Prediction of Acute Myocardial Injury in Noncardiac Surgery in Patients at Risk for Major Adverse Cardiovascular and Cerebrovascular Events: A Multivariable Risk Model

BACKGROUND

The best use of perioperative cardiac biomarkers assessment is still under discussion. Massive postoperative troponin surveillance can result in untenably high workloads and costs for health care systems and potentially harmful interventions for patients. In a cohort of patients at risk for major adverse cardiovascular and cerebrovascular events (MACCEs), we aimed to (1) determine whether preoperative biomarkers can identify patients at major risk for acute myocardial injury in noncardiac surgery, (2) develop a risk model for acute myocardial injury prediction, and (3) propose an algorithm to optimize postoperative troponin surveillance.

METHODS

Prospective, single-center cohort study enrolling consecutive adult patients (≥45 years) at risk for MACCE scheduled for intermediate-to-high-risk noncardiac surgery. Baseline high-sensitivity troponin T (hsTnT) and N-terminal fragment of pro-B-type natriuretic peptide (NT-proBNP), as well as hsTnT on the first 3 postoperative days were obtained. The main outcome was the occurrence of acute myocardial injury. Candidate predictors of acute myocardial injury were baseline concentrations of hsTnT ≥14 ng/L and NT-proBNP ≥300 pg/mL and preoperative and intraoperative variables. A multivariable risk model and a decision curve were constructed.

RESULTS

Of 732 patients, 42.1% had elevated hsTnT and 37.3% had elevated NT-proBNP levels at baseline. Acute myocardial injury occurred in 161 patients (22%). Elevated baseline hsTnT, found in 84% of patients with acute myocardial injury, was strongly associated with this outcome: odds ratio (OR), 12.08 (95% confidence interval [CI], 7.78-19.42). Logistic regression identified 6 other independent predictors for acute myocardial injury: age, sex, estimated glomerular filtration rate (eGFR) <45 mL·min -1 ·1.73 m -2 , functional capacity <4 METs or unknown, NT-proBNP ≥300 pg/mL, and estimated intraoperative blood loss. The c -statistic for the risk model was 77% (95% CI, 0.73-0.81). The net benefit of the model began at a risk threshold of 7%.

CONCLUSIONS

Baseline determination of cardiac biomarkers in patients at risk for MACCE shortly before intermediate- or high-risk noncardiac surgery helps identify those with the highest risk for acute myocardial injury. A baseline hsTnT ≥14 ng/L indicates the need for postoperative troponin surveillance. In patients with baseline hsTnT <14 ng/L, our 6-predictor model will identify additional patients at risk for acute myocardial injury who may also benefit from postoperative surveillance.

Analysis of the prescription process of PCSK9 inhibitors in the cardiology departments of Spanish hospitals and optimization proposal. The IKIGAI study

AIMS

To ascertain the formalities and procedures required for the prescription of PCSK9 inhibitors in the cardiology departments of Spanish hospitals, making proposals for improvement to optimize the prescription process.

METHODS

A first phase of collecting information about the variables and administrative procedures required for the prescription of PCK9 inhibitors and the elaboration of a specific questionnaire and a second phase of collecting data with an online self-administered questionnaire.

RESULTS

A total of 88 hospitals participated in the study (mean number of beds 625; mean number of cardiologists 18 ± 10; 78% university hospitals). There was underuse of PCSK9 inhibitors (real prescription of 30 treatments/year; potential prescription of 80), mainly because of not fulfilling the therapeutic positioning report (52%) and application refusal (31%). Beyond the requirements of the therapeutic positioning report, 1.2 ± 0.4 applications are required with 8.5 ± 4.2 variables. Only 21% of hospitals did not require a previous authorization process and in the remaining hospitals, approval from a committee was necessary. The accumulated time of the prescription process was 6 weeks. Discontinuation rates during follow-up were 9% ± 12%.

CONCLUSIONS

Treatment with PCSK9 inhibitors is clearly underused in Spain. This is mainly due to both inappropriate identification of patients, and complex administrative procedures that could inhibit/discourage prescription by cardiologists and consequently, limit their use. In addition, there is a substantial delay from drug approval tadministration.

Benthic marine litter in shallow fishing grounds in the NW Mediterranean Sea

Fisheries are one of the main economic sectors affected by marine litter, which can damage gear, reduce catch, and require time to repair or clean nets. This study aims to evaluate the type and density of marine litter in two shallow fishing grounds in the NW Mediterranean Sea, both belonging to the Natura 2000 network. Moreover, it quantifies the fraction of marine litter within the total catch to help understand the potential influence of marine litter on fisheries. Two study areas were selected, one in the vicinity of urban populated areas and high navigational traffic and one in a rural site off an agricultural area. The urban area had more benthic marine litter (393 to 198 kg km^-2) including clinker (residue from coal-burning steamships), fabric, plastics, and processed wood and accounting for up to 38% of the total catch. The rural area had far less marine litter (34-56 kg km^-2), accounting for only 5% of the total catch. Marine litter may have potential negative effects on fisheries; thus we propose that government credit trading programs could be promoted to help recover litter from fishing catches, to reduce fishing costs and hazards to marine ecosystems.

A new rational approach to reach LDL-cholesterol concentration objectives after an acute coronary syndrome

INTRODUCTION AND OBJECTIVES

Adequate LDL cholesterol (LDLc) control after an acute coronary syndrome (ACS) is a crucial secondary prevention strategy to minimize the incidence of recurrent myocardial infarction and cardiovascular death. There are tables that predict the necessary dosage of lipid-lowering treatment from the initial LDLc but have not been tested in ACS. Variables associated with optimal LDLc after an ACS were analyzed and the therapeutic yield of the use of Masana's recommendations in this setting.

METHODS

A total number of 326 ACS-patients were included between January-2015 and May-2016. Baseline LDLc concentration and prescribed hypolipemiant treatment at hospital discharge were registered. We analyzed the variables associated with optimal LDLc levels (<70mg/dL) control during follow-up.

RESULTS

Among our patient population (72% male, age 66±13 years), the hypolipemiant treatment at hospital discharge fulfilled the Masana's recommendations in 196 (60%) patients. After a follow-up period of 122 [66-184] days the targeted LDLc levels were achieved in 148 (45%) patients, being this percentage greater among those in whom the Masana's recommendations were fulfilled (109/196, 56%), as compared with the remaining (39/130, 30%; P<.001). The male gender (P<.001), the absence of prior history of dyslipemia (P<.001) and the adherence to Masana's recommendations (P=.007) were independent predictors for the achievement of targeted LDLc levels during follow-up.

CONCLUSIONS

In less than half of ACS-patients adequate mid-term LDLc control is obtained. The dosage of the lipid-lowering therapy according to Masana's recommendations helps to achieve this important therapeutic goal.

Ceftolozane-tazobactam for the treatment of ventilator-associated infections by colistin-resistant Pseudomonas aeruginosa

The use of colistin for the treatment of multiresistant bacteria has led to the emergence of colistin-resistant strains of Gram-negative bacilli. Treatment of infections caused by these pan-drug-resistant bacteria is difficult owing to the paucity of effective antibiotics. We report two cases of ventilator-associated respiratory infection caused by pan-drug-resistant, colistin-resistant Pseudomonas aeruginosa that were successfully treated with ceftolozane-tazobactam.

Secondary prevention strategies after an acute ST-segment elevation myocardial infarction in the AMI code era: beyond myocardial mechanical reperfusion

BACKGROUND

The AMI code is a regional network enhancing a rapid and widespread access to reperfusion therapy (giving priority to primary angioplasty) in patients with acute ST-segment elevation myocardial infarction (STEMI). We aimed to assess the long-term control of conventional cardiovascular risk factors after a STEMI among patients included in the AMI code registry.

DESIGN AND METHODS

Four hundred and fifty-four patients were prospectively included between June-2009 and April-2013. Clinical characteristics were collected at baseline. The long-term control of cardiovascular risk factors and cardiovascular morbidity/mortality was assessed among the 6-months survivors.

RESULTS

A total of 423 patients overcame the first 6 months after the STEMI episode, of whom 370 (87%) underwent reperfusion therapy (363, 98% of them, with primary angioplasty). At 1-year follow-up, only 263 (62%) had adequate blood pressure control, 123 (29%) had LDL-cholesterol within targeted levels, 126/210 (60%) smokers had withdrawn from their habit and 40/112 (36%) diabetic patients had adequate glycosylated hemoglobin levels. During a median follow-up of 20 (11-30) months, cumulative mortality of 6 month-survivors was 6.1%, with 9.9% of hospital cardiovascular readmissions. The lack of assessment of LDL and HDL-cholesterol were significantly associated with higher mortality and cardiovascular readmission rates.

CONCLUSIONS

Whereas implementation of the AMI code resulted in a widespread access to rapid reperfusion therapy, its long-term therapeutic benefit may be partially counterbalanced by a manifestly suboptimal control of cardiovascular risk factors. Further efforts should be devoted to secondary prevention strategies after STEMI.

QT interval in newborns of different ethnic origin: usefulness of neonatal ECG screening

The cost-effectiveness of neonatal electrocardiographic (ECG) screening has been questioned. The objective of this study was to establish normal values for the QT interval in newborns of different ethnic origin. Between 2005 and 2006, ECGs were obtained during the first 48 h of life from 1305 at-term newborns at the Hospital del Mar in Barcelona, Spain. The mean corrected QT interval (QTc) was 417.79+/-28.47 ms. A QTc longer than 440 ms was observed in 240 newborns (18.33%). The frequency of a pathologic QTc in Spanish newborns was 17.9%, compared with 27.7% in those of Maghreb or Near Eastern origin (P=.016), and 28.2% in those of Indian or Pakistani origin (P=.033). The QTc may vary for genetic reasons. A routine neonatal ECG is advisable only in ethnic groups in which the QTc is lengthened, to help counter the greater risk of sudden death in these infants.

Reduction in door-to-needle time to meet clinical guideline recommendations. Outcomes after 1 year

The aim of this study was to reduce the door-to-needle time in patients with ST-elevation acute myocardial infarction by setting up a chest pain service. We compared the door-to-needle time and outcomes at the end of first year of follow-up in patients who received fibrinolysis in the 2 years before implementation of the service (Group 1) and those who received fibrinolysis in the 2 years after its creation (Group 2). In Group 1, the median door-to-needle time was 40 min (P(25-75), 23-52 min); in Group 2, it was 27 min (P(25-75), 15-43 min; P=.003). In addition, the use of reperfusion therapy increased from 55.2% in Group 1 to 64.7% in Group 2 (P< .01). After a follow-up period of 1 year, there was no difference in the rate of revascularization, hospital readmission, reinfarction or cardiovascular mortality.

[Acute coronary syndrome during a cesarean section in a healthy young woman]

Acute coronary syndrome (ACS) during pregnancy and delivery is a rare event that is usually related to prior disease or family history. Factors that contribute to the appearance of ACS during delivery in women with healthy coronary arteries include high doses of drugs to suppress contractions or increase uterine muscle tone and cardiovascular instability of any kind. Clinical and electrocardiographic abnormalities (eg, ST segment depression) that are suggestive of ACS have been reported to occur during cesarean section but without subsequent enzyme or echocardiographic abnormalities.

Endothelial dysfunction of the non-infarct related, angiographically normal, coronary artery in patients with an acute myocardial infarction

BACKGROUND

Patients with acute myocardial infarction and single-vessel disease may have early atherosclerosis in other angiographically normal coronary arteries.

METHODS

Coronary endothelial responses were analysed in 20 non-diabetic patients with an acute myocardial infarction and one-vessel disease. In an angiographically normal, non-infarct related, coronary artery serial acetylcholine doses of 10(-7) M, 10(-6) M, 10(-5) M and 10(-4) M and nitroglycerin 40 micrograms were infused over 3 min. The responses of the coronary vessel were measured with quantitative angiography. Coronary blood flow was also measured with a Doppler catheter in 11 of the 20 patients.

RESULTS

Four patients showed a trend towards vasodilation during acetylcholine infusion in the proximal and distal segments: from 2.49 +/- 0.23 mm to 2.95 +/- 0.42 mm and 2.43 +/- 0.56 mm to 2.81 +/- 0.66 mm, respectively. Coronary vascular resistance decreased to 57 +/- 4% (P = 0.03). The other 16 patients presented vasoconstriction in the proximal and distal segments: 2.61 +/- 0.75 mm to 2.03 +/- 0.65 mm (P = 0.0001), and 2.40 +/- 0.58 to 1.81 +/- 0.56 mm (P = 0.0036), respectively. Nitroglycerin caused vasodilation in the proximal (2.69 +/- 0.61 mm, P = 0.017, ANOVA) and distal segments (2.48 +/- 0.45 mm, P = 0.009, ANOVA). Coronary vascular resistance increased to 141 +/- 43% (P = 0.03) over the basal value in this group of patients.

CONCLUSION

Endothelial dysfunction of the epicardial and resistance vessels was found in angiographically normal coronary arteries of patients with one-vessel disease in 75% of this population.

Improvement of exercise-induced ischaemia and myocardial perfusion after aminophylline

BACKGROUND

Previous studies have suggested that aminophylline improves exercise-induced ischaemia by preventing the redistribution of the coronary flow from ischaemic to non-ischaemic myocardium. The purpose of the study was to assess whether aminophylline improves myocardial perfusion in zones supplied by collateral circulation.

METHODS

Twenty-three patients with an occluded coronary artery and collateral circulation from a non-diseased vessel underwent two symptom-limited exercise 99mTc-MIBI, single-photon emission computed tomography (SPECT) myocardial scintigraphy experiments, which were preceded by an intravenous infusion of either aminophylline (5 mg/kg over 20 min) or saline solution in a randomized double-blind control procedure. The MIBI SPECT images were analysed by two experienced observers who were blinded to each other's data.

RESULTS

All patients underwent cardiac catheterization. For 16 patients this was because of stable angina and the remaining eight were post-myocardial infarction patients with a positive exercise test. Aminophylline significantly increased the time to the onset of ischaemia in the 15 patients with a positive exercise test (mean +/- SD, 6.5 +/- 1.9 compared with 5.3 +/- 1.8 min, P < 0.005); and ischaemia occurred at higher rate-pressure product (230 +/- 68 compared with 195 +/- 68 HB x mmHg, P < 0.03). After aminophylline, exercise ST-segment depression was 1.1 +/- 0.5 mV, compared with 1.5 +/- 0.8 mV after placebo (P < 0.01). All patients had perfusion defects that resolved partially or completely in the rest images. The imaging score was significantly lower after aminophylline infusion than after placebo (9.7 +/- 9 compared with 12.1 +/- 10, P < 0.01).

CONCLUSIONS

Aminophylline significantly delayed the time to onset of exercise-induced ischaemia and improved perfusion in zones supplied by collateral circulation. Aminophylline-like drugs may be useful in the treatment of selected patients with ischaemic heart disease.