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Horcicka A, Fischer L, Weigand MA, Larmann J. [Cardiac biomarkers prior to noncardiac surgery]. DIE ANAESTHESIOLOGIE 2024; 73:365-375. [PMID: 38829520 DOI: 10.1007/s00101-024-01417-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/18/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Cardiac biomarkers, such as high-sensitivity cardiac troponin (hs-cTn) and brain natriuretic peptide (BNP) or N‑terminal prohormone of brain natriuretic peptide (NT-proBNP) are measured perioperatively to improve the prognosis and risk prediction. The European Society of Cardiology (ESC), European Society of Anesthesiology and Intensive Care (ESAIC) and the German Society of Anesthesiology and Intensive Care Medicine (DGAI) have recently published guidelines on the use of cardiac biomarkers prior to surgery. OBJECTIVE/RESEARCH QUESTION This article provides an overview of the available evidence on perioperative troponin and BNP/NT-proBNP measurements. Current guideline recommendations are presented and discussed. MATERIAL AND METHODS MEDLINE, Cochrane and google.scholar were searched for relevant keywords. Titles and abstracts of identified papers were checked for relevance and published results were summarized. Guideline recommendations from the ESC, ESAIC and DGAI are presented, compared and evaluated based on the available literature. In addition, the significance of new perioperative cardiac biomarkers is discussed based on the existing evidence. RESULTS The definitions, diagnosis and management of cardiovascular events in the perioperative context differ from those in the nonsurgical setting. The evidence for the measurement of hs-cTn and BNP/NT-proBNP is evaluated differently in the guidelines and the resulting recommendations are partly contradictory. In particular, recommendations for changes in perioperative management based on biomarker measurements diverge. The ESC guidelines propose an algorithm that uses preoperative biomarkers as the basis for additional cardiac investigations. In particular, invasive coronary angiography is recommended for patients with stable chronic coronary syndrome who have no preoperative cardiac symptoms but elevated biomarkers. In contrast, the ESAIC guidelines emphasize that the available evidence is not sufficient to use perioperative biomarker measurements as a basis for a change in perioperative management. DISCUSSION Treating physicians should coordinate interdisciplinary (surgery, anesthesiology, cardiology) recommendations for clinical practice based on the aforementioned guidelines. If cardiac biomarkers are routinely determined in high-risk patients, this should be done in accordance with the ESC algorithm.
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Affiliation(s)
- Anna Horcicka
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Universität Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
| | - Lilli Fischer
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Universität Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
| | - Markus A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Universität Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
| | - Jan Larmann
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Universität Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland.
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Kamber F, Roth S, Bolliger D, Seeberger E, Nienhaus J, Mueller C, Lurati Buse G, Mauermann E. Perioperative copeptin: predictive value and risk stratification in patients undergoing major noncardiac surgery-a prospective observational cohort study. Can J Anaesth 2024; 71:330-342. [PMID: 38243094 PMCID: PMC10923994 DOI: 10.1007/s12630-023-02677-y] [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: 11/30/2022] [Revised: 09/18/2023] [Accepted: 09/18/2023] [Indexed: 01/21/2024] Open
Abstract
PURPOSE Biomarkers can aid in perioperative risk stratification. While preoperative copeptin has been associated with adverse events, intraoperative information is lacking and this association may rather reflect a baseline risk. Knowledge about correlations between postoperative copeptin measurements and clinically relevant outcomes is scarce. We examined the association of perioperative copeptin concentrations with postoperative all-cause mortality and/or major adverse cardiac and cerebrovascular events (MACCE) at 12 months and 30 days as well as with perioperative myocardial injury (PMI). METHODS We conducted a prospective observational cohort study of adults undergoing noncardiac surgery with intermediate to high surgical risk in Basel, Switzerland, and Düsseldorf, Germany from February 2016 to December 2020. We measured copeptin and cardiac troponin before surgery, immediately after surgery (0 hr) and once between the second and fourth postoperative day (POD 2-4). RESULTS A primary outcome event of a composite of all-cause mortality and/or MACCE at 12 months occurred in 48/502 patients (9.6%). Elevated preoperative copeptin (> 14 pmol·L-1), immediate postoperative copeptin (> 90 pmol·L-1), and copeptin on POD 2-4 (> 14 pmol·L-1) were associated with lower one-year MACCE-free and/or mortality-free survival (hazard ratio [HR], 2.89; 95% confidence interval [CI], 1.62 to 5.2; HR, 2.07; 95% CI, 1.17 to 3.66; and HR, 2.47; 95% CI, 1.36 to 4.46, respectively). Multivariable analysis continued to show an association for preoperative and postoperative copeptin on POD 2-4. Furthermore, elevated copeptin on POD 2-4 showed an association with 30-day MACCE-free survival (HR, 2.15; 95% CI, 1.18 to 3.91). A total of 64 of 489 patients showed PMI (13.1%). Elevated preoperative copeptin was not associated with PMI, while immediate postoperative copeptin was modestly associated with PMI. CONCLUSION The results of the present prospective observational cohort study suggest that perioperative copeptin concentrations can help identify patients at risk for all-cause mortality and/or MACCE. Other identified risk factors were revised cardiac risk index, body mass index, surgical risk, and preoperative hemoglobin. TRIAL REGISTRATION ClinicalTrials.gov (NCT02687776); first submitted 9 February 2016.
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Affiliation(s)
- Firmin Kamber
- Anesthesiology Clinic, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
- Department of Perioperative Medicine, Hospital Olten, Olten, Switzerland.
- Faculty of Medicine, University of Basel, Basel, Switzerland.
| | - Sebastian Roth
- University of Anesthesiology, University Hospital Dusseldorf, Düsseldorf, Germany
| | - Daniel Bolliger
- Anesthesiology Clinic, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Esther Seeberger
- Anesthesiology Clinic, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Johannes Nienhaus
- University of Anesthesiology, University Hospital Dusseldorf, Düsseldorf, Germany
| | - Christian Mueller
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Giovanna Lurati Buse
- University of Anesthesiology, University Hospital Dusseldorf, Düsseldorf, Germany
| | - Eckhard Mauermann
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Zurich City Hospital, Zurich, Switzerland
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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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Mieszczański P, Górniewski G, Błaszczyk B, Pacholczyk M, Trzebicki J. Copeptin (CTproAVP) - A Biomarker of a Circulatory Impairment in Liver Transplant Recipients? A Prospective, Observational Study. Transplant Proc 2021; 53:1969-1974. [PMID: 34243965 DOI: 10.1016/j.transproceed.2021.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/01/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Copeptin, an easily measured and stable surrogate marker of arginine vasopressin, is a biomarker of a homeostasis disorder and a circulatory impairment in a wide spectrum of morbidities. The aim of this study was to evaluate the potential of copeptin as a biomarker of a circulatory impairment in patients undergoing liver transplantation (LT). METHODS This was a prospective, observational study. Blood samples were obtained from 38 patients undergoing LT. Serum copeptin level was measured by means of a sandwich immunoassay pre-, intra-, and postoperatively up to 21 days after the operation. RESULTS The mean concentration of copeptin remained in the range of values slightly below 1000 pg/mL during the analyzed observation period and remained higher than the values observed in healthy individuals. Intraoperative and immediately postoperative copeptin levels did not correlate with hemodynamic parameters. There was also no correlation between preoperative copeptin levels (C1) and preoperative Model for End-Stage Liver Disease scores, serum creatinine levels, plasma transaminase levels, international normalized ratio, or hematocrit (Spearman ρ, P > .05). CONCLUSIONS Preoperative copeptin levels are elevated in most LT recipients and remain elevated for 21 days after surgery. There was no correlation between the concentration of copeptin and the Model for End-Stage Liver Disease-Sodium score or the cause of a hepatic failure. It cannot be concluded that copeptin is a biomarker of a circulatory impairment in patients with transplanted liver in the perioperative period. The secretion of vasopressin, as measured by copeptin concentration during and after LT, requires further study.
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Affiliation(s)
- Piotr Mieszczański
- Departments of 1st Anaesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland.
| | - Grzegorz Górniewski
- Departments of 1st Anaesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland; Departments of Anaesthesiology and Intensive Care Teaching Section, Medical University of Warsaw, Warsaw, Poland
| | - Beata Błaszczyk
- Departments of 1st Anaesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Marek Pacholczyk
- Departments of General Surgery and Transplantology, Medical University of Warsaw, Warsaw, Poland
| | - Janusz Trzebicki
- Departments of 1st Anaesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
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[Cardiac biomarkers in noncardiac surgery patients : Review of cardiac biomarkers for risk stratification and detection of postoperative adverse cardiac events]. Med Klin Intensivmed Notfmed 2021; 117:381-388. [PMID: 33564901 DOI: 10.1007/s00063-021-00788-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/18/2020] [Accepted: 01/10/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Yearly, more than 200 million people worldwide undergo noncardiac surgery of whom about 5% will suffer adverse cardiac events. Therefore, risk stratification and early detection of these events is crucial. OBJECTIVES The goal of this review is to summarize the currently available evidence on the role of biomarkers in perioperative cardiac risk assessment. It presents current data of the established biomarkers troponin and brain natriuretic peptide (BNP), and it also reports on new biomarkers that are still under evaluation, e.g. copeptin (a marker of neurohumoral activation) and presepsin (an inflammation marker). MATERIALS AND METHODS Narrative review. RESULTS AND CONCLUSION According to currently available data, there is a strong association between preoperative troponin or BNP values and postoperative adverse cardiac events and mortality. However, to date, there is only a weak recommendation for routine measurement of these biomarkers even in high-risk patients because the evidence on outcome improvement is still very limited. The evidence on treatment options in case of increased postoperative troponin values is also scarce so that international guidelines come to different conclusions regarding postoperative measurement of toponin. Meanwhile, several new biomarkers are under evaluation.
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Yamashita K, Abe T, Hayata Y, Hirose T, Hiraga S, Fukuba R, Takemura J, Tonomura R, Yamamoto K, Yokoyama S, Taniguchi S. Copeptin concentration following cardiac surgery as a prognostic marker of postoperative acute kidney injury: a prospective cohort study. J Thorac Dis 2020; 12:6609-6617. [PMID: 33282362 PMCID: PMC7711377 DOI: 10.21037/jtd-20-2323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Copeptin, the C-terminal portion of the arginine vasopressin precursor, is a novel candidate biomarker. This study investigated the prognostic value of copeptin levels following cardiac surgery for the occurrence of postoperative acute kidney injury. Methods We studied 23 patients who underwent cardiac surgery between January 2018 and December 2019. The primary endpoint was postoperative acute kidney injury onset. Copeptin levels were measured before, right after, and daily for 7 days. The patients were divided into two groups according to the copeptin levels: low (values <43.7 pmol/L) and high (values ≥43.7 pmol/L). Correlations between copeptin levels and variables, such as central venous pressure, were assessed by bivariate analysis. Results The high copeptin group exhibited significantly higher levels of arginine vasopressin and cortisol following surgery, compared to those of the low copeptin group. The copeptin concentration following surgery was correlated to central venous pressure (P=0.03) and norepinephrine administered dose (P=0.008). Also, the copeptin levels right after surgery robustly predicted the onset of postoperative acute kidney injury (area under the receiver operating characteristic curve of 0.83, P=0.004). Conclusions Elevated copeptin levels in patients following cardiac surgery predicted postoperative acute kidney injury development. Therefore, the copeptin concentration after surgery could represent a promising clinical biomarker of the postoperative cardiac outcome.
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Affiliation(s)
- Keigo Yamashita
- Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine, Kashihara City, Nara, Japan
| | - Takehisa Abe
- Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine, Kashihara City, Nara, Japan
| | - Yoshihiro Hayata
- Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine, Kashihara City, Nara, Japan
| | - Tomoaki Hirose
- Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine, Kashihara City, Nara, Japan
| | - Shun Hiraga
- Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine, Kashihara City, Nara, Japan
| | - Ryohei Fukuba
- Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine, Kashihara City, Nara, Japan
| | - Junichi Takemura
- Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine, Kashihara City, Nara, Japan
| | - Rei Tonomura
- Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine, Kashihara City, Nara, Japan
| | - Kazuki Yamamoto
- Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine, Kashihara City, Nara, Japan
| | - Shinya Yokoyama
- Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine, Kashihara City, Nara, Japan
| | - Shigeki Taniguchi
- Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine, Kashihara City, Nara, Japan
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Gillmann HJ, Dieding J, Schrimpf C, Janssen H, Sahlmann B, Rustum S, Aper T, Lichtinghagen R, Teebken OE, Theilmeier G, Larmann J. Prospective evaluation of preoperative lung ultrasound for prediction of perioperative outcome and myocardial injury in adult patients undergoing vascular surgery (LUPPO study). Minerva Anestesiol 2020; 86:1151-1160. [DOI: 10.23736/s0375-9393.20.14393-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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The concept of peri-operative medicine to prevent major adverse events and improve outcome in surgical patients: A narrative review. Eur J Anaesthesiol 2020; 36:889-903. [PMID: 31453818 DOI: 10.1097/eja.0000000000001067] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
: Peri-operative Medicine is the patient-centred and value-based multidisciplinary peri-operative care of surgical patients. Peri-operative stress, that is the collective response to stimuli occurring before, during and after surgery, is, together with pre-existing comorbidities, the pathophysiological basis of major adverse events. The ultimate goal of Peri-operative Medicine is to promote high quality recovery after surgery. Clinical scores and/or biomarkers should be used to identify patients at high risk of developing major adverse events throughout the peri-operative period. Allocation of high-risk patients to specific care pathways with peri-operative organ protection, close surveillance and specific early interventions is likely to improve patient-relevant outcomes, such as disability, health-related quality of life and mortality.
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Janssen H, Felgner L, Kummer L, Gillmann HJ, Schrimpf C, Rustum S, Lichtinghagen R, Sahlmann B, Weigand MA, Teebken OE, Theilmeier G, Larmann J. Sequential Surgical Procedures in Vascular Surgery Patients Are Associated With Perioperative Adverse Cardiac Events. Front Cardiovasc Med 2020; 7:13. [PMID: 32133374 PMCID: PMC7040239 DOI: 10.3389/fcvm.2020.00013] [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: 08/01/2019] [Accepted: 01/28/2020] [Indexed: 01/31/2023] Open
Abstract
Patients at elevated cardiovascular risk are prone to perioperative cardiovascular complications, like myocardial injury after non-cardiac surgery (MINS). We have demonstrated in a mouse model of atherosclerosis that perioperative stress leads to an increase in plaque volume and higher plaque vulnerability. Regulatory T cells (Tregs) play a pivotal role in development and destabilization of atherosclerotic plaques. For this exploratory post-hoc analysis we identified 40 patients recruited into a prospective perioperative biomarker study, who within the inclusion period underwent sequential open vascular surgery. On the basis of protein markers measured in the biomarker study, we evaluated the perioperative inflammatory response in patients' plasma before and after index surgery as well as before and after a second surgical procedure. We also analyzed available immunohistochemistry samples to describe plaque vulnerability in patients who underwent bilateral carotid endarterectomy (CEA) in two subsequent surgical procedures. Finally, we assessed if MINS was associated with sequential surgery. The inflammatory response of both surgeries was characterized by postoperative increases of interleukin-6,−10, Pentraxin 3 and C-reactive protein with no clear-cut difference between the two time points of surgery. Plaques from CEA extracted during the second surgery contained less Tregs, as measured by Foxp3 staining, than plaques from the first intervention. The 2nd surgical procedure was associated with MINS. In conclusion, we provide descriptive evidence that sequential surgical procedures involve repeat inflammation, and we hypothesize that elevated rates of cardiovascular complications after the second procedure could be related to reduced levels of intraplaque Tregs, a finding that deserves confirmatory testing and mechanistic exploration in future populations.
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Affiliation(s)
- Henrike Janssen
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany.,Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hanover, Germany
| | - Larissa Felgner
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Laura Kummer
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hans-Jörg Gillmann
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hanover, Germany
| | - Claudia Schrimpf
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hanover, Germany
| | - Saad Rustum
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hanover, Germany
| | - Ralf Lichtinghagen
- Institute for Clinical Chemistry, Medical School Hannover, Hanover, Germany
| | - Bianca Sahlmann
- Department of Human Medicine, Perioperative Inflammation and Infection, Faculty of Medicine and Health Sciences, University of Oldenburg, Oldenburg, Germany
| | - Markus A Weigand
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Omke E Teebken
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hanover, Germany
| | - Gregor Theilmeier
- Department of Human Medicine, Perioperative Inflammation and Infection, Faculty of Medicine and Health Sciences, University of Oldenburg, Oldenburg, Germany.,Department of Anesthesiology, University Medical Center Groningen, Groningen, Netherlands
| | - Jan Larmann
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany.,Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hanover, Germany
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Peri-operative copeptin concentrations and their association with myocardial injury after vascular surgery: A prospective observational cohort study. Eur J Anaesthesiol 2019; 35:682-690. [PMID: 29750698 DOI: 10.1097/eja.0000000000000815] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Copeptin levels in conjunction with cardiac troponin may be used to rule out early myocardial infarction in patients presenting with chest pain. Raised pre-operative copeptin has been shown to be associated with postoperative cardiac events. However, very little is known about the peri-operative time course of copeptin or the feasibility of very early postoperative copeptin measurement to diagnose or rule-out myocardial injury. OBJECTIVES In this preparatory analysis for a larger trial, we sought to examine the time course of peri-operative copeptin and identify the time at which concentrations returned to pre-operative levels. Second, in an explorative analysis, we sought to examine the association of copeptin in general and at various time points with myocardial injury occurring within the first 48 h. DESIGN Preparatory analysis of a prospective, observational cohort study. SETTING Single university centre from February to July 2016. PATIENTS A total of 30 consecutive adults undergoing vascular surgery. INTERVENTION Serial peri-operative copeptin measurements. MAIN OUTCOME MEASURE We measured copeptin concentrations before and immediately after surgery (0 h), then at 2, 4, 6 and 8 h after surgery and on the first and second postoperative day. Postoperative concentrations were compared with pre-operative levels with a Wilcoxon signed-rank test. Second, we explored an association between postoperative copeptin concentrations and myocardial injury by the second postoperative day. Myocardial injury was defined as a 5 ng l increase between pre-operative and postoperative high-sensitivity cardiac troponin T with an absolute peak of at least 20 ng l. RESULTS Immediate postoperative copeptin concentrations (median [interquartile range]) increased nearly eight-fold from pre-operative values (8.5 [3.6 to 13.8] to 64.75 pmol l [29.6 to 258.7]; P < 0.001). Copeptin concentrations remained elevated until returning to baseline on the second postoperative day. Postoperative copeptin was significantly higher in patients experiencing myocardial injury than in those who did not (P = 0.02). The earliest most promising single time point for diagnosis may be immediately after surgery (0 h). The receiver-operating characteristics curve for immediate postoperative copeptin and myocardial injury by the second postoperative day was 0.743 (95% confidence interval 0.560 to 0.926). CONCLUSION Copeptin concentrations are greatly increased after vascular surgery and remain so until the 2nd postoperative day. Postoperative copeptin concentrations appear to be higher in patients who go on to exhibit myocardial injury. Immediate postoperative copeptin concentrations show promise for eliminating or identifying those at risk of myocardial injury. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02687776, Mauermann/Lurati Buse.
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Reis PV, Lopes AI, Leite D, Moreira J, Mendes L, Ferraz S, Amaral T, Mourão J, Abelha F. Major Cardiac Events in Patients Admitted to Intensive Care After Vascular Noncardiac Surgery: A Retrospective Cohort. Semin Cardiothorac Vasc Anesth 2019; 23:293-299. [DOI: 10.1177/1089253218825442] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction. Patients proposed to vascular noncardiac surgery (VS) have several comorbidities associated with major adverse cardiac events (MACE). We evaluated incidence, predictors, and outcomes, and compared different scores to predict MACE after VS. Methods. We included all patients admitted from 2006 to 2013. Perioperative MACE included cardiac arrhythmias, myocardial infarction (MI), cardiogenic pulmonary edema (CPE), acute heart failure (AHF), and cardiac arrest (CA). Lee Revised Cardiac Risk Index (RCRI), Vascular Quality Initiative (VQI-CRI), Vascular Study Group of New England (VSG-CRI), and South African Vascular Surgical (SAVS-CRI) Cardiac Risk Indexes were calculated and analyzed. We performed multivariate logistic regression to assess independent predictors with calculation of odds ratio (OR) and 95% confidence interval (CI). To reduce overfitting, we used leave-one-out cross-validation approach. The Predictive ability of scores was tested using area under receiver operating characteristic curve (AUROC). Results. A total of 928 patients were included. We observed 81 MACE (28 MI, 22 arrhythmias, 10 CPE, 9 AHF, 12 CA) in 60 patients (6.5%): 3.3% in intermediate-risk surgery and 9.8% in high-risk surgery. Previous history of coronary artery disease (OR = 3.2, CI = 1.8-5.7), atrial fibrillation (OR = 5.1, CI = 2.4-11.0), insulin-treated diabetes mellitus (OR = 3.26, CI = 1.51-7.06), mechanical ventilation (OR = 2.75, CI = 1.41-4.63), and heart rate (OR = 1.02, CI = 1.01-1.03) at admission were considered independent risk factors in multivariate analysis. The AUROC of our model was 0.79, compared with RCRI (0.66), VSG-CRI (0.69), VQI-CRI (0.71), and SAVS-CRI (0.73). Conclusions. Observed MACE were within predicted range (1% to 5% after intermediate-risk surgery and >5% after high-risk surgery). SAVS-CRI and VQI-CRI had slightly better predictive capacity than VSG-CRI or RCRI.
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Affiliation(s)
- Pedro Videira Reis
- São João Hospital Centre, Porto, Portugal
- Universidade do Porto, Porto, Portugal
| | | | | | | | | | | | | | - Joana Mourão
- São João Hospital Centre, Porto, Portugal
- Universidade do Porto, Porto, Portugal
| | - Fernando Abelha
- São João Hospital Centre, Porto, Portugal
- Universidade do Porto, Porto, Portugal
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Time course of copeptin during a model of experimental pain and hyperalgesia: A randomised volunteer crossover trial. Eur J Anaesthesiol 2018; 34:306-314. [PMID: 28106611 DOI: 10.1097/eja.0000000000000592] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND A reliable biomarker for quantifying pain or hyperalgesia has yet to be found. A surrogate marker of arginine vasopressin, copeptin, is elevated in a number of states of physiological and psychological stress and may have a role in quantifying pain and/or hyperalgesia. OBJECTIVES To evaluate copeptin as a biomarker for pain or hyperalgesia developing after 120 min of sustained electrical stimulation. DESIGN Secondary analysis of a randomised, double-blinded, crossover trial. SETTING Single, tertiary university hospital from September 2014 to January 2015. PARTICIPANTS A total of 16 healthy, opioid-naïve white men with no confounding medication or history of pain. INTERVENTIONS Copeptin and cortisol were measured five times during an established model of transdermal electrical stimulation designed to assess pain and hyperalgesia. MAIN OUTCOME MEASURES The primary outcome was the change in copeptin concentration after 120 min of sustained electrical stimulation. Secondary outcomes were copeptin and cortisol concentrations after a subsequent period of rest and analyses of copeptin and cortisol concentrations were made in high-dose and low-dose fentanyl groups separately. RESULTS Total copeptin concentrations were not significantly elevated after 120 min [9.15 pmol l (interquartile ranges (IQR), 3.45 to 35.45 pmol l); P = 0.150] compared with baseline [6.15 pmol l (IQR, 3.60 to 10.62 pmol l)]. In the high-dose fentanyl group, there was a significant increase in copeptin within individuals [P = 0.001; median, 37.9 pmol l (IQR, 8.1 to 62 pmol l)] after 120 min, and in the low-dose fentanyl group a significant decrease in copeptin concentrations within individuals [P = 0.006; median, 4.7 pmol l (IQR, 3.13 to 9.35 pmol l)]. No correlation between copeptin concentration and either the area under the pain curve or area under the hyperalgesia curve could be found, indicating that the observed differences may be due to other fentanyl-mediated effects. CONCLUSION Copeptin concentrations do not appear to be associated directly with pain and hyperalgesia. Instead, some fentanyl-mediated effect or effects appear to have greatly increased copeptin concentrations from baseline to 120 min. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT02252458.
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Sheng X, Lin L, Guo F, Liang S, Chen H, Fang Y, Ding M. Copeptin level in the early prediction of cardiorenal syndrome in rats. Exp Ther Med 2018; 16:937-944. [PMID: 30112047 DOI: 10.3892/etm.2018.6239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 05/24/2018] [Indexed: 12/21/2022] Open
Abstract
Copeptin (CPP) has been considered as a useful marker for prediction of prognosis in heart diseases. However, CPP has not been investigated sufficiently in cardiorenal syndrome (CRS). The present study aimed to investigate the value of CPP level in predicting CRS in rats with partial nephrectomy combined with myocardial infarction (SNX + MI). A total of 60 male Sprague-Dawley rats were used to establish the CRS model by partial nephrectomy combined with MI. The rats were randomly divided into blank control (CK), SNX, MI and CRS groups. Changes in serum and urine CPP concentrations, hemodynamics, blood pressure, and renal function were examined 1-5 weeks after modeling. The predictive values of CPP in the occurrence of CRS in rats were evaluated using receiver operating characteristic (ROC) curve. The results showed that serum CPP in the CRS group in 1-5 weeks and urine CPP in 3 weeks after modeling increased significantly compared with the CK group. Also, serum B-type natriuretic peptide (BNP) in 1 and 3 weeks and urine BNP in 4-5 weeks after modeling increased significantly. No correlation was found between serum or urine CPP, BNP and BUN levels 1 week after modeling in the CRS group. The ROC curve analysis showed that the area under the curve of CRS predicted by serum CPP at 1 week was 0.908 with 56.59 pg/ml as the cutoff point, and its diagnostic sensitivity and specificity were 87.5 and 80.0%, respectively. To conclude, SNX + MI may be used to establish CRS rat model with cardiac and renal damage. Serum CPP may serve as a specific biomarker for the early prediction of CRS.
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Affiliation(s)
- Xiaosheng Sheng
- Department of Cardiology, Jinhua People's Hospital, Jinhua, Zhejiang 321000, P.R. China
| | - Li Lin
- Department of Cardiology, Jinhua People's Hospital, Jinhua, Zhejiang 321000, P.R. China
| | - Fangming Guo
- Department of Medical Sciences, Jinhua Polytechnic, Jinhua, Zhejiang 321007, P.R. China
| | - Shuxia Liang
- Endoscopy Center, Jinhua Hospital of Zhejiang University, Jinhua, Zhejiang 321001, P.R. China
| | - Haohao Chen
- Department of Medical Sciences, Jinhua Polytechnic, Jinhua, Zhejiang 321007, P.R. China
| | - Yuanshu Fang
- Department of Laboratory Animals Center, Jinhua Institute for Food and Drug Control, Jinhua, Zhejiang 321000, P.R. China
| | - Mingxing Ding
- Department of Medical Sciences, Jinhua Polytechnic, Jinhua, Zhejiang 321007, P.R. China
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15
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Abstract
Purpose of Review The central question of preoperative assessment is not “What can be done?” but “What should be done and how?” Predicting a patient’s risk of unwanted outcomes is vital to answering this question. This review discusses risk prediction tools currently available and anticipates future developments. Recent Findings Simple, parsimonious risk scales and scores are being replaced by complex risk prediction models as high-capacity information systems become ubiquitous. The accuracy of risk estimation will be further increased by improved assessment of physical fitness, frailty, and incorporation of existing and novel biomarkers. However, the limitations of risk prediction for individual patient care must be recognized. Summary Risk prediction is transforming from clinical estimation to statistical science. Predictions should be used within the context of a patient’s baseline risk (life expectancy independent of surgery), personal circumstances, quality of life, their expectations and values, and consideration of outcomes that are meaningful for the patient.
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Affiliation(s)
- Pragya Ajitsaria
- 1Department of Anaesthesia & Perioperative Medicine, John Hunter Hospital, Locked Bag 1 HRMC, Newcastle, NSW 2310 Australia.,2University of Newcastle, Newcastle, NSW Australia
| | - Sabry Z Eissa
- 1Department of Anaesthesia & Perioperative Medicine, John Hunter Hospital, Locked Bag 1 HRMC, Newcastle, NSW 2310 Australia.,2University of Newcastle, Newcastle, NSW Australia
| | - Ross K Kerridge
- 1Department of Anaesthesia & Perioperative Medicine, John Hunter Hospital, Locked Bag 1 HRMC, Newcastle, NSW 2310 Australia.,2University of Newcastle, Newcastle, NSW Australia
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16
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Krane V, Genser B, Kleber ME, Drechsler C, März W, Delgado G, Allolio B, Wanner C, Fenske W. Copeptin Associates with Cause-Specific Mortality in Patients with Impaired Renal Function: Results from the LURIC and the 4D Study. Clin Chem 2017; 63:997-1007. [PMID: 28280053 DOI: 10.1373/clinchem.2016.266254] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Accepted: 01/11/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND In chronic kidney disease (CKD) arginine vasopressin (AVP) cannot efficiently act via renal V2-receptors. AVP is upregulated leading to augmented activation of V1a- and V1b-receptors, which might contribute to the increase in cardiovascular and infectious complications in CKD. Here, we evaluate copeptin, a surrogate of AVP, and its association with cause specific mortality among patients within the whole spectrum of renal function. METHODS Copeptin was measured in baseline samples from the LURIC (n = 3131 patients with coronary angiograms) and the 4D-Study (n = 1241 type 2 diabetic hemodialysis patients). Patients were stratified into 4 groups: estimated glomerular filtration rate (eGFR) ≥90 mL/min/1.73 m2, 60-89 mL/min/1.73 m2, <60 mL/min/1.73 m2, and hemodialysis. The association of copeptin with mortality was assessed by Cox proportional hazards regression during 9.9 years of median follow-up in the Ludwigshafen Risk and Cardiovascular Health (LURIC) study and 4 years of median follow-up in the German Diabetes Dialysis Study (4D-Study). RESULTS Median copeptin increased with decreasing eGFR: 5.6 [interquartile range (IQR), 3.1-8.1] pmol/L (eGFR ≥90 mL/min/1.73 m2), 6.7 (2.9-10.5) pmol/L (eGFR 60-89 mL/min/1.73 m2), 15.3 (6.7-23.9) pmol/L (eGFR <60 mL/min/1.73 m2), and 80.8 (51.2-122) pmol/L (hemodialysis), respectively. Per SD increase in copeptin, the risk of coronary, infectious, and all-cause mortality increased by 25, 30, and 15% [hazard ratios (HR), 1.25; 95% CI, 1.13-1.39; HR, 1.30; 95% CI, 0.98-1.71; and HR, 1.15; 95% CI, 1.05-1.25], respectively, in patients with eGFR 60-89 mL/min/1.73 m2. Except for coronary death, results were similar among patients with more advanced renal disease. No significant association was found in patients with normal renal function. CONCLUSIONS Copeptin concentrations were independently associated with coronary, infectious, and all-cause mortality in patients with renal impairment. In patients with normal renal function no significant association was found.
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Affiliation(s)
- Vera Krane
- Department of Medicine 1, Division of Nephrology, and .,Comprehensive Heart Failure Centre, University Hospital of Würzburg, Würzburg, Germany
| | - Bernd Genser
- Instituto de Saúde Coletiva, Federal University of Bahia, Salvador, Brazil.,BGStats Consulting, Vienna, Austria
| | - Marcus E Kleber
- Medical Clinic V (Nephrology, Hypertensiology, Rheumatology, Endocrinology, Diabetology), Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Christiane Drechsler
- Department of Medicine 1, Division of Nephrology, and.,Comprehensive Heart Failure Centre, University Hospital of Würzburg, Würzburg, Germany
| | - Winfried März
- Medical Clinic V (Nephrology, Hypertensiology, Rheumatology, Endocrinology, Diabetology), Medical Faculty Mannheim, University of Heidelberg, Germany.,Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria.,Synlab Academy, Synlab Services GmbH, Mannheim, Germany
| | - Graciela Delgado
- Medical Clinic V (Nephrology, Hypertensiology, Rheumatology, Endocrinology, Diabetology), Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Bruno Allolio
- Comprehensive Heart Failure Centre, University Hospital of Würzburg, Würzburg, Germany.,Department of Internal Medicine 1, Division of Endocrinology, University of Würzburg, Würzburg, Germany
| | - Christoph Wanner
- Department of Medicine 1, Division of Nephrology, and.,Comprehensive Heart Failure Centre, University Hospital of Würzburg, Würzburg, Germany
| | - Wiebke Fenske
- Leipzig University Medical Center, IFB Adiposity Diseases, Leipzig, Germany
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Gillmann HJ, Meinders A, Larmann J, Sahlmann B, Schrimpf C, Aper T, Lichtinghagen R, Teebken OE, Theilmeier G. Adrenomedullin Is Associated With Surgical Trauma and Impaired Renal Function in Vascular Surgery Patients. J Intensive Care Med 2017; 34:67-76. [PMID: 28110613 DOI: 10.1177/0885066616689554] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND: Patients undergoing vascular surgery are prone to perioperative organ injury because of both higher prevalence of cardiovascular risk factors and the extent of surgery. Early detection of organ failure is essential to facilitate appropriate medical care. Midregional pro-adrenomedullin (MR-proADM) has been investigated in acute medical care settings to guide clinical decision-making regarding patient pathways and to identify patients prone to imminent cardiovascular or inflammatory complications. In this study, we evaluated the impact of perioperative MR-proADM levels as an early marker of perioperative cardiovascular and inflammatory stress reactions and kidney injury. METHODS: The study was conducted as a monocentric, prospective, noninterventional trial at Hannover Medical School, Germany. A total of 454 consecutive patients who underwent open vascular surgery were followed from the day prior to until 30 days after surgery. The composite primary end point was defined as the occurrence of major adverse cardiac events (MACEs), acute kidney injury (AKI), or systemic inflammatory response syndrome (SIRS). Measurements were correlated with both medical history and postoperative MACE, AKI, or SIRS using univariate and multivariate regression analysis. RESULTS: One hundred thirty-nine (31%) of the patients reached the primary end point within the study interval. Midregional pro-adrenomedullin change was associated with the combined primary end point and with the intensity of surgical trauma. Midregional pro-adrenomedullin change was increased in patients reaching the secondary end points, SIRS (optimal cutoff: 0.2 nmol/L) and AKI (optimal cutoff: 0.7 nmol/L), but not in patients with MACEs. CONCLUSION: Increased levels of MR-proADM within the perioperative setting (1) were linked to the invasiveness of surgery and (2) identified patients with ongoing loss of renal function. Increased MR-proADM levels may therefore identify a subgroup of patients prone to excessive cardiovascular stress but did not directly correlate with adverse cardiac events. Consistently low levels of MR-proADM may identify a subgroup of patients with acceptable low risk to guide discharge from high-density care units.
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Affiliation(s)
- Hans-Jörg Gillmann
- 1 Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Antje Meinders
- 1 Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Jan Larmann
- 1 Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany.,2 Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Bianca Sahlmann
- 3 Department of Medicine, Perioperative Inflammation and Infection, Faculty of Medicine and Health Sciences, University of Oldenburg, Oldenburg, Germany
| | - Claudia Schrimpf
- 4 Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Thomas Aper
- 4 Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Ralf Lichtinghagen
- 5 Department of Clinical Chemistry, Hannover Medical School, Hannover, Germany
| | - Omke E Teebken
- 6 Department of Vascular Surgery, Klinikum Peine, Peine, Germany
| | - Gregor Theilmeier
- 3 Department of Medicine, Perioperative Inflammation and Infection, Faculty of Medicine and Health Sciences, University of Oldenburg, Oldenburg, Germany
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Underwood CF, Hildreth CM, Wyse BF, Boyd R, Goodchild AK, Phillips JK. Uraemia: an unrecognized driver of central neurohumoral dysfunction in chronic kidney disease? Acta Physiol (Oxf) 2017; 219:305-323. [PMID: 27247097 DOI: 10.1111/apha.12727] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 01/21/2016] [Accepted: 05/31/2016] [Indexed: 12/12/2022]
Abstract
Chronic kidney disease (CKD) carries a large cardiovascular burden in part due to hypertension and neurohumoral dysfunction - manifesting as sympathetic overactivity, baroreflex dysfunction and chronically elevated circulating vasopressin. Alterations within the central nervous system (CNS) are necessary for the expression of neurohumoral dysfunction in CKD; however, the underlying mechanisms are poorly defined. Uraemic toxins are a diverse group of compounds that accumulate as a direct result of renal disease and drive dysfunction in multiple organs, including the brain. Intensive haemodialysis improves both sympathetic overactivity and cardiac baroreflex sensitivity in renal failure patients, indicating that uraemic toxins participate in the maintenance of autonomic dysfunction in CKD. In rodents exposed to uraemia, immediate early gene expression analysis suggests upregulated activity of not only pre-sympathetic but also vasopressin-secretory nuclei. We outline several potential mechanisms by which uraemia might drive neurohumoral dysfunction in CKD. These include superoxide-dependent effects on neural activity, depletion of nitric oxide and induction of low-grade systemic inflammation. Recent evidence has highlighted superoxide production as an intermediate for the depolarizing effect of some uraemic toxins on neuronal cells. We provide preliminary data indicating augmented superoxide production within the hypothalamic paraventricular nucleus in the Lewis polycystic kidney rat, which might be important for mediating the neurohumoral dysfunction exhibited in this CKD model. We speculate that the uraemic state might serve to sensitize the central actions of other sympathoexcitatory factors, including renal afferent nerve inputs to the CNS and angiotensin II, by way of recruiting convergent superoxide-dependent and pro-inflammatory pathways.
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Affiliation(s)
- C. F. Underwood
- Department of Biomedical Sciences; Macquarie University; Sydney NSW Australia
| | - C. M. Hildreth
- Department of Biomedical Sciences; Macquarie University; Sydney NSW Australia
| | - B. F. Wyse
- Department of Biomedical Sciences; Macquarie University; Sydney NSW Australia
| | - R. Boyd
- Department of Biomedical Sciences; Macquarie University; Sydney NSW Australia
| | - A. K. Goodchild
- Department of Biomedical Sciences; Macquarie University; Sydney NSW Australia
| | - J. K. Phillips
- Department of Biomedical Sciences; Macquarie University; Sydney NSW Australia
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Elevated copeptin is a prognostic factor for mortality even in patients with renal dysfunction. Int J Cardiol 2016; 221:327-32. [PMID: 27404700 DOI: 10.1016/j.ijcard.2016.07.058] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 07/04/2016] [Indexed: 01/06/2023]
Abstract
BACKGROUND Copeptin has turned out to give valuable prognostic information for future cardiovascular events. However, since its plasma concentration directly depends on renal function, the value of copeptin as a predictor for outcome also in patients with chronic kidney disease (CKD) is unknown. METHODS In this single-center substudy of the German Coronary Artery Disease-REnal Failure (CAD-REF) registry, 301 patients with an angiographically diagnosed stenosis ≥50% in at least one major coronary vessel were included. Estimated glomerular filtration rate (eGFR) was determined using the MDRD formula and patients were classified according to their CKD stage. Copeptin concentrations were measured before initial angiography. Follow-up was performed at 180days, study endpoint was all-cause mortality. RESULTS Of the 301 included patients, 35 (11.6%) patients had no CKD, 113 (37.5%) had CKD stage 1 or 2, 117 (38.9%) had CKD stage 3, and 36 (12.0%) had CKD stage 4 or 5. Copeptin was elevated (≥14pmol/L) in 81 (26.9%) patients and normal (<14pmol/L) in 220 (73.1%) patients. Copeptin values significantly increased with decreasing eGFR (p<0.001) and were strongly correlated with creatinine values (r=0.567, p<0.001). During 180days of follow-up, 15 patients (5.0%) died, 10 of them with elevated copeptin values. Multivariate Cox regression analysis showed that copeptin was the sole predictor for mortality (HRR 5.317 (95% CI 1.653-17.098), p=0.005), independent of serum creatinine. CONCLUSION Elevated copeptin can be used as a valuable prognostic factor for intermediate-term mortality in patients with both coronary artery and renal disease.
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Janković R, Marković D, Savić N, Dinić V. Beyond the Limits: Clinical Utility of Novel Cardiac Biomarkers. BIOMED RESEARCH INTERNATIONAL 2015; 2015:187384. [PMID: 26504786 PMCID: PMC4609335 DOI: 10.1155/2015/187384] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 08/03/2015] [Accepted: 08/17/2015] [Indexed: 01/08/2023]
Abstract
Preoperative assessment of cardiovascular risk is essential when it comes to extensive noncardiac surgery procedures. Therefore, accurate and timely diagnosis of myocyte damage is vital. In modern medical practice it is believed that the so-called "multimarker" approach is the most appropriate and most accurate, but new research points out that there are novel biomarkers which could be used independently. Studies that evaluate miRNA, H-FABP, and MR-PAMP give encouraging results. When it comes to miRNA clinical studies show high statistical significance, especially in the case of acute myocardial infarction (P = 0.001). Statistical significance of P = 0.007 was found in acute coronary syndrome, when H-FABP was measured. Biochemical marker MR-PAMP showed statistical significance of P < 0.0001 in most clinical studies.
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Affiliation(s)
- Radmilo Janković
- Center for Anesthesiology and Reanimatology, Clinical Center in Niš, Bulevar Dr. Zorana Djindjića 48, 18000 Niš, Serbia
- Department for Anesthesia and Intensive Care, School of Medicine, University of Niš, Bulevar Dr. Zorana Đinđića 81, 18000 Niš, Serbia
| | - Danica Marković
- Center for Anesthesiology and Reanimatology, Clinical Center in Niš, Bulevar Dr. Zorana Djindjića 48, 18000 Niš, Serbia
| | - Nenad Savić
- Center for Anesthesiology and Reanimatology, Clinical Center in Niš, Bulevar Dr. Zorana Djindjića 48, 18000 Niš, Serbia
| | - Vesna Dinić
- Center for Anesthesiology and Reanimatology, Clinical Center in Niš, Bulevar Dr. Zorana Djindjića 48, 18000 Niš, Serbia
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Łukaszyk E, Małyszko J. Copeptin: Pathophysiology and potential clinical impact. Adv Med Sci 2015; 60:335-41. [PMID: 26233637 DOI: 10.1016/j.advms.2015.07.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 06/29/2015] [Accepted: 07/02/2015] [Indexed: 12/24/2022]
Abstract
Copeptin, a C-terminal part of the precursor pre-provasopressin is a novel biomarker of arginine-vasopressin (AVP) system. Measurements of AVP concentration are not used in clinical practice because of technical difficulties. Copeptin is synthesized in stoichiometric ratio with AVP, hence it reflects vasopressin concentration in human plasma and serum. This review outlines current research concerning the role of copeptin as a prognostic marker in different diseases and its potential clinical value.
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