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SenthilKumar G, Verhagen NB, Nimmer K, Yang X, Castro CEF, Szabo A, Taylor BW, Wainaina N, Gould JC, Kothari AN. Risk of Early Postoperative Cardiovascular and Cerebrovascular Complication in Patients with Preoperative COVID-19 Undergoing Cancer Surgery. J Am Coll Surg 2024; 238:1085-1097. [PMID: 38348959 PMCID: PMC11330174 DOI: 10.1097/xcs.0000000000001039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
BACKGROUND As the COVID-19 pandemic shifts to an endemic phase, an increasing proportion of patients with cancer and a preoperative history of COVID-19 will require surgery. This study aimed to assess the influence of preoperative COVID-19 on postoperative risk for major adverse cardiovascular and cerebrovascular events (MACEs) among those undergoing surgical cancer resection. Secondary objectives included determining optimal time-to-surgery guidelines based on COVID-19 severity and discerning the influence of vaccination status on MACE risk. STUDY DESIGN National COVID Cohort Collaborative Data Enclave, a large multi-institutional dataset, was used to identify patients that underwent surgical cancer resection between January 2020 and February 2023. Multivariate regression analysis adjusting for demographics, comorbidities, and risk of surgery was performed to evaluate risk for 30-day postoperative MACE. RESULTS Of 204,371 included patients, 21,313 (10.4%) patients had a history of preoperative COVID-19. History of COVID-19 was associated with an increased risk for postoperative composite MACE as well as 30-day mortality. Among patients with mild disease who did not require hospitalization, MACE risk was elevated for up to 4 weeks after infection. Postoperative MACE risk remained elevated more than 8 weeks after infection in those with moderate disease. Vaccination did not reduce risk for postoperative MACE. CONCLUSIONS Together, these data highlight that assessment of the severity of preoperative COVID-19 infection should be a routine component of both preoperative patient screening as well as surgical risk stratification. In addition, strategies beyond vaccination that increase patients' cardiovascular fitness and prevent COVID-19 infection are needed.
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Affiliation(s)
- Gopika SenthilKumar
- Department of Physiology and Anesthesiology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Nathaniel B. Verhagen
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Kaitlyn Nimmer
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Xin Yang
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Carlos E. Figueroa Castro
- Department of Medicine, Division of Infectious Diseases, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Aniko Szabo
- Department of Biostatistics, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Brad W. Taylor
- Clinical and Translational Science Institute of Southeastern Wisconsin, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Njeri Wainaina
- Department of Medicine, Division of Infectious Diseases, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Jon C. Gould
- Division of Minimally Invasive and Gastrointestinal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Anai N. Kothari
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
- Clinical and Translational Science Institute of Southeastern Wisconsin, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
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Zahid JA, Orhan A, Hadi NAH, Ekeloef S, Gögenur I. Myocardial injury and long-term oncological outcomes in patients undergoing surgery for colorectal cancer. Int J Colorectal Dis 2023; 38:234. [PMID: 37725173 PMCID: PMC10509133 DOI: 10.1007/s00384-023-04528-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 09/21/2023]
Abstract
PURPOSE Myocardial injury after noncardiac surgery (MINS) is associated with increased mortality and postoperative complications. In patients with colorectal cancer (CRC), postoperative complications are a risk factor for cancer recurrence and disease-free survival. This study investigates the association between MINS and long-term oncological outcomes in patients with CRC in an ERAS setting. METHODS This retrospective cohort study was conducted at Zealand University Hospital, Denmark, between June 2015 and July 2017. Patients undergoing CRC surgery were included if troponin was measured twice after surgery. Outcomes were all-cause mortality, recurrence, and disease-free survival within five years of surgery. RESULTS Among 586 patients, 42 suffered MINS. After five years, 36% of patients with MINS and 26% without MINS had died, p = 0.15. When adjusted for sex, age and UICC, the hazard ratio (aHR) for 1-year all-cause mortality, recurrence, and disease-free survival were 2.40 [0.93-6.22], 1.47 [0.19-11.29], and 2.25 [0.95-5.32] for patients with MINS compared with those without, respectively. Further adjusting for ASA status, performance status, smoking, and laparotomies, the aHR for 3- and 5-year all-cause mortality were 1.05 [0.51-2.15] and 1.11 [0.62-1.99], respectively. Similarly, the aHR for 3- and 5-year recurrence were 1.38 [0.46-4.51], and 1.49 [0.56-3.98] and for 3- and 5-year disease-free survival the aHR were 1.19 [0.63-2.23], and 1.19 [0.70-2.03]. CONCLUSION In absolute numbers, we found no difference in all-cause mortality and recurrence in patients with and without MINS. In adjusted Cox regression analyses, the hazard was increased for all-cause mortality, recurrence, and disease-free survival in patients with MINS without reaching statistical significance.
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Affiliation(s)
- Jawad Ahmad Zahid
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, University of Copenhagen, Lykkebækvej 1, 4600 Køge, Copenhagen, Denmark.
| | - Adile Orhan
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, University of Copenhagen, Lykkebækvej 1, 4600 Køge, Copenhagen, Denmark
| | - Noor Al-Huda Hadi
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, University of Copenhagen, Lykkebækvej 1, 4600 Køge, Copenhagen, Denmark
| | - Sarah Ekeloef
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, University of Copenhagen, Lykkebækvej 1, 4600 Køge, Copenhagen, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, University of Copenhagen, Lykkebækvej 1, 4600 Køge, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Chen Q, Cui S, Huang J, Wang J, Wang D, Wang H, Lyu S, Lang R. Venous thromboembolism in patients undergoing distal cholangiocarcinoma surgery: Prevalence, risk factors, and outcomes. Asian J Surg 2023; 46:3648-3655. [PMID: 36797089 DOI: 10.1016/j.asjsur.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 02/03/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND To investigate venous thromboembolism (VTE) in patients undergoing distal cholangiocarcinoma (dCCA) surgery, we performed a single-center study to assess its prevalence, risk factors, prognosis. METHOD We studied a total of 177 patients undergoing dCCA surgery from January 2017 to April 2022. Demographic, clinical data, laboratory data (including lower extremity ultrasound findings), and outcome variables were obtained, and compared between VTE and non-VTE groups. RESULTS Of the 177 patients undergoing dCCA surgery (aged 65.2 ± 9.6 years; 108 (61.0%) male), 64 patients developed VTE after surgery. Logistic multivariate analysis showed that, age, operation procedure, TNM stage, ventilator duration and preoperative D-dimer were independent risk factors. Based on these factors, we constructed the nomogram to predict VTE after dCCA for the first time. The areas under the receiver operating curve (ROC) of the nomogram were 0.80 (95% CI: 0.72-0.88) and 0.79 (95% CI: 0.73-0.89) in the training and validation groups, respectively. Patients developed VTE had a worse prognosis by Kaplan-Meier curve analysis (p = 0.001). CONCLUSION The prevalence of VTE is high and is associated with adverse outcomes in patients undergoing dCCA surgery. We developed a nomogram assessing VTE risk, which may help clinicians to screen out people at high risk for VTE and to undertake rational preventive measures.
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Affiliation(s)
- Qing Chen
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing ChaoYang Hospital, Capital Medical University, Beijing, 100020, China
| | - Songping Cui
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing ChaoYang Hospital, Capital Medical University, Beijing, 100020, China
| | - Jincan Huang
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing ChaoYang Hospital, Capital Medical University, Beijing, 100020, China
| | - Jing Wang
- Department of Thoaracic Surgery, Beijing ChaoYang Hospital, Capital Medical University, Beijing, 100020, China
| | - Di Wang
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing ChaoYang Hospital, Capital Medical University, Beijing, 100020, China
| | - Hanxuan Wang
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing ChaoYang Hospital, Capital Medical University, Beijing, 100020, China
| | - Shaocheng Lyu
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing ChaoYang Hospital, Capital Medical University, Beijing, 100020, China.
| | - Ren Lang
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing ChaoYang Hospital, Capital Medical University, Beijing, 100020, China.
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SenthilKumar G, Verhagen NB, Sheriff SA, Yang X, Figueroa Castro CE, Szabo A, Taylor BW, Wainaina N, Lauer K, Gould JC, Kothari AN. Preoperative SARS-CoV-2 infection increases risk of early postoperative cardiovascular complications following noncardiac surgery. Am J Physiol Heart Circ Physiol 2023; 324:H721-H731. [PMID: 36930659 PMCID: PMC10151044 DOI: 10.1152/ajpheart.00097.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/09/2023] [Accepted: 03/14/2023] [Indexed: 03/18/2023]
Abstract
As the coronavirus disease 2019 (COVID-19) pandemic progresses to an endemic phase, a greater number of patients with a history of COVID-19 will undergo surgery. Major adverse cardiovascular and cerebrovascular events (MACE) are the primary contributors to postoperative morbidity and mortality; however, studies assessing the relationship between a previous severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and postoperative MACE outcomes are limited. Here, we analyzed retrospective data from 457,804 patients within the N3C Data Enclave, the largest national, multi-institutional data set on COVID-19 in the United States. However, 7.4% of patients had a history of COVID-19 before surgery. When comorbidities, age, race, and risk of surgery were controlled, patients with preoperative COVID-19 had an increased risk for 30-day postoperative MACE. MACE risk was influenced by an interplay between COVID-19 disease severity and time between surgery and infection; in those with mild disease, MACE risk was not increased even among those undergoing surgery within 4 wk following infection. In those with moderate disease, risk for postoperative MACE was mitigated 8 wk after infection, whereas patients with severe disease continued to have elevated postoperative MACE risk even after waiting for 8 wk. Being fully vaccinated decreased the risk for postoperative MACE in both patients with no history of COVID-19 and in those with breakthrough COVID-19 infection. Together, our results suggest that a thorough assessment of the severity, vaccination status, and timing of SARS-CoV-2 infection must be a mandatory part of perioperative stratification.NEW & NOTEWORTHY With an increasing proportion of patients undergoing surgery with a prior history of COVID-19, it is crucial to understand the impact of SARS-CoV-2 infection on postoperative cardiovascular/cerebrovascular risk. Our work assesses a large, national, multi-institutional cohort of patients to highlight that COVID-19 infection increases risk for postoperative major adverse cardiovascular and cerebrovascular events (MACE). MACE risk is influenced by an interplay between disease severity and time between infection and surgery, and full vaccination reduces the risk for 30-day postoperative MACE. These results highlight the importance of stratifying time-to-surgery guidelines based on disease severity.
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Affiliation(s)
- Gopika SenthilKumar
- Department of Physiology and Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Nathaniel B Verhagen
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Salma A Sheriff
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Xin Yang
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Carlos E Figueroa Castro
- Division of Infectious Diseases, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Aniko Szabo
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Brad W Taylor
- Clinical and Translational Science Institute of Southeastern Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Njeri Wainaina
- Division of Infectious Diseases, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Kathryn Lauer
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Jon C Gould
- Division of Minimally Invasive and Gastrointestinal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Anai N Kothari
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
- Clinical and Translational Science Institute of Southeastern Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
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Wahlstrøm KL, Hansen HF, Kvist M, Burcharth J, Lykkesfeldt J, Gögenur I, Ekeloef S. Effect of Remote Ischaemic Preconditioning on Perioperative Endothelial Dysfunction in Non-Cardiac Surgery: A Randomised Clinical Trial. Cells 2023; 12:cells12060911. [PMID: 36980253 PMCID: PMC10047371 DOI: 10.3390/cells12060911] [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: 11/14/2022] [Revised: 02/24/2023] [Accepted: 03/11/2023] [Indexed: 03/18/2023] Open
Abstract
Endothelial dysfunction result from inflammation and excessive production of reactive oxygen species as part of the surgical stress response. Remote ischemic preconditioning (RIPC) potentially exerts anti-oxidative and anti-inflammatory properties, which might stabilise the endothelial function after non-cardiac surgery. This was a single centre randomised clinical trial including 60 patients undergoing sub-acute laparoscopic cholecystectomy due to acute cholecystitis. Patients were randomised to RIPC or control. The RIPC procedure consisted of four cycles of five minutes of ischaemia and reperfusion of one upper extremity. Endothelial function was assessed as the reactive hyperaemia index (RHI) and circulating biomarkers of nitric oxide (NO) bioavailability (L-arginine, asymmetric dimethylarginine (ADMA), L-arginine/ADMA ratio, tetra- and dihydrobiopterin (BH4 and BH2), and total plasma biopterin) preoperative, 2–4 h after surgery and 24 h after surgery. RHI did not differ between the groups (p = 0.07). Neither did levels of circulating biomarkers of NO bioavailability change in response to RIPC. L-arginine and L-arginine/ADMA ratio was suppressed preoperatively and increased 24 h after surgery (p < 0.001). The BH4/BH2-ratio had a high preoperative level, decreased 2–4 h after surgery and remained low 24 h after surgery (p = 0.01). RIPC did not influence endothelial function or markers of NO bioavailability until 24 h after sub-acute laparoscopic cholecystectomy. In response to surgery, markers of NO bioavailability increased, and oxidative stress decreased. These findings support that a minimally invasive removal of the inflamed gallbladder countereffects reduced markers of NO bioavailability and increased oxidative stress caused by acute cholecystitis.
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Affiliation(s)
- Kirsten L. Wahlstrøm
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Lykkebækvej 1, 4600 Køge, Denmark
- Correspondence:
| | - Hannah F. Hansen
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Lykkebækvej 1, 4600 Køge, Denmark
| | - Madeline Kvist
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Lykkebækvej 1, 4600 Køge, Denmark
| | - Jakob Burcharth
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Lykkebækvej 1, 4600 Køge, Denmark
| | - Jens Lykkesfeldt
- Section of Experimental Animal Models, Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Ridebanevej 9, 1871 Frederiksberg C, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Lykkebækvej 1, 4600 Køge, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
| | - Sarah Ekeloef
- Center for Surgical Science, Department of Surgery, Zealand University Hospital, Lykkebækvej 1, 4600 Køge, Denmark
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Strickland SS, Quintela EM, Wilson MJ, Lee MJ. Long-term major adverse cardiovascular events following myocardial injury after non-cardiac surgery: meta-analysis. BJS Open 2023; 7:7142743. [PMID: 37104754 PMCID: PMC10129390 DOI: 10.1093/bjsopen/zrad021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/12/2022] [Accepted: 01/27/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Myocardial injury after non-cardiac surgery is diagnosed following asymptomatic troponin elevation in the perioperative interval. Myocardial injury after non-cardiac surgery is associated with high mortality rates and significant rates of major adverse cardiac events within the first 30 days following surgery. However, less is known regarding its impact on mortality and morbidity beyond this time. This systematic review and meta-analysis aimed to establish the rates of long-term morbidity and mortality associated with myocardial injury after non-cardiac surgery. METHODS MEDLINE, Embase and Cochrane CENTRAL were searched, and abstracts screened by two reviewers. Observational studies and control arms of trials, reporting mortality and cardiovascular outcomes beyond 30 days in adult patients diagnosed with myocardial injury after non-cardiac surgery, were included. Risk of bias was assessed using the Quality in Prognostic Studies tool. A random-effects model was used for the meta-analysis of outcome subgroups. RESULTS Searches identified 40 studies. The meta-analysis of 37 cohort studies found a rate of major adverse cardiac events-associated myocardial injury after non-cardiac surgery of 21 per cent and mortality following myocardial injury after non-cardiac surgery was 25 per cent at 1-year follow-up. A non-linear increase in mortality rate was observed up to 1 year after surgery. Major adverse cardiac event rates were also lower in elective surgery compared with a subgroup including emergency cases. The analysis demonstrated a wide variety of accepted myocardial injury after non-cardiac surgery and major adverse cardiac events diagnostic criteria within the included studies. CONCLUSION A diagnosis of myocardial injury after non-cardiac surgery is associated with high rates of poor cardiovascular outcomes up to 1 year after surgery. Work is needed to standardize diagnostic criteria and reporting of myocardial injury after non-cardiac surgery-related outcomes. REGISTRATION This review was prospectively registered with PROSPERO in October 2021 (CRD42021283995).
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Affiliation(s)
- Scarlett S Strickland
- Academic Directorate of General Surgery, Sheffield Teaching Hospitals, Sheffield, UK
| | - Ella M Quintela
- Department of Anaesthesia, Sheffield Teaching Hospitals, Sheffield, UK
- Centre for Urgent and Emergency Care Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Matthew J Wilson
- Department of Anaesthesia, Sheffield Teaching Hospitals, Sheffield, UK
- Centre for Urgent and Emergency Care Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Matthew J Lee
- Academic Directorate of General Surgery, Sheffield Teaching Hospitals, Sheffield, UK
- Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, UK
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Shcheblykin DV, Bolgov AA, Pokrovskii MV, Stepenko JV, Tsuverkalova JM, Shcheblykina OV, Golubinskaya PA, Korokina LV. Endothelial dysfunction: developmental mechanisms and therapeutic strategies. RESEARCH RESULTS IN PHARMACOLOGY 2022. [DOI: 10.3897/rrpharmacology.8.80376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Introduction: Every year the importance of the normal functioning of the endothelial layer of the vascular wall in maintaining the health of the body becomes more and more obvious.
The physiological role of the endothelium: The endothelium is a metabolically active organ actively involved in the regulation of hemostasis, modulation of inflammation, maintenance of hemovascular homeostasis, regulation of angiogenesis, vascular tone, and permeability.
Risk factors for the development of endothelial dysfunction: Currently, insufficient bioavailability of nitric oxide is considered the most significant risk factor for endothelial dysfunction.
Mechanisms of development of endothelial dysfunction: The genesis of endothelial dysfunction is a multifactorial process. Among various complex mechanisms, this review examines oxidative stress, inflammation, hyperglycemia, vitamin D deficiency, dyslipidemia, excess visceral fat, hyperhomocysteinemia, hyperuricemia, as well as primary genetic defect of endotheliocytes, as the most common causes in the population underlying the development of endothelial dysfunction.
Markers of endothelial dysfunction in various diseases: This article discusses the main biomarkers of endothelial dysfunction currently used, as well as promising biomarkers in the future for laboratory diagnosis of this pathology.
Therapeutic strategies: Therapeutic approaches to the endothelium in order to prevent or reduce a degree of damage to the vascular wall are briefly described.
Conclusion: Endothelial dysfunction is a typical pathological process involved in the pathogenesis of many diseases. Thus, pharmacological agents with endothelioprotective properties can provide more therapeutic benefits than a drug without such an effect.
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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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9
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Kristiansen P, Oreskov JO, Ekeloef S, Gögenur I, Burcharth J. Patient perceptive focus on recovery: An exploratory study on follow-up after major emergency abdominal surgery. Acta Anaesthesiol Scand 2021; 65:1259-1266. [PMID: 34028006 DOI: 10.1111/aas.13925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 05/05/2021] [Accepted: 05/11/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Optimal recovery can be defined as the adequate in-hospital length of stay with minimal postoperative complications and readmissions. The quality of recovery beyond the immediate postoperative period after major emergency abdominal surgery is yet to be fully described. We hypothesized that long-term measures of overall recovery were affected after surgery. The study aimed to investigate patient-focused recovery-related parameters 1 year after major emergency abdominal surgery. METHOD This is a prospective study including patients undergoing major emergency abdominal surgery at a Danish secondary referral center. Three questionnaires were answered regarding the recovery following the procedure; Activities Assessment Scale (AAS); Quality of Recovery-15 (QoR-15), and Self-complete Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS). All questionnaires were answered at postoperative days (PODs) 14, 30, 90, and 365. RESULTS Eighty-two patients were included, and 68 were available for follow-up until 1 year after surgery. The response rates differed between the follow-up time points, with a response rate of 85% (n = 59) at POD30 and 50% (n = 36) at POD365. A decrease in the level of physical function following surgery was observed in 60% of the patients at POD14, which improved to 36% at POD365. Twenty-four patients (48%) reported postoperative pain at POD14, which declined to 9 (26%) at POD365. The maximum overall recovery was reached at POD30, which remained stable throughout the study period. CONCLUSION One in three patients reported physical functional impairment, and one in four patients reported pain 1 year after their surgical procedure.
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Affiliation(s)
- Puk Kristiansen
- Center for Surgical Science Department of Surgery Zealand University Hospital Køge Denmark
| | - Jakob Ohm Oreskov
- Center for Surgical Science Department of Surgery Zealand University Hospital Køge Denmark
| | - Sarah Ekeloef
- Center for Surgical Science Department of Surgery Zealand University Hospital Køge Denmark
| | - Ismail Gögenur
- Center for Surgical Science Department of Surgery Zealand University Hospital Køge Denmark
| | - Jakob Burcharth
- Center for Surgical Science Department of Surgery Zealand University Hospital Køge Denmark
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10
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Mizunoya K, Yagi Y, Morimoto Y, Hirano S. Altered microvascular reactivity assessed by near-infrared spectroscopy after hepato-pancreato-biliary surgery. J Clin Monit Comput 2021; 36:703-712. [PMID: 33829357 DOI: 10.1007/s10877-021-00697-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/23/2021] [Indexed: 11/25/2022]
Abstract
Little is known about microcirculatory dysfunction following abdominal surgeries. This study aimed to evaluate changes in microvascular reactivity (MVR) before and after major abdominal surgery, assessed by near-infrared spectroscopy in conjunction with a vascular occlusion test. This prospective observational study included 50 adult patients who underwent hepato-pancreato-biliary surgery lasting ≥ 8 h. MVR was assessed by tissue oxygen saturation (StO2) changes in the plantar region of the foot during 3 min of vascular occlusion and subsequent release under general anesthesia before and after surgery. The primary outcome was alteration in the recovery slope of StO2 (RecStO2) and recovery time (tM) between the preoperative and postoperative values. Postoperative short-term outcome was represented by the Post-operative Morbidity Survey (POMS) score on the morning of postoperative day 2. After surgery, RecStO2 was reduced (0.74% [0.58-1.06]/s vs. 0.89% [0.62-1.41]/s, P = 0.001), and tM was longer (57.0 [42.9-71.0] s vs. 41.3 [35.5-56.5] s, P < 0.001), compared to the preoperative values. Macrohemodynamic variables such as cardiac index, arterial pressure, and stroke volume during postoperative measurement did not differ with or without relative MVR decline. In addition, the POMS score was not associated with postoperative alterations in microcirculatory responsiveness. MVR in the plantar region of the foot was reduced after major hepato-pancreato-biliary surgery regardless of macrocirculatory adequacy. Impaired MVR was not associated with short-term outcomes as long as macrocirculatory indices were well maintained. The impact of relative microcirculatory changes, especially combined with inadequate macrocirculation, on postoperative complications remains to be elucidated.Clinical Trial Registrations UMIN-CTR trial ID: 000033461.
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Affiliation(s)
- Kazuyuki Mizunoya
- Department of Anesthesiology, Hokkaido University Hospital, Kita-ku, Sapporo, N14, W5060-8648, Japan.
| | - Yasunori Yagi
- Department of Anesthesiology, Hokkaido University Hospital, Kita-ku, Sapporo, N14, W5060-8648, Japan
| | - Yuji Morimoto
- Department of Anesthesiology, Hokkaido University Hospital, Kita-ku, Sapporo, N14, W5060-8648, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Hospital, Sapporo, Japan
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11
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Ekeloef S, Gundel O, Falkenberg A, Mathiesen O, Gögenur I. The effect of remote ischaemic preconditioning on endothelial function after hip fracture surgery. Acta Anaesthesiol Scand 2021; 65:169-175. [PMID: 33048342 DOI: 10.1111/aas.13724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/22/2020] [Accepted: 09/30/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Endothelial dysfunction seems to play a role in the pathophysiology of myocardial injury after surgery. The aim of this randomised clinical trial was to examine whether remote ischaemic preconditioning in relation to hip fracture surgery ameliorates post-operative systemic endothelial dysfunction. METHODS This was a planned single-centre pilot sub-study of a multicentre, randomised clinical trial. Patients ≥45 years with a cardiovascular risk factor were randomised to remote ischaemic preconditioning (RIPC) or control (standard treatment) performed in relation with their hip fracture operation. RIPC consisted of four cycles of 5 minutes forearm ischaemia and reperfusion. The procedure was performed non-invasively with a tourniquet. The endothelial function was assessed with non-invasive digital pulse amplitude tonometry on post-operative day 1 and expressed as the reactive hyperaemia index (RHI). Endothelial dysfunction was defined as RHI < 1.22. RESULTS Between February 2015 and December 2016, 18 patients were allocated to the RIPC group and 20 patients to the control group. The endothelial function was impaired in both groups on post-operative day 1. RHI did not differ between the groups, 1.47 (95% CI 1.20-1.75) in the RIPC group vs. 1.54 (95% CI 1.17-1.91) in the control group, P = .76. Endothelial dysfunction was present in 3/18 patients (16.7%) in the RIPC group and 8/20 patients (40%) in the control group, P = .11. CONCLUSION No beneficial effect of remote ischaemic preconditioning on the systemic endothelial dysfunction, assessed at a single time point on post-operative day one, was detected after hip fracture surgery.
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Affiliation(s)
- Sarah Ekeloef
- Center for Surgical Science Department of Surgery Zealand University Hospital Koege Denmark
| | - Ossian Gundel
- Center for Surgical Science Department of Surgery Zealand University Hospital Koege Denmark
| | - Andreas Falkenberg
- Center for Surgical Science Department of Surgery Zealand University Hospital Koege Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research Department of Anaesthesiology Zealand University Hospital Koege Denmark
- Department of Clinical Medicine Copenhagen University Copenhagen Denmark
| | - Ismail Gögenur
- Center for Surgical Science Department of Surgery Zealand University Hospital Koege Denmark
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12
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Ertelt A, Stumpff F, Merle R, Kuban S, Bollinger L, Liertz S, Gehlen H. Asymmetric dimethylarginine-A potential cardiac biomarker in horses. J Vet Cardiol 2020; 33:43-51. [PMID: 33360109 DOI: 10.1016/j.jvc.2020.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 11/06/2020] [Accepted: 11/17/2020] [Indexed: 12/22/2022]
Abstract
INTRODUCTION/OBJECTIVES Asymmetric dimethylarginine (ADMA) is a cardiac biomarker in humans, symmetric dimethylarginine (SDMA) a renal biomarker in humans, cats, and dogs. The purpose of this prospective study was to investigate if measuring serum ADMA and SDMA concentrations via ELISA allows detection of cardiac disease in horses in a routine laboratory setting. In this context, reference values in horses were established. ANIMALS, MATERIALS, AND METHODS Seventy-eight horses with no known medical history were compared to 23 horses with confirmed structural cardiac disease with/or without arrhythmias. Horses underwent physical examination, electrocardiography, echocardiography and venous blood sampling and were staged based on the severity of cardiac disease from 0 to II. Asymmetric dimethylarginine and SDMA were measured via ELISA and crosschecked using liquid chromatograph triple quadrupole mass spectrometry. Reference intervals with 90th percent confidence intervals were evaluated and standard software was used to test for significant differences in ADMA, SDMA, and the l-arginine/ADMA ratio between groups. RESULTS The reference ranges were 1.7-3.8 μmol/L and 0.3-0.8 μmol/L for ADMA and SDMA, respectively. Serum ADMA was higher in horses with heart disease compared to healthy horses (p < 0.01) and highest in horses with stage II heart disease (p = 0.02). The l-Arginine/ADMA ratio was significantly higher in healthy animals than those with cardiac disease (p = 0.001). CONCLUSIONS Reference values for serum ADMA and SDMA using ELISA methods are presented in horses. This study confirms the association between heart disease and increased serum ADMA concentration as well as a decreased l-Arginine/ADMA ratio in horses.
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Affiliation(s)
- A Ertelt
- Equine Clinic, Internal Medicine, Freie Universitaet Berlin, Oertzenweg 19b, 14193, Berlin, Germany.
| | - F Stumpff
- Institute of Veterinary Physiology, Freie Universitaet Berlin, Oertzenweg 19b, 14163, Berlin, Germany
| | - R Merle
- Institute for Veterinary Epidemiology and Biostatistics, Freie Universitaet Berlin, Koenigsweg 67, 14163, Berlin, Germany
| | - S Kuban
- Equine Clinic, Internal Medicine, Freie Universitaet Berlin, Oertzenweg 19b, 14193, Berlin, Germany
| | - L Bollinger
- Equine Clinic, Internal Medicine, Freie Universitaet Berlin, Oertzenweg 19b, 14193, Berlin, Germany
| | - S Liertz
- Equine Clinic, Internal Medicine, Freie Universitaet Berlin, Oertzenweg 19b, 14193, Berlin, Germany
| | - H Gehlen
- Equine Clinic, Internal Medicine, Freie Universitaet Berlin, Oertzenweg 19b, 14193, Berlin, Germany
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13
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Sanches E, Topal B, Proczko M, Stepaniak PS, Severin R, Phillips SA, Sabbahi A, Pujol Rafols J, Pouwels S. Endothelial function in obesity and effects of bariatric and metabolic surgery. Expert Rev Cardiovasc Ther 2020; 18:343-353. [DOI: 10.1080/14779072.2020.1767594] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Elijah Sanches
- Department of Surgery, Haaglanden Medical Center, The Hague, The Netherlands
| | - Besir Topal
- Department of Cardiothoracic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Monika Proczko
- Department of General, Endocrine and Transplant Surgery, University Medical Center, Gdansk University, Gdansk, Poland
| | - Pieter S. Stepaniak
- Department of Operating Rooms, Catharina Hospital, Eindhoven, The Netherlands
| | - Rich Severin
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
- Doctor of Physical Therapy Program, Robbins College of Health and Human Sciences, Baylor University, Waco, TX, USA
| | - Shane A. Phillips
- Department of Physical Therapy, Integrative Physiologic Laboratory, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Ahmad Sabbahi
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
- Department of Physical Therapy, Integrative Physiologic Laboratory, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Sjaak Pouwels
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
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