1
|
Nuttall GA, Merren MP, Naranjo J, Portner ER, Ambrose AR, Rihal CS. Perioperative Mortality: A Retrospective Cohort Study of 75,446 Noncardiac Surgery Patients. Mayo Clin Proc Innov Qual Outcomes 2024; 8:435-442. [PMID: 39263428 PMCID: PMC11387539 DOI: 10.1016/j.mayocpiqo.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/20/2024] [Accepted: 07/01/2024] [Indexed: 09/13/2024] Open
Abstract
Objective To evaluate whether major adverse cardiac events (MACE) continue to be a major causative factor for mortality after noncardiac surgery. Patients and Methods We performed retrospective study of 75,410 adult noncardiac surgery patients at Mayo Clinic Rochester, between January 1, 2016, and May 4, 2018. Electronic medical records were reviewed and data collected on all deaths within 30 days (n=692 patients) of surgery. The incidence of death due to MACE was calculated. Results Postoperative MACE occurred in 150 patients (21.4 events per 10,000 patients; 95% CI, 18.2-25.2 events per 10,000 patients) with most occurring within 3 days of surgery (n=113). Postoperative MACE events were associated with atrial fibrillation with rapid rate response in 25 patients (16.7%), sepsis in 15 patients (10%), and bleeding in 15 patients (10%). There were 12 intraoperative deaths of which 9 were due to exsanguination (75%) and the remaining 3 (25%) due to cardiac arrest. Of the 56 deaths on the first 24 hours after surgery, 7 were due to hemorrhage, 17 due to cardiovascular causes, 20 due to sepsis, and 7 due to neurologic disease. The leading cause of total death over 30 days postoperatively was sepsis (28%), followed by malignancy (27%), cardiovascular disease (12%) neurologic disease (12%), and hemorrhage (5%). Conclusion MACE was not the leading cause of death both intraoperatively and postoperatively.
Collapse
Affiliation(s)
- Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Michael P Merren
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Julian Naranjo
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Erica R Portner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Amanda R Ambrose
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | | |
Collapse
|
2
|
Liu C, Zhang K, Yang X, Meng B, Lou J, Liu Y, Cao J, Liu K, Mi W, Li H. Development and Validation of an Explainable Machine Learning Model for Predicting Myocardial Injury After Noncardiac Surgery in Two Centers in China: Retrospective Study. JMIR Aging 2024; 7:e54872. [PMID: 39087583 PMCID: PMC11294761 DOI: 10.2196/54872] [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: 11/25/2023] [Revised: 04/01/2024] [Accepted: 05/24/2024] [Indexed: 08/02/2024] Open
Abstract
Background Myocardial injury after noncardiac surgery (MINS) is an easily overlooked complication but closely related to postoperative cardiovascular adverse outcomes; therefore, the early diagnosis and prediction are particularly important. Objective We aimed to develop and validate an explainable machine learning (ML) model for predicting MINS among older patients undergoing noncardiac surgery. Methods The retrospective cohort study included older patients who had noncardiac surgery from 1 northern center and 1 southern center in China. The data sets from center 1 were divided into a training set and an internal validation set. The data set from center 2 was used as an external validation set. Before modeling, the least absolute shrinkage and selection operator and recursive feature elimination methods were used to reduce dimensions of data and select key features from all variables. Prediction models were developed based on the extracted features using several ML algorithms, including category boosting, random forest, logistic regression, naïve Bayes, light gradient boosting machine, extreme gradient boosting, support vector machine, and decision tree. Prediction performance was assessed by the area under the receiver operating characteristic (AUROC) curve as the main evaluation metric to select the best algorithms. The model performance was verified by internal and external validation data sets with the best algorithm and compared to the Revised Cardiac Risk Index. The Shapley Additive Explanations (SHAP) method was applied to calculate values for each feature, representing the contribution to the predicted risk of complication, and generate personalized explanations. Results A total of 19,463 eligible patients were included; among those, 12,464 patients in center 1 were included as the training set; 4754 patients in center 1 were included as the internal validation set; and 2245 in center 2 were included as the external validation set. The best-performing model for prediction was the CatBoost algorithm, achieving the highest AUROC of 0.805 (95% CI 0.778-0.831) in the training set, validating with an AUROC of 0.780 in the internal validation set and 0.70 in external validation set. Additionally, CatBoost demonstrated superior performance compared to the Revised Cardiac Risk Index (AUROC 0.636; P<.001). The SHAP values indicated the ranking of the level of importance of each variable, with preoperative serum creatinine concentration, red blood cell distribution width, and age accounting for the top three. The results from the SHAP method can predict events with positive values or nonevents with negative values, providing an explicit explanation of individualized risk predictions. Conclusions The ML models can provide a personalized and fairly accurate risk prediction of MINS, and the explainable perspective can help identify potentially modifiable sources of risk at the patient level.
Collapse
Affiliation(s)
- Chang Liu
- Department of Anesthesiology, The First Medical Center, Chinese People's Liberation Army General Hospital, 28th Fuxing Road, Haidian District, Beijing, 100853, China, 86 15010665099
- Medical School of Chinese People's Liberation Army General Hospital, Beijing, China
- National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Kai Zhang
- Department of Anesthesiology, The First Medical Center, Chinese People's Liberation Army General Hospital, 28th Fuxing Road, Haidian District, Beijing, 100853, China, 86 15010665099
- Medical School of Chinese People's Liberation Army General Hospital, Beijing, China
- National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Xiaodong Yang
- Institute of Computing Technology Chinese Academy of Science, Beijing, China
| | - Bingbing Meng
- Department of Anesthesiology, The First Medical Center, Chinese People's Liberation Army General Hospital, 28th Fuxing Road, Haidian District, Beijing, 100853, China, 86 15010665099
- Medical School of Chinese People's Liberation Army General Hospital, Beijing, China
- National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Jingsheng Lou
- Department of Anesthesiology, The First Medical Center, Chinese People's Liberation Army General Hospital, 28th Fuxing Road, Haidian District, Beijing, 100853, China, 86 15010665099
- Medical School of Chinese People's Liberation Army General Hospital, Beijing, China
- National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yanhong Liu
- Department of Anesthesiology, The First Medical Center, Chinese People's Liberation Army General Hospital, 28th Fuxing Road, Haidian District, Beijing, 100853, China, 86 15010665099
- Medical School of Chinese People's Liberation Army General Hospital, Beijing, China
- National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Jiangbei Cao
- Department of Anesthesiology, The First Medical Center, Chinese People's Liberation Army General Hospital, 28th Fuxing Road, Haidian District, Beijing, 100853, China, 86 15010665099
- Medical School of Chinese People's Liberation Army General Hospital, Beijing, China
- National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Kexuan Liu
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Weidong Mi
- Department of Anesthesiology, The First Medical Center, Chinese People's Liberation Army General Hospital, 28th Fuxing Road, Haidian District, Beijing, 100853, China, 86 15010665099
- Medical School of Chinese People's Liberation Army General Hospital, Beijing, China
- National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Hao Li
- Department of Anesthesiology, The First Medical Center, Chinese People's Liberation Army General Hospital, 28th Fuxing Road, Haidian District, Beijing, 100853, China, 86 15010665099
- Medical School of Chinese People's Liberation Army General Hospital, Beijing, China
- National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing, China
| |
Collapse
|
3
|
An Y, Wang T, Li L, Li Z, Liang C, Wang P, Jia X, Song H, Zhao L. Impact of neuromuscular block on myocardial injury after non-cardiac surgery (MINS) incidence in the early postoperative stage of older patients undergoing laparoscopic colorectal cancer resection: a randomized controlled study. BMC Geriatr 2024; 24:509. [PMID: 38862916 PMCID: PMC11167868 DOI: 10.1186/s12877-024-05125-8] [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: 08/02/2023] [Accepted: 05/31/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Myocardial injury after non-cardiac surgery (MINS) is a common and serious complication in older patients. This study investigates the impact of neuromuscular block on the MINS incidence and other cardiovascular complications in the early postoperative stage of older patients undergoing laparoscopic colorectal cancer resection. METHODS 70 older patients who underwent laparoscopic colorectal cancer resection were separated into the deep neuromuscular block group and moderate neuromuscular block group for 35 cases in each group (n = 1:1). The deep neuromuscular block group maintained train of four (TOF) = 0, post-tetanic count (PTC) 1-2, and the moderate neuromuscular block group maintained TOF = 1-2 during the operation. Sugammadex sodium was used at 2 mg/kg or 4 mg/kg for muscle relaxation antagonism at the end of surgery. The MINS incidence was the primary outcome and compared with Fisher's exact test. About the secondary outcomes, the postoperative pain was analyzed with Man-Whitney U test, the postoperative nausea and vomiting (PONV) and the incidence of cardiovascular complications were analyzed with Chi-square test, intraoperative mean artery pressure (MAP) and cardiac output (CO) ratio to baseline, length of stay and dosage of anesthetics were compared by two independent samples t-test. RESULTS MINS was not observed in both groups. The highest incidence of postoperative cardiovascular complications was lower limbs deep vein thrombosis (14.3% in deep neuromuscular block group and 8.6% in moderate neuromuscular group). The numeric rating scale (NRS) score in the deep neuromuscular block group was lower than the moderate neuromuscular block group 72 h after surgery (0(1,2) vs 0(1,2), P = 0.018). The operation time in the deep neuromuscular block group was longer (356.7(107.6) vs 294.8 (80.0), min, P = 0.008), the dosage of propofol and remifentanil was less (3.4 (0.7) vs 3.8 (1.0), mg·kg-1·h-1, P = 0.043; 0.2 (0.06) vs 0.3 (0.07), μg·kg-1·min-1, P < 0.001), and the length of hospital stay was shorter than the moderate neuromuscular block group (18.4 (4.9) vs 22.0 (8.3), day, P = 0.028). The differences of other outcomes were not statistically significant. CONCLUSIONS Maintaining different degrees of the neuromuscular block under TOF guidance did not change the MINS incidence within 7 days after surgery in older patients who underwent laparoscopic colorectal cancer resection. TRIAL REGISTRATION The present study was registered in the Chinese Clinical Trial Registry (10/02/2021, ChiCTR2100043323).
Collapse
Affiliation(s)
- Yi An
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Lixia Li
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Zhongjia Li
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Chuanyu Liang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Pei Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Xuefei Jia
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Hongyi Song
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Lei Zhao
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China.
| |
Collapse
|
4
|
Fan G, Lai H, Wang X, Feng Y, Cao Z, Qiu Y, Wen S. Development and external validation of a perioperative clinical model for predicting myocardial injury after major abdominal surgery: A retrospective cohort study. Heliyon 2024; 10:e30940. [PMID: 38799735 PMCID: PMC11126854 DOI: 10.1016/j.heliyon.2024.e30940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 05/29/2024] Open
Abstract
Purpose We aimed to develop and validate a predictive model for myocardial injury in individuals undergoing major abdominal surgery. Methods This multicenter retrospective cohort analysis included 3546 patients aged ≥45 years who underwent major abdominal surgeries at two Chinese tertiary hospitals. The primary outcome was myocardial injury after noncardiac surgery (MINS), defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The LASSO algorithm and logistic regression were used to construct a predictive model for postoperative MINS in the development cohort, and the performance of this prediction model was validated in an external independent cohort. Results A total of 3546 patients were included in our study. MINS manifested in 338 (9.53 %) patients after surgery. The definitive predictive model for MINS was developed by incorporating age, American Society of Anesthesiologists (ASA) classification, preoperative hemoglobin concentration, preoperative serum ALB concentration, blood loss, total infusion volume, and operation time. The area under the curve (AUC) of our model was 0.838 and 0.821 in the derivation and validation cohorts, respectively. Conclusions Preoperative hemoglobin levels, preoperative serum ALB concentrations, infusion volume, and blood loss are independent predictors of MINS. Our predictive model can prove valuable in identifying patients at moderate-to-high risk prior to non-cardiac surgery.
Collapse
Affiliation(s)
- Guifen Fan
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hanjin Lai
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiwen Wang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yulu Feng
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhongming Cao
- Department of Anesthesiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Yuxin Qiu
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shihong Wen
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
5
|
Tsukimoto S, Kitaura A, Yamamoto R, Hirase C, Nakao S, Nakajima Y, Sanuki T. Comparative Analysis of the Hemodynamic Effects of Remimazolam and Propofol During General Anesthesia: A Retrospective Study. Cureus 2024; 16:e58340. [PMID: 38752064 PMCID: PMC11095992 DOI: 10.7759/cureus.58340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2024] [Indexed: 05/18/2024] Open
Abstract
PURPOSE Hypotension is common during anesthesia induction. However, minimal hemodynamic effects of remimazolam anesthesia have been reported. We hypothesized that remimazolam would have weaker hemodynamic effects than would propofol. To test this, we simultaneously evaluated the hemodynamics using the estimated continuous cardiac output (esCCO) system and heart rate variability (HRV) during anesthesia induction. METHODS This was a single-center, observational, retrospective study of patients undergoing dental surgery under general anesthesia between 2020 and 2022. Seventy patients were divided into two groups: remimazolam (R group; n=34) and propofol (P group; n=36). The information obtained from the anesthesia records, patient information, esCCO system parameters, and HRV were integrated and analyzed. The percentages of various parameters were set to 100% for the pre-induction phase as the baseline. RESULTS The %MAP (noninvasive mean arterial blood pressure) decreased over a narrower range in the R compared to the P group (-17.8% (-26.3%, -11.9%) vs. -22.6% (-32.9%, -17.0%); P=0.039). The %HR (heart rate) increased significantly in the R group and decreased in the P group (+10.7% (+6.5%, +18.6%) vs. -6.5% (-14.5%, +8.4%); P<0.01). The %SVesCCO (stroke volume calculated using the esCCO system) decreased significantly in both groups, but the R group showed a smaller difference compared to the P group (- 5.1% (-7.7%, -2.1%) vs. -10.0% (-13.8%, -5.6%); P<0.01). The rates of change in %LF nu (normalized unit of low frequency) and %HF nu (normalized unit of high frequency) were lower for the R than for the P group, although the difference was not significant (+6.8% (-14.5%, 32.4%) vs. +9.2% (-7.2%, +59.7%), P=0.30; +7.9% (-51.0%, +66.9%) vs. +22.8% (-26.1%, +61.6%), P=0.57). CONCLUSION Remimazolam demonstrated a lower MAP reduction rate than propofol. A compensatory increase in HR occurred with a decrease in stroke volume. However, the HR increase was not attributable to the autonomic nervous system.
Collapse
Affiliation(s)
- Shota Tsukimoto
- Department of Dental Anesthesiology, Kanagawa Dental University, Yokosuka, JPN
| | | | - Rina Yamamoto
- Department of Anesthesiology, Kindai University, Osaka, JPN
| | | | - Shinichi Nakao
- Perioperative Management Center, Okanami General Hospital, Mie, JPN
| | | | - Takuro Sanuki
- Department of Dental Anesthesiology, Kanagawa Dental University, Yokosuka, JPN
| |
Collapse
|
6
|
Bollen Pinto B, Ackland GL. Pathophysiological mechanisms underlying increased circulating cardiac troponin in noncardiac surgery: a narrative review. Br J Anaesth 2024; 132:653-666. [PMID: 38262855 DOI: 10.1016/j.bja.2023.12.017] [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: 06/12/2023] [Revised: 11/23/2023] [Accepted: 12/15/2023] [Indexed: 01/25/2024] Open
Abstract
Assay-specific increases in circulating cardiac troponin are observed in 20-40% of patients after noncardiac surgery, depending on patient age, type of surgery, and comorbidities. Increased cardiac troponin is consistently associated with excess morbidity and mortality after noncardiac surgery. Despite these findings, the underlying mechanisms are unclear. The majority of interventional trials have been designed on the premise that ischaemic cardiac disease drives elevated perioperative cardiac troponin concentrations. We consider data showing that elevated circulating cardiac troponin after surgery could be a nonspecific marker of cardiomyocyte stress. Elevated concentrations of circulating cardiac troponin could reflect coordinated pathological processes underpinning organ injury that are not necessarily caused by ischaemia. Laboratory studies suggest that matching of coronary artery autoregulation and myocardial perfusion-contraction coupling limit the impact of systemic haemodynamic changes in the myocardium, and that type 2 ischaemia might not be the likeliest explanation for cardiac troponin elevation in noncardiac surgery. The perioperative period triggers multiple pathological mechanisms that might cause cardiac troponin to cross the sarcolemma. A two-hit model involving two or more triggers including systemic inflammation, haemodynamic strain, adrenergic stress, and autonomic dysfunction might exacerbate or initiate acute myocardial injury directly in the absence of cell death. Consideration of these diverse mechanisms is pivotal for the design and interpretation of interventional perioperative trials.
Collapse
Affiliation(s)
- Bernardo Bollen Pinto
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland.
| | - Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| |
Collapse
|
7
|
Kanstrup CTB, Svarre KJ, Rasmussen MC, Serup CM, Lundstrøm LH, Kleif J, Bertelsen CA. The effects of troponin screening among patients undergoing acute high-risk abdominal surgery: A retrospective cohort study. Acta Anaesthesiol Scand 2024; 68:476-484. [PMID: 38213306 DOI: 10.1111/aas.14371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/29/2023] [Accepted: 12/14/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Acute high-risk abdominal (AHA) surgery is associated with a high short-term mortality rate. This might be partly attributed to myocardial injury after non-cardiac surgery (MINS) defined by elevated postoperative troponin levels. The myocardial injury is often asymptomatic; thus, troponin screening seems to be the best diagnostic method. We aimed to assess whether implementing troponin screening with subsequent individualised interventions as standard care is associated with reduced mortality after AHA surgery. We also explored the treatment implications in the screening period. METHODS A retrospective cohort of 558 patients undergoing surgery from February 2018 to March 2021 was included. The patients undergoing surgery before March 2019 served as the historical control group, while the screening group consisted of patients undergoing surgery from March 1, 2019. Troponin I was to be measured 6-12 h postoperatively and in the morning of the succeeding 4 days. Patients with myocardial injury were assessed, and treatment was individualised after multiple disciplinary consultations. The primary outcome was the unadjusted 30-day mortality rates. Inverse probability treatment weighting was used to adjust for selection bias. RESULTS We included 558 patients: 382 in the screening group and 176 in the historical control group. In the screening group, 15 patients (3.9%) died before the first blood sampling, and in 31 patients (8.1%), troponin screening was omitted, leaving only 336 patients screened. Myocardial injury was diagnosed in 81 patients (24.1%) of the 336 patients. Of these, 59 (72.8%) had a cardiac consultation. No interventions or alterations in relation to myocardial injury were done in 67 patients (82.7%). The 30-day mortality was 13.8% (95% CI 8.7%-18.9%) in the control group and 11.1% (95% CI 8.0%-14.3%) in the screening group. The absolute risk difference was -2.7% (95% CI -8.7%-3.3%; p = .38), which was unchanged after adjustment. The difference remained unchanged after 90 days and 1 year. CONCLUSION The implementation of postoperative troponin screening was not associated with reduced mortality after AHA surgery. Research on the prevention and treatment of MINS is warranted before the implementation of standard troponin screening.
Collapse
Affiliation(s)
- Charlotte T B Kanstrup
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Graduate School, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kristina Johansen Svarre
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Maja Christine Rasmussen
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Camilla Mattesen Serup
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lars Hyldborg Lundstrøm
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Jakob Kleif
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Claus Anders Bertelsen
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
8
|
Martinez-Perez S, van Waes JAR, Vernooij LM, Cuthbertson BH, Beattie WS, Wijeysundera DN, van Klei WA. Postoperative troponin surveillance to detect myocardial infarction: an observational cohort modelling study. Br J Anaesth 2024; 132:667-674. [PMID: 38233301 DOI: 10.1016/j.bja.2023.12.019] [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: 10/16/2023] [Revised: 11/29/2023] [Accepted: 12/18/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Clinical presentation of postoperative myocardial infarction (POMI) is often silent. Several international guidelines recommend routine troponin surveillance in patients at risk. We compared how these different guidelines select patients for surveillance after noncardiac surgery with our established risk stratification model. METHODS We used outcome data from two prospective studies: Measurement of Exercise Tolerance before Surgery (METS) and Troponin Elevation After Major non-cardiac Surgery (TEAMS). We compared the major American, Canadian, and European guideline recommendations for troponin surveillance with our established risk stratification model. For each guideline and model, we quantified the number of patients requiring monitoring, % POMI detected, sensitivity, specificity, diagnostic odds ratio, and number needed to screen (NNS). RESULTS METS and TEAMS contributed 2350 patients, of whom 319 (14%) had myocardial injury, 61 (2.5%) developed POMI, and 14 (0.6%) died. Our risk stratification model selected fewer patients for troponin monitoring (20%), compared with the Canadian (78%) and European (79%) guidelines. The sensitivity to detect POMI was highest with the Canadian and European guidelines (0.85; 95% confidence interval [CI] 0.74-0.92). Specificity was highest using the American guidelines (0.91; 95% CI 0.90-0.92). Our risk stratification model had the best diagnostic odds ratio (2.5; 95% CI 1.4-4.2) and a lower NNS (21 vs 35) compared with the guidelines. CONCLUSIONS Most postoperative myocardial infarctions were detected by the Canadian and European guidelines but at the cost of low specificity and a higher number of patients undergoing screening. Patient selection based on our risk stratification model was optimal.
Collapse
Affiliation(s)
- Selene Martinez-Perez
- Department of Anesthesiology and Pain Management, Toronto General Hospital/University Health Network Toronto, Toronto, ON, Canada
| | - Judith A R van Waes
- Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lisette M Vernooij
- Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Anesthesiology, Intensive Care and Pain Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - W Scott Beattie
- Department of Anesthesiology and Pain Management, Toronto General Hospital/University Health Network Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesiology, St. Michael's Hospital, Toronto, ON, Canada
| | - Wilton A van Klei
- Department of Anesthesiology and Pain Management, Toronto General Hospital/University Health Network Toronto, Toronto, ON, Canada; Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
| |
Collapse
|
9
|
Lan H, Cao H, Liu S, Gong X, Huang X, Rong H, Xu B, Chen H, Jiao Z, Lin Y, Guan X. Efficacy of remimazolam tosilate versus propofol for total intravenous anaesthesia in urological surgery: A randomised clinical trial. Eur J Anaesthesiol 2024; 41:208-216. [PMID: 38165145 DOI: 10.1097/eja.0000000000001938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Remimazolam is a novel ultra-short-acting benzodiazepine sedative that acts on the gamma-aminobutyric acid type A receptor (GABAAR). OBJECTIVE To compare the efficacies of remimazolam (RMZ), and propofol (PROP) combined with remifentanil and cisatracurium for total intravenous anaesthesia (TIVA) in patients undergoing urological surgery. DESIGN A prospective, single-blind, randomised, noninferiority clinical trial. SETTING Single centre from 1 January 2022 to 30 March 2022. PATIENTS A total of 146 adult patients undergoing elective urological surgery. INTERVENTION Patients were randomly allocated in a 1 : 1 ratio to the PROP or RMZ groups. In the PROP group, anaesthesia was induced with propofol at 100 mg min -1 to reach a bispectral index score (BIS) of 40 to 60. After loss of consciousness (LOC), intravenous fentanyl 3 μg kg -1 was administered, followed by cisatracurium 0.3 mg kg -1 . Patients were intubated 3 min after cisatracurium administration. Anaesthesia was maintained with the combination of propofol (plasma concentration: 2.5 to 4 μg ml -1 ) and remifentanil (plasma concentration: 2.5 to 4 ng ml -1 ). In the RMZ group, anaesthesia was induced with remimazolam tosilate starting at 10 mg kg -1 h -1 to reach a BIS of 40 to 60 and maintained between 0.2 and 2 mg kg -1 h -1 . After LOC, fentanyl and cisatracurium were administered and intubation was performed as in the PROP group. Anaesthesia was maintained with a combination of remimazolam (0.2 to 2 mg kg -1 h -1 ) and remifentanil (plasma concentration: 2.5 to 4 ng ml -1 ). MAIN OUTCOME MEASURES The primary outcome was the TIVA success rate. The predefined noninferiority margin considered an absolute difference of 6% in the primary outcome between the groups. The secondary outcomes were vital signs, anaesthesia and surgery characteristics, and adverse events. RESULTS All patients completed the trial. The success rates of TIVA with remimazolam and propofol were 100 and 98.6%, respectively. The incidence of hypotension during anaesthesia was lower in the RMZ group (26%) than in the PROP group (46.6%) ( P = 0.016). The median [IQR] total consumption of ephedrine during anaesthesia was higher in the PROP group 10 [0 to 12.5] mg than in the RMZ group 0 [0 to 10] mg ( P = 0.0002). The incidence of injection pain was significantly higher in the PROP group (76.7%) than in the RMZ group (0; P < 0.001). No significant differences in the controllability of the anaesthesia depth, anaesthesia and surgery characteristics, or vital signs were observed between the groups. CONCLUSION Remimazolam demonstrated noninferior efficacy to propofol combined with remifentanil and cisatracurium for TIVA in patients undergoing urological surgery. TRIAL REGISTRATION Chictr.org.cn, identifier: ChiCTR2100050923. CLINICAL REGISTRATION The study was registered in the Chinese Clinical Trial Registry (ChiCTR2100050923, Principal investigator: Xuehai Guan, Date of registration: 8 November 2021, https://www.chictr.org.cn/showproj.html?proj=133466 ).
Collapse
Affiliation(s)
- Hongmeng Lan
- From the Department of Anaesthesiology, The First Affiliated Hospital of Guangxi Medical University (HL, HC, SL, XG, XH, HR, ZJ, YL, XG), Department of Rehabilitation, People's Hospital of Guangxi Zhuang Autonomous Region (BX) and Department of Rehabilitation, The First Affiliated Hospital of Guangxi Medical University (HC)
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Alvarez Torres E, Bartoszko J, Martinez Perez S, Tait G, Santema M, Beattie WS, McCluskey SA, van Klei WA. Effect of a national guideline on postoperative troponin surveillance: a retrospective cohort study. Can J Anaesth 2024; 71:322-329. [PMID: 37973786 DOI: 10.1007/s12630-023-02647-4] [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: 03/17/2023] [Revised: 07/19/2023] [Accepted: 08/08/2023] [Indexed: 11/19/2023] Open
Abstract
PURPOSE We aimed to evaluate the effect of the 2017 Canadian Cardiovascular Society (CCS) guidelines on troponin surveillance after noncardiac surgery. METHODS This was a single-centre, retrospective, observational study. Patients aged 40 yr or older undergoing intermediate- to high-risk elective noncardiac surgery between 2016 and 2021 were included. We compared the number and percentage of troponin tests ordered before and after the guidelines were published and compared patient characteristics, specifically cardiovascular comorbidity, using odds ratio's (OR) with 95% confidence intervals (CIs). Outcomes were myocardial injury, myocardial infarction (MI), and in-hospital mortality. RESULTS The cohort included 36,386 patients and the median age was 63 yr. Between 2016 and 2018, troponin surveillance was done in 2,461 (13%) of the 19,046 patients, compared with 2,398 (14%) of the 17,340 patients who had surgery between 2019 and 2021 (OR, 1.08; 95% CI, 1.02 to 1.15). Patients who had surgery in the second period had less cardiovascular comorbidity; the adjusted OR for troponin surveillance was 1.14 (95% CI, 1.07 to 1.21). In the two periods, troponin was elevated in 561 (2.9%) and 470 (2.7%) patients, an MI was documented in 54 (0.3%) and 36 (0.2%) patients, and 95 (0.5%) and 73 (0.4%) patients died, respectively. After adjustment for baseline differences in the two periods, the ORs for MI and mortality were 0.83 (95% CI, 0.54 to 1.27) and 0.88 (95% CI, 0.64 to 1.19), respectively. CONCLUSION Although the odds of troponin ordering were slightly but significantly higher after publication of the CCS guidelines, the odds for detecting an MI and for mortality did not change.
Collapse
Affiliation(s)
- Eva Alvarez Torres
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada
| | - Justyna Bartoszko
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Selene Martinez Perez
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada
| | - Gordon Tait
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada
| | - Michael Santema
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada
| | - W Scott Beattie
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Stuart A McCluskey
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Wilton A van Klei
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada.
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
- Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
- Department of Anesthesia and Pain Management, Toronto General Hospital, 200 Elizabeth Street, 3EN-464, Toronto, ON, M5G 2C4, Canada.
| |
Collapse
|
11
|
Kanstrup CTB, Serup CM, Svarre KJ, Rasmussen MC, Lundstrøm LH, Kleif J, Bertelsen CA. Association between troponin I levels and mortality among patients undergoing acute high-risk abdominal surgery-A cohort study. World J Surg 2024; 48:361-370. [PMID: 38284768 DOI: 10.1002/wjs.12035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/20/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND Myocardial injury after noncardiac surgery (MINS) is associated with 30-day mortality in heterogeneous surgical populations but is barely described after acute high-risk abdominal surgery. The impact of dynamic changes has not previously been investigated. The objectives were to determine the incidence of MINS in this population, the association between mortality and MINS, and whether plasma troponin I (TnI) dynamics have any impact on mortality. METHODS A prospective cohort study of 341 patients undergoing acute high-risk gastrointestinal surgery was conducted. Plasma TnI was measured at the first four postoperative days. MINS was defined as any increased TnI level >59 ng/L. TnI dynamic required either two succeeding measurements of TnI >59 ng/L with a >20% increase/fall or one measurement of TnI >59 ng/L with a succeeding measurement of TnI <59 ng/L with a >50% decrease. Adjusted mortality rates were calculated using inverse probability of treatment weighting and competing risk analyses. RESULTS The incidence of MINS was 23.8% and dynamic TnI changes occurred in 15.6% of the patients. The unadjusted 30-day and 1-year mortality were 19.8% and 35.9% in patients with MINS, compared with 2.7% and 11.6%, respectively, in patients without MINS (p < 0.001). After adjusting, the differences remained significant. There was no difference in mortality between patients with or without dynamic changes in TnI level. CONCLUSION MINS occurred frequently and was associated with increased mortality. TnI monitoring might help identify patients with increased risk of mortality and improve care. Research on preventive measures and treatments is warranted. TRIAL REGISTRATION NUMBER AND AGENCY ClinicalTrials.gov Identifier: NCT05933837, retrospective registered.
Collapse
Affiliation(s)
- Charlotte Tiffanie Bendtz Kanstrup
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Graduate School, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Camilla Mattesen Serup
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kristina Johansen Svarre
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Maja Christine Rasmussen
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lars Hyldborg Lundstrøm
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Jakob Kleif
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Claus Anders Bertelsen
- Department of Surgery, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
- Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
12
|
Vernooij LM, van Waes JAR, Grobben RB, van Lier F, Feng S, Machina M, McKenny M, Nathoe HM, Wijeysundera DN, van Klei WA, Beattie WS. Postoperative myocardial injury phenotypes and self-reported disability in patients undergoing noncardiac surgery: a multicentre observational study. Br J Anaesth 2024; 132:35-44. [PMID: 38057252 DOI: 10.1016/j.bja.2023.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 10/10/2023] [Accepted: 10/13/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Postoperative myocardial injury (PMI) comprises a spectrum of mechanisms resulting in troponin release. The impact of different PMI phenotypes on postoperative disability remains unknown. METHODS This was a multicentre prospective cohort study including patients aged ≥50 yr undergoing elective major noncardiac surgery. Patients were stratified in five groups based on the occurrence of PMI and clinical information on postoperative adverse events: PMI classified as myocardial infarction (MI; according to fourth definition), PMI plus adverse event other than MI, clinically silent PMI (PMI without adverse events), adverse events without PMI, and neither PMI nor an adverse event (reference). The primary endpoint was 6-month self-reported disability (assessed by WHO Disability Assessment Schedule 2.0 [WHODAS]). Disability-free survival was defined as WHODAS ≤16%. RESULTS We included 888 patients of mean age 69 (range 53-91) yr, of which 356 (40%) were women; 151 (17%) patients experienced PMI, and 625 (71%) experienced 6-month disability-free survival. Patients with PMI, regardless of its phenotype, had higher preoperative disability scores than patients without PMI (difference in WHODAS; β: 3.3, 95% confidence interval [CI]: 0.5-6.2), but scores remained stable after surgery (β: 1.2, 95% CI: -3.2-5.6). Before surgery, patients with MI (n=36, 4%) were more disabled compared with patients without PMI and no adverse events (β: 5.5, 95% CI: 0.3-10.8). At 6 months, patients with MI and patients without PMI but with adverse events worsened in disability score (β: 11.2, 95% CI: 2.3-20.2; β: 8.1, 95% CI: 3.0-13.2, respectively). Patients with clinically silent PMI did not change in disability score at 6 months (β: 1.39, 95% CI: -4.50-7.29, P=0.642). CONCLUSIONS Although patients with postoperative myocardial injury had higher preoperative self-reported disability, disability scores did not change at 6 months after surgery. However, patients experiencing myocardial infarction worsened in disability score after surgery.
Collapse
Affiliation(s)
- Lisette M Vernooij
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands; Department of Anesthesiology, Intensive Care and Pain Medicine, St Antonius Hospital, Nieuwegein, The Netherlands.
| | - Judith A R van Waes
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Remco B Grobben
- Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Felix van Lier
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Simon Feng
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Matthew Machina
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada; Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Michael McKenny
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada; Department of Anesthesiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Hendrik M Nathoe
- Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Duminda N Wijeysundera
- Department of Anesthesia, St. Michael's Hospital - Unity Health Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Wilton A van Klei
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands; Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - W Scott Beattie
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network Toronto, Toronto, ON, Canada
| |
Collapse
|
13
|
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.
Collapse
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)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Mases A, Beltrán de Heredia S, Gallart L, Román L, Bosch L, Núñez M, Rueda M, Recasens L, Sabaté S. Prediction of Acute Myocardial Injury in Noncardiac Surgery in Patients at Risk for Major Adverse Cardiovascular and Cerebrovascular Events: A Multivariable Risk Model. Anesth Analg 2023; 137:1116-1126. [PMID: 37043386 DOI: 10.1213/ane.0000000000006469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
BACKGROUND The best use of perioperative cardiac biomarkers assessment is still under discussion. Massive postoperative troponin surveillance can result in untenably high workloads and costs for health care systems and potentially harmful interventions for patients. In a cohort of patients at risk for major adverse cardiovascular and cerebrovascular events (MACCEs), we aimed to (1) determine whether preoperative biomarkers can identify patients at major risk for acute myocardial injury in noncardiac surgery, (2) develop a risk model for acute myocardial injury prediction, and (3) propose an algorithm to optimize postoperative troponin surveillance. METHODS Prospective, single-center cohort study enrolling consecutive adult patients (≥45 years) at risk for MACCE scheduled for intermediate-to-high-risk noncardiac surgery. Baseline high-sensitivity troponin T (hsTnT) and N-terminal fragment of pro-B-type natriuretic peptide (NT-proBNP), as well as hsTnT on the first 3 postoperative days were obtained. The main outcome was the occurrence of acute myocardial injury. Candidate predictors of acute myocardial injury were baseline concentrations of hsTnT ≥14 ng/L and NT-proBNP ≥300 pg/mL and preoperative and intraoperative variables. A multivariable risk model and a decision curve were constructed. RESULTS Of 732 patients, 42.1% had elevated hsTnT and 37.3% had elevated NT-proBNP levels at baseline. Acute myocardial injury occurred in 161 patients (22%). Elevated baseline hsTnT, found in 84% of patients with acute myocardial injury, was strongly associated with this outcome: odds ratio (OR), 12.08 (95% confidence interval [CI], 7.78-19.42). Logistic regression identified 6 other independent predictors for acute myocardial injury: age, sex, estimated glomerular filtration rate (eGFR) <45 mL·min -1 ·1.73 m -2 , functional capacity <4 METs or unknown, NT-proBNP ≥300 pg/mL, and estimated intraoperative blood loss. The c -statistic for the risk model was 77% (95% CI, 0.73-0.81). The net benefit of the model began at a risk threshold of 7%. CONCLUSIONS Baseline determination of cardiac biomarkers in patients at risk for MACCE shortly before intermediate- or high-risk noncardiac surgery helps identify those with the highest risk for acute myocardial injury. A baseline hsTnT ≥14 ng/L indicates the need for postoperative troponin surveillance. In patients with baseline hsTnT <14 ng/L, our 6-predictor model will identify additional patients at risk for acute myocardial injury who may also benefit from postoperative surveillance.
Collapse
Affiliation(s)
- Anna Mases
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Sandra Beltrán de Heredia
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Lluís Gallart
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Bellaterra, Barcelona, Spain
| | - Lorena Román
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
| | - Laia Bosch
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
| | - Maria Núñez
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
| | - Mireia Rueda
- From the Department of Anesthesiology, Hospital del Mar, Barcelona, Spain
| | - Lluís Recasens
- Department of Cardiology, Hospital del Mar, Barcelona, Spain
| | - Sergi Sabaté
- Department of Anesthesiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| |
Collapse
|
15
|
Liu H, Zhang J, Peng K, Meng X, Shan X, Huo W, Liu H, Lei Y, Ji F. Protocol: dexmedetomidine on myocardial injury after noncardiac surgery-a multicenter, double-blind, controlled trial. Perioper Med (Lond) 2023; 12:57. [PMID: 37951962 PMCID: PMC10638683 DOI: 10.1186/s13741-023-00348-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 11/02/2023] [Indexed: 11/14/2023] Open
Abstract
AIMS Myocardial injury after noncardiac surgery (MINS) is common in elderly patients and considered as an independent predictor of 30-day mortality after noncardiac surgery. Dexmedetomidine possesses cardiac-protective profile. Previous clinical studies have found that perioperative application of dexmedetomidine is associated with decreased 1-year mortality in patients undergoing cardiac surgery. The current study protocol aims to investigate the effects of dexmedetomidine on the incidence of MINS, complications, and 30-day mortality in elderly patients subjected to noncardiac surgery. METHODS A multicenter, randomized, controlled, double-blind, prospective trial is designed to explore cardiac protection of dexmedetomidine in the elderly patients undergoing noncardiac surgery. A total of 960 patients aged over 65 years will be recruited and randomly assigned to dexmedetomidine group (group Dex) and normal saline placebo group (group NS) in a ratio of 1:1. Patients in group Dex will receive a bolus dose of 0.5 μg/kg dexmedetomidine within 10 min before surgical incision, followed by a consistent infusion at the rate of 0.3-0.5 μg/kg/h throughout the operation. Group NS patients will receive the same volume of normal saline. The primary outcome is the incidence of MINS via detecting the hs-TnT level within 3 days after the operation. The secondary outcome includes myocardial ischemic symptoms, the incidence of major adverse cardiovascular events (MACE) in hospital, length of ICU and postoperative hospital stay, the incidence of inhospital complications, and 30-day all-cause mortality. DISCUSSION The results of the current study will illustrate the effect of dexmedetomidine on myocardial injury for elderly patients undergoing major noncardiac surgery. TRIAL REGISTRATION The trial was registered with Chinese Clinical Trial Registry (CHICTR) on Aug 24, 2021 (ChiCTR2100049946, http://www.chictr.org.cn/showproj.aspx?proj=131804 ).
Collapse
Affiliation(s)
- Huayue Liu
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Anesthesiology, Soochow University, Suzhou, China
| | - Juan Zhang
- Department of Pain Medicine, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Ke Peng
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Anesthesiology, Soochow University, Suzhou, China
| | - Xiaowen Meng
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Anesthesiology, Soochow University, Suzhou, China
| | - Xisheng Shan
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Wenwen Huo
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hong Liu
- Department of Anesthesiology and Pain Medicine, University of California Davis Health, Sacramento, CA, USA
| | - Yishan Lei
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, China.
| | - Fuhai Ji
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, China.
- Institute of Anesthesiology, Soochow University, Suzhou, China.
| |
Collapse
|
16
|
Stahlschmidt A, Passos SC, Dornelles DD, Polanczyk C, Gutierrez CS, Minuzzi RR, Castro SMJ, Stefani LC. Troponin elevation as a marker of short deterioration and one-year death in a high-risk surgical patient cohort in a low and middle income country setting: a postoperative approach to increase surveillance. Can J Anaesth 2023; 70:1776-1788. [PMID: 37853279 DOI: 10.1007/s12630-023-02558-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 04/02/2023] [Accepted: 04/28/2023] [Indexed: 10/20/2023] Open
Abstract
PURPOSE Myocardial injury after noncardiac surgery is common and mostly asymptomatic. The ideal target population that will benefit from routine troponin measurements in low and middle income countries (LMICs) is unclear. This study aims to evaluate the clinical outcomes of a cohort of high-risk surgical patients according to high-sensitivity troponin T (hsTnT) in an LMIC setting. METHODS We conducted a prospective cohort study of 442 high-risk patients undergoing noncardiac surgery at a Brazilian hospital between February 2019 and March 2020. High-sensitivity troponin T levels were measured preoperatively, 24 hr, and 48 hr after surgery and stratified into three groups: normal (< 20 ng·L-1); minor elevation (20-65 ng·L-1); and major elevation (> 65 ng·L-1). We performed survival analysis to determine the association between myocardial injury and one-year mortality. We described medical interventions and evaluated unplanned intensive care unit (ICU) admission and complications using multivariable models. RESULTS Postoperative myocardial injury occurred in 45% of patients. Overall, 30-day mortality was 8%. Thirty-day and one-year mortality were higher in patients with hsTnT ≥ 20 ng·L-1. One-year mortality was 18% in the unaltered troponin group vs 31% and 41% for minor and major elevation groups, respectively. Multivariable analysis of one-year survival showed a hazard ratio (HR) of 1.94 (95% confidence interval [CI], 1.22 to 3.09) for the minor elevation group and a HR of 2.73 (95% CI, 1.67 to 4.45) for the troponin > 65 ng·L-1 group. Patients with altered troponin had more unplanned ICU admissions (13% vs 5%) and more complications (78% vs 48%). CONCLUSION This study supports evidence that hsTnT is an important prognostic marker and a strong predictor of all-cause mortality after surgery. Troponin measurement in high-risk surgical patients could potentially be used as tool to scale-up care in LMIC settings. STUDY REGISTRATION ClinicalTrials.gov (NCT04187664); first submitted 5 December 2019.
Collapse
Affiliation(s)
- Adriene Stahlschmidt
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Sávio C Passos
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Debora D Dornelles
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Carisi Polanczyk
- Cardiology Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Claudia S Gutierrez
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Rosangela R Minuzzi
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Stela M J Castro
- Department of Statistics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Luciana C Stefani
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
- Department of Surgery, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.
- Anaesthesia and Perioperative Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Rua Ramiro Barcelos, 2350, Porto Alegre, RS, 90035-903, Brazil.
| |
Collapse
|
17
|
van Klei WA, van Waes JAR, Beattie WS. Routine post-operative troponin surveillance after non-cardiac surgery: are we ready? Eur Heart J 2023; 44:3440-3442. [PMID: 37525944 DOI: 10.1093/eurheartj/ehad487] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 06/30/2023] [Accepted: 07/18/2023] [Indexed: 08/02/2023] Open
Affiliation(s)
- Wilton A van Klei
- Department of Anesthesiology, University Health Network Toronto, Toronto General Hospital, 200 Elizabeth Street, 3EN-464, Toronto, ON M5G 2C4, Canada
- Department of Anesthesiology, University of Toronto, Toronto, M5G 1E2 ON, Canada
- Department of Anesthesiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Judith A R van Waes
- Department of Anesthesiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - W Scott Beattie
- Department of Anesthesiology, University Health Network Toronto, Toronto General Hospital, 200 Elizabeth Street, 3EN-464, Toronto, ON M5G 2C4, Canada
- Department of Anesthesiology, University of Toronto, Toronto, M5G 1E2 ON, Canada
| |
Collapse
|
18
|
Xing Z, Wang L, Ye X, Yao J. The myocardial protective effect of TAP block preemptive analgesia on elderly patients with coronary heart disease undergoing laparoscopic surgery. Asian J Surg 2023; 46:3865-3866. [PMID: 37076341 DOI: 10.1016/j.asjsur.2023.03.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/28/2023] [Indexed: 04/21/2023] Open
Affiliation(s)
- Zhen Xing
- The First Affiliated Hospital of Hebei North University, Zhangjiakou, 075000, China.
| | - Li Wang
- The First Affiliated Hospital of Hebei North University, Zhangjiakou, 075000, China
| | - Xiaoming Ye
- Hebei North University, Zhangjiakou, 075000, China
| | - Jie Yao
- The First Affiliated Hospital of Hebei North University, Zhangjiakou, 075000, China
| |
Collapse
|
19
|
Cho YJ, Hyeon C, Nam K, Lee S, Ju JW, Kang J, Han JK, Kim HS, Jeon Y. Effects of low versus high inspired oxygen fraction on myocardial injury after transcatheter aortic valve implantation: A randomized clinical trial. PLoS One 2023; 18:e0281232. [PMID: 37531368 PMCID: PMC10395822 DOI: 10.1371/journal.pone.0281232] [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: 01/17/2023] [Accepted: 07/18/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Oxygen therapy is used in various clinical situation, but its clinical outcomes are inconsistent. The relationship between the fraction of inspired oxygen (FIO2) during transcatheter aortic valve implantation (TAVI) and clinical outcomes has not been well studied. We investigated the association of FIO2 (low vs. high) and myocardial injury in patients undergoing TAVI. METHODS Adults undergoing transfemoral TAVI under general anesthesia were randomly assigned to receive FIO2 0.3 or 0.8 during procedure. The primary outcome was the area under the curve (AUC) for high-sensitivity cardiac troponin I (hs-cTnI) during the first 72 h following TAVI. Secondary outcomes included the AUC for postprocedural creatine kinase-myocardial band (CK-MB), acute kidney injury and recovery, conduction abnormalities, pacemaker implantation, stroke, myocardial infarction, and in-hospital mortality. RESULTS Between October 2017 and April 2022, 72 patients were randomized and 62 were included in the final analysis (n = 31 per group). The median (IQR) AUC for hs-cTnI in the first 72 h was 42.66 (24.82-65.44) and 71.96 (35.38-116.34) h·ng/mL in the FIO2 0.3 and 0.8 groups, respectively (p = 0.066). The AUC for CK-MB in the first 72 h was 257.6 (155.6-322.0) and 342.2 (195.4-485.2) h·ng/mL in the FIO2 0.3 and 0.8 groups, respectively (p = 0.132). Acute kidney recovery, defined as an increase in the estimated glomerular filtration rate ≥ 25% of baseline in 48 h, was more common in the FIO2 0.3 group (65% vs. 39%, p = 0.042). Other clinical outcomes were comparable between the groups. CONCLUSIONS The FIO2 level did not have a significant effect on periprocedural myocardial injury following TAVI. However, considering the marginal results, a benefit of low FIO2 during TAVI could not be ruled out.
Collapse
Affiliation(s)
- Youn Joung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Cheun Hyeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Karam Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Seohee Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Jae-Woo Ju
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Jeehoon Kang
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Jung-Kyu Han
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Yunseok Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| |
Collapse
|
20
|
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:zrad021. [PMID: 37104754 PMCID: PMC10129390 DOI: 10.1093/bjsopen/zrad021] [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: 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).
Collapse
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
| |
Collapse
|
21
|
Korsgaard S, Schmidt M, Maeng M, Jakobsen L, Pedersen L, Christiansen CF, Sørensen HT. Long-Term Outcomes of Perioperative Versus Nonoperative Myocardial Infarction: A Danish Population-Based Cohort Study (2000–2016). Circ Cardiovasc Qual Outcomes 2022; 15:e008212. [DOI: 10.1161/circoutcomes.121.008212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Perioperative myocardial infarction is a serious cardiovascular complication of noncardiac surgery. The clinical course of perioperative myocardial infarction, other than all-cause mortality, is largely unknown. We examined long-term fatal and nonfatal outcomes of perioperative myocardial infarction compared with nonoperative myocardial infarction.
Methods:
We conducted a population-based cohort study of first-time myocardial infarction in Denmark from 2000 to 2016. We calculated cumulative incidence of all-cause mortality, cardiac mortality, recurrent myocardial infarction, heart failure, stroke, venous thromboembolism, acute kidney injury, and kidney failure with replacement therapy. We computed 5-year risk ratios adjusted for age, sex, year of diagnosis, educational level, and comorbidities.
Results:
We identified 5068 patients with perioperative myocardial infarction and 137 862 patients with nonoperative myocardial infarction. The 5-year risk of all-cause mortality was 67.5% (95% CI, 66.1%–69.0%) for perioperative myocardial infarction patients and 38.0% (95% CI, 37.7%–38.3%) for nonoperative myocardial infarction patients. The adjusted risk ratio of all-cause mortality was 1.13 (95% CI, 1.11–1.16) at 5 years. After adjustment, we found no association between patients with perioperative myocardial infarction and 5-year cardiac mortality, recurrent myocardial infarction, heart failure, stroke, or kidney failure with replacement therapy when compared with nonoperative myocardial infarction patients. Perioperative myocardial infarction patients had a higher relative risk of venous thromboembolism (5-year risk ratio, 1.21 [95% CI, 1.01–1.46]) and acute kidney injury (5-year risk ratio, 1.37 [95% CI, 1.22–1.53]).
Conclusions:
Compared with nonoperative myocardial infarction patients, perioperative myocardial infarction patients had elevated risk of all-cause mortality, venous thromboembolism, and acute kidney failure. In addition to the myocardial infarction component of perioperative myocardial infarction, this poor prognosis seemed associated with the surgery or underlying comorbidities. These findings warrant further research on strategies to reduce the risk of perioperative myocardial infarction and on strategies to manage perioperative myocardial infarction.
Collapse
Affiliation(s)
- Søren Korsgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Denmark. (S.K., M.S., L.P., C.F.C., H.T.S.)
- Department of Clinical Medicine, Aarhus University, Denmark (S.K., M.S., M.M., L.J., L.P., C.F.C., H.T.S.)
| | - Morten Schmidt
- Department of Clinical Epidemiology, Aarhus University Hospital, Denmark. (S.K., M.S., L.P., C.F.C., H.T.S.)
- Department of Cardiology, Aarhus University Hospital, Denmark. (M.S., M.M., L.J.)
- Department of Clinical Medicine, Aarhus University, Denmark (S.K., M.S., M.M., L.J., L.P., C.F.C., H.T.S.)
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Denmark. (M.S., M.M., L.J.)
- Department of Clinical Medicine, Aarhus University, Denmark (S.K., M.S., M.M., L.J., L.P., C.F.C., H.T.S.)
| | - Lars Jakobsen
- Department of Cardiology, Aarhus University Hospital, Denmark. (M.S., M.M., L.J.)
- Department of Clinical Medicine, Aarhus University, Denmark (S.K., M.S., M.M., L.J., L.P., C.F.C., H.T.S.)
| | - Lars Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Denmark. (S.K., M.S., L.P., C.F.C., H.T.S.)
- Department of Clinical Medicine, Aarhus University, Denmark (S.K., M.S., M.M., L.J., L.P., C.F.C., H.T.S.)
| | - Christian Fynbo Christiansen
- Department of Clinical Epidemiology, Aarhus University Hospital, Denmark. (S.K., M.S., L.P., C.F.C., H.T.S.)
- Department of Clinical Medicine, Aarhus University, Denmark (S.K., M.S., M.M., L.J., L.P., C.F.C., H.T.S.)
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Denmark. (S.K., M.S., L.P., C.F.C., H.T.S.)
- Department of Clinical Medicine, Aarhus University, Denmark (S.K., M.S., M.M., L.J., L.P., C.F.C., H.T.S.)
| |
Collapse
|
22
|
Stahlschmidt A, Passos SC, Cardoso GR, Schuh GJ, Gutierrez CS, Castro SMJ, Caumo W, Pearse RM, Stefani LC. Enhanced peri-operative care to improve outcomes for high-risk surgical patients in Brazil: a single-centre before-and-after cohort study. Anaesthesia 2022; 77:416-427. [PMID: 35167136 DOI: 10.1111/anae.15671] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 01/02/2022] [Accepted: 01/05/2022] [Indexed: 01/02/2023]
Abstract
Mortality and morbidity for high-risk surgical patients are often high, especially in low-resource settings. Enhanced peri-operative care has the potential to reduce preventable deaths but must be designed to meet local needs. This before-and-after cohort study aimed to assess the effectiveness of a postoperative 48-hour enhanced care pathway for high-risk surgical patients ('high-risk surgical bundle') who did not meet the criteria for elective admission to intensive care. The pathway comprised of six elements: risk identification and communication; adoption of a high-risk post-anaesthesia care unit discharge checklist; prompt nursing admission to ward; intensification of vital signs monitoring; troponin measurement; and prompt access to medical support if required. The primary outcome was in-hospital mortality. Data describing 1189 patients from two groups, before and after implementation of the pathway, were compared. The usual care group comprised a retrospective cohort of high-risk surgical patients between September 2015 and December 2016. The intervention group prospectively included high-risk surgical patients from February 2019 to March 2020. Unadjusted mortality rate was 10.5% (78/746) for the usual care and 6.3% (28/443) for the intervention group. After adjustment, the intervention effect remained significant (RR 0.46 (95%CI 0.30-0.72). The high-risk surgical bundle group received more rapid response team calls (24% vs. 12.6%; RR 0.63 [95%CI 0.49-0.80]) and surgical re-interventions (18.9 vs. 7.5%; RR 0.41 [95%CI 0.30-0.59]). These data suggest that a clinical pathway based on enhanced surveillance for high-risk surgical patients in a resource-constrained setting could reduce in-hospital mortality.
Collapse
Affiliation(s)
- A Stahlschmidt
- Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - S C Passos
- Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - G R Cardoso
- School of Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - G J Schuh
- School of Medicine, Department of Surgery, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - C S Gutierrez
- Department of Surgery, Anaesthesia and Peri-operative Medicine Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - S M J Castro
- Department of Statistics, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - W Caumo
- Pain and Palliative Care Service, Laboratory of Pain and Neuromodulation, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - R M Pearse
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | | | - L C Stefani
- Department of Surgery, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| |
Collapse
|
23
|
Foëx P, Chew MS, De Hert S. Cardiac Biomarkers to Assess Perioperative Myocardial Injury in Noncardiac Surgery Patients: Tools or Toys? Anesth Analg 2022; 134:253-256. [PMID: 35030120 DOI: 10.1213/ane.0000000000005788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Pierre Foëx
- From the Nuffield Division of Anaesthetics, University of Oxford, Oxford, United Kingdom
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences; Linköping University Hospital, Linköping, Sweden
| | - Stefan De Hert
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital - Ghent University, Ghent, Belgium
| |
Collapse
|
24
|
Buse GL, Matot I. Pro-Con Debate: Cardiac Troponin Measurement as Part of Routine Follow-up of Myocardial Damage Following Noncardiac Surgery. Anesth Analg 2022; 134:257-265. [PMID: 35030121 DOI: 10.1213/ane.0000000000005714] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Elevated troponin levels within 3 days of surgery, independent of the presence of symptoms, are strongly linked to increased risk of short- and long-term morbidity and mortality. However, the value of screening with troponin measurements is controversial. The Canadian Cardiovascular Society guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery recommends measuring daily troponin for 48 to 72 hours after surgery in high-risk patients. Nevertheless, others doubt this recommendation, in part because postoperative elevated levels of troponin describe very little in terms of disease or event-specific pathogenesis and etiology, and thus, tailoring an intervention remains a challenge. This Pro-Con debate offers evidence-based data to stimulate physician understanding of daily practice and its significance in this matter, and assist in determining whether to use (Pro) or not to use (Con) this surveillance.
Collapse
Affiliation(s)
- Giovanna Lurati Buse
- From the Anesthesiology Department, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Idit Matot
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel Aviv Medical School, Tel Aviv University, Tel-Aviv, Israel
| |
Collapse
|
25
|
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.
Collapse
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
| |
Collapse
|
26
|
Chew MS, Puelacher C, Patel A, Hammarskjöld F, Lyckner S, Kollind M, Jawad M, Andersson U, Fredrikson M, Sperber J, Johnsson P, Elander L, Zeuchner J, Linhardt M, De Geer L, Rolander WG, Gagnö G, Didriksson H, Pearse R, Mueller C, Andersson H. Identification of myocardial injury using perioperative troponin surveillance in major noncardiac surgery and net benefit over the Revised Cardiac Risk Index. Br J Anaesth 2021; 128:26-36. [PMID: 34857357 DOI: 10.1016/j.bja.2021.10.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 09/12/2021] [Accepted: 10/05/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Patients with perioperative myocardial injury are at risk of death and major adverse cardiovascular and cerebrovascular events (MACCE). The primary aim of this study was to determine optimal thresholds of preoperative and perioperative changes in high-sensitivity cardiac troponin T (hs-cTnT) to predict MACCE and mortality. METHODS Prospective, observational, cohort study in patients ≥50 yr of age undergoing elective major noncardiac surgery at seven hospitals in Sweden. The exposures were hs-cTnT measured before and days 0-3 after surgery. Two previously published thresholds for myocardial injury and two thresholds identified using receiver operating characteristic analyses were evaluated using multivariable logistic regression models and externally validated. The weighted comparison net benefit method was applied to determine the additional value of hs-cTnT thresholds when compared with the Revised Cardiac Risk Index (RCRI). The primary outcome was a composite of 30-day all-cause mortality and MACCE. RESULTS We included 1291 patients between April 2017 and December 2020. The primary outcome occurred in 124 patients (9.6%). Perioperative increase in hs-cTnT ≥14 ng L-1 above preoperative values provided statistically optimal model performance and was associated with the highest risk for the primary outcome (adjusted odds ratio 2.9, 95% confidence interval 1.8-4.7). Validation in an independent, external cohort confirmed these findings. A net benefit over RCRI was demonstrated across a range of clinical thresholds. CONCLUSIONS Perioperative increases in hsTnT ≥14 ng L-1 above baseline values identifies acute perioperative myocardial injury and provides a net prognostic benefit when added to RCRI for the identification of patients at high risk of death and MACCE. CLINICAL TRIAL REGISTRATION NCT03436238.
Collapse
Affiliation(s)
- Michelle S Chew
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Christian Puelacher
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - Akshaykumar Patel
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Fredrik Hammarskjöld
- Department of Anesthesiology and Intensive Care, Ryhov County Hospital, Jönköping, Sweden
| | - Sara Lyckner
- Department of Anesthesiology, Mälarsjukhuset, Centre for Clinical Research Sörmland, Eskilstuna, Sweden
| | - Malin Kollind
- Department of Anaesthesia and Intensive Care, Centralsjukhuset Kristianstad, Kristianstad, Sweden
| | - Monir Jawad
- Department of Anaesthesia and Intensive Care, Centralsjukhuset Kristianstad, Kristianstad, Sweden; Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Ulrika Andersson
- Department of Clinical Sciences Lund, Anaesthesiology and Intensive Care, Skåne University Hospital Lund, Lund University, Sweden
| | - Mats Fredrikson
- Department of Clinical and Experimental Medicine, Faculty of Medicine and Health, Linköping University, Linköping, Sweden
| | - Jesper Sperber
- Department of Anesthesiology, Mälarsjukhuset, Centre for Clinical Research Sörmland, Eskilstuna, Sweden
| | - Patrik Johnsson
- Department of Clinical Sciences, Anaesthesiology and Intensive Care, Skåne University Hospital Malmö, Lund University, Sweden
| | - Louise Elander
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Vrinnevi Hospital, Norrköping, Sweden
| | - Jakob Zeuchner
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Vrinnevi Hospital, Norrköping, Sweden
| | - Michael Linhardt
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Lina De Geer
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Wictor Gääw Rolander
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Gunilla Gagnö
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Helén Didriksson
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Rupert Pearse
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Christian Mueller
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, University Basel, Basel, Switzerland
| | - Henrik Andersson
- Departments of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| |
Collapse
|
27
|
Myocardial injury after noncardiac surgery: facts, fallacies and how to approach clinically. Curr Opin Crit Care 2021; 27:670-675. [PMID: 34520410 DOI: 10.1097/mcc.0000000000000885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW Acute myocardial injury occurs commonly during perioperative care. There is still considerable confusion regarding its diagnosis and definition, and a lack of consensus on who and how to screen, exacerbated by a lack of studies addressing how to manage patients with detected myocardial injury. RECENT FINDINGS Far from a benign biochemical anomaly, myocardial injury occurring perioperatively is largely a silent disease and is not necessarily because of ischaemia. Preoperative, postoperative, and perioperative changes in cardiac troponins (cTns) are independently associated with increased mortality and adverse cardiovascular outcomes. Routine screening with cTns is required for reliable detection of myocardial injury. Measurement of changes (from preoperative to postoperative) will detect acute events as well as identify patients with chronic troponin increases. SUMMARY This review aims to bring together current literature regarding myocardial injury that is detected perioperatively, identifies knowledge gaps for future research and provides suggestions for management.
Collapse
|
28
|
Ruetzler K, Smilowitz NR, Berger JS, Devereaux PJ, Maron BA, Newby LK, de Jesus Perez V, Sessler DI, Wijeysundera DN. Diagnosis and Management of Patients With Myocardial Injury After Noncardiac Surgery: A Scientific Statement From the American Heart Association. Circulation 2021; 144:e287-e305. [PMID: 34601955 DOI: 10.1161/cir.0000000000001024] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Myocardial injury after noncardiac surgery is defined by elevated postoperative cardiac troponin concentrations that exceed the 99th percentile of the upper reference limit of the assay and are attributable to a presumed ischemic mechanism, with or without concomitant symptoms or signs. Myocardial injury after noncardiac surgery occurs in ≈20% of patients who have major inpatient surgery, and most are asymptomatic. Myocardial injury after noncardiac surgery is independently and strongly associated with both short-term and long-term mortality, even in the absence of clinical symptoms, electrocardiographic changes, or imaging evidence of myocardial ischemia consistent with myocardial infarction. Consequently, surveillance of myocardial injury after noncardiac surgery is warranted in patients at high risk for perioperative cardiovascular complications. This scientific statement provides diagnostic criteria and reviews the epidemiology, pathophysiology, and prognosis of myocardial injury after noncardiac surgery. This scientific statement also presents surveillance strategies and treatment approaches.
Collapse
|
29
|
Prevalence and risk factors of myocardial and acute kidney injury following radical nephrectomy with vena cava thrombectomy: a retrospective cohort study. BMC Anesthesiol 2021; 21:243. [PMID: 34641781 PMCID: PMC8513361 DOI: 10.1186/s12871-021-01462-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 09/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Radical nephrectomy with thrombectomy is the mainstay treatment for patients with renal cell carcinoma with vena cava thrombus. But the procedure is full of challenge, with high incidence of major complications and mortality. Herein, we investigated the incidence and predictors of myocardial injury and acute kidney injury (AKI) in patients following radical nephrectomy with inferior vena cava thrombectomy. METHODS Patients who underwent nephrectomy with thrombectomy between January 2012 and June 2020 were retrospectively reviewed. Myocardial injury was diagnosed when peak cardiac troponin I was higher than 0.03 ng/ml. AKI was diagnosed according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Multivariable logistic regression models were used to identify predictors of myocardial injury or AKI after surgery. RESULTS A total of 143 patients were included in the final analysis. Myocardial injury and AKI occurred in 37.8 and 42.7% of patients after this surgery, respectively. Male sex (odds ratio [OR] 0.27, 95% confidence interval [CI] 0.10-0.71; P = 0.008) was associated with a lower risk, whereas high level Mayo classification (compared with Mayo level I + II, Mayo level III + IV: OR 4.21, 95% CI 1.42-12.4; P = 0.009), acute normovolemic hemodilution before surgery (OR 2.66, 95% CI 1.10-6.41; P = 0.029), long duration of intraoperative tachycardia (per 20 min: OR 1.49, 95% CI 1.10-2.16; P = 0.036), and long duration of surgery (per 1 h, OR 1.48, 95% CI 1.03-2.16, P = 0.009) were associated with a higher risk of myocardial injury. High body mass index (OR 1.18, 95% CI 1.06-1.33; P = 0.004) and long duration of intraoperative hypotension (per 20 min: OR 1.30, 95% CI 1.04-1.64; P = 0.024) were associated with a higher risk, whereas selective renal artery embolism before surgery (OR 0.20, 95% CI 0.07-0.59, P = 0.004) was associated with a lower risk of AKI. CONCLUSION Myocardial injury and AKI were common in patients recovering from radical nephrectomy with inferior vena cava thrombectomy. Whether interventions targeting the above modifiable factors can improve outcomes require further studies.
Collapse
|
30
|
Gualandro DM, Puelacher C, Lurati Buse G, Glarner N, Cardozo FA, Vogt R, Hidvegi R, Strunz C, Bolliger D, Gueckel J, Yu PC, Liffert M, Arslani K, Prepoudis A, Calderaro D, Hammerer-Lercher A, Lampart A, Steiner LA, Schären S, Kindler C, Guerke L, Osswald S, Devereaux PJ, Caramelli B, Mueller C. Incidence and outcomes of perioperative myocardial infarction/injury diagnosed by high-sensitivity cardiac troponin I. Clin Res Cardiol 2021; 110:1450-1463. [PMID: 33768367 PMCID: PMC8405484 DOI: 10.1007/s00392-021-01827-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/21/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Perioperative myocardial infarction/injury (PMI) diagnosed by high-sensitivity troponin (hs-cTn) T is frequent and a prognostically important complication of non-cardiac surgery. We aimed to evaluate the incidence and outcome of PMI diagnosed using hs-cTnI, and compare it to PMI diagnosed using hs-cTnT. METHODS We prospectively included 2455 patients at high cardiovascular risk undergoing 3111 non-cardiac surgeries, for whom hs-cTnI and hs-cTnT concentrations were measured before surgery and on postoperative days 1 and 2. PMI was defined as a composite of perioperative myocardial infarction (PMIInfarct) and perioperative myocardial injury (PMIInjury), according to the Fourth Universal Definition of Myocardial Infarction. All-cause mortality was the primary endpoint. RESULTS Using hs-cTnI, the incidence of overall PMI was 9% (95% confidence interval [CI] 8-10%), including PMIInfarct 2.6% (95% CI 2.0-3.2) and PMIInjury 6.1% (95% CI 5.3-6.9%), which was lower versus using hs-cTnT: overall PMI 15% (95% CI 14-16%), PMIInfarct 3.7% (95% CI 3.0-4.4) and PMIInjury 11.3% (95% CI 10.2-12.4%). All-cause mortality occurred in 52 (2%) patients within 30 days and 217 (9%) within 1 year. Using hs-cTnI, both PMIInfarct and PMIInjury were independent predictors of 30-day all-cause mortality (adjusted hazard ratio [aHR] 2.5 [95% CI 1.1-6.0], and aHR 2.8 [95% CI 1.4-5.5], respectively) and, 1-year all-cause mortality (aHR 2.0 [95% CI 1.2-3.3], and aHR 1.8 [95% CI 1.2-2.7], respectively). Overall, the prognostic impact of PMI diagnosed by hs-cTnI was comparable to the prognostic impact of PMI using hs-cTnT. CONCLUSIONS Using hs-cTnI, PMI is less common versus using hs-cTnT. Using hs-cTnI, both PMIInfarct and PMIInjury remain independent predictors of 30-day and 1-year mortality.
Collapse
Affiliation(s)
- Danielle M Gualandro
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4056, Basel, Switzerland.
- Interdisciplinary Medicine in Cardiology Unit, Cardiology Department, Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil.
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4056, Basel, Switzerland
| | - Giovanna Lurati Buse
- Department of Anesthesiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Noemi Glarner
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4056, Basel, Switzerland
| | - Francisco A Cardozo
- Interdisciplinary Medicine in Cardiology Unit, Cardiology Department, Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil
| | - Ronja Vogt
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4056, Basel, Switzerland
| | - Reka Hidvegi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4056, Basel, Switzerland
- Department of Anesthesiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Celia Strunz
- Laboratory Medicine, Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil
| | - Daniel Bolliger
- Department of Anesthesiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Johanna Gueckel
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4056, Basel, Switzerland
| | - Pai C Yu
- Interdisciplinary Medicine in Cardiology Unit, Cardiology Department, Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil
| | - Marcel Liffert
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4056, Basel, Switzerland
- Department of Anesthesiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ketina Arslani
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4056, Basel, Switzerland
| | - Alexandra Prepoudis
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4056, Basel, Switzerland
| | - Daniela Calderaro
- Interdisciplinary Medicine in Cardiology Unit, Cardiology Department, Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil
| | | | - Andreas Lampart
- Department of Anesthesiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Luzius A Steiner
- Department of Laboratory Medicine, University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Stefan Schären
- Department of Spinal Surgery, University Hospital Basel, Basel, Switzerland
| | - Christoph Kindler
- Department of Anesthesiology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Lorenz Guerke
- Department of Vascular Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Stefan Osswald
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4056, Basel, Switzerland
| | - P J Devereaux
- Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Anesthesiology, Perioperative Medicine, and Surgical Research Unit C/o Hamilton General Hospital, McMaster University, Hamilton, Canada
| | - Bruno Caramelli
- Interdisciplinary Medicine in Cardiology Unit, Cardiology Department, Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4056, Basel, Switzerland
| |
Collapse
|
31
|
Hofer IS, Cheng D, Grogan T. A Retrospective Analysis Demonstrates That a Failure to Document Key Comorbid Diseases in the Anesthesia Preoperative Evaluation Associates With Increased Length of Stay and Mortality. Anesth Analg 2021; 133:698-706. [PMID: 33591117 PMCID: PMC8280237 DOI: 10.1213/ane.0000000000005393] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The introduction of electronic health records (EHRs) has helped physicians access relevant medical information on their patients. However, the design of EHRs can make it hard for clinicians to easily find, review, and document all of the relevant data, leading to documentation that is not fully reflective of the complete history. We hypothesized that the incidence of undocumented key comorbid diseases (atrial fibrillation [afib], congestive heart failure [CHF], chronic obstructive pulmonary disease [COPD], diabetes, and chronic kidney disease [CKD]) in the anesthesia preoperative evaluation was associated with increased postoperative length of stay (LOS) and mortality. METHODS Charts of patients >18 years who received anesthesia in an inpatient facility were reviewed in this retrospective study. For each disease, a precise algorithm was developed to look for key structured data (medications, lab results, structured medical history, etc) in the EHR. Additionally, the checkboxes from the anesthesia preoperative evaluation were queried to determine the presence or absence of the documentation of the disease. Differences in mortality were modeled with logistic regression, and LOS was analyzed using linear regression. RESULTS A total of 91,011 cases met inclusion criteria (age 18-89 years; 52% women, 48% men; 70% admitted from home). Agreement between the algorithms and the preoperative note was >84% for all comorbidities other than chronic pain (63.5%). The algorithm-detected disease not documented by the anesthesia team in 34.5% of cases for chronic pain (vs 1.9% of cases where chronic pain was documented but not detected by the algorithm), 4.0% of cases for diabetes (vs 2.1%), 4.3% of cases for CHF (vs 0.7%), 4.3% of cases for COPD (vs 1.1%), 7.7% of cases for afib (vs 0.3%), and 10.8% of cases for CKD (vs 1.7%). To assess the association of missed documentation with outcomes, we compared patients where the disease was detected by the algorithm but not documented (A+/P-) with patients where the disease was documented (A+/P+). For all diseases except chronic pain, the missed documentation was associated with a longer LOS. For mortality, the discrepancy was associated with increased mortality for afib, while the differences were insignificant for the other diseases. For each missed disease, the odds of mortality increased 1.52 (95% confidence interval [CI], 1.42-1.63) and the LOS increased by approximately 11%, geometric mean ratio of 1.11 (95% CI, 1.10-1.12). CONCLUSIONS Anesthesia preoperative evaluations not infrequently fail to document disease for which there is evidence of disease in the EHR data. This missed documentation is associated with an increased LOS and mortality in perioperative patients.
Collapse
Affiliation(s)
- Ira S Hofer
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | | |
Collapse
|
32
|
Serrano AB, Gomez-Rojo M, Ureta E, Nuñez M, Fernández Félix B, Velasco E, Burgos J, Popova E, Urrutia G, Gomez V, Del Rey JM, Sanjuanbenito A, Zamora J, Monteagudo JM, Pestaña D, de la Torre B, Candela-Toha Á. Preoperative clinical model to predict myocardial injury after non-cardiac surgery: a retrospective analysis from the MANAGE cohort in a Spanish hospital. BMJ Open 2021; 11:e045052. [PMID: 34348944 PMCID: PMC8340283 DOI: 10.1136/bmjopen-2020-045052] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To determine preoperative factors associated to myocardial injury after non-cardiac surgery (MINS) and to develop a prediction model of MINS. DESIGN Retrospective analysis. SETTING Tertiary hospital in Spain. PARTICIPANTS Patients aged ≥45 years undergoing major non-cardiac surgery and with at least two measures of troponin levels within the first 3 days of the postoperative period. All patients were screened for the MANAGE trial. PRIMARY AND SECONDARY OUTCOME MEASURES We used multivariable logistic regression analysis to study risk factors associated with MINS and created a score predicting the preoperative risk for MINS and a nomogram to facilitate bed-side use. We used Least Absolute Shrinkage and Selection Operator method to choose the factors included in the predictive model with MINS as dependent variable. The predictive ability of the model was evaluated. Discrimination was assessed with the area under the receiver operating characteristic curve (AUC) and calibration was visually assessed using calibration plots representing deciles of predicted probability of MINS against the observed rate in each risk group and the calibration-in-the-large (CITL) and the calibration slope. We created a nomogram to facilitate obtaining risk estimates for patients at pre-anaesthesia evaluation. RESULTS Our cohort included 3633 patients recruited from 9 September 2014 to 17 July 2017. The incidence of MINS was 9%. Preoperative risk factors that increased the risk of MINS were age, American Status Anaesthesiology classification and vascular surgery. The predictive model showed good performance in terms of discrimination (AUC=0.720; 95% CI: 0.69 to 0.75) and calibration slope=1.043 (95% CI: 0.90 to 1.18) and CITL=0.00 (95% CI: -0.12 to 0.12). CONCLUSIONS Our predictive model based on routinely preoperative information is highly affordable and might be a useful tool to identify moderate-high risk patients before surgery. However, external validation is needed before implementation.
Collapse
Affiliation(s)
- Ana Belen Serrano
- Department of Anesthesiology and Surgical Critical Care, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Maria Gomez-Rojo
- Department of Anesthesiology and Surgical Critical Care, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Eva Ureta
- Department of Anesthesiology and Surgical Critical Care, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Monica Nuñez
- Department of Anesthesiology and Surgical Critical Care, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Borja Fernández Félix
- Clinical Biostatistics Unit, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Elisa Velasco
- Department of Cardiology, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Javier Burgos
- Department of Urology, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Ekaterine Popova
- Biomedical Research Institute, Iberoamerican Cochrane Center, (IIB Sant Pau), Barcelona, Catalunya, Spain
| | - Gerard Urrutia
- CIBER Epidemiología y Salud Pública (CIBERESP), Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Cataluña, Spain
| | - Victoria Gomez
- Department of Urology, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Jose Manuel Del Rey
- Department of Biochemistry, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Alfonso Sanjuanbenito
- Department of General Surgery, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Javier Zamora
- Clinical Biostatistics Unit, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Comunidad de Madrid, Spain
- Institute of metabolism and systems researchs, University of Birmingham, Birmingham, UK
| | | | - David Pestaña
- Department of Anesthesiology and Surgical Critical Care, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
- Universidad Alcalá de Henares, Madrid, Spain
| | - Basilio de la Torre
- Department of Traumatology, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| | - Ángel Candela-Toha
- Department of Anesthesiology and Surgical Critical Care, Ramon y Cajal University Hospital. IRYCIS, Madrid, Spain
| |
Collapse
|
33
|
Weersink CSA, van Waes JAR, Grobben RB, Nathoe HM, van Klei WA. Patient Selection for Routine Troponin Monitoring After Noncardiac Surgery. J Am Heart Assoc 2021; 10:e019912. [PMID: 34219462 PMCID: PMC8483467 DOI: 10.1161/jaha.120.019912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Myocardial infarction is an important complication after noncardiac surgery. Therefore, perioperative troponin surveillance is recommended for patients at risk. The aim of this study was to identify patients at high risk of perioperative myocardial infarction (POMI), in order to aid appropriate selection and to omit redundant laboratory measurements in patients at low risk. Methods and Results This observational cohort study included patients ≥60 years of age who underwent intermediate to high risk noncardiac surgery. Routine postoperative troponin I monitoring was performed. The primary outcome was POMI. Classification and regression tree analysis was used to identify patient groups with varying risks of POMI. In each subgroup, the number needed to screen to identify 1 patient with POMI was calculated. POMI occurred in 216 (4%) patients and other myocardial injury in 842 (15%) of the 5590 included patients. Classification and regression tree analysis divided patients into 14 subgroups in which the risk of POMI ranged from 1.7% to 42%. Using a risk of POMI ≥2% to select patients for routine troponin I monitoring, this monitoring would be advocated in patients ≥60 years of age undergoing emergency surgery, or those undergoing elective surgery with a Revised Cardiac Risk Index class >2 (ie >1 risk factor). The number needed to screen to detect a patient with POMI would be 14 (95% CI 14–14) and 26% of patients with POMI would be missed. Conclusions To improve selection of high‐risk patients ≥60 years of age, routine postoperative troponin I monitoring could be considered in patients undergoing emergency surgery, or in patients undergoing elective surgery classified as having a revised cardiac risk index class >2.
Collapse
Affiliation(s)
- Corien S A Weersink
- Department of Anesthesiology University Medical Center Utrecht Utrecht The Netherlands
| | - Judith A R van Waes
- Department of Anesthesiology University Medical Center Utrecht Utrecht The Netherlands
| | - Remco B Grobben
- Department of Cardiology University Medical Center Utrecht Utrecht The Netherlands
| | - Hendrik M Nathoe
- Department of Cardiology University Medical Center Utrecht Utrecht The Netherlands
| | - Wilton A van Klei
- Department of Anesthesiology University Medical Center Utrecht Utrecht The Netherlands
| |
Collapse
|
34
|
Sazgary L, Puelacher C, Lurati Buse G, Glarner N, Lampart A, Bolliger D, Steiner L, Gürke L, Wolff T, Mujagic E, Schaeren S, Lardinois D, Espinola J, Kindler C, Hammerer-Lercher A, Strebel I, Wildi K, Hidvegi R, Gueckel J, Hollenstein C, Breidthardt T, Rentsch K, Buser A, Gualandro DM, Mueller C. Incidence of major adverse cardiac events following non-cardiac surgery. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2021; 10:550–558. [PMID: 33620378 PMCID: PMC8245139 DOI: 10.1093/ehjacc/zuaa008] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/19/2020] [Accepted: 07/31/2020] [Indexed: 12/16/2022]
Abstract
AIMS Major adverse cardiac events (MACE) triggered by non-cardiac surgery are prognostically important perioperative complications. However, due to often asymptomatic presentation, the incidence and timing of postoperative MACE are incompletely understood. METHODS AND RESULTS We conducted a prospective observational study implementing a perioperative screening for postoperative MACE [cardiovascular death (CVD), acute heart failure (AHF), haemodynamically relevant arrhythmias, spontaneous myocardial infarction (MI), and perioperative myocardial infarction/injury (PMI)] in patients at increased cardiovascular risk (≥65 years OR ≥45 years with history of cardiovascular disease) undergoing non-cardiac surgery at a tertiary hospital. All patients received serial measurements of cardiac troponin to detect asymptomatic MACE. Among 2265 patients (mean age 73 years, 43.4% women), the incidence of MACE was 15.2% within 30 days, and 20.6% within 365 days. CVD occurred in 1.2% [95% confidence interval (CI) 0.9-1.8] and in 3.7% (95% CI 3.0-4.5), haemodynamically relevant arrhythmias in 1.2% (95% CI 0.9-1.8) and in 2.1% (95% CI 1.6-2.8), AHF in 1.6% (95% CI 1.2-2.2) and in 4.2% (95% CI 3.4-5.1), spontaneous MI in 0.5% (95% CI 0.3-0.9) and in 1.6% (95% CI 1.2-2.2), and PMI in 13.2% (95% CI 11.9-14.7) and in 14.8% (95% CI 13.4-16.4) within 30 days and within 365 days, respectively. The MACE-incidence was increased above presumed baseline rate until Day 135 (95% CI 104-163), indicating a vulnerable period of 3-5 months. CONCLUSION One out of five high-risk patients undergoing non-cardiac surgery will develop one or more MACE within 365 days. The risk for MACE remains increased for about 5 months after non-cardiac surgery. TRIAL REGISTRATION https://www.clinicaltrials.gov. Unique identifier: NCT02573532.
Collapse
Affiliation(s)
- Lorraine Sazgary
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
| | - Christian Puelacher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
| | - Giovanna Lurati Buse
- Department of Anesthesiology, University Hospital Dusseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
- Department of Anesthesiology, University Hospital Basel, Spitalstrasse 21 4031 Basel, University of Basel, Basel, Switzerland
| | - Noemi Glarner
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
| | - Andreas Lampart
- Department of Anesthesiology, University Hospital Basel, Spitalstrasse 21 4031 Basel, University of Basel, Basel, Switzerland
| | - Daniel Bolliger
- Department of Anesthesiology, University Hospital Basel, Spitalstrasse 21 4031 Basel, University of Basel, Basel, Switzerland
| | - Luzius Steiner
- Department of Anesthesiology, University Hospital Basel, Spitalstrasse 21 4031 Basel, University of Basel, Basel, Switzerland
| | - Lorenz Gürke
- Department of Vascular Surgery, University Hospital Basel, Spitalstrasse 21 4031 Basel, University of Basel, Basel, Switzerland
| | - Thomas Wolff
- Department of Vascular Surgery, University Hospital Basel, Spitalstrasse 21 4031 Basel, University of Basel, Basel, Switzerland
| | - Edin Mujagic
- Department of Vascular Surgery, University Hospital Basel, Spitalstrasse 21 4031 Basel, University of Basel, Basel, Switzerland
| | - Stefan Schaeren
- Department of Traumatology & Orthopedics, Spitalstrasse 21 4031 Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Didier Lardinois
- Department of Thoracic Surgery, University Hospital Basel, Spitalstrasse 21 4031 Basel, University of Basel, Basel, Switzerland
| | - Jacqueline Espinola
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
- Department of Anesthesiology, Cantonal Hospital Aarau, Tellstrasse 25 5001 Aarau, Switzerland
| | - Christoph Kindler
- Department of Anesthesiology, Cantonal Hospital Aarau, Tellstrasse 25 5001 Aarau, Switzerland
| | | | - Ivo Strebel
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
| | - Karin Wildi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
- Department of Anesthesiology, University Hospital Basel, Spitalstrasse 21 4031 Basel, University of Basel, Basel, Switzerland
| | - Reka Hidvegi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
| | - Johanna Gueckel
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
| | - Christina Hollenstein
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
| | - Tobias Breidthardt
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Petersgraben 4 4031 Basel, Switzerland
| | - Katharina Rentsch
- Department of Laboratory Medicine, University Hospital Basel, University of Basel, Petersgraben 4 4031 Basel, Switzerland
| | - Andreas Buser
- Blood Bank and Department of Hematology, University Hospital Basel, University of Basel, Petersgraben 4 4031 Basel, Switzerland
| | - Danielle M Gualandro
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
- Department of Cardiology, Incor, University of Sao Paulo, Av. Dr. Enéas Carvalho de Aguiar, 44 - Cerqueira César, São Paulo - SP, 05403-900 Sao Paulo, Brazil
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Basel, Switzerland
| |
Collapse
|
35
|
Beattie WS. The emergence of a postoperative myocardial injury epidemic: true or false? Can J Anaesth 2021; 68:1109-1119. [PMID: 34008088 DOI: 10.1007/s12630-021-02027-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 04/05/2021] [Accepted: 04/12/2021] [Indexed: 02/06/2023] Open
Affiliation(s)
- W Scott Beattie
- Department of Anesthesia and Pain Management, University of Toronto, Toronto, ON, Canada.
| |
Collapse
|
36
|
Remimazolam Anesthesia for MitraClip Implantation in a Patient with Advanced Heart Failure. Case Rep Anesthesiol 2021; 2021:5536442. [PMID: 34035965 PMCID: PMC8116154 DOI: 10.1155/2021/5536442] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/30/2021] [Indexed: 12/30/2022] Open
Abstract
Remimazolam, a novel and ultrashort-acting benzodiazepine, has been available for general anesthesia in Japan. The administration of remimazolam does not induce injection pain, has been reported to have less cardiovascular depressant effects during general anesthesia, and flumazenil can antagonize the effects of remimazolam. However, in clinical trials, no patient who is complicated with severe heart failure or undergoes cardiac surgery was included. We present anesthetic management with remimazolam for MitraClip® implantation in a patient with severe mitral regurgitation and advanced heart failure. Remimazolam was administered both in anesthetic induction and maintenance with less cardiovascular depressant effects. After surgical procedures were completed, the patient smoothly recovered from anesthesia and the tracheal was extubated just after administration of flumazenil. Remimazolam may be able to achieve appropriate anesthetic management in patients complicated with severe cardiovascular diseases.
Collapse
|
37
|
Abstract
PURPOSE OF REVIEW After successfully reducing mortality in the operating room, the time has come for anesthesiologists to conquer postoperative complications. This review aims to raise awareness about myocardial injury after noncardiac surgery (MINS), its definition, diagnosis, clinical importance, and treatment. RECENT FINDINGS MINS, defined as an elevated postoperative troponin judged to be due to myocardial ischemia (with or without ischemic features), occurs in up to one in five patients having noncardiac surgery and is responsible for 16% of all postoperative deaths within 30 days of surgery. New evidence on risk factors, etiology, potential prevention strategies, treatment options, and the economic impact of MINS highlights the actionability of perioperative clinicians in caring for adult patients who are considered to be at risk of cardiovascular complications. SUMMARY Millions of patients safely going through surgery suffer MINS and die shortly after the procedure every year. Without a structured approach to predicting, preventing, diagnosing, and treating MINS, we lose the opportunity to provide our patients with the best chance of deriving benefit from noncardiac surgery. The perioperative community needs to come together, appreciate the clinical relevance of MINS, and step up with high-quality research in the future.
Collapse
|
38
|
Howell SJ, Brown OI, Beattie WS. Aetiology of perioperative myocardial injury: a scientific conundrum with profound clinical implications. Br J Anaesth 2020; 125:642-646. [DOI: 10.1016/j.bja.2020.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 01/05/2023] Open
|
39
|
|
40
|
Ghersin I, Zahran M, Azzam ZS, Suleiman M, Bahouth F. Prognostic value of cardiac troponin levels in patients presenting with supraventricular tachycardias. J Electrocardiol 2020; 62:200-203. [PMID: 32980810 DOI: 10.1016/j.jelectrocard.2020.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/06/2020] [Accepted: 09/01/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND An association between paroxysmal supraventricular tachycardias (PSVT) and elevated cardiac troponin I (cTnI) has been reported in small studies, even in the absence of significant coronary artery or structural heart disease. We sought to explore the prognostic significance of elevated cTnI among patients presenting with PSVT. METHODS This is a retrospective single-center observational study conducted between January 2014 and Decemebr 2016. 165 patients (60% men, mean age 55 ± 17 year-old) with an acute episode of regular supraventricular tachyarrhythmia were admitted to the emergency department at Rambam Medical Center. 131 patients had at least one serum cTnI value measured. Of those, 57 had a positive result, defined as serum cTnI of more than 0.028 ng/dL. RESULTS Multivariate analysis showed that heart rate > 150 beats per minute (bpm) on admission (OR = 3.9; 95% CI 1.1.6-9.5; p < 0.003) and history of coronary artery disease (CAD) (OR = 3.4; 95% CI 1.2-10.1; p = 0.026) were the only independent predictors of cTnI elevation. After mean follow-up period of 23 ± 7 months, the combined primary outcome of death, coronary intervention (PCI) or myocardial infarction (MI) occurred in 7 patients (12.3%) out of 57 patients with positive cTnI and in zero patients with negative cTn (p = 0.002). Cox proportional hazard model showed that elevated cTnI on admission was an independent predictor of adverse outcomes only in patients with known coronary artery disease (CAD) (HR = 3.3, p = 0.05). CONCLUSION Elevated cTnI among patients presenting with PSVT appears to have prognostic significance only in patients with history of CAD. In this patient group elevated cTnI is associated with increased risk of adverse cardiac outcomes. We therefore believe serum cTnI should be measured selectively, such as in patients with symptoms of ischemic chest pain and a high pretest likelihood of having CAD.
Collapse
Affiliation(s)
- Itai Ghersin
- Department of Internal Medicine B, Rambam Health Care Campus, Haifa, Israel.
| | - Maria Zahran
- Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Zaher S Azzam
- Department of Internal Medicine B, Rambam Health Care Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Mahmoud Suleiman
- Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel; Department of Cardiology, Rambam Health Care Campus, Haifa, Israel
| | - Fadel Bahouth
- Department of Cardiology, Rambam Health Care Campus, Haifa, Israel; Department of Internal Medicine H, Rambam Health Care Campus, Haifa, Israel
| |
Collapse
|
41
|
Akkermans A, Vernooij LM, van Klei WA, van Waes JA. Postoperative visits by dedicated anesthesiologists in patients with elevated troponin: a retrospective cohort study evaluating postoperative care utility and early detection of complications. Perioper Med (Lond) 2020; 9:22. [PMID: 32695315 PMCID: PMC7364643 DOI: 10.1186/s13741-020-00152-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 06/10/2020] [Indexed: 11/23/2022] Open
Abstract
Background An elevated cardiac troponin level after noncardiac surgery is associated with both morbidity and mortality. Guidelines suggest routine troponin monitoring in high-risk patients. We implemented a dedicated anesthesia team to conduct follow-up on patients with postoperative troponin elevation. We hypothesized that these visits would facilitate early detection of complications. Therefore, the aim of this study was to evaluate the effect of postoperative visits by dedicated anesthesiologists on early detection of complications and care utility. Methods This retrospective observational study included patients aged ≥ 60 years with an elevated troponin within the first 3 days after noncardiac surgery. Troponin elevation was detected by routine biomarker monitoring. The primary outcome was early detected myocardial infarctions by the dedicated anesthesiologist. Other outcomes were overall detected complications, additional diagnostic tests and treatment advised by the anesthesiologist, consultation of another medical specialist, and advised postoperative follow-up at the outpatient cardiac clinic within 1 week after surgery. Results Of the 811 patients, 509 (63%) received a postoperative consultation by the anesthesiologist. Anesthesiologists were involved in the early detection of 59% of all myocardial infarctions and in 12% of all complications. Besides cardiac ischemia, patients were also often diagnosed with noncardiac complications, including respiratory failure (8.9%), pneumonia (13.2%), and acute kidney injury (17.5%) within 1 week after surgery. In 75% of patients, anesthesiologists ordered additional diagnostics, most frequently existing of electrocardiograms and additional cardiac enzyme testing. Additionally, change in treatment was advised, most often a medication change, in 16% of patients. Conclusions Standard consultation of a dedicated anesthesiologist resulted in an early detection of 59% of all myocardial infarctions and involved a change in treatment in a considerable number of patients with postoperative troponin elevation. Whether this may improve patient outcomes remains to be elucidated.
Collapse
Affiliation(s)
- Annemarie Akkermans
- Department of Anesthesiology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Lisette M Vernooij
- Department of Anesthesiology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands.,Department of Epidemiology, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wilton A van Klei
- Department of Anesthesiology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Judith A van Waes
- Department of Anesthesiology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| |
Collapse
|
42
|
Immediate postoperative high-sensitivity troponin T concentrations and long-term patient-reported health-related quality of life: A prospective cohort study. Eur J Anaesthesiol 2020; 37:680-687. [PMID: 32618756 DOI: 10.1097/eja.0000000000001234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Myocardial injury after noncardiac surgery is associated with mortality and major adverse postoperative cardiovascular events. The effect of postoperative troponin concentrations on patient-reported health-related quality of life (HRQoL) is unknown. OBJECTIVE The study examined the association between immediate postoperative troponin concentrations and self-reported HRQoL 1 year after surgery. DESIGN Prospective cohort study. SETTING Single-centre tertiary care hospital in the Netherlands between July 2012 and 2015. PATIENTS Patients aged at least 60 years undergoing moderate and major noncardiac surgery. INTERVENTION None. MAIN OUTCOME MEASURES HRQoL total score was assessed with the EuroQol five-dimensional questionnaire. Tobit regression analysis was used to determine the association between postoperative troponin concentrations and 1-year HRQoL. Peak high-sensitivity troponin T values were divided into four categories: less than 14, 14 to 49, 50 to 149 and at least 150 ng l. RESULTS A total of 3085 patients with troponin measurements were included. 2634 (85.4%) patients were alive at 1-year follow-up of whom 1297 (49.2%) returned a completed questionnaire. The median score for HRQoL was 0.82 (0.85, 0.81, 0.77 and 0.71 per increasing troponin category). Multivariable analysis revealed betas of -0.06 [95% confidence interval (CI) -0.09 to -0.02], -0.11 (95% CI -0.18 to -0.04) and -0.18 (95% CI -0.29 to -0.07) for troponin levels of 14 to 49, 50 to 149 and at least 150 ng l when compared with values less than 14 ng l. Other independent predictors for lower HRQoL were chronic obstructive pulmonary disease, female sex, peripheral arterial disease and increasing age. CONCLUSION Higher levels of postoperative troponin measured immediately after surgery were independently associated with lower self-reported HRQoL total score at 1-year follow-up.
Collapse
|
43
|
Uchoa RB, Caramelli B. Troponin I as a mortality marker after lung resection surgery - a prospective cohort study. BMC Anesthesiol 2020; 20:118. [PMID: 32429842 PMCID: PMC7236915 DOI: 10.1186/s12871-020-01037-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 05/12/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiovascular complications associated with thoracic surgery increase morbidity, mortality, and treatment costs. Elevated cardiac troponin level represents a predictor of complications after non-cardiac surgeries, but its role after thoracic surgeries remains undetermined. The objective of this study was to analyze the relationship between troponin I elevation and morbidity and mortality after one year in patients undergoing lung resection surgery. METHODS This prospective cohort study evaluated 151 consecutive patients subjected to elective lung resection procedures using conventional and video-assisted thoracoscopic techniques at a University Hospital in Brazil, from July 2012 to November 2015. Preoperative risk stratification was performed using the scores obtained by the American College of Physicians (ACP) and the Society of Cardiology of the state of São Paulo (EMAPO) scoring systems. Troponin I levels were measured in the immediate postoperative period (POi) and on the first and second postoperative days. RESULTS Most patients had a low risk for complications according to the ACP (96.7%) and EMAPO (82.8%) scores. Approximately 49% of the patients exhibited increased troponin I (≥0.16 ng/ml), at least once, and 22 (14.6%) died in one year. Multivariate analysis showed that the elevation of troponin I, on the first postoperative day, correlated with a 12-fold increase in mortality risk within one year (HR 12.02, 95% CI: 1.82-79.5; p = 0.01). CONCLUSIONS In patients undergoing lung resection surgery, with a low risk of complications according to the preoperative evaluation scores, an increase in troponin I levels above 0.16 ng/ml in the first postoperative period correlated with an increase in mortality within one year.
Collapse
Affiliation(s)
- Ricardo B Uchoa
- Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Rua Maestro Elias Lobo 596, São Paulo, SP, CEP 01433-000, Brazil
| | - Bruno Caramelli
- Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Rua Maestro Elias Lobo 596, São Paulo, SP, CEP 01433-000, Brazil.
| |
Collapse
|
44
|
Ackland GL, Abbott TEF, Jones TF, Leuwer M, Pearse RM. Early elevation in plasma high-sensitivity troponin T and morbidity after elective noncardiac surgery: prospective multicentre observational cohort study. Br J Anaesth 2020; 124:535-543. [PMID: 32147104 DOI: 10.1016/j.bja.2020.02.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 01/28/2020] [Accepted: 02/03/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Elevated high-sensitivity troponin (hsTnT) after noncardiac surgery is associated with higher mortality, but the temporal relationship between early elevated troponin and the later development of noncardiac morbidity remains unclear. METHODS Prospective observational study of patients aged ≥45 yr undergoing major noncardiac surgery at four UK hospitals (two masked to hsTnT). The exposure of interest was early elevated troponin, as defined by hsTnT >99th centile (≥15 ng L-1) within 24 h after surgery. The primary outcome was morbidity 72 h after surgery, defined by the Postoperative Morbidity Survey (POMS). Secondary outcomes were time to become morbidity-free and Clavien-Dindo ≥grade 3 complications. RESULTS Early elevated troponin (median 21 ng L-1 [16-32]) occurred in 992 of 4335 (22.9%) patients undergoing elective noncardiac surgery (mean [standard deviation, sd] age, 65 [11] yr; 2385 [54.9%] male). Noncardiac morbidity was more frequent in 494/992 (49.8%) patients with early elevated troponin compared with 1127/3343 (33.7%) patients with hsTnT <99th centile (odds ratio [OR]=1.95; 95% confidence interval [CI], 1.69-2.25). Patients with early elevated troponin had a higher risk of proven/suspected infectious morbidity (OR=1.54; 95% CI, 1.24-1.91) and critical care utilisation (OR=2.05; 95% CI, 1.73-2.43). Clavien-Dindo ≥grade 3 complications occurred in 167/992 (16.8%) patients with early elevated troponin, compared with 319/3343 (9.5%) patients with hsTnT <99th centile (OR=1.78; 95% CI, 1.48-2.14). Absence of early elevated troponin was associated with morbidity-free recovery (OR=0.44; 95% CI, 0.39-0.51). CONCLUSIONS Early elevated troponin within 24 h of elective noncardiac surgery precedes the subsequent development of noncardiac organ dysfunction and may help stratify levels of postoperative care in real time.
Collapse
Affiliation(s)
- Gareth L Ackland
- William Harvey Research Institute, Queen Mary University of London, London, UK.
| | - Tom E F Abbott
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Timothy F Jones
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Martin Leuwer
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Rupert M Pearse
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | | | | | | | | |
Collapse
|
45
|
De Hert SG, Lurati Buse GA. Cardiac Biomarkers for the Prediction and Detection of Adverse Cardiac Events After Noncardiac Surgery: A Narrative Review. Anesth Analg 2020; 131:187-195. [DOI: 10.1213/ane.0000000000004711] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
|
46
|
Abstract
Myocardial injury after noncardiac surgery (MINS) is a common postoperative complication associated with adverse cardiovascular outcomes. The purpose of this systematic review was to determine the incidence, clinical features, pathogenesis, management, and outcomes of MINS. We searched PubMed, Embase, Central and Web of Science databases for studies reporting the incidence, clinical features, and prognosis of MINS. Data analysis was performed with a mixed-methods approach, with quantitative analysis of meta-analytic methods for incidence, management, and outcomes, and a qualitative synthesis of the literature to determine associated preoperative factors and MINS pathogenesis. A total of 195 studies met study inclusion criteria. Among 169 studies reporting outcomes of 530,867 surgeries, the pooled incidence of MINS was 17.9% [95% confidence interval (CI), 16.2-19.6%]. Patients with MINS were older, more frequently men, and more likely to have cardiovascular risk factors and known coronary artery disease. Postoperative mortality was higher among patients with MINS than those without MINS, both in-hospital (8.1%, 95% CI, 4.4-12.7% vs 0.4%, 95% CI, 0.2-0.7%; relative risk 8.3, 95% CI, 4.2-16.6, P < 0.001) and at 1-year after surgery (20.6%, 95% CI, 15.9-25.7% vs 5.1%, 95% CI, 3.2-7.4%; relative risk 4.1, 95% CI, 3.0-5.6, P < 0.001). Few studies reported mechanisms of MINS or the medical treatment provided. In conclusion, MINS occurs frequently in clinical practice, is most common in patients with cardiovascular disease and its risk factors, and is associated with increased short- and long-term mortality. Additional investigation is needed to define strategies to prevent MINS and treat patients with this diagnosis.
Collapse
|
47
|
Marsman M, van Waes JAR, Grobben RB, Weersink CSA, van Klei WA. Added value of subjective assessed functional capacity before non-cardiac surgery in predicting postoperative myocardial injury. Eur J Prev Cardiol 2020; 28:262-269. [PMID: 33891688 DOI: 10.1177/2047487320906918] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 01/27/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Functional capacity is used as an indicator for cardiac testing before non-cardiac surgery and is often performed subjectively. However, the value of subjectively estimated functional capacity in predicting cardiac complications is under debate. We determined the predictive value of subjectively assessed functional capacity on postoperative cardiac complications and mortality. DESIGN An observational cohort study in patients aged 60 years and over undergoing elective inpatient non-cardiac surgery in a tertiary referral hospital. METHODS Subjective functional capacity was determined by anaesthesiologists. The primary outcome was postoperative myocardial injury. Secondary outcomes were postoperative inhospital myocardial infarction and one year mortality. Logistic regression analysis and area under the receiver operating curves were used to determine the added value of functional capacity. RESULTS A total of 4879 patients was included; 824 (17%) patients had a poor subjective functional capacity. Postoperative myocardial injury occurred in 718 patients (15%). Poor functional capacity was associated with myocardial injury (relative risk (RR) 1.7, 95% confidence interval (CI) 1.5-2.0; P < 0.001), postoperative myocardial infarction (RR 2.9, 95% CI 1.9-4.2; P < 0.001) and one year mortality (RR 1.7, 95% CI 1.4-2.0; P < 0.001). After adjustment for other predictors, functional capacity was still a significant predictor for myocardial injury (odds ratio (OR) 1.3, 95% CI 1.0-1.7; P = 0.023), postoperative myocardial infarction (OR 2.0, 95% CI 1.3-3.0; P = 0.002) and one year mortality (OR 1.4, 95% CI 1.1-1.8; P = 0.003), but had no added value on top of other predictors. CONCLUSIONS Subjectively assessed functional capacity is a predictor of postoperative myocardial injury and death, but had no added value on top of other preoperative predictors.
Collapse
Affiliation(s)
- Marije Marsman
- Department of Anesthesiology, Universitair Medisch Centrum Utrecht, The Netherlands
| | - Judith A R van Waes
- Department of Anesthesiology, Universitair Medisch Centrum Utrecht, The Netherlands
| | - Remco B Grobben
- Department of Cardiology, Universitair Medisch Centrum Utrecht, The Netherlands
| | - Corien S A Weersink
- Department of Anesthesiology, Universitair Medisch Centrum Utrecht, The Netherlands
| | - Wilton A van Klei
- Department of Anesthesiology, Universitair Medisch Centrum Utrecht, The Netherlands
| |
Collapse
|
48
|
González-Tallada A, Borrell-Vega J, Coronado C, Morales P, de Miguel M, Ferreira-González I, de Nadal M. Myocardial Injury After Noncardiac Surgery: Incidence, Predictive Factors, and Outcome in High-Risk Patients Undergoing Thoracic Surgery: An Observational Study. J Cardiothorac Vasc Anesth 2020; 34:426-432. [DOI: 10.1053/j.jvca.2019.08.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 08/04/2019] [Accepted: 08/07/2019] [Indexed: 11/11/2022]
|
49
|
Meershoek AJA, Leunissen TC, van Waes JAR, Klei WA, Huisman A, de Groot MCH, Hoefer IE, van Solinge WW, Moll FL, de Borst GJ. Reticulated Platelets as Predictor of Myocardial Injury and 30 Day Mortality After Non-cardiac Surgery. Eur J Vasc Endovasc Surg 2019; 59:309-318. [PMID: 31812606 DOI: 10.1016/j.ejvs.2019.06.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 04/09/2019] [Accepted: 06/22/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE A pre-operative marker for identification of patients at risk of peri-operative adverse events and 30 day mortality might be the percentage of young, reticulated platelets (pRP). This study aimed to determine the predictive value of pre-operative pRP on post-operative myocardial injury (PMI) and 30 day mortality, in patients aged ≥ 60 years undergoing moderate to high risk non-cardiac surgery. METHODS The incidence of PMI (troponin I > 0.06 μg/L) and 30 day mortality was compared for patients with normal and high pRP (≥2.82%) obtained from The Utrecht Patient Orientated Database. The predictive pRP value was assessed using logistic regression. A prediction model for PMI or 30 day mortality with known risk factors was compared with a model including increased pRP using the area under the receiving operator characteristics curve (AUROC). RESULTS In total, 26.5% (607/2289) patients showed pre-operative increased pRP. Increased pRP was associated with more PMI and 30 day mortality compared with normal pRP (36.1% vs. 28.3%, p < .001 and 8.6% vs. 3.6%, p < .001). The median pRP was higher in patients suffering PMI and 30 day mortality compared with not (2.21 [IQR: 1.57-3.11] vs. 2.07 [IQR: 1.52-1.78], p = .002, and 2.63 [IQR: 1.76-4.15] vs. 2.09 [IQR: 1.52-3.98], p < .001). pRP was independently related to PMI (OR: 1.28 [95% CI: 1.04-1.59], p = .02) and 30 day mortality (OR: 2.35 [95% CI: 1.56-3.55], p < .001). Adding increased pRP to the predictive model of PMI or 30 day mortality did not increase the AUROC 0.71 vs. 0.72, and 0.80 vs. 0.81. CONCLUSION In patients undergoing major non-cardiac surgery, increased pre-operative pRP is related to 30 day mortality and PMI.
Collapse
Affiliation(s)
- Armelle J A Meershoek
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Tesse C Leunissen
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands; Department of Clinical Chemistry and Haematology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Judith A R van Waes
- Department of Anaesthesiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Wilton A Klei
- Department of Anaesthesiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Albert Huisman
- Department of Clinical Chemistry and Haematology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Mark C H de Groot
- Department of Clinical Chemistry and Haematology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Imo E Hoefer
- Department of Clinical Chemistry and Haematology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Wouter W van Solinge
- Department of Clinical Chemistry and Haematology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Frans L Moll
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands.
| |
Collapse
|
50
|
Bojesen RD, Fitzgerald P, Munk-Madsen P, Eriksen JR, Kehlet H, Gögenur I. The clinical implication of the association between hypoxaemia and postoperative troponin I: a reply. Anaesthesia 2019; 75:128-129. [PMID: 31794643 DOI: 10.1111/anae.14917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | | | | | | | - H Kehlet
- Zealand University Hospital, Køge, Denmark
| | - I Gögenur
- Zealand University Hospital, Køge, Denmark
| |
Collapse
|