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M'Pembele R, Roth S, Lurati Buse G. [The role of cardiac biomarkers in perioperative risk evaluation of noncardiac surgery patients-A summary of the ESAIC guidelines 2023]. DIE ANAESTHESIOLOGIE 2024; 73:44-50. [PMID: 38063866 PMCID: PMC10791894 DOI: 10.1007/s00101-023-01363-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/23/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND The recently published ESAIC guidelines highlight the clinical value of cardiac troponins (cTn) and B‑type natriuretic peptides (BNP) for risk assessment in patients undergoing noncardiac surgery. OBJECTIVE Summary of the ESAIC guideline recommendations. MATERIAL AND METHODS The evidence for the recommendations was extracted from studies that investigated the perioperative role of cTn and BNP as prognostic factors, for risk prediction and for therapeutic guidance. To collate this evidence 12 relevant endpoints as well as risk benefit analyses of systematic screening were considered to issue the strength of the recommendations. RESULTS The body of evidence for these guidelines was based on 115 studies. The evidence varied significantly across the 12 predefined endpoints. Additionally, there was a gradient in evidence for the use of cTn and BNP as prognostic factors, for risk prediction and for therapeutic guidance. The guidelines issue a weak recommendation for the use of preoperative, postoperative and combined measurement of cTn as well as for preoperative BNP measurement to assess the prognosis. For risk prediction a weak recommendation was formulated for combined and postoperative cTn and preoperative BNP measurements. No recommendation could be given for the evidence on biomarkers as data were very limited. CONCLUSION Both cTn and BNP can be used as prognostic factors or to predict the risk for selected endpoints. Therapeutic interventions should not be guided by cardiac biomarker levels.
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Affiliation(s)
- René M'Pembele
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Moorenstr. 5, 40225, Düsseldorf, Deutschland.
- CARID (Cardiovascular Research Institute Düsseldorf), Universitätsklinikum Düsseldorf, Heinrich Heine Universität, Düsseldorf, Deutschland.
| | - Sebastian Roth
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Moorenstr. 5, 40225, Düsseldorf, Deutschland
- CARID (Cardiovascular Research Institute Düsseldorf), Universitätsklinikum Düsseldorf, Heinrich Heine Universität, Düsseldorf, Deutschland
| | - Giovanna Lurati Buse
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Moorenstr. 5, 40225, Düsseldorf, Deutschland
- CARID (Cardiovascular Research Institute Düsseldorf), Universitätsklinikum Düsseldorf, Heinrich Heine Universität, Düsseldorf, Deutschland
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Lurati Buse G, Bollen Pinto B, Abelha F, Abbott TEF, Ackland G, Afshari A, De Hert S, Fellahi JL, Giossi L, Kavsak P, Longrois D, M'Pembele R, Nucaro A, Popova E, Puelacher C, Richards T, Roth S, Sheka M, Szczeklik W, van Waes J, Walder B, Chew MS. ESAIC focused guideline for the use of cardiac biomarkers in perioperative risk evaluation. Eur J Anaesthesiol 2023; 40:888-927. [PMID: 37265332 DOI: 10.1097/eja.0000000000001865] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND In recent years, there has been increasing focus on the use of cardiac biomarkers in patients undergoing noncardiac surgery. AIMS The aim of this focused guideline was to provide updated guidance regarding the pre-, post- and combined pre-and postoperative use of cardiac troponin and B-type natriuretic peptides in adult patients undergoing noncardiac surgery. METHODS The guidelines were prepared using Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology. This included the definition of critical outcomes, a systematic literature search, appraisal of certainty of evidence, evaluation of biomarker measurement in terms of the balance of desirable and undesirable effects including clinical outcomes, resource use, health inequality, stakeholder acceptance, and implementation. The panel differentiated between three different scopes of applications: cardiac biomarkers as prognostic factors, as tools for risk prediction, and for biomarker-enhanced management strategies. RESULTS In a modified Delphi process, the task force defined 12 critical outcomes. The systematic literature search resulted in over 25,000 hits, of which 115 full-text articles formed the body of evidence for recommendations. The evidence appraisal indicated heterogeneity in the certainty of evidence across critical outcomes. Further, there was relevant gradient in the certainty of evidence across the three scopes of application. Recommendations were issued and if this was not possible due to limited evidence, clinical practice statements were produced. CONCLUSION The ESAIC focused guidelines provide guidance on the perioperative use of cardiac troponin and B-type natriuretic peptides in patients undergoing noncardiac surgery, for three different scopes of application.
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Affiliation(s)
- Giovanna Lurati Buse
- From the Department of Anaesthesiology, University Hospital Dusseldorf, Dusseldorf, Germany (GLB, RMP, AN, SR), Division of Anaesthesiology, Geneva University Hospitals (HUG), Geneva, Switzerland (BBP, MS, BW), Department of Anesthesiology, Centro Hospitalar Universitário de São João, Porto, Portugal (FA), Cardiovascular Research and Development Center (UnIC@RISE), Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal (FA), William Harvey Research Institute, Queen Mary University of London, London, UK (TEA, GA), Department of Anaesthesia and Perioperative Medicine, Royal London Hospital, Barts Health NHS Trust, London, UK (GA), Department of Paediatric and Obstetric Anaesthesia, Rigshospitalet & Department of Clinical Medicine, Copenhagen University, Denmark (AA), Department of Anaesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium (SDH), Service d'Anesthésie-Réanimation, Hôpital Universitaire Louis Pradel, Hospices Civils de Lyon, 59 boulevard Pinel, 69500 Lyon, France (J-LF), "Patients as Partners" program, Geneva University Hospitals (HUG), Geneva, Switzerland (LG), Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada (PK), Department of Anesthesiology and Intensive Care, Bichat Claude-Bernard Hospital, Assistance Publique-Hopitaux de Paris - Nord, University of Paris, INSERM U1148, Paris, France (DL), Institut d'Investigació Biomèdica Sant Pau (IIB SANT PAU), Barcelona, Spain (EP), Centro Cochrane Iberoamericano, Barcelona, Spain (EP), Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel-Stadt, Switzerland (CP), Department of Internal Medicine, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Basel-Stadt, Switzerland (CP), Division of Surgery, University of Western Australia, Perkins South Building, Fiona Stanley Hospital, Murdoch, Perth, WA, Australia (TR), Institute of Clinical Trials and Methodology and Division of Surgery, University College London, UK (TR), Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland (WS), Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (JvW), Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University Hospital, Sweden (MSC)
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Yang L, Shi S, Li J, Fang Z, Guo J, Kang W, Shi J, Yuan S, Yan F, Zhou C. Postoperative elevated cardiac troponin levels predict all-cause mortality and major adverse cardiovascular events following noncardiac surgery: A dose-response meta-analysis of prospective studies. J Clin Anesth 2023; 90:111229. [PMID: 37573706 DOI: 10.1016/j.jclinane.2023.111229] [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: 02/28/2023] [Revised: 07/24/2023] [Accepted: 08/08/2023] [Indexed: 08/15/2023]
Abstract
STUDY OBJECTIVE To perform a dose-response meta-analysis for the association between postoperative myocardial injury (PMI) in noncardiac surgery and the risk of all-cause mortality or major adverse cardiovascular event (MACE). DESIGN Dose-response meta-analysis of prospective studies with weighted (WL) or generalized (GL) linear and restricted cubic spline (RCS) regression. SETTING Teaching hospitals. PATIENTS Adult patients undergoing noncardiac surgery. INTERVENTIONS No. MEASUREMENTS The primary outcome was all-cause mortality. The secondary outcome was MACE. MAIN RESULTS 29 studies (53,518 patients) were included. The overall incidence of PMI was 26.0% (95% CI 21.0% to 32.0%). Compared to those without PMI, patients with PMI had an increased risk of all-cause mortality at short- (<12 months) (cardiac troponin[cTn]I: unadj OR 1.71,95%CI 1.22 to 2.41, P < 0.001; cTnT: unadj OR 2.33,95%CI 2.07 to 2.63, P < 0.001), and long-term (≥ 12 months) (cTnI: unadj OR 1.80, 95%CI 1.63 to 1.99; cTnT: unadj OR 1.47,95%CI 1.33 to 1.62) (All P < 0.001) follow-up. For MACE, the group with elevated values was associated with an increased risk (cTnI: unadj OR 1.98, 95% CI 1.13 to 3.47, P = 0.018; cTnT: unadj OR 2.29, 95% CI 1.88 to 2.79, P < 0.001). Dose-response analysis showed positive associations between PMI (per 1× upper reference limit[URL] increment) and all-cause mortality both at short- (unadj OR) (WL, OR 1.09, 95% CI 1.09 to 1.10; GL, OR 1.06, 95% CI 1.06 to 1.07; RCS in the range of 1-2× URL, OR = 2.43, 95%CI 2.25 to 2.62) and long-term follow-up (unadj HR) (WL, OR 1.16, 95% CI 1.14 to 1.17; GL, OR 1.15, 95% CI 1.13 to 1.16; RCS in the range of 1-2.75× URL, OR = 1.23, 95%CI 1.13 to 1.33), and MACE at longest follow-up (unadj OR) (WL: OR 1.53, 95% CI 1.49 to 1.57; GL: OR 1.46, 95% CI 1.42 to 1.50; RCS in the range of 1-2 x URL, OR = 3.10, 95%CI 2.51 to 3.81) (All P < 0.001). For mild cTn increase below URL, the risk of mortality increased with every increment of 0.25xURL (WL, OR 1.03, 95% CI 1.02 to 1.03; GL, OR 1.05, 95% CI 1.03 to 1.07; RCS in the range of 0-0.5 URL, OR = 9.41, 95% CI 7.41 to 11.95) (All P < 0.001). CONCLUSIONS This study shows positive WL or GL and RCS dose-response relationships between PMI and all-cause mortality at short (< 12 mons)- and long-term (≥ 12 mons) follow-up, and MACE at longest follow-up. For mild cTn increase below URL, the risk of mortality also increases even with every increment of 0.25× URL.
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Affiliation(s)
- Lijing Yang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Sheng Shi
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Jun Li
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Zhongrong Fang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Jingfei Guo
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Wenying Kang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Jia Shi
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Su Yuan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Fuxia Yan
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Chenghui Zhou
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China; Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China.
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Vernooij LM, van Klei WA, Moons KG, Takada T, van Waes J, Damen JA. The comparative and added prognostic value of biomarkers to the Revised Cardiac Risk Index for preoperative prediction of major adverse cardiac events and all-cause mortality in patients who undergo noncardiac surgery. Cochrane Database Syst Rev 2021; 12:CD013139. [PMID: 34931303 PMCID: PMC8689147 DOI: 10.1002/14651858.cd013139.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The Revised Cardiac Risk Index (RCRI) is a widely acknowledged prognostic model to estimate preoperatively the probability of developing in-hospital major adverse cardiac events (MACE) in patients undergoing noncardiac surgery. However, the RCRI does not always make accurate predictions, so various studies have investigated whether biomarkers added to or compared with the RCRI could improve this. OBJECTIVES Primary: To investigate the added predictive value of biomarkers to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery. Secondary: To investigate the prognostic value of biomarkers compared to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery. Tertiary: To investigate the prognostic value of other prediction models compared to the RCRI to preoperatively predict in-hospital MACE and other adverse outcomes in patients undergoing noncardiac surgery. SEARCH METHODS We searched MEDLINE and Embase from 1 January 1999 (the year that the RCRI was published) until 25 June 2020. We also searched ISI Web of Science and SCOPUS for articles referring to the original RCRI development study in that period. SELECTION CRITERIA We included studies among adults who underwent noncardiac surgery, reporting on (external) validation of the RCRI and: - the addition of biomarker(s) to the RCRI; or - the comparison of the predictive accuracy of biomarker(s) to the RCRI; or - the comparison of the predictive accuracy of the RCRI to other models. Besides MACE, all other adverse outcomes were considered for inclusion. DATA COLLECTION AND ANALYSIS We developed a data extraction form based on the CHARMS checklist. Independent pairs of authors screened references, extracted data and assessed risk of bias and concerns regarding applicability according to PROBAST. For biomarkers and prediction models that were added or compared to the RCRI in ≥ 3 different articles, we described study characteristics and findings in further detail. We did not apply GRADE as no guidance is available for prognostic model reviews. MAIN RESULTS We screened 3960 records and included 107 articles. Over all objectives we rated risk of bias as high in ≥ 1 domain in 90% of included studies, particularly in the analysis domain. Statistical pooling or meta-analysis of reported results was impossible due to heterogeneity in various aspects: outcomes used, scale by which the biomarker was added/compared to the RCRI, prediction horizons and studied populations. Added predictive value of biomarkers to the RCRI Fifty-one studies reported on the added value of biomarkers to the RCRI. Sixty-nine different predictors were identified derived from blood (29%), imaging (33%) or other sources (38%). Addition of NT-proBNP, troponin or their combination improved the RCRI for predicting MACE (median delta c-statistics: 0.08, 0.14 and 0.12 for NT-proBNP, troponin and their combination, respectively). The median total net reclassification index (NRI) was 0.16 and 0.74 after addition of troponin and NT-proBNP to the RCRI, respectively. Calibration was not reported. To predict myocardial infarction, the median delta c-statistic when NT-proBNP was added to the RCRI was 0.09, and 0.06 for prediction of all-cause mortality and MACE combined. For BNP and copeptin, data were not sufficient to provide results on their added predictive performance, for any of the outcomes. Comparison of the predictive value of biomarkers to the RCRI Fifty-one studies assessed the predictive performance of biomarkers alone compared to the RCRI. We identified 60 unique predictors derived from blood (38%), imaging (30%) or other sources, such as the American Society of Anesthesiologists (ASA) classification (32%). Predictions were similar between the ASA classification and the RCRI for all studied outcomes. In studies different from those identified in objective 1, the median delta c-statistic was 0.15 and 0.12 in favour of BNP and NT-proBNP alone, respectively, when compared to the RCRI, for the prediction of MACE. For C-reactive protein, the predictive performance was similar to the RCRI. For other biomarkers and outcomes, data were insufficient to provide summary results. One study reported on calibration and none on reclassification. Comparison of the predictive value of other prognostic models to the RCRI Fifty-two articles compared the predictive ability of the RCRI to other prognostic models. Of these, 42% developed a new prediction model, 22% updated the RCRI, or another prediction model, and 37% validated an existing prediction model. None of the other prediction models showed better performance in predicting MACE than the RCRI. To predict myocardial infarction and cardiac arrest, ACS-NSQIP-MICA had a higher median delta c-statistic of 0.11 compared to the RCRI. To predict all-cause mortality, the median delta c-statistic was 0.15 higher in favour of ACS-NSQIP-SRS compared to the RCRI. Predictive performance was not better for CHADS2, CHA2DS2-VASc, R2CHADS2, Goldman index, Detsky index or VSG-CRI compared to the RCRI for any of the outcomes. Calibration and reclassification were reported in only one and three studies, respectively. AUTHORS' CONCLUSIONS Studies included in this review suggest that the predictive performance of the RCRI in predicting MACE is improved when NT-proBNP, troponin or their combination are added. Other studies indicate that BNP and NT-proBNP, when used in isolation, may even have a higher discriminative performance than the RCRI. There was insufficient evidence of a difference between the predictive accuracy of the RCRI and other prediction models in predicting MACE. However, ACS-NSQIP-MICA and ACS-NSQIP-SRS outperformed the RCRI in predicting myocardial infarction and cardiac arrest combined, and all-cause mortality, respectively. Nevertheless, the results cannot be interpreted as conclusive due to high risks of bias in a majority of papers, and pooling was impossible due to heterogeneity in outcomes, prediction horizons, biomarkers and studied populations. Future research on the added prognostic value of biomarkers to existing prediction models should focus on biomarkers with good predictive accuracy in other settings (e.g. diagnosis of myocardial infarction) and identification of biomarkers from omics data. They should be compared to novel biomarkers with so far insufficient evidence compared to established ones, including NT-proBNP or troponins. Adherence to recent guidance for prediction model studies (e.g. TRIPOD; PROBAST) and use of standardised outcome definitions in primary studies is highly recommended to facilitate systematic review and meta-analyses in the future.
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Affiliation(s)
- Lisette M Vernooij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Wilton A van Klei
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Anesthesiologist and R. Fraser Elliott Chair in Cardiac Anesthesia, Department of Anesthesia and Pain Management Toronto General Hospital, University Health Network and Professor, Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Karel Gm Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Judith van Waes
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Johanna Aag Damen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Toda H, Nakamura K, Shimizu K, Ejiri K, Iwano T, Miyoshi T, Nakagawa K, Yoshida M, Watanabe A, Nishii N, Hikasa Y, Hayashi M, Morita H, Morimatsu H, Ito H. Effects of Bisoprolol Transdermal Patches for Prevention of Perioperative Myocardial Injury in High-Risk Patients Undergoing Non-Cardiac Surgery ― Multicenter Randomized Controlled Study ―. Circ J 2020; 84:642-649. [DOI: 10.1253/circj.cj-19-0871] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Hironobu Toda
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Kazuyoshi Shimizu
- Department of Anesthesiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Kentaro Ejiri
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Takayuki Iwano
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Toru Miyoshi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Koji Nakagawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Masashi Yoshida
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Atsuyuki Watanabe
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Nobuhiro Nishii
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Yukiko Hikasa
- Department of Anesthesiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Masao Hayashi
- Department of Anesthesiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hiroshi Morita
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hiroshi Morimatsu
- Department of Anesthesiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
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Whittaker JD, Downes F, Becker H, Garnham A, Wall M. In Response to "Biomarkers in Peripheral Vascular Surgery". J Cardiothorac Vasc Anesth 2019; 33:1481. [PMID: 30737124 DOI: 10.1053/j.jvca.2019.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Indexed: 11/11/2022]
Affiliation(s)
| | - Frederick Downes
- Black Country Vascular Network, Russell's Hall Hospital, Dudley, UK
| | - Helga Becker
- Black Country Vascular Network, Russell's Hall Hospital, Dudley, UK
| | - Andrew Garnham
- Black Country Vascular Network, Russell's Hall Hospital, Dudley, UK
| | - Michael Wall
- Black Country Vascular Network, Russell's Hall Hospital, Dudley, UK
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Główczyńska R, Raszeja-Wyszomirska J, Janik M, Kostrzewa K, Zygmunt M, Zborowska H, Krawczyk M, Galas M, Niewińsk G, Krawczyk M, Zieniewicz K, Milkiewicz P, Opolski G. Troponin I Is Not a Predictor of Early Cardiovascular Morbidity in Liver Transplant Recipients. Transplant Proc 2018; 50:2022-2026. [DOI: 10.1016/j.transproceed.2018.02.136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 02/06/2018] [Indexed: 01/06/2023]
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9
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Toda H, Nakamura K, Nakagawa K, Watanabe A, Miyoshi T, Nishii N, Shimizu K, Hayashi M, Morita H, Morimatsu H, Ito H. Diastolic Dysfunction Is a Risk of Perioperative Myocardial Injury Assessed by High-Sensitivity Cardiac Troponin T in Elderly Patients Undergoing Non-Cardiac Surgery. Circ J 2018; 82:775-782. [PMID: 29151453 DOI: 10.1253/circj.cj-17-0747] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND High-sensitivity cardiac troponin T (hs-cTnT) is useful for detecting myocardial injury and is expected to become a prognostic marker in patients undergoing non-cardiac surgery. The aim of this pilot study evaluating the efficacy of β-blocker therapy in a perioperative setting (MAMACARI study) was to assess perioperative myocardial injury (PMI) in elderly patients with preserved ejection fraction (EF) undergoing non-cardiac surgery.Methods and Results:In this prospective observational cohort study of 151 consecutive patients with preserved EF and aged >60 years who underwent non-cardiac surgery, serum levels of hs-cTnT were measured before and on postoperative days 1 and 3 after surgery. PMI was defined as postoperative hs-cTnT >0.014 ng/mL and relative hs-cTnT change ≥20%. A total of 36 (23.8%) of the patients were diagnosed as having PMI. The incidence of a composite of cardiovascular events within 30 days after surgery, including myocardial infarction, stroke, worsening heart failure, atrial fibrillation and pulmonary embolism, was significantly higher in patients with PMI than in patients without PMI (odds ratio (OR) 9.25, P<0.001, 95% confidence interval (CI) 2.65-32.3). Multivariate analysis revealed that left ventricular diastolic dysfunction defined by echocardiography was independently associated with PMI (OR: 3.029, 95% CI: 1.341-6.84, P=0.008). CONCLUSIONS PMI is frequently observed in elderly patients undergoing non-cardiac surgery. Diastolic dysfunction is an independent predictor of PMI.
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Affiliation(s)
- Hironobu Toda
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Koji Nakagawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Atsuyuki Watanabe
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Toru Miyoshi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Nobuhiro Nishii
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Kazuyoshi Shimizu
- Department of Anesthesiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Masao Hayashi
- Department of Anesthesiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hiroshi Morita
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences.,Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hiroshi Morimatsu
- Department of Anesthesiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
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van Waes JAR, Grobben RB, Nathoe HM, Kemperman H, de Borst GJ, Peelen LM, van Klei WA. One-Year Mortality, Causes of Death, and Cardiac Interventions in Patients with Postoperative Myocardial Injury. Anesth Analg 2017; 123:29-37. [PMID: 27111647 DOI: 10.1213/ane.0000000000001313] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND To evaluate the role of routine troponin surveillance in patients undergoing major noncardiac surgery, unblinded screening with cardiac consultation per protocol was implemented at a tertiary care center. In this study, we evaluated 1-year mortality, causes of death, and consequences of cardiac consultation of this protocol. METHODS This observational cohort included 3224 patients ≥60 years old undergoing major noncardiac surgery. Troponin I was measured routinely on the first 3 postoperative days. Myocardial injury was defined as troponin I >0.06 μg/L. Regression analysis was used to determine the association between myocardial injury and 1-year mortality. The causes of death, the diagnoses of the cardiologists, and interventions were determined for different levels of troponin elevation. RESULTS Postoperative myocardial injury was detected in 715 patients (22%) and was associated with 1-year all-cause mortality (relative risk [RR] 1.4, P = 0.004; RR 1.6, P < 0.001; and RR 2.2, P < 0.001 for minor, moderate, and major troponin elevation, respectively). Cardiac death within 1 year occurred in 3%, 5%, and 11% of patients, respectively, in comparison with 3% of the patients without myocardial injury (P = 0.059). A cardiac consultation was obtained in 290 of the 715 patients (41%). In 119 (41%) of these patients, the myocardial injury was considered to be attributable to a predisposing cardiac condition, and in 111 patients (38%), an intervention was initiated. CONCLUSIONS Postoperative myocardial injury was associated with an increased risk of 1-year all-cause but not cardiac mortality. A cardiac consultation with intervention was performed in less than half of these patients. The small number of interventions may be explained by a low suspicion of a cardiac etiology in most patients and lack of consensus for standardized treatment in these patients.
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Affiliation(s)
- Judith A R van Waes
- From the *Department of Anesthesiology; †Department of Cardiology; ‡Department of Clinical Chemistry and Haematology; §Department of Surgery; and ‖Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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12
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Patelis N, Kouvelos GN, Koutsoumpelis A, Moris D, Matsagkas MI, Arnaoutoglou E. An update on predictive biomarkers for major adverse cardiovascular events in patients undergoing vascular surgery. J Clin Anesth 2016; 33:105-16. [PMID: 27555142 DOI: 10.1016/j.jclinane.2016.03.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 09/27/2015] [Accepted: 03/05/2016] [Indexed: 10/21/2022]
Abstract
Cardiovascular complications signify a major cause of morbidity and mortality in patients undergoing vascular surgery adversely affecting both short- and long-term prognosis. During the last decade, unmet needs for a distinct cardiovascular risk assessment have led to an intensive research for establishment of biomarkers with sufficient predictive value. This literature review aims in examining the value of several biomarkers in predicting the incidence of major adverse cardiac events in vascular surgery patients. We reviewed the English language literature and analyzed the biomarkers as independent predictors or in correlation with other factors. We found several biomarkers showing a significant predictive value for a major adverse cardiovascular event in patients undergoing vascular surgery. These biomarkers can be used in clinical practice as outcome predictors, although sensitivity and specificity varies. Detection of subclinical cardiovascular damage may improve total risk estimation and facilitate clinical assessment of patients at risk for future cardiovascular events. The wide variety of sensitivity and specificity in predicting a MACE of these biomarkers exert the need for future trials in which these markers will be tested as adjunctive tools of cardiovascular risk estimation scoring systems.
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Affiliation(s)
- Nikolaos Patelis
- First Department of Surgery, Vascular Surgery Division, National & Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece.
| | - George N Kouvelos
- Department of Surgery, Vascular Surgery Unit, Medical School, University of Ioannina, Ioannina, Greece
| | - Andreas Koutsoumpelis
- First Department of Surgery, Vascular Surgery Division, National & Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Demetrios Moris
- First Department of Surgery, National & Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Miltiadis I Matsagkas
- Department of Surgery, Vascular Surgery Unit, Medical School, University of Ioannina, Ioannina, Greece
| | - Eleni Arnaoutoglou
- Department of Anesthesiology, Medical School, University of Ioannina, Ioannina, Greece
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Vanniyasingam T, Rodseth RN, Lurati Buse GA, Bolliger D, Burkhart CS, Cuthbertson BH, Gibson SC, Mahla E, Leibowitz DW, Biccard BM, Thabane L. Predicting the occurrence of major adverse cardiac events within 30 days of a vascular surgery: an empirical comparison of the minimum p value method and ROC curve approach using individual patient data meta-analysis. SPRINGERPLUS 2016; 5:304. [PMID: 27066338 PMCID: PMC4783313 DOI: 10.1186/s40064-016-1936-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 02/25/2016] [Indexed: 12/16/2022]
Abstract
We aimed to compare the minimum p value method and the area under the receiver operating characteristics (ROC) curve approach to categorize continuous biomarkers for the prediction of postoperative 30-day major adverse cardiac events in noncardiac vascular surgery patients. Individual-patient data from six cohorts reporting B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NTproBNP) were obtained. These biomarkers were dichotomized using the minimum p value method and compared with previously reported ROC curve-derived thresholds using logistic regression analysis. A final prediction model was developed, internally validated, and assessed for its sensitivity to clustering effects. Finally, a preoperative risk score system was proposed. Thresholds identified by the minimum p value method and ROC curve approach were 115.57 pg/ml (p < 0.001) and 116 pg/ml for BNP, and 241.7 pg/ml (p = 0.001) and 277.5 pg/ml for NTproBNP, respectively. The minimum p value thresholds were slightly stronger predictors based on our logistic regression analysis. The final model included a composite predictor of the minimum p value method’s BNP and NTproBNP thresholds [odds ratio (OR) = 8.5, p < 0.001], surgery type (OR = 2.5, p = 0.002), and diabetes (OR = 2.1, p = 0.015). Preoperative risks using the scoring system ranged from 2 to 49 %. The minimum p value method and ROC curve approach identify similar optimal thresholds. We propose to replace the revised cardiac risk index with our risk score system for individual-specific preoperative risk stratification after noncardiac nonvascular surgery.
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Affiliation(s)
- Thuva Vanniyasingam
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Health Sciences Centre, Room 2C7, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada
| | - Reitze N Rodseth
- Perioperative Research Unit, Department of Anaesthetics, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Pietermaritzburg, South Africa ; Department of Anaesthetics, Grey's Hospital, Pietermaritzburg, South Africa
| | - Giovanna A Lurati Buse
- Department of Anaesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Daniel Bolliger
- Department of Anaesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | | | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON Canada
| | | | - Elisabeth Mahla
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - David W Leibowitz
- Division of Cardiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Bruce M Biccard
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Health Sciences Centre, Room 2C7, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada ; Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON Canada ; Biostatistics Unit, St Joseph's Healthcare, Hamilton, ON Canada ; Departments of Paediatrics and Anaesthesia, McMaster University, Hamilton, ON Canada ; Centre for Evaluation of Medicine, St Joseph's Healthcare, Hamilton, ON Canada
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Toscano FV, Apinis A, Leff JD. Pre-operative Risk Stratification Update for Cardiac and Major Vascular Surgery. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-015-0136-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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15
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Ryan L, Rajah C, Simmers D, Potgieter D, Rodseth RN. Preoperative B-type natriuretic peptides in patients undergoing noncardiac surgery: a cumulative meta-analysis. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2015. [DOI: 10.1080/22201181.2015.1075938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Shang C. B-type natriuretic peptide-guided therapy for perioperative medicine? Open Heart 2014; 1:e000105. [PMID: 25332815 PMCID: PMC4189229 DOI: 10.1136/openhrt-2014-000105] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 05/22/2014] [Accepted: 07/15/2014] [Indexed: 12/27/2022] Open
Abstract
The recent guideline from the European Society of Cardiology and European Society of Anesthesiology recommended the use of B-type natriuretic peptide (BNP) as preoperative testing for high-risk cardiac patients undergoing non-cardiac surgery. In this article, the potential benefits, risks and details for implementing BNP testing in perioperative medicine are discussed. Review of four related lines of research including the use of BNP test for preoperative prognosis, BNP test for screening asymptomatic heart failure, BNP as prognostic test in asymptomatic, non-heart failure patients and using BNP for detecting silent myocardial ischaemia showed converging cut-off levels of BNP for risk stratification. BNP has better OR and relative risk in comparison with Revised Cardiac Risk Index (RCRI) in predicting perioperative cardiac risk. BNP-guided therapy can be low risk based on current evidence on non-surgical patients, including treating asymptomatic patients without heart failure to prevent cardiovascular complications. At present, there is lack of direct evidence supporting perioperative BNP testing. Further research with randomised controlled trials is needed to confirm the benefit of BNP-guided management. Preoperative BNP testing may be considered in patients with RCRI above 0 undergoing intermediate or high-risk surgery. BNP-guided therapy is likely a beneficial addition to perioperative medicine. Its combination with β-blocker titration, RCRI and perioperative cardiovascular monitoring can be a major advance in reducing cardiac risk resulting in a dynamic, individualised optimisation process.
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Affiliation(s)
- Charles Shang
- Department of Medicine , Baylor College of Medicine , Houston, Texas , USA
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Young YR, Sheu BF, Li WC, Hsieh TM, Hung CW, Chang SS, Lee CC. Predictive value of plasma brain natriuretic peptide for postoperative cardiac complications--a systemic review and meta-analysis. J Crit Care 2014; 29:696.e1-10. [PMID: 24793659 DOI: 10.1016/j.jcrc.2014.03.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 03/02/2014] [Accepted: 03/25/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND We aimed to undertake a systematic review and meta-analysis of studies addressing perioperative natriuretic peptide (NP) levels to predict postoperative major adverse cardiac events (MACE) after major surgery. METHODS We searched MEDLINE and Embase with no language restrictions up to May 2013. The end points were major cardiac complications. We summarized test performance characteristics with the use of forest plots, hierarchical summary receiver operating characteristic curves, and bivariate random effects models. RESULTS Of the 662 retrieved articles, 24 studies satisfied the predefined eligibility criteria, including 5438 patients along with 712 (13.1%) events. After major surgery, the diagnostic odds ratio (DOR) of NP in predicting postoperative MACE was 14.3 (95% confidence interval [CI], 9.87-20.7) for overall population, 13.9 (8.43-22.8) for patients undergoing cardiac surgery, and 15.0 (8.84-25.5) for patients undergoing noncardiac surgery. The pooled sensitivity was 0.84 (95% CI, 0.79-0.88) and specificity was 0.76 (95% CI, 0.71-0.81). Postoperative measurement (DOR, 18.9; 7.68-46.3) was associated with higher predictive value than preoperative measurement (DOR, 13.6; 7.68-46.3). Results were similar for a subgroup with the composite outcome including mortality (DOR, 16.4; 10.6-25.5). B-type natriuretic peptide was associated with higher predictive accuracy (area under the summary receiver operating characteristic, 0.84; 0.81-0.87) than N-terminal pro-b-type natriuretic peptide (area under the summary receiver operating characteristic, 0.90; 0.87-0.92). CONCLUSIONS The existing literature suggests that perioperative NP testing have reasonable accuracy and can be useful in perioperative risk stratification. Natriuretic peptide testing has high rule-out value and low rule-in value for predicting postoperative MACE. Medical decisions should be made in the context of these characteristics.
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Affiliation(s)
- Yui-Rwei Young
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi Branch, Puzih City, Chiayi County, 613, Taiwan; Chang Gung University College of Medicine, Gueishan Township, Taoyuan County, 333, Taiwan
| | - Bor-Fuh Sheu
- Chang Gung University College of Medicine, Gueishan Township, Taoyuan County, 333, Taiwan; Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou Branch, Gueishan Township, Taoyuan County, 333, Taiwan
| | - Wen-Cheng Li
- Chang Gung University College of Medicine, Gueishan Township, Taoyuan County, 333, Taiwan; Department of Occupation Medicine, Chang-Gung Memorial Hospital, Chiayi Branch, Puzih City, Chiayi County, 613, Taiwan
| | - Ting-Min Hsieh
- Chang Gung University College of Medicine, Gueishan Township, Taoyuan County, 333, Taiwan; Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital, Kaohsiung Branch, Kaohsiung County, 833, Taiwan
| | - Chi-Wei Hung
- Chang Gung University College of Medicine, Gueishan Township, Taoyuan County, 333, Taiwan; Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung County, 833, Taiwan
| | - Shy-Shin Chang
- Chang Gung University College of Medicine, Gueishan Township, Taoyuan County, 333, Taiwan; Department of Family Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Chien-Chang Lee
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA; Department of Emergency Medicine, National Taiwan University Hospital, Douliou, Yunlin Branch, Taiwan and Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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Clinical use of ultrasensitive cardiac troponin I assay in intermediate- and high-risk surgery patients. DISEASE MARKERS 2013; 35:945-53. [PMID: 24489430 PMCID: PMC3893737 DOI: 10.1155/2013/169356] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 12/04/2013] [Indexed: 11/17/2022]
Abstract
Background. Cardiac troponin levels have been reported to add value in the detection of cardiovascular complications in noncardiac surgery. A sensitive cardiac troponin I (cTnI) assay could provide more accurate prognostic information. Methods. This study prospectively enrolled 142 patients with at least one Revised Cardiac Risk Index risk factor who underwent noncardiac surgery. cTnI levels were measured postoperatively. Short-term cardiac outcome predictors were evaluated. Results. cTnI elevation was observed in 47 patients, among whom 14 were diagnosed as having myocardial infarction (MI). After 30 days, 16 patients had major adverse cardiac events (MACE). Excluding patients with a final diagnosis of MI, predictors of cTnI elevation included dialysis, history of heart failure, transoperative major bleeding, and elevated levels of pre- and postoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP). Maximal cTnI values showed the highest sensitivity (94%), specificity (75%), and overall accuracy (AUC 0.89; 95% CI 0.80–0.98) for postoperative MACE. Postoperative cTnI peak level (OR 9.4; 95% CI 2.3–39.2) and a preoperative NT-proBNP level ≥917 pg/mL (OR 3.47; 95% CI 1.05–11.6) were independent risk factors for MACE. Conclusions. cTnI was shown to be an independent prognostic factor for cardiac outcomes and should be considered as a component of perioperative risk assessment.
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Lins EM, Barros JW, Appolonio F, Anacleto E, Lima EC. Acute myocardial infarctation in patients with critical ischemia underwent lower limb revascularization. J Vasc Bras 2013. [DOI: 10.1590/jvb.2013.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND: Atherosclerosis is the main cause of peripheral artery occlusive disease (PAOD) of the lower limbs. Patients with PAOD often also have obstructive atherosclerosis in other arterial sites, mainly the coronary arteries. This means that patients who undergo infrainguinal bypass to treat critical ischemia have a higher risk of AMI. There are, however, few reports in the literature that have assessed this risk properly. OBJECTIVE: The aim of this study was to determine the incidence of acute myocardial infarction in patients who underwent infrainguinal bypass to treat critical ischemia of the lower limbs caused by PAOD. MATERIAL AND METHODS: A total of 64 patients who underwent 82 infrainguinal bypass operations, from February 2011 to July 2012 were studied. All patients had electrocardiograms and troponin I blood assays during the postoperative period (within 72 hours). RESULTS: There were abnormal ECG findings and elevated blood troponin I levels suggestive of AMI in five (6%) of the 82 operations performed. All five had conventional surgery. The incidence of AMI as a proportion of the 52 conventional surgery cases was 9.6%. Two patients died. CONCLUSION: There was a 6% AMI incidence among patients who underwent infrainguinal bypass due to PAOD. Considering only cases operated using conventional surgery, the incidence of AMI was 9.6%.
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20
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Rodseth RN, Biccard BM, Le Manach Y, Sessler DI, Lurati Buse GA, Thabane L, Schutt RC, Bolliger D, Cagini L, Cardinale D, Chong CPW, Chu R, Cnotliwy M, Di Somma S, Fahrner R, Lim WK, Mahla E, Manikandan R, Puma F, Pyun WB, Radović M, Rajagopalan S, Suttie S, Vanniyasingam T, van Gaal WJ, Waliszek M, Devereaux PJ. The prognostic value of pre-operative and post-operative B-type natriuretic peptides in patients undergoing noncardiac surgery: B-type natriuretic peptide and N-terminal fragment of pro-B-type natriuretic peptide: a systematic review and individual patient data meta-analysis. J Am Coll Cardiol 2013; 63:170-80. [PMID: 24076282 DOI: 10.1016/j.jacc.2013.08.1630] [Citation(s) in RCA: 211] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 08/07/2013] [Accepted: 08/12/2013] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The objective of this study was to determine whether measuring post-operative B-type natriuretic peptides (NPs) (i.e., B-type natriuretic peptide [BNP] and N-terminal fragment of proBNP [NT-proBNP]) enhances risk stratification in adult patients undergoing noncardiac surgery, in whom a pre-operative NP has been measured. BACKGROUND Pre-operative NP concentrations are powerful independent predictors of perioperative cardiovascular complications, but recent studies have reported that elevated post-operative NP concentrations are independently associated with these complications. It is not clear whether there is value in measuring post-operative NP when a pre-operative measurement has been done. METHODS We conducted a systematic review and individual patient data meta-analysis to determine whether the addition of post-operative NP levels enhanced the prediction of the composite of death and nonfatal myocardial infarction at 30 and ≥180 days after surgery. RESULTS Eighteen eligible studies provided individual patient data (n = 2,179). Adding post-operative NP to a risk prediction model containing pre-operative NP improved model fit and risk classification at both 30 days (corrected quasi-likelihood under the independence model criterion: 1,280 to 1,204; net reclassification index: 20%; p < 0.001) and ≥180 days (corrected quasi-likelihood under the independence model criterion: 1,320 to 1,300; net reclassification index: 11%; p = 0.003). Elevated post-operative NP was the strongest independent predictor of the primary outcome at 30 days (odds ratio: 3.7; 95% confidence interval: 2.2 to 6.2; p < 0.001) and ≥180 days (odds ratio: 2.2; 95% confidence interval: 1.9 to 2.7; p < 0.001) after surgery. CONCLUSIONS Additional post-operative NP measurement enhanced risk stratification for the composite outcomes of death or nonfatal myocardial infarction at 30 days and ≥180 days after noncardiac surgery compared with a pre-operative NP measurement alone.
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Affiliation(s)
- Reitze N Rodseth
- Perioperative Research Group, Department of Anaesthetics, Grey's Hospital, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Pietermaritzburg, South Africa; Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada; Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio.
| | - Bruce M Biccard
- Perioperative Research Group, Department of Anaesthetics, Grey's Hospital, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Yannick Le Manach
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada; Departments of Anesthesia, Clinical Epidemiology, and Biostatistics, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Giovana A Lurati Buse
- Department of Anaesthesia and Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Lehana Thabane
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada; Departments of Clinical Epidemiology and Biostatistics/Anesthesia/Pediatrics, McMaster University, Hamilton, Ontario, Canada; Biostatistics Unit, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Robert C Schutt
- Department of Internal Medicine, University of Virginia, Charlottesville, Virginia
| | - Daniel Bolliger
- Department of Anaesthesia and Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Lucio Cagini
- Department of Surgical Science, University of Perugia, Ospedale S. Maria, Perugia, Italy
| | | | - Carol P W Chong
- Departments of Aged Care, Northern Clinical Research Centre, The Northern Hospital, Epping, Victoria, Australia, and The Department of Medicine, Austin and Northern Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rong Chu
- Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Miłosław Cnotliwy
- Department of Vascular and General Surgery and Angiology, Pomeranian Medical University, Szczecin, Poland
| | - Salvatore Di Somma
- Department of Medical-Surgery Sciences and Translational Medicine, University La Sapienza, and Emergency Department, Sant'Andrea Hospital, Rome, Italy
| | - René Fahrner
- Division of General, Visceral and Vascular Surgery, University Hospital, Jena, Germany
| | - Wen Kwang Lim
- Departments of Aged Care, Northern Clinical Research Centre, The Northern Hospital, Epping, Victoria, Australia, and The Department of Medicine, Austin and Northern Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Elisabeth Mahla
- Department of Anesthesia and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Ramaswamy Manikandan
- Departments of Urology, Stepping Hill Hospital, Stockport, United Kingdom, and Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, United Kingdom
| | - Francesco Puma
- Department of Surgical Science, University of Perugia, Ospedale S. Maria, Perugia, Italy
| | - Wook B Pyun
- Division of Cardiology, Department of Internal Medicine, Ewha Womans University, School of Medicine, Mokdong Hospital, Seoul, Korea
| | - Milan Radović
- Clinic of Nephrology, University of Belgrade, School of Medicine, Belgrade, Serbia
| | - Sriram Rajagopalan
- Department of Vascular Surgery, University Hospital of North Staffordshire, Stoke on Trent, United Kingdom
| | - Stuart Suttie
- Department of Vascular Surgery, Ninewells Hospital and Medical School, Dundee, United Kingdom
| | | | - William J van Gaal
- Department of Cardiology, University of Melbourne, Northern Health, Epping, Victoria, Australia
| | - Marek Waliszek
- Cardiac Diagnostics Unit, M. Pirogow Provincial Specialist Hospital, Lodz, Poland
| | - P J Devereaux
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada; Departments of Medicine, Clinical Epidemiology, and Biostatistics, Hamilton Health Sciences, Hamilton, Ontario, Canada
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van Waes JA, Nathoe HM, de Graaff JC, Kemperman H, de Borst GJ, Peelen LM, van Klei WA, Buhre WF, de Graaff JC, Kalkman CJ, van Klei WA, van Waes JA, van Wolfswinkel L, Doevendans PA, Nathoe HM, Grobben RG, Grobbee DE, Peelen LM, Kemperman H, van Solinge WW, Leiner T, de Borst GJ, Leenen LP, Moll FL. Myocardial Injury After Noncardiac Surgery and its Association With Short-Term Mortality. Circulation 2013; 127:2264-71. [DOI: 10.1161/circulationaha.113.002128] [Citation(s) in RCA: 216] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background—
To identify patients at risk for postoperative myocardial injury and death, measuring cardiac troponin routinely after noncardiac surgery has been suggested. Such monitoring was implemented in our hospital. The aim of this study was to determine the predictive value of postoperative myocardial injury, as measured by troponin elevation, on 30-day mortality after noncardiac surgery.
Methods and Results—
This observational, single-center cohort study included 2232 consecutive intermediate- to high-risk noncardiac surgery patients aged ≥60 years who underwent surgery in 2011. Troponin was measured on the first 3 postoperative days. Log binomial regression analysis was used to estimate the association between postoperative myocardial injury (troponin I level >0.06 μg/L) and all-cause 30-day mortality. Myocardial injury was found in 315 of 1627 patients in whom troponin I was measured (19%). All-cause death occurred in 56 patients (3%). The relative risk of a minor increase in troponin (0.07–0.59 μg/L) was 2.4 (95% confidence interval, 1.3–4.2;
P
<0.01), and the relative risk of a 10- to 100-fold increase in troponin (≥0.60 μg/L) was 4.2 (95% confidence interval, 2.1–8.6;
P
<0.01). A myocardial infarction according to the universal definition was diagnosed in 10 patients (0.6%), of whom 1 (0.06%) had ST-segment elevation myocardial infarction.
Conclusions—
Postoperative myocardial injury is an independent predictor of 30-day mortality after noncardiac surgery. Implementation of postoperative troponin monitoring as standard of care is feasible and may be helpful in improving the prognosis of patients undergoing noncardiac surgery.
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Affiliation(s)
- Judith A.R. van Waes
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hendrik M. Nathoe
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jurgen C. de Graaff
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hans Kemperman
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert Jan de Borst
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Linda M. Peelen
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wilton A. van Klei
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
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Blackshear JL, Brott TG. Ascertainment of any and all neurologic and myocardial damage in carotid revascularization: the key to optimization? Expert Rev Cardiovasc Ther 2013; 11:469-84. [PMID: 23570360 DOI: 10.1586/erc.13.25] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The majority of carotid revascularization procedures performed at present are in asymptomatic patients. Since such procedures convey no immediate benefit, but rather protect from future hazard, optimization of procedural safety is mandatory. The authors focus their discussion on the methodologies that assess periprocedural myocardial damage and brain injury, as used in past clinical trials, from the fields of perioperative medicine and neurovascular imaging, and discuss methodologies to reduce both events in carotid revascularization.
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Affiliation(s)
- Joseph L Blackshear
- Division of Cardiovascular Diseases, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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23
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Bolliger D, Seeberger MD, Lurati Buse G, Christen P, Seeberger E, Ruppen W, Filipovic M. The influence of pre-admission hypoglycaemic therapy on cardiac morbidity and mortality in type 2 diabetic patients undergoing major non-cardiac surgery: a prospective observational study*. Anaesthesia 2011; 67:149-57. [DOI: 10.1111/j.1365-2044.2011.06963.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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24
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Jung S, Kittleson M. The Effect of Atenolol on NT-proBNP and Troponin in Asymptomatic Cats with Severe Left Ventricular Hypertrophy because of Hypertrophic Cardiomyopathy: A Pilot Study. J Vet Intern Med 2011; 25:1044-9. [DOI: 10.1111/j.1939-1676.2011.0754.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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25
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Priebe HJ. Preoperative cardiac management of the patient for non-cardiac surgery: an individualized and evidence-based approach. Br J Anaesth 2011; 107:83-96. [DOI: 10.1093/bja/aer121] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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26
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Rodseth RN, Lurati Buse GA, Bolliger D, Burkhart CS, Cuthbertson BH, Gibson SC, Mahla E, Leibowitz DW, Biccard BM. The Predictive Ability of Pre-Operative B-Type Natriuretic Peptide in Vascular Patients for Major Adverse Cardiac Events. J Am Coll Cardiol 2011; 58:522-9. [DOI: 10.1016/j.jacc.2011.04.018] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Revised: 02/22/2011] [Accepted: 04/12/2011] [Indexed: 10/17/2022]
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27
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Redfern G, Rodseth RN, Biccard BM. Outcomes in vascular surgical patients with isolated postoperative troponin leak: a meta-analysis. Anaesthesia 2011; 66:604-10. [DOI: 10.1111/j.1365-2044.2011.06763.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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28
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Lurati Buse GA, Koller MT, Burkhart C, Seeberger MD, Filipovic M. The Predictive Value of Preoperative Natriuretic Peptide Concentrations in Adults Undergoing Surgery. Anesth Analg 2011; 112:1019-33. [DOI: 10.1213/ane.0b013e31820f286f] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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29
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Biccard BM, Naidoo P. The role of brain natriuretic peptide in prognostication and reclassification of risk in patients undergoing vascular surgery*. Anaesthesia 2011; 66:379-85. [DOI: 10.1111/j.1365-2044.2011.06694.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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30
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Fellahi JL, Piriou V, Longrois D. [Cardiac biomarkers in perioperative risk stratification]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2011; 30:126-140. [PMID: 21282034 DOI: 10.1016/j.annfar.2010.11.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Accepted: 11/25/2010] [Indexed: 05/30/2023]
Abstract
OBJECTIVES The field of new cardiac biomarkers has triggered physicians' enthusiasm because of their potential diagnostic and prognostic values for routine clinical practice in the surgical setting. The objective of the present article is to review the role of new cardiac biomarkers and their potential additive clinical value in predicting short- and long-term risk following cardiac and non-cardiac surgery. DATA SOURCES A PubMed(®) database research in English and French languages published until June 2010. Keywords were cardiac biomarkers, troponins, cardiac troponin I (cTnI), natriuretic peptides, B-type natriuretic peptide (BNP), C-reactive protein (CRP), multiple markers approach, risk stratification, clinical risk scores. DATA SYNTHESIS Numerous publications deal with the diagnostic and prognostic values of new cardiac biomarkers in cardiac and non-cardiac surgical settings and provide an increasing evidence of their interest, validating different hierarchical steps which are mandatory before recommending a wide use of biomarkers for routine practice. Even if the first studies demonstrating an additional prognostic value of serum postoperative cTnI and/or preoperative BNP when compared with clinical predictive models are now available, we still lack data concerning an actual positive impact of new biomarkers measurements on clinical decision making or practice, as well as patient care and outcome. CONCLUSIONS While use of new cardiac biomarkers in the perioperative period appears to be a simple and objective tool for risk stratification at the bedside, we still need to remain cautious concerning their additional clinical value on existing predictive models for routine practice.
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Affiliation(s)
- J-L Fellahi
- Pôle anesthésie-réanimation-Samu-hémovigilance-coordination hospitalière, CHU de Caen, UFR de médecine, université de Caen-Basse Normandie, avenue de la Côte-de-Nacre, Caen cedex 9, France.
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31
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Flu WJ, Schouten O, van Kuijk JP, Poldermans D. Perioperative cardiac damage in vascular surgery patients. Eur J Vasc Endovasc Surg 2010; 40:1-8. [PMID: 20400340 DOI: 10.1016/j.ejvs.2010.03.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2009] [Accepted: 03/11/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patients undergoing vascular surgery are at increased risk for developing cardiac complications. Majority of patients with perioperative myocardial damage are asymptomatic. Our objective is to review the available literature addressing the prevalence and prognostic implications of perioperative myocardial damage in vascular surgery patients. METHODS An Internet-based literature search was performed using MEDLINE to identify all published reports on perioperative myocardial damage in vascular surgery patients. Only those studies published from 2000 to 2010 evaluating myocardial damage using troponin I or T, with or without symptoms of angina pectoris were included. RESULTS Thirteen studies evaluating the prevalence of perioperative myocardial ischaemia or infarction were included in the study. The incidence of perioperative myocardial ischaemia ranged from 14% to 47% and the incidence of perioperative myocardial infarction ranged from 1% to 26%. In addition, 10 studies evaluating the prognostic value of perioperative myocardial ischaemia towards postoperative mortality or the occurrence of major adverse cardiac events were included. In the retrieved studies, hazard ratios varied from 1.9 to 9.0. CONCLUSION The high prevalence and asymptomatic nature of perioperative myocardial damage, combined with a substantial influence on postoperative mortality of vascular surgery patients, underline the importance of early detection and adequate management of perioperative myocardial damage. This article provides an extended overview regarding the prevalence and prognostic value of perioperative myocardial ischaemia and infarction in vascular surgery patients. In addition, treatment options to reduce the risk of perioperative myocardial damage are provided based on the current available literature.
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Affiliation(s)
- W-J Flu
- Department of Anesthesiology, Erasmus Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
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Sellevold OFM, Stenseth R. [Non-cardiac surgery in patients with cardiac disease]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2010; 130:623-7. [PMID: 20349010 DOI: 10.4045/tidsskr.08.0309] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Patients with cardiac disease have a higher incidence of cardiovascular events after non-cardiac surgery than those without such disease. This paper provides an overview of perioperative examinations and treatment. MATERIAL AND METHODS Own experience and systematic literature search through work with European guidelines constitute the basis for recommendations given in this article. RESULTS Beta-blockers should not be discontinued before surgery. High-risk patients may benefit from beta-blockers administered before major non-cardiac surgery. Slow dose titration is recommended. Echocardiography should be performed before preoperative beta-blockade to exclude latent heart failure. Statins should be considered before elective surgery and coronary intervention (stenting or surgery) before high-risk surgery. Otherwise, interventions should be evaluated irrespective of planned non-cardiac surgery. Patients with unstable coronary syndrome should only undergo non-cardiac surgery on vital indications. Neuraxial techniques are optimal for postoperative pain relief and thus for postoperative mobilization. Thromboprophylaxis is important, but increases the risk of epidural haematoma and requires systematic follow-up with respect to diagnostics and treatment. INTERPRETATION Little evidence supports the use of different anaesthetic methods in cardiac patients that undergo non-cardiac surgery than in other patients. Stable circulation, sufficient oxygenation, good pain relief, thromboprophylaxis, enteral nutrition and early mobilization are important factors for improving the perioperative course. Close cooperation between anaesthesiologist, surgeon and cardiologist improves logistics and treatment.
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Affiliation(s)
- Olav F Münter Sellevold
- Institutt for sirkulasjon og bildedannelse, Norges teknisk-naturvitenskapelige universitet og St. Olavs hospital, Prinsesse Kristinas gate 3, 7030 Trondheim, Norway.
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Daniels LB. Natriuretic Peptides and Assessment of Cardiovascular Disease Risk in Asymptomatic Persons. CURRENT CARDIOVASCULAR RISK REPORTS 2010; 4:120-127. [PMID: 20672100 PMCID: PMC2894089 DOI: 10.1007/s12170-010-0078-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Current tools for cardiovascular disease (CVD) risk assessment in asymptomatic individuals are imperfect. Preventive measures aimed only at individuals deemed high risk by current algorithms neglect large numbers of low-risk and intermediate-risk individuals who are destined to develop CVD and who would benefit from early and aggressive treatment. Natriuretic peptides have the potential both to identify individuals at risk for future cardiovascular events and to help detect subclinical CVD. Choosing the appropriate subpopulation to target for natriuretic peptide testing will help maximize the performance and the cost effectiveness. The combined use of multiple risk markers, including biomarkers, genetic testing, and imaging or other noninvasive measures of risk, offers promise for further refining risk assessment algorithms. Recent studies have highlighted the utility of natriuretic peptides for preoperative risk stratification; however, cost effectiveness and outcomes studies are needed to affirm this and other uses of natriuretic peptides for cardiovascular risk assessment in asymptomatic individuals.
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Affiliation(s)
- Lori B. Daniels
- Division of Cardiology, University of California, San Diego, MC 0986, 9350 Campus Point Drive, Suite 1D, La Jolla, CA 92037-1300 USA
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Bolliger D, Seeberger MD, Filipovic M. Pre-Operative Cardiac Risk Assessment in Noncardiac Surgery. J Am Coll Cardiol 2009; 54:1607-8. [DOI: 10.1016/j.jacc.2009.06.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2009] [Accepted: 06/18/2009] [Indexed: 10/20/2022]
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