Prediction of perioperative myocardial infarction/injury in high-risk patients after noncardiac surgery

AIMS

Perioperative myocardial infarction/injury (PMI) is a surprisingly common yet difficult-to-predict cardiac complication in patients undergoing noncardiac surgery. We aimed to assess the incremental value of preoperative cardiac troponin (cTn) concentration in the prediction of PMI.

METHODS AND RESULTS

Among prospectively recruited patients at high cardiovascular risk (age ≥65 years or ≥45 years with preexisting cardiovascular disease), PMI was defined as an absolute increase in high-sensitivity cTnT (hs-cTnT) concentration of ≥14 ng/L (the 99th percentile) above the preoperative concentration. Perioperative myocardial infarction/injury was centrally adjudicated by two independent cardiologists using serial measurements of hs-cTnT. Using logistic regression, three models were derived: Model 1 including patient- and procedure-related information, Model 2 adding routinely available laboratory values, and Model 3 further adding preoperative hs-cTnT concentration. Models were also compared vs. preoperative hs-cTnT alone. The findings were validated in two independent cohorts. Among 6944 patients, PMI occurred in 1058 patients (15.2%). The predictive accuracy as quantified by the area under the receiver operating characteristic curve was 0.73 [95% confidence interval (CI) 0.71-0.74] for Model 1, 0.75 (95% CI 0.74-0.77) for Model 2, 0.79 (95% CI 0.77-0.80) for Model 3, and 0.74 for hs-cTnT alone. Model 3 included 10 preoperative variables: age, body mass index, known coronary artery disease, metabolic equivalent >4, risk of surgery, emergency surgery, planned duration of surgery, haemoglobin, platelet count, and hs-cTnT. These findings were confirmed in both independent validation cohorts (n = 722 and n = 966).

CONCLUSION

Preoperative cTn adds incremental value above patient- and procedure-related variables as well as routine laboratory variables in the prediction of PMI.

Guideline adherence to statin therapy and association with short-term and long-term cardiac complications following noncardiac surgery: A cohort study

BACKGROUND

Peri-operative complications are common and associated with high morbidity and mortality. Optimising the use of statins might be of important benefit in peri-operative care and reduce morbidity and mortality.

OBJECTIVE

To evaluate adherence to current guideline recommendations regarding statin therapy and its association with peri-operative and long-term cardiac complications.

DESIGN

Prospective cohort study.

SETTING

Multicentre study with enrolment from October 2014 to February 2018.

PATIENTS

Eight thousand one hundred and sixteen high-risk inpatients undergoing major noncardiac surgery who were eligible for the institutional peri-operative myocardial injury/infarction (PMI) active surveillance and response program.

MAIN OUTCOME MEASURES

Class I indications for statin therapy were derived from the current ESC Clinical Practice Guidelines during the time of enrolment. PMI was prospectively defined as an absolute increase in cTn concentration of the 99th percentile in healthy individuals above the preoperative concentration within the first three postoperative days. Long-term cardiac complications included cardiovascular death and spontaneous myocardial infarction (MI) within 120 days.

RESULTS

The mean age was 73.7 years; 45.2% were women. Four thousand two hundred and twenty-seven of 8116 patients (52.1%) had a class I indication for statin therapy. Of these, 2440 of 4227 patients (57.7%) were on statins preoperatively. Adherence to statins was lower in women than in men (46.9 versus 63.9%, P  < 0.001). PMI due to type 1 myocardial infarction/injury (T1MI; n  = 42), or likely type 2 MI (lT2MI; n  = 466) occurred in 508 of 4170 (12.2%) patients. The weighted odds ratio in patients on statin therapy was 1.15 [95% confidence interval (CI) 1.01 to 1.31, P  = 0.036]. During the 120-day follow-up, 192 patients (4.6%) suffered cardiovascular death and spontaneous MI. After multivariable adjustment, preoperative use of statins was associated with reduced risk; weighted hazard ratio 0.59 (95% CI 0.41 to 0.86, P  = 0.006).

CONCLUSION

Adherence to guideline-recommended statin therapy was suboptimal, particularly in women. Statin use was associated with an increased risk of PMI due to T1MI and lT2MI but reduced risk of cardiovascular death and spontaneous MI within 120 days.

TRIAL REGISTRATION

Clinicaltrials.gov identifier NCT02573532.

Acute heart failure after non-cardiac surgery: incidence, phenotypes, determinants and outcomes

AIMS

Primary acute heart failure (AHF) is a common cause of hospitalization. AHF may also develop postoperatively (pAHF). The aim of this study was to assess the incidence, phenotypes, determinants and outcomes of pAHF following non-cardiac surgery.

METHODS AND RESULTS

A total of 9164 consecutive high-risk patients undergoing 11 262 non-cardiac inpatient surgeries were prospectively included. The incidence, phenotypes, determinants and outcome of pAHF, centrally adjudicated by independent cardiologists, were determined. The incidence of pAHF was 2.5% (95% confidence interval [CI] 2.2-2.8%); 51% of pAHF occurred in patients without known heart failure (de novo pAHF), and 49% in patients with chronic heart failure. Among patients with chronic heart failure, 10% developed pAHF, and among patients without a history of heart failure, 1.5% developed pAHF. Chronic heart failure, diabetes, urgent/emergent surgery, atrial fibrillation, cardiac troponin elevations above the 99th percentile, chronic obstructive pulmonary disease, anaemia, peripheral artery disease, coronary artery disease, and age, were independent predictors of pAHF in the logistic regression model. Patients with pAHF had significantly higher all-cause mortality (44% vs. 11%, p < 0.001) and AHF readmission (15% vs. 2%, p < 0.001) within 1 year than patients without pAHF. After Cox regression analysis, pAHF was an independent predictor of all-cause mortality (adjusted hazard ratio [aHR] 1.7 [95% CI 1.3-2.2]; p < 0.001) and AHF readmission (aHR 2.3 [95% CI 1.5-3.7]; p < 0.001). Findings were confirmed in an external validation cohort using a prospective multicentre cohort of 1250 patients (incidence of pAHF 2.4% [95% CI 1.6-3.3%]).

CONCLUSIONS

Postoperative AHF frequently developed following non-cardiac surgery, being de novo in half of cases, and associated with a very high mortality.

Cardiovascular imaging following perioperative myocardial infarction/injury

Patients developing perioperative myocardial infarction/injury (PMI) have a high mortality. PMI work-up and therapy remain poorly defined. This prospective multicenter study included high-risk patients undergoing major non-cardiac surgery within a systematic PMI screening and clinical response program. The frequency of cardiovascular imaging during PMI work-up and its yield for possible type 1 myocardial infarction (T1MI) was assessed. Automated PMI detection triggered evaluation by the treating physician/cardiologist, who determined selection/timing of cardiovascular imaging. T1M1 was considered with the presence of a new wall motion abnormality within 30 days in transthoracic echocardiography (TTE), a new scar or ischemia within 90 days in myocardial perfusion imaging (MPI), and Ambrose-Type II or complex lesions within 7 days of PMI in coronary angiography (CA). In patients with PMI, 21% (268/1269) underwent at least one cardiac imaging modality. TTE was used in 13% (163/1269), MPI in 3% (37/1269), and CA in 5% (68/1269). Cardiology consultation was associated with higher use of cardiovascular imaging (27% versus 13%). Signs indicative of T1MI were found in 8% of TTE, 46% of MPI, and 63% of CA. Most patients with PMI did not undergo any cardiovascular imaging within their PMI work-up. If performed, MPI and CA showed high yield for signs indicative of T1MI.Trial registration: https://clinicaltrials.gov/ct2/show/NCT02573532 .

Incidence and outcomes of perioperative myocardial infarction/injury diagnosed by high-sensitivity cardiac troponin I

BACKGROUND

 Perioperative myocardial infarction/injury (PMI) diagnosed by high-sensitivity troponin (hs-cTn) T is frequent and a prognostically important complication of non-cardiac surgery. We aimed to evaluate the incidence and outcome of PMI diagnosed using hs-cTnI, and compare it to PMI diagnosed using hs-cTnT.

METHODS

We prospectively included 2455 patients at high cardiovascular risk undergoing 3111 non-cardiac surgeries, for whom hs-cTnI and hs-cTnT concentrations were measured before surgery and on postoperative days 1 and 2. PMI was defined as a composite of perioperative myocardial infarction (PMIInfarct) and perioperative myocardial injury (PMIInjury), according to the Fourth Universal Definition of Myocardial Infarction. All-cause mortality was the primary endpoint.

RESULTS

Using hs-cTnI, the incidence of overall PMI was 9% (95% confidence interval [CI] 8-10%), including PMIInfarct 2.6% (95% CI 2.0-3.2) and PMIInjury 6.1% (95% CI 5.3-6.9%), which was lower versus using hs-cTnT: overall PMI 15% (95% CI 14-16%), PMIInfarct 3.7% (95% CI 3.0-4.4) and PMIInjury 11.3% (95% CI 10.2-12.4%). All-cause mortality occurred in 52 (2%) patients within 30 days and 217 (9%) within 1 year. Using hs-cTnI, both PMIInfarct and PMIInjury were independent predictors of 30-day all-cause mortality (adjusted hazard ratio [aHR] 2.5 [95% CI 1.1-6.0], and aHR 2.8 [95% CI 1.4-5.5], respectively) and, 1-year all-cause mortality (aHR 2.0 [95% CI 1.2-3.3], and aHR 1.8 [95% CI 1.2-2.7], respectively). Overall, the prognostic impact of PMI diagnosed by hs-cTnI was comparable to the prognostic impact of PMI using hs-cTnT.

CONCLUSIONS

Using hs-cTnI, PMI is less common versus using hs-cTnT. Using hs-cTnI, both PMIInfarct and PMIInjury remain independent predictors of 30-day and 1-year mortality.

Adherence to the European Society of Cardiology/European Society of Anaesthesiology recommendations on preoperative cardiac testing and association with positive results and cardiac events: a cohort study

BACKGROUND

European Society of Cardiology/European Society of Anaesthesiology (ESC/ESA) guidelines inform cardiac workup before noncardiac surgery based on an algorithm. Our primary hypotheses were that there would be associations between (i) the groups stratified according to the algorithms and major adverse cardiac events (MACE), and (ii) over- and underuse of cardiac testing and MACE.

METHODS

This is a secondary analysis of a multicentre prospective cohort. Major adverse cardiac events were a composite of cardiac death, myocardial infarction, acute heart failure, and life-threatening arrhythmia at 30 days. For each cardiac test, pathological findings were defined a priori. We used multivariable logistic regression to measure associations.

RESULTS

We registered 359 MACE at 30 days amongst 6976 patients; classification in a higher-risk group using the ESC/ESA algorithm was associated with 30-day MACE; however, discrimination of the ESC/ESA algorithms for 30-day MACE was modest; area under the curve 0.64 (95% confidence interval: 0.61-0.67). After adjustment for sex, age, and ASA physical status, discrimination was 0.72 (0.70-0.75). Overuse or underuse of cardiac tests were not consistently associated with MACE. There was no independent association between test recommendation class and pathological findings (P=0.14 for stress imaging; P=0.35 for transthoracic echocardiography; P=0.52 for coronary angiography).

CONCLUSIONS

Discrimination for MACE using the ESC/ESA guidelines algorithms was limited. Overuse or underuse of cardiac tests was not consistently associated with cardiovascular events. The recommendation class of preoperative cardiac tests did not influence their yield.

CLINICAL TRIAL REGISTRATION

NCT02573532.

Association between self-reported functional capacity and major adverse cardiac events in patients at elevated risk undergoing noncardiac surgery: a prospective diagnostic cohort study

BACKGROUND

Perioperative cardiovascular guidelines endorse functional capacity estimation, based on 'cut-off' daily activities for risk assessment and climbing two flights of stairs to approximate 4 metabolic equivalents. We assessed the association between self-reported functional capacity and postoperative cardiac events.

METHODS

Consecutive patients at elevated cardiovascular risk undergoing in-patient noncardiac surgery were included in this predefined secondary analysis. Self-reported ability to walk up two flights of stairs was extracted from electronic charts. The primary endpoint was a composite of cardiac death and cardiac events at 30 days. Secondary endpoints included the same composite at 1 yr, all-cause mortality, and myocardial injury.

RESULTS

Among the 4560 patients, mean (standard deviation) age 73 (SD 8 yr) yr, classified as American Society of Anesthesiologists physical status ≥3 in 61% (n=2786/4560), the 30-day and 1-yr incidences of major adverse cardiac events were 5.7% (258/4560) and 11.2% (509/4560), respectively. Functional capacity less than two flights of stairs was associated with the 30-day composite endpoint (adjusted hazard ratio 1.63, 95% confidence interval [CI] 1.23-2.15) and all other endpoints. The addition of functional capacity information to the revised cardiac risk index (RCRI) significantly improved risk classification (functional capacity plus RCRI vs RCRI: net reclassification improvement [NRI]_Events 6.2 [95% CI 3.6-9.9], NRI_Nonevents19.2 [95% CI 18.1-20.0]).

CONCLUSIONS

In patients at high cardiovascular risk undergoing noncardiac surgery, self-reported functional capacity less than two flights of stairs was independently associated with major adverse cardiac events and all-cause mortality at 30 days and 1 yr. The addition of self-reported functional capacity to surgical and clinical risk improved risk classification.

CLINICAL TRIAL REGISTRATION

INCT 02573532.

Incidence of major adverse cardiac events following non-cardiac surgery

AIMS

Major adverse cardiac events (MACE) triggered by non-cardiac surgery are prognostically important perioperative complications. However, due to often asymptomatic presentation, the incidence and timing of postoperative MACE are incompletely understood.

METHODS AND RESULTS

We conducted a prospective observational study implementing a perioperative screening for postoperative MACE [cardiovascular death (CVD), acute heart failure (AHF), haemodynamically relevant arrhythmias, spontaneous myocardial infarction (MI), and perioperative myocardial infarction/injury (PMI)] in patients at increased cardiovascular risk (≥65 years OR ≥45 years with history of cardiovascular disease) undergoing non-cardiac surgery at a tertiary hospital. All patients received serial measurements of cardiac troponin to detect asymptomatic MACE. Among 2265 patients (mean age 73 years, 43.4% women), the incidence of MACE was 15.2% within 30 days, and 20.6% within 365 days. CVD occurred in 1.2% [95% confidence interval (CI) 0.9-1.8] and in 3.7% (95% CI 3.0-4.5), haemodynamically relevant arrhythmias in 1.2% (95% CI 0.9-1.8) and in 2.1% (95% CI 1.6-2.8), AHF in 1.6% (95% CI 1.2-2.2) and in 4.2% (95% CI 3.4-5.1), spontaneous MI in 0.5% (95% CI 0.3-0.9) and in 1.6% (95% CI 1.2-2.2), and PMI in 13.2% (95% CI 11.9-14.7) and in 14.8% (95% CI 13.4-16.4) within 30 days and within 365 days, respectively. The MACE-incidence was increased above presumed baseline rate until Day 135 (95% CI 104-163), indicating a vulnerable period of 3-5 months.

CONCLUSION

One out of five high-risk patients undergoing non-cardiac surgery will develop one or more MACE within 365 days. The risk for MACE remains increased for about 5 months after non-cardiac surgery.

TRIAL REGISTRATION

https://www.clinicaltrials.gov. Unique identifier: NCT02573532.

Biomarker-Based Preoperative Risk Stratification for Patients Undergoing Non-Cardiac Surgery

Perioperative morbidity and mortality remains a substantial problem and is strongly associated with patients’ cardiac comorbidities. Guidelines for the cardiovascular assessment and management of patients at risk of cardiac issues while undergoing non-cardiac surgery are traditionally based on the exclusion of active or unstable cardiac conditions, determination of the risk of surgery, the functional capacity of the patient, and the presence of cardiac risk factors. In the last two decades, strong evidence showed an association between cardiac biomarkers and adverse cardiac events, with newer guidelines incorporating this knowledge. This review describes a biomarker-based risk-stratification pathway and discusses potential treatment strategies for patients suffering from postoperative myocardial injury or infarction.

P2532Incidence and outcome of perioperative myocardial infarction/injury after non-cardiac surgeries diagnosed by high-sensitivity cardiac troponin I

Background

In order to differentiate perioperative myocardial infarction/injury (PMI) after non-cardiac surgery from preexisting cardiomyocyte injury from chronic disorders, recent studies have shown the importance of using an acute absolute increase as a criterion for PMI. For high-sensitivity troponin T (hs-cTnT), PMI defined as an absolute increase of 14ng/L (the 99th percentile) has been shown to be strongly associated with 30-day mortality. Until now, no data on hs-cTnI are available. This is a major unmet clinical need, as relevant differences between hs-cTnT and hs-cTnI have recently been identified and, as worldwide hs-cTnI is more commonly used as compared to hs-cTnT. We hypothesized that applying the same criterion to hs-cTnI, would reveal a similar association with outcomes.

Purpose

To evaluate the incidence and outcome of PMI diagnosed by hs-cTnI after non-cardiac surgery.

Methods

We included prospectively consecutive high cardiovascular risk patients undergoing non-cardiac surgery. Hs-cTnI concentrations were measured before surgery and, daily after surgery, for three days. PMI was defined as an absolute rise of ≥26ng/L (the 99th percentile of the assay studied) from baseline values. The primary outcome was major adverse cardiovascular events (MACE), a composite of cardiovascular death, myocardial infarction, acute heart failure and arrhythmias, and the secondary outcome was all-cause mortality, within 30 days and one year.

Results

We included 2,018 patients submitted to 2,551 surgeries. Patients had median age of 73 years (IQR 68–79) and 56% were male. After surgery, 231 patients (9%, 95% CI 8–10%) fulfilled PMI diagnostic criterion. Patients with PMI had higher rates of MACE than patients without PMI, at 30 days (13% vs. 2%; P<0.001) and, at one-year follow-up (25% vs. 8%; P<0.001). All-cause mortality was also higher in PMI patients within 30 days and one year (9% vs. 1.5% and, 22% vs. 8%, respectively; P<0.001). In multivariate cox regression analysis, PMI showed a hazard ratio (HR) of 4.7 (95% CI, 2.9–7.6; P<0.001) within 30 days, and a HR of 2.7 (95% CI, 2.0–3.7; P<0.001) within one year for the occurrence of MACE. For total mortality, PMI showed a HR of 3.8 (95% CI, 2.1–6.8; P<0.001) within 30 days and a HR of 2.0 (95% CI, 1.4–2.7; P<0.001) after one year.

Conclusion

PMI is frequent and associated with high rates of MACE and mortality in short- and long-term follow-up after non-cardiac surgery, regardless of the high-sensitivity troponin assay used for diagnosis.

Acknowledgement/Funding

Swiss Heart Foundation, University basel, Abbott, Astra zeneca, Forschungsfond Kantonsspital Aarau, Cardiovascular Research Foundation Basel, FAPESP

P5980Etiology of perioperative myocardial injuries after non-cardiac surgery and associated outcomes

Background

Perioperative myocardial injuries (PMI) are a common complication following non-cardiac surgery associated with significantly increased postoperative mortality. Due to its mostly asymptomatic presentation it is currently often missed in clinical routine. With the advent of routine screening PMI will be an increasingly recognised. Therefore, a more detailed understanding of the different etiologies causing PMI is needed to guide management.

Methods

We included consecutive high-risk patients (defined as known cardiovascular disease or aged ≥65 years) undergoing major non-cardiac surgery at two hospitals into this prospective multicenter observational study. All patients received a systematic screening using cardiac troponin (cTn) in clinical routine for detection of PMI, defined as an absolute cTn-rise from baseline values within 3 days of surgery. Patients were contacted to assess occurrence of major adverse events (MACE) including all-cause death at 30-days. First, we identified preoperative existing comorbidities as well as perioperative factors associated with PMI by multivariable regression analysis. Second, PMI were centrally adjudicated to identify predefined subtypes (“type I myocardial infarction (T1MI)”, “acute heart failure” (AHF), “tachyarrhythmia”, “extra-cardiac” triggers, “unknown”) by two independent reviewers using all clinical information available, and subtypes tested for association with 30-day (MACE).

Results

From 2014 to 2016 we enrolled 4250 patients undergoing 5375 surgeries. PMI occurred after 785 (14,5%) surgeries. Occurrence of PMI was more frequent with older age and cardiovascular comorbidities, especially insulin-dependent diabetes mellitus and chronic kidney disease. Perioperatively multiple known type II triggers (hypotension, bleeding, hypoxemia, tachycardia, length of surgery) were associated with PMI. Only 5,0% of PMI were adjudicated as “T1MI”, 4,3% as “AHF”, 4,3% as “tachyarrhythmia”, 12,0% “extra-cardiac” and the majority of 74,4% as “unknown”. The subtypes were associated increased MACE-rates (24% for T1MI, 40% for “AHF”, 22% for “tachyarrhythmia”, 24% for “extra-cardiac”, 7,1% for “unknown”) compared to non-PMI patients (1,8%, p<0,001 see Figure).

MACE within 30 days following surgery

Conclusion

PMI occurs more likely in patients with preoperative existing comorbidities, PMI are associated with type II triggers in the intra- as well as postoperative period. We identified subtypes allowing a risk-stratification to identify high-risk types and guide clinical management.

Acknowledgement/Funding

Swiss National Science Foundation, Swiss Heart Foundation, Cardiovascular Research Foundation Basel, Roche

Daytime variation of perioperative myocardial injury in non-cardiac surgery and effect on outcome

Objective

Recently, daytime variation in perioperative myocardial injury (PMI) has been observed in patients undergoing cardiac surgery. We aim at investigating whether daytime variation also occurs in patients undergoing non-cardiac surgery.

Methods

In a prospective diagnostic study, we evaluated the presence of daytime variation in PMI in patients at increased cardiovascular risk undergoing non-cardiac surgery, as well as its possible impact on the incidence of acute myocardial infarction (AMI), and death during 1-year follow-up in a propensity score–matched cohort. PMI was defined as an absolute increase in high-sensitivity cardiac troponin T (hs-cTnT) concentration of ≥14 ng/L from preoperative to postoperative measurements.

Results

Of 1641 patients, propensity score matching defined 630 with similar baseline characteristics, half undergoing non-cardiac surgery in the morning (starting from 8:00 to 11:00) and half in the afternoon (starting from 14:00 to 17:00). There was no difference in PMI incidence between both groups (morning: 50, 15.8% (95% CI 12.3 to 20.3); afternoon: 52, 16.4% (95% CI 12.7 to 20.9), p=0.94), nor if analysing hs-cTnT release as a quantitative variable (median morning group: 3 ng/L (95% CI 1 to 7 ng/L); median afternoon group: 2 ng/L (95% CI 0 to 7 ng/L; p=0.16). During 1-year follow-up, the incidence of AMI was 1.2% (95% CI 0.4% to 3.2%) among morning surgeries versus 4.1% (95% CI 2.3% to 6.9%) among the afternoon surgeries (corrected HR for afternoon surgery 3.44, bootstrapped 95% CI 1.33 to 10.49, p log-rank=0.03), whereas no difference in mortality emerged (p=0.70).

Conclusions

Although there is no daytime variation in PMI in patients undergoing non-cardiac surgery, the incidence of AMI during follow-up is increased in afternoon surgeries and requires further study.

Clinical trial registration

NCT02573532;Results.

Construct and longitudinal validity of a modified Huang clinical scoring system in adult cystic fibrosis patients

This study reports on the evaluation of a modified Huang scoring system in adult cystic fibrosis patients for construct and longitudinal validity. Two studies were performed. In the first study, the scoring system was applied to 59 adult cystic fibrosis patients prospectively followed at the Montreal Chest Institute. The total score and all the subscores distinguished between patients with the expected mild degree of disease severity seen in patients colonized with only Staphylococcus aureus, compared to the more advanced disease severity seen in patients colonized with Pseudomonas aeruginosa or multiple resistant pseudomonads. The relationship between disease severity assessed by forced expiratory volume in one second per cent predicted and the nonpulmonary function subscores was significant and linear (for the radiological subscore, r2=0.694, p<0.0001) and curvilinear (for the clinical and complications subscores, r2=0.622, p=0.0192 and r2=0.508, p=0.0009 respectively). In the second study, 20 patients retrospectively recorded were added to the prospective group. There was a good association between changes in nonpulmonary function subscores and changes in spirometry over a mean follow-up period of 779+/-204 days, at all levels of disease severity. The contribution of changes in clinical and complications subscores to the changes in total score became progressively more significant with more advanced disease severity. In conclusion, significant evidence for the construct validity of the scoring system as a discriminative instrument and for the longitudinal validity as an evaluative instrument was demonstrated. It may prove of value in assessing outcome of therapeutic interventions in clinical trials in patients with cystic fibrosis.

Internal consistency reliability and predictive validity of a modified N. Huang clinical scoring system in adult cystic fibrosis patients

We described a modified N. Huang scoring system and its application as a measure of disease status and progression in a population of adult cystic fibrosis patients. We evaluated the scoring for internal consistency reliability and predictive validity. We applied the scoring system to 109 adult cystic fibrosis patients followed at the Montreal Chest Institute. Complete data were available on 36 deceased patients. The total score represented the sum of the clinical, radiological and pulmonary function subscores, minus the complications subscore. It ranged between 0 (worst health) and 100 points (best health). The total score showed a high degree of internal consistency and reliability with an estimated Cronbach coefficient alpha of 0.934. Both total score and forced expiratory volume in one second (FEV1) percentage predicted were significant predictors of survival at 36 and 24 months. However, there was a progressive decrease in the discriminating power of FEV1 percentage pred for predicting survival at 24, 18, 12 and 6 months. The total score showed a progressive and consistent pattern clearly predicting the outcome. A total score < 41, < 38, < 35 and < 30 points was associated with a poor prognosis for survival at 24, 18, 12, and 6 months, respectively. The clinical and complications subscores were the most discriminating components of the total score. The total score of the modified N. Huang scoring system offered a better discriminating scale, as compared to forced expiratory volume in one second % predicted, in the prognostic evaluation of end-stage cystic fibrosis patients. It could be of value in decisions for lung transplantation in these patients.

Chylothorax associated with tuberculous spondylitis

A patient is described with bilateral chylothorax which was associated with tuberculous spondylitis. The tuberculous spondylitis appeared at two widely separated thoracic levels. A similar association has not been reported previously. Anti-tuberculous treatment resulted in healing of the spondylitis and resolution of the chylothorax.