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Mahendran S, Thiagalingam A, Hillis G, Halliwell R, Pleass HC, Chow CK. Cardiovascular risk management in the peri-operative setting. Med J Aust 2023. [PMID: 37302136 DOI: 10.5694/mja2.51988] [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: 11/29/2022] [Revised: 03/17/2023] [Accepted: 03/27/2023] [Indexed: 06/13/2023]
Abstract
Peri-operative cardiovascular events occur in up to 3% of patients undergoing non-cardiac surgery. Accurate cardiovascular risk assessment is important in the peri-operative setting, as it allows informed and shared decisions regarding the appropriateness of proceeding with surgery, guides surgical and anaesthetic approaches, and may influence the use of preventive medications and post-operative cardiac monitoring. Quantitative risk assessment may also inform a reconsideration of choosing a more limited lower risk type of surgery, or conservative management. Pre-operative cardiovascular risk assessment starts with clinical assessment and should include an estimate of functional capacity. Specialised cardiac investigations are rarely indicated specifically to assess pre-operative cardiovascular risk. The decision regarding cardiac investigations is influenced by the nature, extent and urgency of surgery. The strategy of performing pre-operative revascularisation to improve post-operative outcomes is not evidence-based and recent international guidelines recommend against this.
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Affiliation(s)
| | | | | | | | - Henry Cc Pleass
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW
| | - Clara K Chow
- Westmead Hospital, Sydney, NSW
- University of Sydney, Sydney, NSW
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2
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Alasnag M, Tash A. Commentary on the FASTTRACK CABG study. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 50:41-42. [PMID: 36854640 DOI: 10.1016/j.carrev.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023]
Affiliation(s)
- Mirvat Alasnag
- Cardiac Center, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia.
| | - Adel Tash
- Ministry of Health/National Heart Center, Riyadh, Saudi Arabia
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3
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Álvarez-Garcia J, Popova E, Vives-Borrás M, de Nadal M, Ordonez-Llanos J, Rivas-Lasarte M, Moustafa AH, Solé-González E, Paniagua-Iglesias P, Garcia-Moll X, Viladés-Medel D, Leta-Petracca R, Oristrell G, Zamora J, Ferreira-González I, Alonso-Coello P, Carreras-Costa F. Myocardial injury after major non-cardiac surgery evaluated with advanced cardiac imaging: a pilot study. BMC Cardiovasc Disord 2023; 23:78. [PMID: 36765313 PMCID: PMC9911951 DOI: 10.1186/s12872-023-03065-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 01/13/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Myocardial injury after non-cardiac surgery (MINS) is a frequent complication caused by cardiac and non-cardiac pathophysiological mechanisms, but often it is subclinical. MINS is associated with increased morbidity and mortality, justifying the need to its diagnose and the investigation of their causes for its potential prevention. METHODS Prospective, observational, pilot study, aiming to detect MINS, its relationship with silent coronary artery disease and its effect on future adverse outcomes in patients undergoing major non-cardiac surgery and without postoperative signs or symptoms of myocardial ischemia. MINS was defined by a high-sensitive cardiac troponin T (hs-cTnT) concentration > 14 ng/L at 48-72 h after surgery and exceeding by 50% the preoperative value; controls were the operated patients without MINS. Within 1-month after discharge, cardiac computed tomography angiography (CCTA) and magnetic resonance imaging (MRI) studies were performed in MINS and control subjects. Significant coronary artery disease (CAD) was defined by a CAD-RADS category ≥ 3. The primary outcomes were prevalence of CAD among MINS and controls and incidence of major cardiovascular events (MACE) at 1-year after surgery. Secondary outcomes were the incidence of individual MACE components and mortality. RESULTS We included 52 MINS and 12 controls. The small number of included patients could be attributed to the study design complexity and the dates of later follow-ups (amid COVID-19 waves). Significant CAD by CCTA was equally found in 20 MINS and controls (30% vs 33%, respectively). Ischemic patterns (n = 5) and ischemic segments (n = 2) depicted by cardiac MRI were only observed in patients with MINS. One-year MACE were also only observed in MINS patients (15.4%). CONCLUSION This study with advanced imaging methods found a similar CAD frequency in MINS and control patients, but that cardiac ischemic findings by MRI and worse prognosis were only observed in MINS patients. Our results, obtained in a pilot study, suggest the need of further, extended studies that screened systematically MINS and evaluated its relationship with cardiac ischemia and poor outcomes. Trial registration Clinicaltrials.gov identifier: NCT03438448 (19/02/2018).
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Affiliation(s)
- Jesús Álvarez-Garcia
- grid.411347.40000 0000 9248 5770Department of Cardiology, Hospital Universitario Ramon y Cajal, M-607, 9,100, 28034 Madrid, Spain ,grid.413396.a0000 0004 1768 8905Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Sant Quintí 89, 08026 Barcelona, Spain ,grid.512890.7Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Madrid, Spain
| | - Ekaterine Popova
- IIB SANT PAU, Institut d'Investigació Biomèdica Sant Pau, Sant Quintí 77, 08041, Barcelona, Spain. .,Centro Cochrane Iberoamericano, Sant Antoni Maria Claret, 167, 08025, Barcelona, Spain.
| | - Miquel Vives-Borrás
- grid.413396.a0000 0004 1768 8905Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Sant Quintí 89, 08026 Barcelona, Spain ,grid.507085.fFundació Institut d’Investigació Sanitària Illes Balears (IdISBa), Department of Cardiology, Carretera de Valldemossa, 79, 07120 Palma, Balearic Islands Spain ,grid.411164.70000 0004 1796 5984Department of Cardiology, Hospital Universitari Son Espases, Carretera de Valldemossa, 79, Palma, Illes Balears Spain
| | - Miriam de Nadal
- Department of Anaesthesiology and Intensive Care, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron, 119, 08035, Barcelona, Spain.
| | - Jordi Ordonez-Llanos
- grid.413396.a0000 0004 1768 8905Department of Biochemistry, Hospital de la Santa Creu i Sant Pau, Sant Quintí 89, 08026 Barcelona, Spain ,Foundation for Clinical Biochemistry & Molecular Pathology, Barcelona, Spain
| | - Mercedes Rivas-Lasarte
- grid.413396.a0000 0004 1768 8905Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Sant Quintí 89, 08026 Barcelona, Spain ,grid.73221.350000 0004 1767 8416Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, C. Joaquín Rodrigo, 1, 28222 Majadahonda, Madrid, Spain
| | - Abdel-Hakim Moustafa
- grid.413396.a0000 0004 1768 8905Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Sant Quintí 89, 08026 Barcelona, Spain
| | - Eduard Solé-González
- grid.413396.a0000 0004 1768 8905Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Sant Quintí 89, 08026 Barcelona, Spain ,grid.410458.c0000 0000 9635 9413Department of Cardiology, Hospital Clinic i Provincial, C. de Villarroel, 170, 08036 Barcelona, Spain
| | - Pilar Paniagua-Iglesias
- grid.413396.a0000 0004 1768 8905Department of Anaesthesia and Pain Management, Hospital de la Santa Creu i Sant Pau, Sant Quintí 89, 08026 Barcelona, Spain
| | - Xavier Garcia-Moll
- grid.413396.a0000 0004 1768 8905Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Sant Quintí 89, 08026 Barcelona, Spain
| | - David Viladés-Medel
- grid.413396.a0000 0004 1768 8905Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Sant Quintí 89, 08026 Barcelona, Spain
| | - Rubén Leta-Petracca
- grid.413396.a0000 0004 1768 8905Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Sant Quintí 89, 08026 Barcelona, Spain
| | - Gerard Oristrell
- grid.411083.f0000 0001 0675 8654Department of Cardiology, Hospital Universitari Vall d’Hebron, Passeig de la Vall d’Hebron, 119, 08035 Barcelona, Spain
| | - Javier Zamora
- grid.411347.40000 0000 9248 5770Clinical Biostatistics Unit, IRYCIS, Hospital Universitario Ramon y Cajal, M-607, 9,100, 28034 Madrid, Spain ,grid.466571.70000 0004 1756 6246CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Ignacio Ferreira-González
- grid.411083.f0000 0001 0675 8654Department of Cardiology, Hospital Universitari Vall d’Hebron, Passeig de la Vall d’Hebron, 119, 08035 Barcelona, Spain ,grid.466571.70000 0004 1756 6246CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Pablo Alonso-Coello
- IIB SANT PAU, Institut d’Investigació Biomèdica Sant Pau, Sant Quintí 77, 08041 Barcelona, Spain ,grid.466571.70000 0004 1756 6246CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Francesc Carreras-Costa
- grid.413396.a0000 0004 1768 8905Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Sant Quintí 89, 08026 Barcelona, Spain ,grid.512890.7Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Madrid, Spain
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Ninomiya K, Serruys PW, Garg S, Masuda S, Kageyama S, Kotoku N, Morel MA, Taylor C, Puskas JD, Narula J, Schneider U, Doenst T, Tanaka K, De Mey J, La Meir M, Mushtaq S, Bartorelli AL, Pompilio G, Andreini D, Onuma Y. Appropriateness of the modality of revascularization according to the SYNTAX Score II 2020 in the FASTTRACK CABG study: An interim report on patient selection. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 50:34-40. [PMID: 36639338 DOI: 10.1016/j.carrev.2023.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/24/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023]
Abstract
BACKGROUND Personalized long term vital prognosis plays a key role in deciding between percutaneous coronary intervention (PCI) and CABG in patients with complex coronary artery disease. The FASTTRACK CABG trial enrolls patients with the sole guidance of coronary computed tomographic angiography (CCTA) and fractional flow reserve CCTA (FFRCT). The feasibility/non-feasibility of this approach is determined by the surgeon request to have access to the invasive coronary angiography. METHODS This interim analysis, which was requested by the Data and Safety Monitoring Board (DSMB), compared the treatment decision of the "on site" Heart team to the recommended treatment as per the SYNTAX Score II 2020 (SS-2020), which was prospectively assessed by the central core laboratory in the first 57 consecutive patients (half of the planned population) enrolled in this First in Man study. RESULTS The average anatomical SYTAX Score is 35.6 ± 11.5. The SS-2020 predicted 5-year MACE and 10-year all-cause mortality are 14.7 % and 21.6 % following CABG, and 23.0 % and 30.4 % following PCI. Among the enrolled patients the SS-2020 predicts long-term PCI outcomes similar to CABG (absolute risk difference ≤0 % in favor of PCI) in only two patients whilst the remaining 55 patients had a predicted survival benefit with CABG. CONCLUSIONS According to the SS-2020, the first 57 patients recruited into the FASTTRACK CABG trial received the appropriate modality of revascularization and the DSMB allowed the investigators to complete the study.
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Affiliation(s)
- Kai Ninomiya
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland; Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
| | - Scot Garg
- Department of Cardiology, Royal Blackburn Hospital, Blackburn, UK
| | - Shinichiro Masuda
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
| | - Shigetaka Kageyama
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
| | - Nozomi Kotoku
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
| | - Marie Angele Morel
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
| | | | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, USA
| | - Jagat Narula
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ulrich Schneider
- Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Torsten Doenst
- Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Kaoru Tanaka
- Universitair Ziekenhuis Brussel, VUB, Brussels, Belgium
| | - Johan De Mey
- Universitair Ziekenhuis Brussel, VUB, Brussels, Belgium
| | - Mark La Meir
- Universitair Ziekenhuis Brussel, VUB, Brussels, Belgium
| | | | - Antonio L Bartorelli
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy
| | - Giulio Pompilio
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Daniele Andreini
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
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Vernooij LM, van Klei WA, Moons KG, Takada T, van Waes J, Damen JA. The comparative and added prognostic value of biomarkers to the Revised Cardiac Risk Index for preoperative prediction of major adverse cardiac events and all-cause mortality in patients who undergo noncardiac surgery. Cochrane Database Syst Rev 2021; 12:CD013139. [PMID: 34931303 PMCID: PMC8689147 DOI: 10.1002/14651858.cd013139.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The Revised Cardiac Risk Index (RCRI) is a widely acknowledged prognostic model to estimate preoperatively the probability of developing in-hospital major adverse cardiac events (MACE) in patients undergoing noncardiac surgery. However, the RCRI does not always make accurate predictions, so various studies have investigated whether biomarkers added to or compared with the RCRI could improve this. OBJECTIVES Primary: To investigate the added predictive value of biomarkers to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery. Secondary: To investigate the prognostic value of biomarkers compared to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery. Tertiary: To investigate the prognostic value of other prediction models compared to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery. SEARCH METHODS We searched MEDLINE and Embase from 1 January 1999 (the year that the RCRI was published) until 25 June 2020. We also searched ISI Web of Science and SCOPUS for articles referring to the original RCRI development study in that period. SELECTION CRITERIA We included studies among adults who underwent noncardiac surgery, reporting on (external) validation of the RCRI and: - the addition of biomarker(s) to the RCRI; or - the comparison of the predictive accuracy of biomarker(s) to the RCRI; or - the comparison of the predictive accuracy of the RCRI to other models. Besides MACE, all other adverse outcomes were considered for inclusion. DATA COLLECTION AND ANALYSIS We developed a data extraction form based on the CHARMS checklist. Independent pairs of authors screened references, extracted data and assessed risk of bias and concerns regarding applicability according to PROBAST. For biomarkers and prediction models that were added or compared to the RCRI in ≥ 3 different articles, we described study characteristics and findings in further detail. We did not apply GRADE as no guidance is available for prognostic model reviews. MAIN RESULTS We screened 3960 records and included 107 articles. Over all objectives we rated risk of bias as high in ≥ 1 domain in 90% of included studies, particularly in the analysis domain. Statistical pooling or meta-analysis of reported results was impossible due to heterogeneity in various aspects: outcomes used, scale by which the biomarker was added/compared to the RCRI, prediction horizons and studied populations. Added predictive value of biomarkers to the RCRI Fifty-one studies reported on the added value of biomarkers to the RCRI. Sixty-nine different predictors were identified derived from blood (29%), imaging (33%) or other sources (38%). Addition of NT-proBNP, troponin or their combination improved the RCRI for predicting MACE (median delta c-statistics: 0.08, 0.14 and 0.12 for NT-proBNP, troponin and their combination, respectively). The median total net reclassification index (NRI) was 0.16 and 0.74 after addition of troponin and NT-proBNP to the RCRI, respectively. Calibration was not reported. To predict myocardial infarction, the median delta c-statistic when NT-proBNP was added to the RCRI was 0.09, and 0.06 for prediction of all-cause mortality and MACE combined. For BNP and copeptin, data were not sufficient to provide results on their added predictive performance, for any of the outcomes. Comparison of the predictive value of biomarkers to the RCRI Fifty-one studies assessed the predictive performance of biomarkers alone compared to the RCRI. We identified 60 unique predictors derived from blood (38%), imaging (30%) or other sources, such as the American Society of Anesthesiologists (ASA) classification (32%). Predictions were similar between the ASA classification and the RCRI for all studied outcomes. In studies different from those identified in objective 1, the median delta c-statistic was 0.15 and 0.12 in favour of BNP and NT-proBNP alone, respectively, when compared to the RCRI, for the prediction of MACE. For C-reactive protein, the predictive performance was similar to the RCRI. For other biomarkers and outcomes, data were insufficient to provide summary results. One study reported on calibration and none on reclassification. Comparison of the predictive value of other prognostic models to the RCRI Fifty-two articles compared the predictive ability of the RCRI to other prognostic models. Of these, 42% developed a new prediction model, 22% updated the RCRI, or another prediction model, and 37% validated an existing prediction model. None of the other prediction models showed better performance in predicting MACE than the RCRI. To predict myocardial infarction and cardiac arrest, ACS-NSQIP-MICA had a higher median delta c-statistic of 0.11 compared to the RCRI. To predict all-cause mortality, the median delta c-statistic was 0.15 higher in favour of ACS-NSQIP-SRS compared to the RCRI. Predictive performance was not better for CHADS2, CHA2DS2-VASc, R2CHADS2, Goldman index, Detsky index or VSG-CRI compared to the RCRI for any of the outcomes. Calibration and reclassification were reported in only one and three studies, respectively. AUTHORS' CONCLUSIONS Studies included in this review suggest that the predictive performance of the RCRI in predicting MACE is improved when NT-proBNP, troponin or their combination are added. Other studies indicate that BNP and NT-proBNP, when used in isolation, may even have a higher discriminative performance than the RCRI. There was insufficient evidence of a difference between the predictive accuracy of the RCRI and other prediction models in predicting MACE. However, ACS-NSQIP-MICA and ACS-NSQIP-SRS outperformed the RCRI in predicting myocardial infarction and cardiac arrest combined, and all-cause mortality, respectively. Nevertheless, the results cannot be interpreted as conclusive due to high risks of bias in a majority of papers, and pooling was impossible due to heterogeneity in outcomes, prediction horizons, biomarkers and studied populations. Future research on the added prognostic value of biomarkers to existing prediction models should focus on biomarkers with good predictive accuracy in other settings (e.g. diagnosis of myocardial infarction) and identification of biomarkers from omics data. They should be compared to novel biomarkers with so far insufficient evidence compared to established ones, including NT-proBNP or troponins. Adherence to recent guidance for prediction model studies (e.g. TRIPOD; PROBAST) and use of standardised outcome definitions in primary studies is highly recommended to facilitate systematic review and meta-analyses in the future.
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Affiliation(s)
- Lisette M Vernooij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Wilton A van Klei
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Anesthesiologist and R. Fraser Elliott Chair in Cardiac Anesthesia, Department of Anesthesia and Pain Management Toronto General Hospital, University Health Network and Professor, Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Karel Gm Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Judith van Waes
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Johanna Aag Damen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Case BC, Yang M, Qamer SZ, Kumar S, Yerasi C, Forrestal BJ, Chezar-Azerrad C, Medranda GA, Bernardo NL, Rogers T, Satler LF, Hashim H, Satoskar RS, Lalos AT, Waksman R, Ben-Dor I. Pre-Operative Cardiovascular Testing before Liver Transplantation. Am J Cardiol 2021; 152:132-137. [PMID: 34103158 DOI: 10.1016/j.amjcard.2021.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 03/31/2021] [Accepted: 04/05/2021] [Indexed: 10/21/2022]
Abstract
End-stage liver disease (ESLD) is increasingly prevalent and shares many risk factors with coronary artery disease (CAD). No specific guidelines exist for pre-liver transplant evaluation of CAD, and pretransplant cardiovascular testing varies widely. The aim of this study is to characterize pre-transplant cardiac testing practices with post-transplant clinical outcomes. We retrospectively reviewed patients undergoing initial liver transplantation at our transplant center between January 2015 and March 2019. Patients with previous liver transplantation or multi-organ transplantation were excluded. Electronic medical records were reviewed for relevant demographic and clinical data. We included 285 patients with a mean follow-up of 2.4 years. Of 274 patients (96.1%) with pre-transplant transthoracic echocardiogram (TTE), 18 (6.6%) were abnormal. Non-invasive ischemic testing was performed in 193 (68%) patients: 165 (58%) underwent stress TTE, 24 (8%) underwent myocardial perfusion imaging, 3 underwent coronary computed tomography, and 1 underwent exercise electrocardiogram. Sixteen patients (6%) had left heart catheterization of which 10 (63%) were abnormal and 5 proceeded to revascularization before transplant. There were 4 (1.4%) deaths within 30 days of transplant and 23 deaths (8.1%) in total. ST-elevation myocardial infarction was seen in 1 patient within 30 days and 1 patient after 30 days (0.7% total). No cardiovascular deaths were observed. Among patients undergoing liver transplantation, pre-transplantation cardiovascular testing is exceedingly common and post-transplant cardiovascular complications are rare. Additional research is needed to determine the optimal testing and surveillance in this patient population.
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Westhofen T, Schott M, Keller P, Tamalunas A, Atzler M, Ebner B, Schultheiß M, Damm A, Kowalski C, Stief CG, Magistro G. Spinal versus general anesthesia for Holmium laser enucleation of the prostate of high-risk patients - A propensity-score-matched-analysis. Urology 2021; 159:182-190. [PMID: 34339752 DOI: 10.1016/j.urology.2021.04.078] [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: 04/02/2021] [Accepted: 04/30/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare perioperative management and functional outcome of spinal anesthesia (SpA) to general anesthesia (GA) in high-risk patients treated for lower urinary tract symptoms (LUTS) with Holmium laser enucleation of the prostate (HoLEP). METHODS In the current retrospective analysis, a propensity-score-matching of patients treated for LUTS with HoLEP (n=300) in SpA with ASA>2 (n=100), GA with ASA>2 (GA-high-risk) (n=100) or GA with ASA≤2 (GA-low-risk) (n=100) was performed. The impact of anesthesiologic mode on perioperative anesthesiologic outcome, early functional outcome and treatment related adverse events (according to Clavien Dindo), was evaluated. RESULTS Hypotensive episodes were significantly less frequent in the SpA-cohort (9%) compared to the GA-high-risk cohort (32%) and the GA low-risk cohort (22%) (each p<0.05 respectively). SpA-patients showed a significantly shorter median time in post anesthesia care unit (PACU-time: 135min; 120-166.5) compared to GA-high-risk patients (186min; 154-189.5), with significant less referrals to Intermediate care unit (ICU) (1% vs. 9 %); (each p<0.05). PACU-time (99min) and ICU referrals (0%) for GA-low-risk were lower than for both other cohorts. Postoperative requirement for analgesics was significantly lower in the SpA-cohort (2%), compared to both GA-cohorts (74% and 61% respectively; p<0.05). No significant difference was found regarding early functional outcome or treatment related adverse events (AE) (p-range:0.201-1.000). CONCLUSION For patients undergoing HoLEP, SpA provides greater hemodynamic stability and allows faster overall postoperative recovery with preferable pain management. Yielding a comparable functional outcome, it is a safe and efficient alternative to GA in high-risk patients.
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Affiliation(s)
- Thilo Westhofen
- Department of Urology, University Hospital Großhadern, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Melanie Schott
- Department of Urology, University Hospital Großhadern, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Patrick Keller
- Department of Urology, University Hospital Großhadern, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Alexander Tamalunas
- Department of Urology, University Hospital Großhadern, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Atzler
- Department of Urology, University Hospital Großhadern, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Benedikt Ebner
- Department of Urology, University Hospital Großhadern, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Schultheiß
- Department of Anesthesiology, University Hospital Großhadern, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Alexander Damm
- Department of Anesthesiology, University Hospital Großhadern, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Christian Kowalski
- Department of Anesthesiology, University Hospital Großhadern, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Christian G Stief
- Department of Urology, University Hospital Großhadern, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Giuseppe Magistro
- Department of Urology, University Hospital Großhadern, Ludwig-Maximilians-University Munich, Marchioninistrasse 15, 81377, Munich, Germany
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Narula J, Chandrashekhar Y, Ahmadi A, Abbara S, Berman DS, Blankstein R, Leipsic J, Newby D, Nicol ED, Nieman K, Shaw L, Villines TC, Williams M, Hecht HS. SCCT 2021 Expert Consensus Document on Coronary Computed Tomographic Angiography: A Report of the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr 2021; 15:192-217. [PMID: 33303384 PMCID: PMC8713482 DOI: 10.1016/j.jcct.2020.11.001] [Citation(s) in RCA: 141] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Jagat Narula
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Y Chandrashekhar
- University of Minnesota and VA Medical Center, Minneapolis, MN, USA
| | - Amir Ahmadi
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Suhny Abbara
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Ron Blankstein
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | | | - David Newby
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - Edward D Nicol
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | - Leslee Shaw
- New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA
| | - Todd C Villines
- University of Virginia Health System, Charlottesville, VA, USA
| | - Michelle Williams
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - Harvey S Hecht
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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9
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Coronary computed tomography angiography before on-pump cardiac surgery does not reduce the risk of postoperative acute kidney injury compared to coronary angiography. Gen Thorac Cardiovasc Surg 2021; 69:1445-1452. [PMID: 33550545 DOI: 10.1007/s11748-021-01602-8] [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: 10/23/2020] [Accepted: 01/26/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Cardiac surgery and contrast media are both related to acute kidney injury. We investigated whether undergoing coronary computed tomography angiography, which uses less contrast medium, before on-pump cardiac surgery could reduce the risk of postoperative acute kidney injury compared to coronary angiography. METHODS In this retrospective study, 745 and 171 patients underwent coronary angiography and coronary computed tomography angiography, respectively, within 30 days before on-pump cardiac surgery. Postoperative acute kidney injury was defined according to Kidney Disease Improving Global Outcomes Definition and Staging criteria. RESULTS Age, hypertension, cardiopulmonary bypass time, and performing cardiac surgery within 24 h of preoperative angiography (odds ratio: 1.507, 95% confidence interval: 1.111‒2.045, P = 0.008) independently predicted postoperative acute kidney injury on multivariable analysis. After propensity score matching, the acute kidney injury incidence in coronary angiography and computed tomography angiography groups was 43% and 46%, respectively (P = 0.65), and the groups had similar intensive care unit stay (2 days vs. 2 days, P = 0.209), postoperative hospital stay (11 days vs. 12 days, P = 0.084), postoperative continuous renal replacement therapy use (0.6% vs 1.9%, P = 0.314), and in-hospital mortality (0 vs. 1.3%, P = 0.156). In-hospital outcomes were similar among patients who underwent preoperative coronary angiography or computed tomography angiography within 24 h before cardiac surgery. CONCLUSION Although coronary computed tomography angiography uses less contrast medium, it does not reduce the risk of postoperative acute kidney injury or improve in-hospital outcomes compared to coronary angiography.
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10
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Bonou M, Mavrogeni S, Kapelios CJ, Skouloudi M, Aggeli C, Cholongitas E, Papatheodoridis G, Barbetseas J. Preoperative Evaluation of Coronary Artery Disease in Liver Transplant Candidates: Many Unanswered Questions in Clinical Practice. Diagnostics (Basel) 2021; 11:diagnostics11010075. [PMID: 33466478 PMCID: PMC7824885 DOI: 10.3390/diagnostics11010075] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 12/31/2020] [Accepted: 12/31/2020] [Indexed: 12/29/2022] Open
Abstract
Cardiovascular (CV) complications represent the first non-graft-related cause of death and the third overall cause of death among patients undergoing liver transplantation (LT). History of coronary artery disease is related to increased CV mortality following LT. Although it is of paramount importance to stratify CV risk in pre-LT patients, there is no consensus regarding the choice of the optimal non-invasive cardiac imaging test. Algorithms proposed by scientific associations include non-traditional risk factors, which are associated with increased cardiac risk profiles. Thus, an individualized pre-LT evaluation protocol should be followed. As the average age of patients undergoing LT and the number of candidates continue to rise, the “3 W” questions still remain unanswered, Who, Which and When? Who should be screened for coronary artery disease (CAD), which screening modality should be used and when should the asymptomatic waitlisted patients repeat cardiac evaluation? Prospective studies with large sample sizes are warranted to define an algorithm that can provide better risk stratification and more reliable survival prediction.
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Affiliation(s)
- Maria Bonou
- Department of Cardiology, Laiko General Hospital, 11527 Athens, Greece; (M.B.); (M.S.); (J.B.)
| | - Sophie Mavrogeni
- Department of Cardiology, Onassis Cardiac Surgery Center, 17674 Athens, Greece;
| | - Chris J. Kapelios
- Department of Cardiology, Laiko General Hospital, 11527 Athens, Greece; (M.B.); (M.S.); (J.B.)
- Correspondence: or ; Tel.: +30-213-2061032; Fax: +30-213-2061761
| | - Marina Skouloudi
- Department of Cardiology, Laiko General Hospital, 11527 Athens, Greece; (M.B.); (M.S.); (J.B.)
| | - Constantina Aggeli
- First Department of Cardiology, Hippokration General Hospital, Medical School of National & Kapodistrian University, 11527 Athens, Greece;
| | - Evangelos Cholongitas
- First Department of Internal Medicine, Medical School of National & Kapodistrian University, 11527 Athens, Greece;
| | - George Papatheodoridis
- Department of Gastroenterology, Laiko General Hospital, Medical School of National & Kapodistrian University, 11527 Athens, Greece;
| | - John Barbetseas
- Department of Cardiology, Laiko General Hospital, 11527 Athens, Greece; (M.B.); (M.S.); (J.B.)
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11
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Li XM, Xu ZZ, Wen ZP, Pei J, Dai W, Wang HM, Reng J, Zhou P, Xu GH. Usefulness of preoperative coronary computed tomography angiography in high risk non-cardiovascular surgery old patients with unknown or suspected coronary artery disease. BMC Cardiovasc Disord 2020; 20:450. [PMID: 33059589 PMCID: PMC7559787 DOI: 10.1186/s12872-020-01731-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 10/06/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Cumulative evidence has shown that the non-invasive modality of coronary computed tomography angiography (CCTA) has evolved as an alternative to invasive coronary angiography, which can be used to quantify plaque burden and stenosis and identify vulnerable plaque, assisting in diagnosis, prognosis and treatment. With the increasing elderly population, many patients scheduled for non-cardiovascular surgery may have concomitant coronary artery disease (CAD). The aim of this study was to investigate the usefulness of preoperative CCTA to rule out or detect significant CAD in this cohort of patients and the impact of CCTA results to clinical decision-making. METHODS 841 older patients (age 69.5 ± 5.8 years, 74.6% males) with high risk non-cardiovascular surgery including 771 patients with unknown CAD and 70 patients with suspected CAD who underwent preoperative CCTA were retrospectively enrolled. Multivariate logistic regression analysis was performed to determine predictors of significant CAD and the event of cancelling scheduled surgery in patients with significant CAD. RESULTS 677 (80.5%) patients had non-significant CAD and 164 (19.5%) patients had significant CAD. Single-, 2-, and 3- vessel disease was found in 103 (12.2%), 45 (5.4%) and 16 (1.9%) patients, respectively. Multivariate analysis demonstrated that positive ECG analysis and Agatston score were independently associated with significant CAD, and the optimal cutoff of Agatston score was 195.9. The event of cancelling scheduled surgery was increased consistently according to the severity of stenosis and number of obstructive major coronary artery. Multivariate analysis showed that the degree of stenosis was the only independent predictor for cancelling scheduled surgery. In addition, medication using at perioperative period increased consistently according to the severity of stenosis. CONCLUSIONS In older patients referred for high risk non-cardiovascular surgery, preoperative CCTA was useful to rule out or detect significant CAD and subsequently influence patient disposal. However, it might be unnecessary for patients with negative ECG and low Agatston score. Trial registration Retrospectively registered.
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Affiliation(s)
- Xue-Ming Li
- Department of Radiology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, 55# Lan 4 RenMing Road (South), Chengdu, 610041, Sichuan Province, China
| | - Zhong-Zhi Xu
- Department of Radiology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, 55# Lan 4 RenMing Road (South), Chengdu, 610041, Sichuan Province, China
| | - Zhi-Peng Wen
- Department of Radiology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, 55# Lan 4 RenMing Road (South), Chengdu, 610041, Sichuan Province, China
| | - Jiao Pei
- Department of Statistics, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, 55# Lan 4 RenMing Road (South), Chengdu, 610041, Sichuan Province, China
| | - Wei Dai
- Department of Thoracic Surgery, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, 55# Lan 4 RenMing Road (South), Chengdu, 610041, Sichuan Province, China
| | - Huai-Ming Wang
- Department of Anesthesiology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, 55# Lan 4 RenMing Road (South), Chengdu, 610041, Sichuan Province, China
| | - Jing Reng
- Department of Radiology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, 55# Lan 4 RenMing Road (South), Chengdu, 610041, Sichuan Province, China
| | - Peng Zhou
- Department of Radiology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, 55# Lan 4 RenMing Road (South), Chengdu, 610041, Sichuan Province, China.
| | - Guo-Hui Xu
- Department of Radiology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, 55# Lan 4 RenMing Road (South), Chengdu, 610041, Sichuan Province, China.
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12
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Forssten MP, Mohammad Ismail A, Sjolin G, Ahl R, Wretenberg P, Borg T, Mohseni S. The association between the Revised Cardiac Risk Index and short-term mortality after hip fracture surgery. Eur J Trauma Emerg Surg 2020; 48:1885-1892. [PMID: 32944823 PMCID: PMC9192369 DOI: 10.1007/s00068-020-01488-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/04/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE The post-operative mortality after hip fracture surgery is high and has remained largely unchanged during the last decades. The Revised Cardiac Risk Index (RCRI) is a tool used to evaluate the 30-day risk of, among other outcomes, post-operative mortality. The aim of this study is to determine the association between the RCRI score and post-operative mortality in patients undergoing hip fracture surgery. METHODS Data was obtained from the national hip fracture register which was cross-referenced with patients' electronic hospital records. All adults who underwent primary emergency hip fracture surgery in Orebro County, Sweden, between January 1, 2013 and December 31, 2017, were included. Patients were divided into two cohorts: low RCRI (score = 0-1) and high RCRI (score ≥ 2). A Poisson regression model was employed to investigate the association between a high RCRI score and 30- and 90-day post-operative mortality. RESULTS A total of 2443 patients, of whom 446 (18%) had a high RCRI score, were included in the current study. When adjusting for age, sex, comorbidities and type of surgery, the incidence of 30-day mortality increased by 46% in the high RCRI cohort (adj. IRR 1.46, 95% CI, 1.10-1.94, p = 0.010). Similar results were observed for 90-day mortality (adj. IRR 1.50, 95% CI, 1.21-1.84, p < 0.001). CONCLUSION The RCRI is applicable to patients that undergo surgery for traumatic hip fractures. A high RCRI score is associated with an increased incidence of both 30- and 90-day post-operative mortality. Future studies to evaluate these findings are needed.
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Affiliation(s)
- Maximilian Peter Forssten
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85 Orebro, Sweden
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
| | - Ahmad Mohammad Ismail
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85 Orebro, Sweden
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
| | - Gabriel Sjolin
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
- Department of Surgery, Orebro University Hospital, 702 81 Orebro, Sweden
| | - Rebecka Ahl
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
- Department of Surgery, Karolinska University Hospital, 171 76 Stockholm, Sweden
- Division of Surgery, CLINTEC, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Per Wretenberg
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85 Orebro, Sweden
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
| | - Tomas Borg
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85 Orebro, Sweden
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, 701 85 Orebro, Sweden
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13
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Liao CY, Tan TL, Lu YD, Wu CT, Lee MS, Kuo FC. Does preoperative dipyridamole-thallium scanning reduce 90-day cardiac complications and 1-year mortality in patients with femoral neck fractures undergoing hemiarthroplasty? J Orthop Surg Res 2020; 15:385. [PMID: 32894146 PMCID: PMC7487939 DOI: 10.1186/s13018-020-01918-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 08/24/2020] [Indexed: 11/10/2022] Open
Abstract
Background This study aimed to evaluate the effect of dipyridamole-thallium scanning (DTS) on the rates of 90-day cardiac complications and 1-year mortality in patients with a femoral neck fracture treated with hemiarthroplasty. Methods Between 2008 and 2015, 844 consecutive patients who underwent cemented or cementless hemiarthroplasty were identified from the database of a single level-one medical center. One-hundred and thirteen patients (13%) underwent DTS prior to surgery, and 731 patients (87%) did not. Patient characteristics, comorbidities, surgical variables, and length of the delay until surgery were recorded. A propensity score-matched cohort was utilized to reduce recruitment bias in a 1:3 ratio of DTS group to control group, and multivariate logistic regression was performed to control confounding variables. Results The incidence of 90-day cardiac complications was 19.5% in the DTS group and 15.6% in the control group (p = 0.343) among 452 patients after propensity score-matching. The 1-year mortality rate (10.6% vs 13.3%, p = 0.462) was similar in the two groups. In the propensity score-matched patients, utilization of DTS was not associated with a reduction in the rate of 90-day cardiac complications (matched cohort, adjusted odds ratio [aOR] = 1.32; 95% confidence interval [CI] 0.75–2.33, p = 0.332) or the 1-year mortality rate (aOR = 0.62; 95% CI 0.27–1.42, p = 0.259). Risk factors for cardiac complications included an American Society of Anesthesiologists grade ≥ 3 (OR 3.19, 95% CI 1.44–7.08, p = 0.004) and pre-existing cardiac comorbidities (OR 5.56, 95% CI 3.35–9.25, p < 0.001). Risk factors for 1-year mortality were a long time to surgery (aOR 1.15, 95% CI 1.06–1.25, p = 0.001), a greater age (aOR 1.05, 95% CI 1.00 to 1.10, p = 0.040), a low body mass index (BMI; aOR 0.89, 95% CI 0.81–0.98, p = 0.015), and the presence of renal disease (aOR 4.43, 95% CI 1.71–11.46, p = 0.002). Discussion Preoperative DTS was not associated with reductions in the rates of 90-day cardiac complications or 1-year mortality in patients with a femoral neck fracture undergoing hemiarthroplasty. The necessity for DTS should be re-evaluated in elderly patients with femoral neck fractures, given that this increases the length of the delay until surgery. Level of evidence Prognostic level III
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Affiliation(s)
- Chin-Yi Liao
- Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, No. 123, Ta Pei Road, Niao Sung Dist, Kaohsiung, Taiwan
| | - Timothy L Tan
- Rothman Institute Orthopedic Research Department, Thomas Jefferson University, Rothman Institute Sheridan Building, Suite 1000, 25 S 9th Street, Philadelphia, PA, 19107, USA
| | - Yu-Der Lu
- Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, No. 123, Ta Pei Road, Niao Sung Dist, Kaohsiung, Taiwan
| | - Cheng-Ta Wu
- Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, No. 123, Ta Pei Road, Niao Sung Dist, Kaohsiung, Taiwan
| | - Mel S Lee
- Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, No. 123, Ta Pei Road, Niao Sung Dist, Kaohsiung, Taiwan
| | - Feng-Chih Kuo
- Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, No. 123, Ta Pei Road, Niao Sung Dist, Kaohsiung, Taiwan.
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14
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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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Serum Alkaline Phosphatase as a Predictor of Cardiac and Cerebrovascular Complications after Lumbar Spinal Fusion Surgery in Elderly: A Retrospective Study. J Clin Med 2019; 8:jcm8081111. [PMID: 31357535 PMCID: PMC6723677 DOI: 10.3390/jcm8081111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 07/19/2019] [Accepted: 07/25/2019] [Indexed: 12/20/2022] Open
Abstract
We retrospectively enrolled 1395 patients aged > 65 years undergoing posterior lumbar spinal fusion surgery and classified them into tertiles based on serum Alkaline Phosphatase (ALP) levels (<63, 63–79, >79 IU/L). The primary outcome was the incidence of 30-day major adverse cardiac and cerebrovascular events (MACCE; composite endpoint defined as the occurrence of ≥1 of the following events: new-onset myocardial infarction, stroke, or cardiovascular mortality). The incidence of the composite endpoint was the highest in the third serum ALP tertile (0.4% vs. 0.2% vs. 2.2% in the first, second, and third tertile, respectively, p = 0.003). Multivariate analysis showed that the third serum ALP tertile was an independent predictor of the composite endpoint of MACCE (odds ratio 4.507, 95% confidence interval 1.378–14.739, p = 0.013). The optimal cut-off value of preoperative serum ALP showing the best discriminatory capacity to predict postoperative MACCE (measured by receiver-operating characteristic curve analysis) was 83 IU/L (area under curve 0.694, 95% confidence interval 0.574–0.813, p = 0.016). Preoperative serum ALP levels were independently associated with the composite endpoint of postoperative 30-days MACCE. We suggest that serum ALP can be used as a biomarker to predict cardiac and cerebrovascular complications following lumbar spinal fusion surgery in elderly patients.
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16
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Koshy AN, Ha FJ, Gow PJ, Han HC, Amirul-Islam FM, Lim HS, Teh AW, Farouque O. Computed tomographic coronary angiography in risk stratification prior to non-cardiac surgery: a systematic review and meta-analysis. Heart 2019; 105:1335-1342. [PMID: 31018953 DOI: 10.1136/heartjnl-2018-314649] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/25/2019] [Accepted: 03/28/2019] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES Utility of CT coronary angiography (CTA) and coronary artery calcium (CAC) scoring in risk stratification prior to non-cardiac surgery is unclear. Although current guidelines recommend stress testing in intermediate-high risk individuals, over one-third of perioperative major adverse cardiovascular events (MACE) occur in patients with a negative study. This systematic review and meta-analysis evaluates the value of CTA and CAC score in preoperative risk prognostication prior to non-cardiac surgery. METHODS MEDLINE, PubMed and EMBASE databases were searched for articles published up to June 2018. Summary ORs for degree of coronary artery disease (CAD) and perioperative MACE were pooled using a random-effects model. RESULTS Eleven studies were included. Two hundred and fifty-two (7.2%) MACE occurred in 3480 patients. Risk of perioperative MACE rose with the severity and extent of CAD on CTA (no CAD 2.0%; non-obstructive 4.1%; obstructive single-vessel 7.1%; obstructive multivessel 23.1%, p<0.001). Multivessel disease (MVD) demonstrated the greatest risk (OR 8.9, 95% CI 5.1 to 15.3, p<0.001). Increasing CAC score was associated with higher perioperative MACE (CAC score: ≥100 OR 5.1, ≥1000 OR 10.4, both p<0.01). In a cohort deemed high risk by established clinical indices, absence of MVD on CTA demonstrated a negative predictive value of 96% (95% CI 92.8 to 98.4) for predicting freedom from MACE. CONCLUSIONS Severity and extent of CAD on CTA conferred incremental risk for perioperative MACE in patients undergoing non-cardiac surgery. The 'rule-out' capability of CTA is comparable to other non-invasive imaging modalities and offers a viable alternative for risk stratification of patients undergoing non-cardiac surgery. TRIAL REGISTRATION NUMBER CRD42018100883.
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Affiliation(s)
- Anoop N Koshy
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Austin Health Clinical School, University of Melbourne, Parkville, Melbourne, Victoria, Australia.,Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | | | - Paul J Gow
- Austin Health Clinical School, University of Melbourne, Parkville, Melbourne, Victoria, Australia.,Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | - Hui-Chen Han
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Austin Health Clinical School, University of Melbourne, Parkville, Melbourne, Victoria, Australia
| | - F M Amirul-Islam
- Department of Statistics, Data Science and Epidemiology, Swinburne University of Technology, Melbourne, Victoria, Australia
| | - Han S Lim
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Austin Health Clinical School, University of Melbourne, Parkville, Melbourne, Victoria, Australia
| | - Andrew W Teh
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Austin Health Clinical School, University of Melbourne, Parkville, Melbourne, Victoria, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Austin Health Clinical School, University of Melbourne, Parkville, Melbourne, Victoria, Australia
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17
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Peri-operative endothelial dysfunction in patients undergoing minor abdominal surgery. Eur J Anaesthesiol 2019; 36:130-134. [DOI: 10.1097/eja.0000000000000935] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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18
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Li P, Lei Y, Li Q, Lakshmipriya T, Gopinath SCB, Gong X. Diagnosing Perioperative Cardiovascular Risks in Noncardiac Surgery Patients. JOURNAL OF ANALYTICAL METHODS IN CHEMISTRY 2019; 2019:6097375. [PMID: 31534814 PMCID: PMC6732619 DOI: 10.1155/2019/6097375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 06/16/2019] [Indexed: 05/12/2023]
Abstract
Every year, over 200 million adults are undergoing noncardiac surgery. These noncardiac surgery patients may face the risk of cardiac mortality and morbidity during the perioperative and recovery periods. Around ten million patients who underwent noncardiac surgery experience cardiac complications within the first 30 days of the postoperative period; the complications are myocardial infarction, cardiac death, and cardiac arrest. This cardiovascular risk is mostly faced by the patients having cerebrovascular or cardiac disease and the patients with the age greater than 50 years. Monitoring and treating cardiac diseases with a suitable biomarker during the perioperative period is necessary for the early recovery of noncardiac surgery patients. This review discussed the risk factors and the key guidelines to avoid the cardiovascular risks during the perioperative period of noncardiac surgery patients. In addition, the biomarkers and identification strategies for cardiac diseases are discussed.
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Affiliation(s)
- Panpan Li
- Department of Encephalopathy, Ankang Traditional Chinese Medicine Hospital, No. 47, Bashan East Road, Hanbin District, Ankang City, Shaanxi Province 725000, China
| | - Ying Lei
- Department of Functional (ECG Room), Ankang Traditional Chinese Medicine Hospital, No. 47, Bashan East Road, Hanbin District, Ankang City, Shaanxi Province 725000, China
| | - Qiaomei Li
- Operating Room, Ankang Traditional Chinese Medicine Hospital, No. 47, Bashan East Road, Hanbin District, Ankang City, Shaanxi Province 725000, China
| | - Thangavel Lakshmipriya
- Institute of Nano Electronic Engineering, Universiti Malaysia Perlis, 01000 Kangar, Perlis, Malaysia
| | - Subash C. B. Gopinath
- Institute of Nano Electronic Engineering, Universiti Malaysia Perlis, 01000 Kangar, Perlis, Malaysia
- School of Bioprocess Engineering, Universiti Malaysia Perlis, 02600 Arau, Perlis, Malaysia
| | - Xinwen Gong
- Department of Cardiology, Ankang Traditional Chinese Medicine Hospital, No. 47, Bashan East Road, Hanbin District, Ankang City, Shaanxi Province 725000, China
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19
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Small GR, Ernst J, Gauthier N, Chow BJW. Coronary CTA for Preoperative Risk Assessment in Noncardiac Surgery. CURRENT CARDIOVASCULAR IMAGING REPORTS 2018. [DOI: 10.1007/s12410-018-9461-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
PURPOSE OF REVIEW Coronary artery event includes acute coronary syndrome (ACS), percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) surgery. Following such an event, risk of noncardiac surgery is increased. Of major concern is what can make this surgery safer? RECENT FINDINGS High functional capacity improves cardiovascular (CV) risk; at least 4.0 metabolic equivalents (METs) on stress test are favorable. Risk scores can suggest need for further evaluation. Coronary angiography prior to surgery usually is not indicated since revascularization shows disappointing CV risk reduction results. Due to high association of peripheral arterial disease (PAD) with coronary artery disease (CAD), low ankle-brachial index (ABI) indicates increased CV risk. New perioperative beta blockade has shown disappointing benefit, but if ongoing should be continued. De novo perioperative beta blockade is for the highest CV risk patient undergoing noncardiac vascular surgery. Good evidence supports CV risk reduction from new or existing statin in the perioperative period, especially for the diabetic. Diabetics should also be on an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) secondarily, during the perioperative period to decrease 30-day perioperative mortality. Optimal timing of elective noncardiac surgery following a coronary artery event appears to be 180 days with CV risk decreased by a statin and an ACEI or an ARB.
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Affiliation(s)
- Thomas F Whayne
- Gill Heart and Vascular Institute, University of Kentucky, 326 Wethington Building, 900 South Limestone Street, Lexington, KY, 40536-0200, USA.
| | - Sibu P Saha
- Gill Heart and Vascular Institute, University of Kentucky, 326 Wethington Building, 900 South Limestone Street, Lexington, KY, 40536-0200, USA
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21
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Sundsted KK, Mohabbat AB, Regan DW, Salonen BR, Daniels PR, Mauck KF. Update in perioperative medicine: practice-changing evidence published in 2015. Hosp Pract (1995) 2016; 44:157-63. [PMID: 27400757 DOI: 10.1080/21548331.2016.1210473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Evidence in perioperative medicine is published in a wide variety of journals, given the multidisciplinary nature of its practice which spans medicine and its subspecialties, as well as surgery and anesthesiology. It can be difficult to identify new and important evidence, as perioperative practice continues to evolve in multiple areas such as medication management, anticoagulation and cardiac risk stratification, among others. New, high-quality evidence is published each year, and must be placed into the context of not only existing literature, but also practical real-world patient care. We sought to systematically identify, critically evaluate and concisely summarize the practice implications of 10 articles published in 2015 for the practicing perioperative clinician.
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Affiliation(s)
- Karna K Sundsted
- a Division of General Internal Medicine, Department of Medicine , Mayo Clinic and Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Arya B Mohabbat
- a Division of General Internal Medicine, Department of Medicine , Mayo Clinic and Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Dennis W Regan
- a Division of General Internal Medicine, Department of Medicine , Mayo Clinic and Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Bradley R Salonen
- a Division of General Internal Medicine, Department of Medicine , Mayo Clinic and Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Paul R Daniels
- a Division of General Internal Medicine, Department of Medicine , Mayo Clinic and Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Karen F Mauck
- a Division of General Internal Medicine, Department of Medicine , Mayo Clinic and Mayo Clinic College of Medicine , Rochester , MN , USA
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22
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The Role of Cardiac CT in the Evaluation of Endocarditis. CURRENT CARDIOVASCULAR IMAGING REPORTS 2016. [DOI: 10.1007/s12410-016-9377-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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23
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Schulman-Marcus J, Pashun RA, Feldman DN, Swaminathan RV. Coronary Angiography and Revascularization Prior to Noncardiac Surgery. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:3. [PMID: 26728404 DOI: 10.1007/s11936-015-0427-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OPINION STATEMENT The role of coronary angiography and revascularization, including percutaneous coronary intervention (PCI) prior to noncardiac surgery remains poorly defined. The goal of preoperative angiography and PCI is improved risk stratification and ideally risk reduction of postoperative cardiovascular events, such as myocardial infarction (MI). By current guidelines, these procedures should be performed sparingly in high-risk stable coronary artery disease (CAD) patients and routinely in patients with acute coronary syndrome (ACS). Anatomic assessment of CAD by routine invasive angiography is discouraged, although noninvasive assessment may soon be possible. As prior trials have failed to show a clear benefit in outcomes, PCI should only be considered in patients with high-risk anatomic features. The ideal management of other anatomic disease discovered by angiography is currently unknown. Limited registry data suggest that PCI is used more frequently than recommended, although the features of these procedures remain poorly elaborated. In patients who do undergo preoperative PCI, careful attention must be paid to patient-specific factors including the nature and urgency of surgery and duration of dual antiplatelet therapy. In summary, substantial evidence gaps warrant further research in this important area.
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Affiliation(s)
- Joshua Schulman-Marcus
- Departments of Medicine and Radiology, Weill Cornell Medical College, 1305 York Ave, 8th Avenue, New York, NY, 10021, USA.
| | - Raymond A Pashun
- Department of Medicine, New York Presbyterian Hospital, 505 E 70th St, Suite 450, New York, NY, 10021, USA.
| | - Dmitriy N Feldman
- Greenberg Division of Cardiology, Weill Cornell Medical College, 520 E 70th St, New York, NY, 10021, USA.
| | - Rajesh V Swaminathan
- Greenberg Division of Cardiology, Weill Cornell Medical College, 520 E 70th St, New York, NY, 10021, USA.
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24
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LaBounty TM, Eagle KA. Coronary computed tomographic angiography for preoperative risk: improved area under curve is not enough. Circ Cardiovasc Imaging 2015; 8:CIRCIMAGING.115.003157. [PMID: 25711277 DOI: 10.1161/circimaging.115.003157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Troy M LaBounty
- From the Department of Medicine, University of Michigan Health System, Ann Arbor.
| | - Kim A Eagle
- From the Department of Medicine, University of Michigan Health System, Ann Arbor
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