cardiovascular morbidity and mortality. Thus routine prescription of these drugs in an unselected population remains a controversial issue. A previous version of this review assessing the effectiveness of perioperative beta-blockers in cardiac and non-cardiac surgery was last published in 2018. The previous review has now been split into two reviews according to type of surgery. This is an update, and assesses the evidence in non-cardiac surgery only. OBJECTIVES To assess the effectiveness of perioperatively administered beta-blockers for the prevention of surgery-related mortality and morbidity in adults undergoing non-cardiac surgery. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, Biosis Previews and Conference Proceedings Citation Index-Science on 28 June 2019. We searched clinical trials registers and grey literature, and conducted backward- and forward-citation searching of relevant articles. SELECTION CRITERIA We included RCTs and quasi-randomized studies comparing beta-blockers with a control (placebo or standard care) administered during the perioperative period to adults undergoing non-cardiac surgery. If studies included surgery with different types of anaesthesia, we included them if 70% participants, or at least 100 participants, received general anaesthesia. We excluded studies in which all participants in the standard care control group were given a pharmacological agent that was not given to participants in the intervention group, studies in which all participants in the control group were given a beta-blocker, and studies in which beta-blockers were given with an additional agent (e.g. magnesium). We excluded studies that did not measure or report review outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data, and assessed risks of bias. We assessed the certainty of evidence with GRADE. MAIN RESULTS We included 83 RCTs with 14,967 participants; we found no quasi-randomized studies. All participants were undergoing non-cardiac surgery, and types of surgery ranged from low to high risk. Types of beta-blockers were: propranolol, metoprolol, esmolol, landiolol, nadolol, atenolol, labetalol, oxprenolol, and pindolol. In nine studies, beta-blockers were titrated according to heart rate or blood pressure. Duration of administration varied between studies, as did the time at which drugs were administered; in most studies, it was intraoperatively, but in 18 studies it was before surgery, in six postoperatively, one multi-arm study included groups of different timings, and one study did not report timing of drug administration. Overall, we found that more than half of the studies did not sufficiently report methods used for randomization. All studies in which the control was standard care were at high risk of performance bias because of the open-label study design. Only two studies were prospectively registered with clinical trials registers, which limited the assessment of reporting bias. In six studies, participants in the control group were given beta-blockers as rescue therapy during the study period.The evidence for all-cause mortality at 30 days was uncertain; based on the risk of death in the control group of 25 per 1000, the effect with beta-blockers was between two fewer and 13 more per 1000 (risk ratio (RR) 1.17, 95% confidence interval (CI) 0.89 to 1.54; 16 studies, 11,446 participants; low-certainty evidence). Beta-blockers may reduce the incidence of myocardial infarction by 13 fewer incidences per 1000 (RR 0.72, 95% CI 0.60 to 0.87; 12 studies, 10,520 participants; low-certainty evidence). We found no evidence of a difference in cerebrovascular events (RR 1.65, 95% CI 0.97 to 2.81; 6 studies, 9460 participants; low-certainty evidence), or in ventricular arrhythmias (RR 0.72, 95% CI 0.35 to 1.47; 5 studies, 476 participants; very low-certainty evidence). Beta-blockers may reduce atrial fibrillation or flutter by 26 fewer incidences per 1000 (RR 0.41, 95% CI 0.21 to 0.79; 9 studies, 9080 participants; low-certainty evidence). However, beta-blockers may increase bradycardia by 55 more incidences per 1000 (RR 2.49, 95% CI 1.74 to 3.56; 49 studies, 12,239 participants; low-certainty evidence), and hypotension by 44 more per 1000 (RR 1.40, 95% CI 1.29 to 1.51; 49 studies, 12,304 participants; moderate-certainty evidence).We downgraded the certainty of the evidence owing to study limitations; some studies had high risks of bias, and the effects were sometimes altered when we excluded studies with a standard care control group (including only placebo-controlled trials showed an increase in early mortality and cerebrovascular events with beta-blockers). We also downgraded for inconsistency; one large, well-conducted, international study found a reduction in myocardial infarction, and an increase in cerebrovascular events and all-cause mortality, when beta-blockers were used, but other studies showed no evidence of a difference. We could not explain the reason for the inconsistency in the evidence for ventricular arrhythmias, and we also downgraded this outcome for imprecision because we found few studies with few participants. AUTHORS' CONCLUSIONS The evidence for early all-cause mortality with perioperative beta-blockers was uncertain. We found no evidence of a difference in cerebrovascular events or ventricular arrhythmias, and the certainty of the evidence for these outcomes was low and very low. We found low-certainty evidence that beta-blockers may reduce atrial fibrillation and myocardial infarctions. However, beta-blockers may increase bradycardia (low-certainty evidence) and probably increase hypotension (moderate-certainty evidence). Further evidence from large placebo-controlled trials is likely to increase the certainty of these findings, and we recommend the assessment of impact on quality of life. We found 18 studies awaiting classification; inclusion of these studies in future updates may also increase the certainty of the evidence.
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Affiliation(s)
- Hermann Blessberger
- Kepler University Hospital, Medical Faculty of the Johannes Kepler University LinzDepartment of Cardiology, Med Campus IIIKrankenhausstraße 9LinzAustria4020
| | - Sharon R Lewis
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Michael W Pritchard
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Lizzy J Fawcett
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Hans Domanovits
- Vienna General Hospital, Medical University of ViennaDepartment of Emergency MedicineWähringer Gürtel 18‐20ViennaAustria1090
| | - Oliver Schlager
- Vienna General Hospital, Medical University of ViennaDepartment of Internal Medicine II, Division of AngiologyWähringer Gürtel 18‐20ViennaAustria1090
| | - Brigitte Wildner
- University Library of the Medical University of ViennaInformation Retrieval OfficeWähringer Gürtel 18‐20ViennaAustria1090
| | - Juergen Kammler
- Kepler University Hospital, Medical Faculty of the Johannes Kepler University LinzDepartment of Cardiology, Med Campus IIIKrankenhausstraße 9LinzAustria4020
| | - Clemens Steinwender
- Kepler University Hospital, Medical Faculty of the Johannes Kepler University LinzDepartment of Cardiology, Med Campus IIIKrankenhausstraße 9LinzAustria4020
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Maghami S, Cao Y, Ahl R, Detlofsson E, Matthiessen P, Sarani B, Mohseni S. Beta-blocker Therapy is Associated with Decreased 1-year Mortality After Emergency Laparotomy in Geriatric Patients. Scand J Surg 2019; 110:37-43. [DOI: 10.1177/1457496919877582] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background and Aims: Emergency laparotomy is associated with a great risk of mortality in the elderly. The hyperadrenergic state induced by surgical trauma may play an important role in the pathophysiology of this increased risk. Studies have shown that beta-blocker exposure may be associated with decreased morbidity and mortality in the perioperative period. We aimed to study the effect of beta-blocker on mortality in geriatric patients undergoing emergency laparotomy. Material and Methods: This is a retrospective study of patients who underwent emergency laparotomy between 1 January 2015 and 31 December 2016 at a single institution. The outcomes of interest were the association between post-operative complications and in-hospital and 1-year mortality in patients on beta-blocker therapy (BB(+)) and those who were not (BB(−)). The Poisson regression analysis was used to evaluate the association. Results: A total of 192 patients were included of whom 62 (32.2%) had pre-operative beta-blocker therapy with continued exposure during their hospital stay. The in-hospital mortality was 17.7% in the BB(+) and 23.8% in the BB(−) cohorts ( p = 0.441). One-year mortality was significantly lower in the BB(+) group compared to the BB(−) group (30.6% versus 47.7%; p = 0.038). After adjusting for confounders, the incidence of deaths during 1 year post-operatively decreased by 35% in the BB(+) group (incidence rate ratio = 0.65, p = 0.004). No significant differences in the incidence of post-operative complications between the two groups could be measured. Conclusion: Beta-blocker therapy may be associated with reduced 1-year mortality following emergency laparotomy in geriatric patients.
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Affiliation(s)
- S. Maghami
- Center for Trauma and Critical Care, Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Y. Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Orebro, Sweden
| | - R. Ahl
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - E. Detlofsson
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - P. Matthiessen
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - B. Sarani
- Center for Trauma and Critical Care, Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - S. Mohseni
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
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Eldrup-Jorgensen J. The role of cardiac risk stratification in preoperative beta blockade. J Vasc Surg 2019; 70:1021. [PMID: 31445645 DOI: 10.1016/j.jvs.2019.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 05/18/2019] [Indexed: 10/26/2022]
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Abbott TEF, Pearse RM, Archbold RA, Ahmad T, Niebrzegowska E, Wragg A, Rodseth RN, Devereaux PJ, Ackland GL. A Prospective International Multicentre Cohort Study of Intraoperative Heart Rate and Systolic Blood Pressure and Myocardial Injury After Noncardiac Surgery: Results of the VISION Study. Anesth Analg 2019; 126:1936-1945. [PMID: 29077608 PMCID: PMC5815500 DOI: 10.1213/ane.0000000000002560] [Citation(s) in RCA: 124] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND The association between intraoperative cardiovascular changes and perioperative myocardial injury has chiefly focused on hypotension during noncardiac surgery. However, the relative influence of blood pressure and heart rate (HR) remains unclear. We investigated both individual and codependent relationships among intraoperative HR, systolic blood pressure (SBP), and myocardial injury after noncardiac surgery (MINS). METHODS Secondary analysis of the Vascular Events in Noncardiac Surgery Cohort Evaluation (VISION) study, a prospective international cohort study of noncardiac surgical patients. Multivariable logistic regression analysis tested for associations between intraoperative HR and/or SBP and MINS, defined by an elevated serum troponin T adjudicated as due to an ischemic etiology, within 30 days after surgery. Predefined thresholds for intraoperative HR and SBP were: maximum HR >100 beats or minimum HR <55 beats per minute (bpm); maximum SBP >160 mm Hg or minimum SBP <100 mm Hg. Secondary outcomes were myocardial infarction and mortality within 30 days after surgery. RESULTS After excluding missing data, 1197 of 15,109 patients (7.9%) sustained MINS, 454 of 16,031 (2.8%) sustained myocardial infarction, and 315 of 16,061 patients (2.0%) died within 30 days after surgery. Maximum intraoperative HR >100 bpm was associated with MINS (odds ratio [OR], 1.27 [1.07-1.50]; P < .01), myocardial infarction (OR, 1.34 [1.05-1.70]; P = .02), and mortality (OR, 2.65 [2.06-3.41]; P < .01). Minimum SBP <100 mm Hg was associated with MINS (OR, 1.21 [1.05-1.39]; P = .01) and mortality (OR, 1.81 [1.39-2.37]; P < .01), but not myocardial infarction (OR, 1.21 [0.98-1.49]; P = .07). Maximum SBP >160 mm Hg was associated with MINS (OR, 1.16 [1.01-1.34]; P = .04) and myocardial infarction (OR, 1.34 [1.09-1.64]; P = .01) but, paradoxically, reduced mortality (OR, 0.76 [0.58-0.99]; P = .04). Minimum HR <55 bpm was associated with reduced MINS (OR, 0.70 [0.59-0.82]; P < .01), myocardial infarction (OR, 0.75 [0.58-0.97]; P = .03), and mortality (OR, 0.58 [0.41-0.81]; P < .01). Minimum SBP <100 mm Hg with maximum HR >100 bpm was more strongly associated with MINS (OR, 1.42 [1.15-1.76]; P < .01) compared with minimum SBP <100 mm Hg alone (OR, 1.20 [1.03-1.40]; P = .02). CONCLUSIONS Intraoperative tachycardia and hypotension are associated with MINS. Further interventional research targeting HR/blood pressure is needed to define the optimum strategy to reduce MINS.
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Affiliation(s)
- Tom E F Abbott
- From the William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Rupert M Pearse
- From the William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | | | - Tahania Ahmad
- From the William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | | | | | | | - Philip J Devereaux
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Gareth L Ackland
- From the William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
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Pinho-Gomes AC, Azevedo L, Ahn JM, Park SJ, Hamza TH, Farkouh ME, Serruys PW, Milojevic M, Kappetein AP, Stone GW, Lamy A, Fuster V, Taggart DP. Compliance With Guideline-Directed Medical Therapy in Contemporary Coronary Revascularization Trials. J Am Coll Cardiol 2019; 71:591-602. [PMID: 29420954 DOI: 10.1016/j.jacc.2017.11.068] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 11/26/2017] [Accepted: 11/28/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Despite the well-established benefits of secondary cardiovascular prevention, the importance of concurrent medical therapy in clinical trials of coronary revascularization is often overlooked. OBJECTIVES The goal of this study was to assess compliance with guideline-directed medical therapy (GDMT) in clinical trials and its potential impact on the comparison between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). METHODS The Cochrane Central Register of Controlled Trials and MEDLINE were searched from 2005 to August 2017. Clinical trial registries and reference lists of relevant studies were also searched. Randomized controlled trials comparing PCI with drug-eluting stents versus CABG and reporting medical therapy after revascularization were included. The study outcome was compliance with GDMT, defined as the following: 1) any antiplatelet agent plus beta-blocker plus statin (GDMT1); and 2) any antiplatelet agent plus beta-blocker plus statin plus angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (GDMT2). Data collection and analysis were performed according to the methodological recommendations of The Cochrane Collaboration. RESULTS From a total of 439 references, 5 trials were included based on our inclusion and exclusion criteria. Overall, compliance with GDMT1 was low and decreased over time from 67% at 1 year to 53% at 5 years. Compliance with GDMT2 was even lower and decreased from 40% at 1 year to 38% at 5 years. Compliance with both GDMT1 and GDMT2 was higher in PCI than in CABG at all time points. Meta-regression suggested an association between lower use of GDMT1 and adverse clinical outcomes in PCI versus CABG at 5 years. CONCLUSIONS Compliance with GDMT in contemporary clinical trials remains suboptimal and is significantly lower after CABG than after PCI, which may influence the comparison of clinical trial endpoints between those study groups.
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Affiliation(s)
| | - Luis Azevedo
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS) & Centre for Health Technology and Services Research (CINTESIS), Faculty of Medicine, Porto University, Porto, Portugal
| | - Jung-Min Ahn
- Asan Medical Center, University of Ulsan College of Medicine, Ulsan, Republic of South Korea
| | - Seung-Jung Park
- Asan Medical Center, University of Ulsan College of Medicine, Ulsan, Republic of South Korea
| | - Taye H Hamza
- New England Research Institutes, Watertown, Massachusetts
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and Heart & Stroke/Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Gregg W Stone
- The New York Presbyterian Hospital, Columbia University Medical Center, Cardiovascular Research Foundation, New York, New York
| | - Andre Lamy
- Department of Surgery, Division of Cardiac Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Valentin Fuster
- Mount Sinai Cardiovascular Institute, New York, New York; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - David P Taggart
- Department of Cardiac Surgery, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
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Abstract
Cardiac arrhythmias are common after cardiac surgery and have profound sequelae. Bradycardias are typically transient and have reversible causes; however, persistent atrioventricular block is an indicator for permanent pacemaker implantation after valvular surgery. Transcatheter aortic valve surgery is associated with even higher rates of permanent pacemaker implantation. Atrial fibrillation, the most common postoperative arrhythmia, is associated with ischemic stroke, myocardial infarction, congestive heart failure, and short-term mortality. Ventricular arrhythmias have extremely high in-hospital mortality, as well as long-term mortality for those who survive the initial event. Implantable cardioverter-defibrillators have been shown to reduce long-term mortality for these patients.
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Benington S, Bryan A, Milne O, Alkhaffaf B. CPET and cardioesophagectomy: A single centre 10-year experience. Eur J Surg Oncol 2019; 45:2451-2456. [PMID: 31230981 DOI: 10.1016/j.ejso.2019.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 05/10/2019] [Accepted: 06/07/2019] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION CPET is a routine investigation prior to cardioesophagectomy. Over a 10-year period 200 patients had CPET before elective cardioesophagectomy. We examine the relationship between CPET and outcomes in these patients. MATERIALS AND METHODS Complication data were prospectively collected using the Clavien-Dindo system. Logistic regression analysis was used to determine whether 90-day mortality and morbidity were significantly different between fitter and less fit patients. RESULTS 90-day mortality was 5.5%. In univariate analysis the following factors were associated with a significantly increased risk of death at 90 days: anaerobic threshold <11 ml kg-1 min-1 OR (95% CI) = 4.38 (1.23,15.6), p = 0.023; V̇O2 peak <15 ml kg-1 min-1 O2 OR (95% CI) = 5.0 (1.42,15.55), p = 0.012; V̇E/V̇CO2 > 34 OR (95% CI) = 4.07 (1.19,14.0), p = 0.026; diabetes mellitus OR (95% CI) = 5.76 (1.55,21.35) p = 0.009. In multivariate logistic regression analysis both diabetes (OR = 5.76 [1.55,21.4] p = 0.009) and presence of ≥ 1 subthreshold CPET value (OR = 6.72 [1.32,29.8] p = 0.021) were significantly associated with increased risk of death at 90 days. Median (95% CI) survival for patients who had a CPET with 'normal' parameters was 1176 (565, 1787) days, compared with 642 (336, 948) days for patients with ≥ one subthreshold parameter. 15.5% of patients had ECG ischaemia; there were no deaths in this group. CONCLUSION Presence of at least one sub-threshold CPET value at pre-operative testing is associated with increased risk of 90-day mortality and shorter long term survival. These results allow us to better define risks during shared decision-making with patients.
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Affiliation(s)
- Steve Benington
- Department of Anaesthesia & Intensive Care, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Oxford Road, Manchester, M13 9WL, UK.
| | - Angella Bryan
- Department of Anaesthesia & Intensive Care, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Oxford Road, Manchester, M13 9WL, UK; Cardiovascular, Metabolic and Nutritional Sciences, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Owen Milne
- Department of Anaesthesia & Intensive Care, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Oxford Road, Manchester, M13 9WL, UK
| | - Bilal Alkhaffaf
- Department of Oesophago-Gastric Surgery, Manchester Royal Infirmary, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Oxford Road, Manchester, M13 9WL, UK; Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Oxford Road, Manchester, M13 9PL, UK
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Beattie WS, Yang H. Perioperative beta-adrenergic antagonism: panacea or poison? Br J Anaesth 2019; 123:97-100. [PMID: 31248641 DOI: 10.1016/j.bja.2019.05.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 05/16/2019] [Accepted: 05/26/2019] [Indexed: 01/24/2023] Open
Affiliation(s)
- W Scott Beattie
- University Health Network Department of Anesthesia and Pain Medicine, University of Toronto Department of Anesthesia, Toronto, ON, Canada.
| | - Homer Yang
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
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Venkatesan S, Jørgensen ME, Manning HJ, Andersson C, Mozid AM, Coburn M, Moonesinghe SR, Foex P, Mythen M, Grocott MPW, Hardman JG, Myles PR, Sanders RD. Preoperative chronic beta-blocker prescription in elderly patients as a risk factor for postoperative mortality stratified by preoperative blood pressure: a cohort study. Br J Anaesth 2019; 123:118-125. [PMID: 31101323 DOI: 10.1016/j.bja.2019.03.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 03/01/2019] [Accepted: 03/21/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Recent data suggest that beta blockers are associated with increased perioperative risk in hypertensive patients. We investigated whether beta blockers were associated with an increased risk in elderly patients with raised preoperative arterial blood pressure. METHODS We conducted a propensity-score-matched cohort study of primary care data from the UK Clinical Practice Research Datalink (2004-13), including 84 633 patients aged 65 yr or over. Conditional logistic regression models, including factors that were significantly associated with the outcome, were constructed for 30-day mortality after elective noncardiac surgery. The effects of beta blockers (primary outcome), renin-angiotensin system (RAS) inhibitors, calcium-channel blockers, thiazides, loop diuretics, and statins were investigated at systolic and diastolic arterial pressure thresholds. RESULTS Beta blockers were associated with increased odds of postoperative 30-day mortality in patients with systolic hypertension (defined as systolic BP >140 mm Hg; adjusted odds ratio [aOR]: 1.92; 95% confidence interval [CI]: 1.05-3.51). After excluding patients for whom prior data suggest benefit from perioperative beta blockade (patients with prior myocardial infarction or heart failure), rather than adjusting for them, the point estimate shifted slightly (aOR: 2.06; 95% CI: 1.09-3.89). Compared with no use, statins (aOR: 0.35; 95% CI: 0.17-0.75) and thiazides (aOR: 0.28; 95% CI: 0.10-0.78) were associated with lower mortality in patients with systolic hypertension. CONCLUSIONS These data suggest that the safety of perioperative beta blockers may be influenced by preoperative blood pressure thresholds. A randomised controlled trial of beta-blocker withdrawal, in select populations, is required to identify a causal relationship.
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Affiliation(s)
- Sudhir Venkatesan
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Mads Emil Jørgensen
- Department of Internal Medicine, Division of Cardiology, Glostrup Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Helen J Manning
- Department of Obstetrics and Gynecology, University of Wisconsin, Madison, WI, USA
| | - Charlotte Andersson
- The Cardiovascular Research Center, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Abdul M Mozid
- Department of Cardiology, Bristol Heart Institute, Bristol, UK
| | - Mark Coburn
- Department of Anaesthesia, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - S Ramani Moonesinghe
- University College London Hospitals & National Institute of Health Biomedical Research Centre, London, UK
| | - Pierre Foex
- Nuffield Division of Anaesthetics, Oxford University Hospital, Oxford, UK
| | - Monty Mythen
- University College London Hospitals & National Institute of Health Biomedical Research Centre, London, UK
| | - Michael P W Grocott
- Integrative Physiology and Critical Illness, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, UK
| | | | - Puja R Myles
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Robert D Sanders
- Anesthesiology & Critical Care Trials & Interdisciplinary Outcomes Network, Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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Perioperative Quality Initiative consensus statement on preoperative blood pressure, risk and outcomes for elective surgery. Br J Anaesth 2019; 122:552-562. [DOI: 10.1016/j.bja.2019.01.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 12/18/2018] [Accepted: 01/01/2019] [Indexed: 11/17/2022] Open
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Sartini C, Lomivorotov V, Pisano A, Riha H, Baiardo Redaelli M, Lopez-Delgado JC, Pieri M, Hajjar L, Fominskiy E, Likhvantsev V, Cabrini L, Bradic N, Avancini D, Wang CY, Lembo R, Novikov M, Paternoster G, Gazivoda G, Alvaro G, Roasio A, Wang C, Severi L, Pasin L, Mura P, Musu M, Silvetti S, Votta CD, Belletti A, Corradi F, Brusasco C, Tamà S, Ruggeri L, Yong CY, Pasero D, Mancino G, Spadaro S, Conte M, Lobreglio R, Di Fraja D, Saporito E, D'Amico A, Sardo S, Ortalda A, Yavorovskiy A, Riefolo C, Monaco F, Bellomo R, Zangrillo A, Landoni G. A Systematic Review and International Web-Based Survey of Randomized Controlled Trials in the Perioperative and Critical Care Setting: Interventions Increasing Mortality. J Cardiothorac Vasc Anesth 2019; 33:2685-2694. [PMID: 31064730 DOI: 10.1053/j.jvca.2019.03.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/10/2019] [Accepted: 03/11/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Reducing mortality is a key target in critical care and perioperative medicine. The authors aimed to identify all nonsurgical interventions (drugs, techniques, strategies) shown by randomized trials to increase mortality in these clinical settings. DESIGN A systematic review of the literature followed by a consensus-based voting process. SETTING A web-based international consensus conference. PARTICIPANTS Two hundred fifty-one physicians from 46 countries. INTERVENTIONS The authors performed a systematic literature search and identified all randomized controlled trials (RCTs) showing a significant increase in unadjusted landmark mortality among surgical or critically ill patients. The authors reviewed such studies during a meeting by a core group of experts. Studies selected after such review advanced to web-based voting by clinicians in relation to agreement, clinical practice, and willingness to include each intervention in international guidelines. MEASUREMENTS AND MAIN RESULTS The authors selected 12 RCTs dealing with 12 interventions increasing mortality: diaspirin-crosslinked hemoglobin (92% of agreement among web voters), overfeeding, nitric oxide synthase inhibitor in septic shock, human growth hormone, thyroxin in acute kidney injury, intravenous salbutamol in acute respiratory distress syndrome, plasma-derived protein C concentrate, aprotinin in high-risk cardiac surgery, cysteine prodrug, hypothermia in meningitis, methylprednisolone in traumatic brain injury, and albumin in traumatic brain injury (72% of agreement). Overall, a high consistency (ranging from 80% to 90%) between agreement and clinical practice was observed. CONCLUSION The authors identified 12 clinical interventions showing increased mortality supported by randomized controlled trials with nonconflicting evidence, and wide agreement upon clinicians on a global scale.
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Affiliation(s)
- Chiara Sartini
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Antonio Pisano
- Division of Cardiac Anesthesia and Intensive Care Unit, AORN dei Colli - Monaldi Hospital, Naples, Italy
| | - Hynek Riha
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Martina Baiardo Redaelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ludhmila Hajjar
- Instituto do Coracao do Hospital das Clinicas, Sao Paulo, Brazil
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Valery Likhvantsev
- Department of Anesthesiology and Intensive Care, Sechenov First Moscow State Medical University, and Moscow Regional Clinical and Research Institute, Moscow, Russian Federation
| | - Luca Cabrini
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nikola Bradic
- Department of Cardiovascular Anesthesiology and Cardiac Intensive Medicine, University Hospital Dubrava, Zagreb, Croatia
| | - Daniele Avancini
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Chew Yin Wang
- Anaesthesia and Intensive Care, University of Malaya, Kuala Lumpur, Malaysia
| | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maxim Novikov
- Saint Petersburg State University, Saint Petersburg, Russia
| | | | - Gordana Gazivoda
- Institute of Cardiovascular Diseases "Dedinje", Belgrade, Serbia
| | | | - Agostino Roasio
- Department of Anaesthesia and Intensive Care, Ospedale Cardinal Massaia di Asti, Asti, Italy
| | - Chengbin Wang
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Luca Severi
- Anesthesia and Intensive Care, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | | | - Paolo Mura
- Department of Anesthesia and Intensive Care Unit, Policlinico Duilio Casula AOU, Cagliari, Italy
| | - Mario Musu
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy
| | - Simona Silvetti
- IRCCS Istituto Giannina Gaslini, Ospedale Pediatrico, Genoa, Italy
| | - Carmine Domenico Votta
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Corradi
- E.O. Ospedali Galliera, Genova, Italy and Università degli Studi di Pisa, Italy
| | - Claudia Brusasco
- E.O. Ospedali Galliera, Genova, Italy and Università degli Studi di Pisa, Italy
| | - Simona Tamà
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Laura Ruggeri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Chow-Yen Yong
- Anaesthesia and Intensive Care, Hospital Pulau Pinang, Georgetown, Malaysia
| | - Daniela Pasero
- Department of Anesthesia and Intensive Care, A.O.U. Cittàdella Salute e della Scienza, Turin, Italy
| | | | - Savino Spadaro
- Department Morphology, Surgery and Experimental Medicine, Intensive Care Unit, University of Ferrara, Italy
| | | | - Rosetta Lobreglio
- Anesthesia and Intensive Care A.O.U Città della salute e della Scienza, Turin, Italy
| | - Diana Di Fraja
- Division of Cardiac Anesthesia and Intensive Care Unit, AORN dei Colli - Monaldi Hospital, Naples, Italy
| | | | | | - Salvatore Sardo
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy
| | - Alessandro Ortalda
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrey Yavorovskiy
- Department of Anesthesiology and Intensive Care, Sechenov First Moscow State Medical University, and Moscow Regional Clinical and Research Institute, Moscow, Russian Federation
| | - Claudio Riefolo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
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Moreira JB, Wohlwend M, Fenk S, Åmellem I, Flatberg A, Kraljevic J, Marinovic J, Ljubkovic M, Bjørkøy G, Wisløff U. Exercise Reveals Proline Dehydrogenase as a Potential Target in Heart Failure. Prog Cardiovasc Dis 2019; 62:193-202. [DOI: 10.1016/j.pcad.2019.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 03/06/2019] [Indexed: 01/08/2023]
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Metabolic syndrome is associated with increased cardiac morbidity after infrainguinal bypass surgery irrespective of the use of cardiovascular risk-modifying agents. J Vasc Surg 2019; 69:190-198. [DOI: 10.1016/j.jvs.2018.05.239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 05/16/2018] [Indexed: 12/16/2022]
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2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens 2018; 36:1953-2041. [PMID: 30234752 DOI: 10.1097/hjh.0000000000001940] [Citation(s) in RCA: 1772] [Impact Index Per Article: 295.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
: Document reviewers: Guy De Backer (ESC Review Co-ordinator) (Belgium), Anthony M. Heagerty (ESH Review Co-ordinator) (UK), Stefan Agewall (Norway), Murielle Bochud (Switzerland), Claudio Borghi (Italy), Pierre Boutouyrie (France), Jana Brguljan (Slovenia), Héctor Bueno (Spain), Enrico G. Caiani (Italy), Bo Carlberg (Sweden), Neil Chapman (UK), Renata Cifkova (Czech Republic), John G. F. Cleland (UK), Jean-Philippe Collet (France), Ioan Mircea Coman (Romania), Peter W. de Leeuw (The Netherlands), Victoria Delgado (The Netherlands), Paul Dendale (Belgium), Hans-Christoph Diener (Germany), Maria Dorobantu (Romania), Robert Fagard (Belgium), Csaba Farsang (Hungary), Marc Ferrini (France), Ian M. Graham (Ireland), Guido Grassi (Italy), Hermann Haller (Germany), F. D. Richard Hobbs (UK), Bojan Jelakovic (Croatia), Catriona Jennings (UK), Hugo A. Katus (Germany), Abraham A. Kroon (The Netherlands), Christophe Leclercq (France), Dragan Lovic (Serbia), Empar Lurbe (Spain), Athanasios J. Manolis (Greece), Theresa A. McDonagh (UK), Franz Messerli (Switzerland), Maria Lorenza Muiesan (Italy), Uwe Nixdorff (Germany), Michael Hecht Olsen (Denmark), Gianfranco Parati (Italy), Joep Perk (Sweden), Massimo Francesco Piepoli (Italy), Jorge Polonia (Portugal), Piotr Ponikowski (Poland), Dimitrios J. Richter (Greece), Stefano F. Rimoldi (Switzerland), Marco Roffi (Switzerland), Naveed Sattar (UK), Petar M. Seferovic (Serbia), Iain A. Simpson (UK), Miguel Sousa-Uva (Portugal), Alice V. Stanton (Ireland), Philippe van de Borne (Belgium), Panos Vardas (Greece), Massimo Volpe (Italy), Sven Wassmann (Germany), Stephan Windecker (Switzerland), Jose Luis Zamorano (Spain).The disclosure forms of all experts involved in the development of these Guidelines are available on the ESC website www.escardio.org/guidelines.
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Low DE, Allum W, De Manzoni G, Ferri L, Immanuel A, Kuppusamy M, Law S, Lindblad M, Maynard N, Neal J, Pramesh CS, Scott M, Mark Smithers B, Addor V, Ljungqvist O. Guidelines for Perioperative Care in Esophagectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations. World J Surg 2018; 43:299-330. [DOI: 10.1007/s00268-018-4786-4] [Citation(s) in RCA: 239] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Ahl R, Matthiessen P, Fang X, Cao Y, Sjolin G, Lindgren R, Ljungqvist O, Mohseni S. Effect of beta-blocker therapy on early mortality after emergency colonic cancer surgery. Br J Surg 2018; 106:477-483. [DOI: 10.1002/bjs.10988] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 06/18/2018] [Accepted: 07/28/2018] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Emergency colorectal cancer surgery is associated with significant mortality. Induced adrenergic hyperactivity is thought to be an important contributor. Downregulating the effects of circulating catecholamines may reduce the risk of adverse outcomes. This study assessed whether regular preoperative beta-blockade reduced mortality after emergency colonic cancer surgery.
Methods
This cohort study used the prospectively collected Swedish Colorectal Cancer Registry to recruit all adult patients requiring emergency colonic cancer surgery between 2011 and 2016. Patients were subdivided into those receiving regular beta-blocker therapy before surgery and those who were not (control). Demographics and clinical outcomes were compared. Risk factors for 30-day mortality were evaluated using Poisson regression analysis.
Results
A total of 3187 patients were included, of whom 685 (21·5 per cent) used regular beta-blocker therapy before surgery. The overall 30-day mortality rate was significantly reduced in the beta-blocker group compared with controls: 3·1 (95 per cent c.i. 1·9 to 4·7) versus 8·6 (7·6 to 9·8) per cent respectively (P < 0·001). Beta-blocker therapy was the only modifiable protective factor identified in multivariable analysis of 30-day all-cause mortality (incidence rate ratio 0·31, 95 per cent c.i. 0·20 to 0·47; P < 0·001) and was associated with a significant reduction in death of cardiovascular, respiratory, sepsis and multiple organ failure origin.
Conclusion
Preoperative beta-blocker therapy may be associated with a reduction in 30-day mortality following emergency colonic cancer surgery.
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Affiliation(s)
- R Ahl
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - P Matthiessen
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - X Fang
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Y Cao
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Orebro, Sweden
| | - G Sjolin
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - R Lindgren
- Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - O Ljungqvist
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - S Mohseni
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Department of Surgery, Orebro University Hospital, Orebro, Sweden
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Verbree-Willemsen L, Grobben RB, van Waes JA, Peelen LM, Nathoe HM, van Klei WA, Grobbee DE. Causes and prevention of postoperative myocardial injury. Eur J Prev Cardiol 2018; 26:59-67. [PMID: 30207484 PMCID: PMC6287250 DOI: 10.1177/2047487318798925] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Over the past few years non-cardiac surgery has been recognised as a serious circulatory stress test which may trigger cardiovascular events such as myocardial infarction, in particular in patients at high risk. Detection of these postoperative cardiovascular events is difficult as clinical symptoms often go unnoticed. To improve detection, guidelines advise to perform routine postoperative assessment of cardiac troponin. Troponin elevation - or postoperative myocardial injury - can be caused by myocardial infarction. However, also non-coronary causes, such as cardiac arrhythmias, sepsis and pulmonary embolism, may play a role in a considerable number of patients with postoperative myocardial injury. It is crucial to acquire more knowledge about the underlying mechanisms of postoperative myocardial injury because effective prevention and treatment options are lacking. Preoperative administration of beta-blockers, aspirin, statins, clonidine, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, and preoperative revascularisation have all been investigated as preventive options. Of these, only statins should be considered as the initiation or reload of statins may reduce the risk of postoperative myocardial injury. There is also not enough evidence for intraoperative measures such blood pressure optimisation or intensified medical therapy once patients have developed postoperative myocardial injury. Given the impact, better preoperative identification of patients at risk of postoperative myocardial injury, for example using preoperatively measured biomarkers, would be helpful to improve cardiac optimisation.
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Affiliation(s)
- Laura Verbree-Willemsen
- 1 Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Remco B Grobben
- 2 Department of Cardiology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Judith Ar van Waes
- 3 Department of Anaesthesiology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Linda M Peelen
- 1 Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, The Netherlands.,3 Department of Anaesthesiology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Hendrik M Nathoe
- 2 Department of Cardiology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Wilton A van Klei
- 3 Department of Anaesthesiology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Diederick E Grobbee
- 1 Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, The Netherlands
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Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, Clement DL, Coca A, de Simone G, Dominiczak A, Kahan T, Mahfoud F, Redon J, Ruilope L, Zanchetti A, Kerins M, Kjeldsen SE, Kreutz R, Laurent S, Lip GYH, McManus R, Narkiewicz K, Ruschitzka F, Schmieder RE, Shlyakhto E, Tsioufis C, Aboyans V, Desormais I. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J 2018; 39:3021-3104. [PMID: 30165516 DOI: 10.1093/eurheartj/ehy339] [Citation(s) in RCA: 5505] [Impact Index Per Article: 917.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Abbott TEF, Ackland GL, Archbold RA, Wragg A, Kam E, Ahmad T, Khan AW, Niebrzegowska E, Rodseth RN, Devereaux PJ, Pearse RM. Preoperative heart rate and myocardial injury after non-cardiac surgery: results of a predefined secondary analysis of the VISION study. Br J Anaesth 2018; 117:172-81. [PMID: 27440628 PMCID: PMC4954612 DOI: 10.1093/bja/aew182] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2016] [Indexed: 12/15/2022] Open
Abstract
Background Increased baseline heart rate is associated with cardiovascular risk and all-cause mortality in the general population. We hypothesized that elevated preoperative heart rate increases the risk of myocardial injury after non-cardiac surgery (MINS). Methods We performed a secondary analysis of a prospective international cohort study of patients aged ≥45 yr undergoing non-cardiac surgery. Preoperative heart rate was defined as the last measurement before induction of anaesthesia. The sample was divided into deciles by heart rate. Multivariable logistic regression models were used to determine relationships between preoperative heart rate and MINS (determined by serum troponin concentration), myocardial infarction (MI), and death within 30 days of surgery. Separate models were used to test the relationship between these outcomes and predefined binary heart rate thresholds. Results Patients with missing outcomes or heart rate data were excluded from respective analyses. Of 15 087 patients, 1197 (7.9%) sustained MINS, 454 of 16 007 patients (2.8%) sustained MI, and 315 of 16 037 patients (2.0%) died. The highest heart rate decile (>96 beats min−1) was independently associated with MINS {odds ratio (OR) 1.48 [1.23–1.77]; P<0.01}, MI (OR 1.71 [1.34–2.18]; P<0.01), and mortality (OR 3.16 [2.45–4.07]; P<0.01). The lowest decile (<60 beats min−1) was independently associated with reduced mortality (OR 0.50 [0.29–0.88]; P=0.02), but not MINS or MI. The predefined binary thresholds were also associated with MINS, but more weakly than the highest heart rate decile. Conclusions Preoperative heart rate >96 beats min−1 is associated with MINS, MI, and mortality after non-cardiac surgery. This association persists after accounting for potential confounding factors. Clinical trial registration NCT00512109.
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Affiliation(s)
- T E F Abbott
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - G L Ackland
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | | | - A Wragg
- Barts Health NHS Trust, London, UK
| | - E Kam
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - T Ahmad
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - A W Khan
- Shaukat Khanum Memorial Cancer Hospital, Lahore, Pakistan
| | | | - R N Rodseth
- Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - P J Devereaux
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - R M Pearse
- William Harvey Research Institute, Queen Mary University of London, London, UK
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