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Lurati Buse G, Bollen Pinto B, Abelha F, Abbott TEF, Ackland G, Afshari A, De Hert S, Fellahi JL, Giossi L, Kavsak P, Longrois D, M'Pembele R, Nucaro A, Popova E, Puelacher C, Richards T, Roth S, Sheka M, Szczeklik W, van Waes J, Walder B, Chew MS. ESAIC focused guideline for the use of cardiac biomarkers in perioperative risk evaluation. Eur J Anaesthesiol 2023; 40:888-927. [PMID: 37265332 DOI: 10.1097/eja.0000000000001865] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND In recent years, there has been increasing focus on the use of cardiac biomarkers in patients undergoing noncardiac surgery. AIMS The aim of this focused guideline was to provide updated guidance regarding the pre-, post- and combined pre-and postoperative use of cardiac troponin and B-type natriuretic peptides in adult patients undergoing noncardiac surgery. METHODS The guidelines were prepared using Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology. This included the definition of critical outcomes, a systematic literature search, appraisal of certainty of evidence, evaluation of biomarker measurement in terms of the balance of desirable and undesirable effects including clinical outcomes, resource use, health inequality, stakeholder acceptance, and implementation. The panel differentiated between three different scopes of applications: cardiac biomarkers as prognostic factors, as tools for risk prediction, and for biomarker-enhanced management strategies. RESULTS In a modified Delphi process, the task force defined 12 critical outcomes. The systematic literature search resulted in over 25,000 hits, of which 115 full-text articles formed the body of evidence for recommendations. The evidence appraisal indicated heterogeneity in the certainty of evidence across critical outcomes. Further, there was relevant gradient in the certainty of evidence across the three scopes of application. Recommendations were issued and if this was not possible due to limited evidence, clinical practice statements were produced. CONCLUSION The ESAIC focused guidelines provide guidance on the perioperative use of cardiac troponin and B-type natriuretic peptides in patients undergoing noncardiac surgery, for three different scopes of application.
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Affiliation(s)
- Giovanna Lurati Buse
- From the Department of Anaesthesiology, University Hospital Dusseldorf, Dusseldorf, Germany (GLB, RMP, AN, SR), Division of Anaesthesiology, Geneva University Hospitals (HUG), Geneva, Switzerland (BBP, MS, BW), Department of Anesthesiology, Centro Hospitalar Universitário de São João, Porto, Portugal (FA), Cardiovascular Research and Development Center (UnIC@RISE), Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal (FA), William Harvey Research Institute, Queen Mary University of London, London, UK (TEA, GA), Department of Anaesthesia and Perioperative Medicine, Royal London Hospital, Barts Health NHS Trust, London, UK (GA), Department of Paediatric and Obstetric Anaesthesia, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Denmark (AA), Department of Anaesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium (SDH), Service d'Anesthésie-Réanimation, Hôpital Universitaire Louis Pradel, Hospices Civils de Lyon, 59 boulevard Pinel, 69500 Lyon, France (J-LF), "Patients as Partners" program, Geneva University Hospitals (HUG), Geneva, Switzerland (LG), Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada (PK), Department of Anesthesiology and Intensive Care, Bichat Claude-Bernard Hospital, Assistance Publique-Hopitaux de Paris - Nord, University of Paris, INSERM U1148, Paris, France (DL), Institut d'Investigació Biomèdica Sant Pau (IIB SANT PAU), Barcelona, Spain (EP), Centro Cochrane Iberoamericano, Barcelona, Spain (EP), Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel-Stadt, Switzerland (CP), Department of Internal Medicine, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Basel-Stadt, Switzerland (CP), Division of Surgery, University of Western Australia, Perkins South Building, Fiona Stanley Hospital, Murdoch, Perth, WA, Australia (TR), Institute of Clinical Trials and Methodology and Division of Surgery, University College London, UK (TR), Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland (WS), Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (JvW), Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University Hospital, Sweden (MSC)
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Pickney CC, Kuka CC, Nadesakumaran K, Sorour AA, Cremer PC, Insler SR, Caputo FJ, Kirksey L, Rowse JW, Steenberge SP, Quatromoni JG, Lyden SP, Smolock CJ. Value of Routine Troponin Measurement in Open Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2023; 96:166-175. [PMID: 37169247 DOI: 10.1016/j.avsg.2023.04.030] [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: 03/10/2023] [Accepted: 04/24/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Cardiovascular complications are a major cause of morbidity and mortality in the postoperative period after major vascular surgery. Depending on the study population, up to 25% of patients have troponin elevation after noncardiac surgery, yet many do not meet the diagnosis of myocardial infarction (MI). Although outcomes of routine troponin elevation in patients undergoing mixed major vascular surgery have been evaluated, this has not been studied exclusively in elective, open abdominal aortic aneurysm repair (oAAA), especially regarding perioperative and overall mortality. METHODS We conducted a single-center, retrospective review of routine troponin surveillance for consecutive, oAAA from 2014 to 2019. A total of 319 patients were identified and analyzed for management patterns and interventions. The cohort was stratified into groups for comparison based on those in whom troponin was routinely checked (RC) as part of a care strategy during the study period, not routinely checked (NRC), elevated troponin (ET) >0.001 ng/mL, and not elevated. The median follow-up was 21.5 ± 23.8 months. Groups were compared on demographic data, cardiac comorbidities, 30-day and 3-year outcomes for MI and death using two-sample t-tests, Wilcoxon rank sum tests, Pearson chi-square tests, and Fisher exact tests when appropriate. RESULTS Troponin was measured in 83.7% (267/319) of patients who underwent elective oAAA repair. Routine troponin checks were obtained in 79.9% (255/319) of patients. ET was identified in 16.5% of those with RC (42/255) and 4.7% of those with NRC (3/64). Of patients with ET, 37.8% (17/45) had a cardiology consultation, 4.4% (2/45) had a percutaneous coronary intervention (PCI), and 4.4% (2/45) had another cardiac intervention. All 4 patients undergoing PCI or other cardiac intervention had received routine troponin checks. Patients with ET were older (71.2 vs. 68.6; P = 0.04), more likely to receive intraoperative blood products (P = 0.003), had longer operative times (P = 0.011), higher length of stay (9 vs. 7 days; P < 0.01), and higher 30-day MI rate (3 vs. 0; P = 0.04). They had neither longer aortic clamp times nor worse preoperative cardiac function, and the proximal clamp position during oAAA repair did not impact troponin detection. Additionally, 3-year overall mortality was increased in patients who had ET but there was not a significant difference in 3-year mortality between groups receiving routine troponin checks versus not. CONCLUSIONS ET, identified after elective oAAA repair, was associated with a higher risk of 30-day MI and lower overall survival. However, it was not demonstrated that routine assessment of troponin levels postoperatively leads to decreased 3-year mortality in this setting.
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Affiliation(s)
- Cole C Pickney
- Case Western Reserve University School of Medicine, Cleveland, OH.
| | - Casey C Kuka
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Kogulan Nadesakumaran
- Aortic Center and Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Ahmed A Sorour
- Aortic Center and Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Paul C Cremer
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Steven R Insler
- Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, OH
| | - Francis J Caputo
- Aortic Center and Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Levester Kirksey
- Aortic Center and Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Jarrad W Rowse
- Aortic Center and Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Sean P Steenberge
- Aortic Center and Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Jon G Quatromoni
- Aortic Center and Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Sean P Lyden
- Aortic Center and Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Christopher J Smolock
- Aortic Center and Department of Vascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH.
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Zhang L, Guo SY, Wang G, Zheng X, Jia HM, Huang LF, Weng YB, Li WX. Predictive Value of Perioperative Cardiac Troponin I in Patients Undergone Liver Transplantation: A Retrospective Cohort Study. J Inflamm Res 2023; 16:3135-3142. [PMID: 37520668 PMCID: PMC10378647 DOI: 10.2147/jir.s420252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 07/01/2023] [Indexed: 08/01/2023] Open
Abstract
Objective To examine the change rule and clinical significance of cardiac troponin I (cTnI) in the perioperative period of liver transplantation in adults, as well as its association with 28-day mortality. Methods This was a retrospective cohort study: patients who underwent elective orthotopic liver transplantation (OLT) in Beijing Chao-Yang Hospital between June 2015 and June 2020 were selected, and plasma cTnI values were collected through the electronic medical record system within 7 days after surgery. Furthermore, the baseline clinical data of these patients were collected, and the change curve of cTnI values following liver transplantation was plotted. Using univariate and multivariate logistic regression models, the relationship between the level of postoperative cTnI and short-term mortality was investigated. The primary study endpoint was mortality within 28 days after surgery. Results We included 414 patients who had undergone liver transplantation in this study, 48 of whom died within 28 days after surgery. cTnI, a specific marker of myocardial injury, could predict that the postoperative cardiovascular complications were higher in the death group and significantly affect the short-term prognosis of patients; however, its prognostic cut-off value was approximately 0.545 ng/mL (13×URL), indicating that a minor elevation of cTnI after liver transplantation did not significantly affect the prognosis. Moreover, a comparison of the baseline data and postoperative ICU management scores of the two groups revealed that diabetes, maximum value of cTnI >0.545 ng/mL within 7 days, and the need for postoperative renal replacement therapy (RRT) were independent prognostic factors of death within 28 days after liver transplantation. Conclusion Within 7 days after surgery, an increase in cTnI to the maximum value of 0.545 ng/mL (13×URL) could have a significant impact on the short-term prognosis of patients. Diabetes and postoperative RRT were two independent prognostic factors for liver transplantation perioperative mortality.
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Affiliation(s)
- Lei Zhang
- Department of Critical Care, Beijing Lu He Hospital, Capital Medical University, Beijing, 101120, People’s Republic of China
| | - Shu-Yan Guo
- Department of Critical Care, Beijing Lu He Hospital, Capital Medical University, Beijing, 101120, People’s Republic of China
| | - Guan Wang
- Department of Critical Care, Beijing Lu He Hospital, Capital Medical University, Beijing, 101120, People’s Republic of China
| | - Xi Zheng
- Department of Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China
| | - Hui-Miao Jia
- Department of Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China
| | - Li-Feng Huang
- Department of Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China
| | - Yi-bing Weng
- Department of Critical Care, Beijing Lu He Hospital, Capital Medical University, Beijing, 101120, People’s Republic of China
| | - Wen-Xiong Li
- Department of Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People’s Republic of China
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Benscoter AL, Alten JA, Atreya MR, Cooper DS, Byrnes JW, Nelson DP, Ollberding NJ, Wong HR. Biomarker-based risk model to predict persistent multiple organ dysfunctions after congenital heart surgery â€" A prospective observational cohort study. RESEARCH SQUARE 2023:rs.3.rs-2488327. [PMID: 36747744 PMCID: PMC9901021 DOI: 10.21203/rs.3.rs-2488327/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background: Multiple organ dysfunction syndrome (MODS) is an important cause of post-operative morbidity and mortality for children undergoing cardiac surgery requiring cardiopulmonary bypass (CPB). Dysregulated inflammation is widely regarded as a key contributor to bypass-related MODS pathobiology, with considerable overlap of pathways associated with septic shock. The pediatric sepsis biomarker risk model (PERSEVERE) is comprised of seven protein biomarkers of inflammation, and reliably predicts baseline risk of mortality and organ dysfunction among critically ill children with septic shock. We aimed to determine if PERSEVERE biomarkers and clinical data could be combined to derive a new model to assess the risk of persistent CPB-related MODS in the early post-operative period. Methods: This study included 306 patients <18 years old admitted to a pediatric cardiac ICU after surgery requiring cardiopulmonary bypass (CPB) for congenital heart disease. Persistent MODS, defined as dysfunction of two or more organ systems on postoperative day 5, was the primary outcome. PERSEVERE biomarkers were collected 4 and 12 hours after CPB. Classification and Regression Tree methodology was used to derive a model to assess the risk of persistent MODS. Results: The optimal model containing interleukin-8 (IL-8), chemokine ligand 3 (CCL3), and age as predictor variables, had an area under the receiver operating characteristic curve (AUROC) of 0.86 (0.81-0.91) for differentiating those with or without persistent MODS, and a negative predictive value of 99% (95-100). Ten-fold cross-validation of the model yielded a corrected AUROC of 0.75. Conclusions: We present a novel risk prediction model to assess the risk for development of multiple organ dysfunction after pediatric cardiac surgery requiring CPB. Pending prospective validation, our model may facilitate identification of a high-risk cohort to direct interventions and studies aimed at improving outcomes via mitigation of post-operative organ dysfunction. Clinical Trial Registration Number: This study does not meet criteria for a clinical trial per the WHO International Clinical Trials Registry Platform as no intervention was performed.
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Affiliation(s)
- Alexis L. Benscoter
- University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center
| | - Jeffrey A. Alten
- University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center
| | - Mihir R. Atreya
- University of Cincinnati, Cincinnati Children’s Hospital Medical Center
| | - David S. Cooper
- University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center
| | | | | | | | - Hector R. Wong
- University of Cincinnati, Cincinnati Children’s Hospital Medical Center
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Abstract
PURPOSE OF REVIEW One million people die annually following noncardiac surgery and 4% of patients suffer an adverse cardiac event after surgery. As the number of people having surgery grows, our ability to risk stratify patients becomes more important, particularly in the setting of perioperative myocardial ischemia/necrosis. RECENT FINDINGS In recent publications, an increased troponin following noncardiac surgery has been associated with a higher morbidity/mortality in the perioperative setting. The level of troponin elevation associated with increased morbidity/mortality is now believed to be far lower than was previously considered to be pathologic. SUMMARY The presence of troponin elevations following noncardiac surgery, particularly in at-risk patients, may enable practitioners to better identify high-risk patients in the postoperative setting. After recognizing those patients at increased risk for poor outcomes, practitioners can then make interventions, which may decrease the patients' in-hospital, 30-day and potentially long-term mortality.
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Feng H, Wang TL, Cai B. Ischemic stroke predicts myocardial injury after carotid endarterectomy for symptomatic severe carotid artery stenosis. Clin Appl Thromb Hemost 2013; 20:422-6. [PMID: 23615291 DOI: 10.1177/1076029613486018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Myocardial injury following carotid endarterectomy (CEA) is a common cause of morbidity and mortality, and its risk varies depending on the severity and extent of disease. However, when patients with sympotomatic severe carotid stenosis undergo CEA, the frequency and potential predictors of myocardial injury remain unknown. A total of 40 patients (32 men and 8 women) who underwent successful standard CEA were observed. Cardiac troponin I (cTnI) concentrations were assessed before surgery and on postoperative days 1, 2, and 3 in all patients. Myocardial injury was defined as the peak cTnI concentration > 0.04 ng/mL. In all, 42.5% patients had postoperative myocardial injury. Previous ischemic stroke and abnormal ST-segment changes were the preoperative predictors of myocardial injury after CEA, with odds ratios of 4.1 (95% confidence interval, 1.1-16.1; P = .04) and 5.9 (95% confidence interval, 1.3-27.7; P = .04), respectively. Sympotomatic patients with those conditions should receive more attention to myocardial injury, when presented for CEA.
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Affiliation(s)
- Hua Feng
- 1Department of Anesthesiology, Xuanwu Hospital of Capital Medical University, China
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