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Azizi PM, Wijeysundera DN, Wijeysundera HC, Austin PC, Jerath A, Kayssi A, Ko DT. Association Between Hospital Postoperative Troponin Use and Patient Outcomes After Vascular Surgery. Anesth Analg 2023; 137:629-637. [PMID: 36913232 DOI: 10.1213/ane.0000000000006411] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
BACKGROUND Acute myocardial injury after noncardiac surgery, which is most often symptomatically silent, is associated with increased mortality and morbidity. However, it is not known if routine postoperative troponin testing will affect patient outcomes. METHODS We assembled a cohort of patients who underwent carotid endarterectomy or abdominal aortic aneurysm repair in Ontario, Canada, from 2010 to 2017. Hospitals were categorized into high, medium, and low troponin testing intensity based on the proportion of patients who received postoperative troponin testing. Cox proportional hazards modeling was used to assess the association between hospital-specific testing intensity and 30-day and 1-year major adverse cardiovascular events (MACEs) while adjusting for patient-, surgery-, and hospital-level factors. RESULTS The cohort consisted of 18,467 patients from 17 hospitals. Mean age was 72 years, and 74.0% were men. Rates of postoperative troponin testing were 77.5%, 35.8%, and 21.6% in the high-, medium-, and low-testing intensity hospitals, respectively. At 30 days, 5.3%, 5.3%, and 6.5% of patients in high-, medium-, and low-testing intensity hospitals experienced MACE, respectively. Higher troponin testing rate was associated with lower adjusted hazard ratios (HRs) for MACE at 30 days (0.94; 95% confidence interval [CI], 0.89-0.98) and at 1 year (0.97; 95% CI, 0.94-0.99) for each 10% increase in hospital troponin rate. Hospitals with high-testing intensity had higher rates of postoperative cardiology referrals, cardiovascular testing, and rates of new cardiovascular prescriptions. CONCLUSIONS Patients undergoing vascular surgery at hospitals with higher postoperative troponin testing intensity experienced fewer adverse outcomes than patients who had surgery at hospitals with lower testing intensity.
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Affiliation(s)
- Paymon M Azizi
- From the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Duminda N Wijeysundera
- From the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Harindra C Wijeysundera
- From the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Peter C Austin
- From the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Angela Jerath
- From the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ahmed Kayssi
- From the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Dennis T Ko
- From the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Chang Y, Zhou M, Huang J, Wang Y, Shao J. Incidence and risk factors of postoperative acute myocardial injury in noncardiac patients: A systematic review and meta-analysis. PLoS One 2023; 18:e0286431. [PMID: 37319136 PMCID: PMC10270363 DOI: 10.1371/journal.pone.0286431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/16/2023] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION Postoperative myocardial injury after noncardiac surgery is common and is associated with short- and long-term morbidity and mortality. However, the incidence and risk factors for postoperative acute myocardial injury (POAMI) are currently unknown due to inconsistent definitions. METHODS We systematically searched PubMed and Web of Science to identify studies that applied the change value of preoperative and postoperative cardiac troponins to define cardiac injury. We estimated the pooled incidence, risk factors, and 30-day and long-term mortality of POAMI in noncardiac patients. The study protocol was registered with PROSPERO, CRD42023401607. RESULTS Ten cohorts containing 11,494 patients were included for analysis. The pooled incidence of POAMI was 20% (95% CI: 16% to 23%). Preoperative hypertension (OR: 1.47; 95% CI: 1.30 to 1.66), cardiac failure (OR: 2.63; 95% CI: 2.01 to 3.44), renal impairment (OR: 1.66; 95% CI: 1.48 to 1.86), diabetes (OR: 1.43; 95% CI: 1.27 to 1.61), and preoperative beta-blocker intake (OR: 1.65; 95% CI: 1.10 to 2.49) were the risk factors for POAMI. Age (mean difference: 2.08 years; 95% CI: -0.47 to 4.62), sex (male, OR: 1.16; 95% CI: 0.77 to 1.76), body mass index (mean difference: 0.35; 95% CI: -0.86 to 1.57), preoperative coronary artery disease (OR: 2.10; 95% CI: 0.85 to 5.21), stroke (OR: 0.90; 95% CI: 0.50 to 1.59) and preoperative statins intake (OR: 0.65; 95% CI: 0.21 to 2.02) were not associated with POAMI. Patients with POAMI had higher preoperative hsTnT levels (mean difference: 5.92 ng/L; 95% CI: 4.17 to 7.67) and lower preoperative hemoglobin levels (mean difference: -1.29 g/dL; 95% CI: -1.43 to -1.15) than patients without. CONCLUSION Based on this meta-analysis, approximately 1 in 5 of noncardiac patients develop POAMI. However, the lack of a universally recognized definition for POAMI, which incorporates diverse cardiac biomarkers and patient groups, poses a challenge in accurately characterizing its incidence, risk factors, and clinical outcomes.
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Affiliation(s)
- Yuan Chang
- Department of Anesthesiology, the First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Mengjiao Zhou
- Department of Anesthesiology, the First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jing Huang
- Department of Anesthesiology, the First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yanqiong Wang
- Department of Anesthesiology, the First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jianlin Shao
- Department of Anesthesiology, the First Affiliated Hospital of Kunming Medical University, Kunming, China
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Meyer MJ, Jameson SA, Gillig EJ, Aggarwal A, Ratcliffe SJ, Baldwin M, Singh KE, Clouse WD, Blank RS. Clinical implications of preoperative echocardiographic findings on cardiovascular outcomes following vascular surgery: An observational trial. PLoS One 2023; 18:e0280531. [PMID: 36656845 PMCID: PMC9851553 DOI: 10.1371/journal.pone.0280531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 12/29/2022] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Peripheral artery disease and cardiac disease are often comorbid conditions. Echocardiography is a diagnostic tool that can be performed preoperatively to risk stratify patients by a functional cardiac test. We hypothesized that ventricular dysfunction and valvular lesions were associated with an increased incidence of expanded major adverse cardiac events (Expanded MACE). METHODS AND MATERIALS Retrospective cohort study from 2011 to 2020 including all patients from a major academic center who had vascular surgery and an echocardiographic study within two years of the index procedure. RESULTS 813 patients were included in the study; a majority had a history of smoking (86%), an ASA score of 3 (65%), and were male (68%). Carotid endarterectomy was the most common surgery (24%) and the least common surgery was open abdominal aortic aneurysm repair (5%). We found no significant association between the echocardiographic findings of left ventricular dysfunction, right ventricular dysfunction, or valvular lesions and the postoperative development of Expanded MACE. CONCLUSIONS The preoperative echocardiographic findings of left ventricular dysfunction, right ventricular dysfunction and moderate to severe valvular lesions were not predictive of an increased incidence of postoperative Expanded MACE. We identified a significant association between RV dysfunction and post-operative dialysis that should be interpreted carefully due to the small number of outcomes. The transition from open to endovascular surgery and advances in perioperative management may have led to improved cardiovascular outcomes. TRIAL REGISTRATION Trial Registration: NCT04836702 (clinicaltrials.gov). https://www.google.com/search?client=firefox-b-d&q=NCT04836702.
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Affiliation(s)
- Matthew J. Meyer
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
- * E-mail:
| | - Slater A. Jameson
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Edward J. Gillig
- Department of Anesthesiology, Newton Wellesley Hospital, Newton, MA, United States of America
| | - Ankur Aggarwal
- Department of Surgery, Franciscan Physicians Network Vascular Surgeons, Indianapolis, IN, United States of America
| | - Sarah J. Ratcliffe
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Mary Baldwin
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Karen E. Singh
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - W. Darrin Clouse
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, United States of America
| | - Randal S. Blank
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, United States of America
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Valadkhani A, Henningsson R, Nordström JL, Granström A, Hallqvist L, Wahlgren CM, Peterzén B, Eriksson J, Bell M, Gupta A. Postoperative complications and myocardial injury in patients receiving air or oxygen. Acta Anaesthesiol Scand 2022; 66:1185-1192. [DOI: 10.1111/aas.14136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 07/21/2022] [Accepted: 08/11/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Arman Valadkhani
- Department of Perioperative Medicine and Intensive Care (PMI) Karolinska University Hospital Stockholm Sweden
- Department of Pharmacology and Physiology Karolinska Institutet Stockholm Sweden
| | - Ragnar Henningsson
- Department of Anaesthesiology and Intensive Care Central Hospital Karlstad Karlstad Sweden
| | - Johan L. Nordström
- Department of Perioperative Medicine and Intensive Care (PMI) Karolinska University Hospital Stockholm Sweden
| | - Anna Granström
- Department of Perioperative Medicine and Intensive Care (PMI) Karolinska University Hospital Stockholm Sweden
| | - Linn Hallqvist
- Department of Perioperative Medicine and Intensive Care (PMI) Karolinska University Hospital Stockholm Sweden
- Department of Pharmacology and Physiology Karolinska Institutet Stockholm Sweden
| | - Carl Magnus Wahlgren
- Department of Vascular Surgery Karolinska University Hospital, Department of Molecular Medicine and Surgery, Karolinska Institutet Stockholm Sweden
| | - Bengt Peterzén
- Department of Cardiovascular surgery Linköping University Linköping Sweden
| | - Julia Eriksson
- Division of Biostatistics Institute of Environmental Medicine, Karolinska Institutet Stockholm Sweden
| | - Max Bell
- Department of Perioperative Medicine and Intensive Care (PMI) Karolinska University Hospital Stockholm Sweden
- Department of Pharmacology and Physiology Karolinska Institutet Stockholm Sweden
| | - Anil Gupta
- Department of Perioperative Medicine and Intensive Care (PMI) Karolinska University Hospital Stockholm Sweden
- Department of Pharmacology and Physiology Karolinska Institutet Stockholm Sweden
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Liu Y, Huang X, Liu Y, Li D, Zhang J, Yang L. Application value of hypersensitive C-reactive protein, lactic acid and myoglobin in the combined detection of myocarditis. Exp Ther Med 2019; 17:4471-4476. [PMID: 31105785 PMCID: PMC6507525 DOI: 10.3892/etm.2019.7520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 04/12/2019] [Indexed: 12/13/2022] Open
Abstract
Application value of hypersensitive C-reactive protein (hs-CRP), blood lactic acid (LAC) and myoglobin (Mb) in the combined detection of myocarditis was explored. A total of 107 patients with suspected myocarditis treated in The Second Nanning People's Hospital from January 2015 to December 2017 were retrospectively analyzed, of whom 81 patients diagnosed with myocarditis were enrolled into the research group, and 26 non-myocarditis individuals were enrolled into the control group. Fasting venous blood was drawn from all patients to detect the hs-CRP, LAC and Mb, and their levels were compared and analyzed between the two groups. Moreover, the coincidence rate, sensitivity and specificity of single detection and combined detection by hs-CRP, LAC and Mb in the diagnosis of myocarditis were compared and analyzed. There were no significant differences in the sex, age, smoking status, alcohol consumption, chest distress, palpitation, angina and dyspnea between the two groups (P>0.05), proving that patients in both groups were comparable. The levels of hs-CRP, LAC and Mb in the research group were significantly higher than those in the control group, displaying statistically significant differences (P<0.05). According to the receiver operating characteristic (ROC) curve, the area under the curve (AUC), coincidence rate, sensitivity and specificity in the diagnosis of myocarditis, respectively, were 0.610 (95% CI: 0.495–0.725), 58.88, 51.85 and 80.77% for hs-CRP, 0.657 (95% CI: 0.551–0.763), 58.88, 54.32 and 73.08% for LAC, 0.747 (95% CI: 0.651–0.843), 69.16, 64.20 and 84.62% for Mb, and 0.773 (95% CI: 0.680–0.867), 76.64, 79.01 and 69.23% for combined detection. Hs-CRP, LAC and Mb are highly expressed in the serum of patients with myocarditis, and their combined detection has guiding significance for the prevention and treatment of myocarditis.
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Affiliation(s)
- Yang Liu
- Department of Cardiology, The Second Nanning People's Hospital, Nanning, Guangxi Zhuang Autonomous Region 530031, P.R. China
| | - Xuecheng Huang
- Department of Cardiology, The Second Nanning People's Hospital, Nanning, Guangxi Zhuang Autonomous Region 530031, P.R. China
| | - Yuanhang Liu
- Nursing College, Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530031, P.R. China
| | - Dongyang Li
- Nursing College, Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530031, P.R. China
| | - Jingchang Zhang
- Department of Cardiology, The Second Nanning People's Hospital, Nanning, Guangxi Zhuang Autonomous Region 530031, P.R. China
| | - Lihui Yang
- Nursing College, Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region 530031, P.R. China
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Humble CAS, Huang S, Jammer I, Björk J, Chew MS. Prognostic performance of preoperative cardiac troponin and perioperative changes in cardiac troponin for the prediction of major adverse cardiac events and mortality in noncardiac surgery: A systematic review and meta-analysis. PLoS One 2019; 14:e0215094. [PMID: 31009468 PMCID: PMC6476502 DOI: 10.1371/journal.pone.0215094] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 03/26/2019] [Indexed: 12/29/2022] Open
Abstract
Background Increased postoperative cardiac troponin (cTn) independently predicts short-term mortality. Previous studies suggest that preoperative cTn also predicts major adverse cardiovascular events (MACE) and mortality after noncardiac surgery. The value of preoperative and perioperative changes in cTn as a prognostic tool for adverse outcomes has been sparsely investigated. Methods and findings A systematic review and meta-analysis of the prognostic value of cTns for adverse outcome was conducted. Adverse outcome was defined as short-term (in-hospital or <30 days) and long-term (>30 days) MACE and/or all-cause mortality, in adult patients undergoing noncardiac surgery. The study protocol (CRD42018094773) was registered with an international prospective register of systematic reviews (PROSPERO). Preoperative cTn was a predictor of short- (OR 4.3, 95% CI 2.9–6.5, p<0.001, adjusted OR 5.87, 95% CI 3.24–10.65, p<0.001) and long-term adverse outcome (OR 4.2, 95% CI 1.0–17.3, p = 0.05, adjusted HR 2.0, 95% CI 1.4–3.0, p<0.001). Perioperative change in cTn was a predictor of short-term adverse outcome (OR 10.1, 95% CI 3.2–32.3, p<0.001). It was not possible to conduct pooled analyses for adjusted estimates of perioperative change in cTn as predictor of short- (a single study identified) and long-term (no studies identified) adverse outcome. Further, it was not possible to conduct pooled analyses for unadjusted estimates of perioperative change in cTn as predictor of long-term adverse outcome, since only one study was identified. Bivariate analysis of sensitivities and specificities were performed, and overall prognostic performance was summarized using summary receiver operating characteristic (SROC) curves. The pooled sensitivity and specificity for preoperative cTn and short-term adverse outcome was 0.43 and 0.86 respectively (area under the SROC curve of 0.68). There were insufficient studies to construct SROCs for perioperative changes in cTn and for long-term adverse outcome. Conclusion Our study indicates that although preoperative cTn and perioperative change in cTn might be valuable predictors of MACE and/or all-cause mortality in adult noncardiac surgical patients, its overall prognostic performance remains uncertain. Future large, representative, high-quality studies are needed to establish the potential role of cTns in perioperative cardiac risk stratification.
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Affiliation(s)
- Caroline A. S. Humble
- Department of Anesthesiology and Intensive Care, Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Stephen Huang
- Department of Intensive Care Medicine, The University of Sydney, Nepean Hospital, Sydney, Australia
| | - Ib Jammer
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Jonas Björk
- Division of Occupational and Environmental Medicine, Lund University, Lund, Sweden
- Clinical Studies Sweden, Forum South, Skåne University Hospital, Lund, Sweden
| | - Michelle S. Chew
- Department of Anesthesiology and Intensive Care, Medical and Health Sciences, Linköping University, Linköping, Sweden
- * E-mail:
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Monnard M, Larmann J. [74-year-old female for a low anterior rectal resection : Preparation for the medical specialist examination: Part 3]. Anaesthesist 2019; 68:90-94. [PMID: 30989290 DOI: 10.1007/s00101-019-0572-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- M Monnard
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - J Larmann
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.
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Reis PV, Lopes AI, Leite D, Moreira J, Mendes L, Ferraz S, Amaral T, Mourão J, Abelha F. Major Cardiac Events in Patients Admitted to Intensive Care After Vascular Noncardiac Surgery: A Retrospective Cohort. Semin Cardiothorac Vasc Anesth 2019; 23:293-299. [DOI: 10.1177/1089253218825442] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction. Patients proposed to vascular noncardiac surgery (VS) have several comorbidities associated with major adverse cardiac events (MACE). We evaluated incidence, predictors, and outcomes, and compared different scores to predict MACE after VS. Methods. We included all patients admitted from 2006 to 2013. Perioperative MACE included cardiac arrhythmias, myocardial infarction (MI), cardiogenic pulmonary edema (CPE), acute heart failure (AHF), and cardiac arrest (CA). Lee Revised Cardiac Risk Index (RCRI), Vascular Quality Initiative (VQI-CRI), Vascular Study Group of New England (VSG-CRI), and South African Vascular Surgical (SAVS-CRI) Cardiac Risk Indexes were calculated and analyzed. We performed multivariate logistic regression to assess independent predictors with calculation of odds ratio (OR) and 95% confidence interval (CI). To reduce overfitting, we used leave-one-out cross-validation approach. The Predictive ability of scores was tested using area under receiver operating characteristic curve (AUROC). Results. A total of 928 patients were included. We observed 81 MACE (28 MI, 22 arrhythmias, 10 CPE, 9 AHF, 12 CA) in 60 patients (6.5%): 3.3% in intermediate-risk surgery and 9.8% in high-risk surgery. Previous history of coronary artery disease (OR = 3.2, CI = 1.8-5.7), atrial fibrillation (OR = 5.1, CI = 2.4-11.0), insulin-treated diabetes mellitus (OR = 3.26, CI = 1.51-7.06), mechanical ventilation (OR = 2.75, CI = 1.41-4.63), and heart rate (OR = 1.02, CI = 1.01-1.03) at admission were considered independent risk factors in multivariate analysis. The AUROC of our model was 0.79, compared with RCRI (0.66), VSG-CRI (0.69), VQI-CRI (0.71), and SAVS-CRI (0.73). Conclusions. Observed MACE were within predicted range (1% to 5% after intermediate-risk surgery and >5% after high-risk surgery). SAVS-CRI and VQI-CRI had slightly better predictive capacity than VSG-CRI or RCRI.
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Affiliation(s)
- Pedro Videira Reis
- São João Hospital Centre, Porto, Portugal
- Universidade do Porto, Porto, Portugal
| | | | | | | | | | | | | | - Joana Mourão
- São João Hospital Centre, Porto, Portugal
- Universidade do Porto, Porto, Portugal
| | - Fernando Abelha
- São João Hospital Centre, Porto, Portugal
- Universidade do Porto, Porto, Portugal
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