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Hicks MH, Edwards AF. Updates in Cardiopulmonary Care: Highlights of Recent Guidelines. Int Anesthesiol Clin 2025; 63:13-20. [PMID: 40266889 DOI: 10.1097/aia.0000000000000480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2025]
Affiliation(s)
- Megan H Hicks
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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2
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Clerico A, Zaninotto M, Aimo A, Padoan A, Passino C, Fortunato A, Galli C, Plebani M. Advancements and challenges in high-sensitivity cardiac troponin assays: diagnostic, pathophysiological, and clinical perspectives. Clin Chem Lab Med 2025; 63:1260-1278. [PMID: 39915924 DOI: 10.1515/cclm-2024-1090] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2024] [Accepted: 01/19/2025] [Indexed: 05/29/2025]
Abstract
Although significant progress has been made in recent years, some important questions remain regarding the analytical performance, pathophysiological interpretation and clinical use of cardiac troponin I (cTnI) and T (cTnT) measurements. Several recent studies have shown that a progressive and continuous increase in circulating levels of cTnI and cTnT below the cut-off value (i.e. the 99th percentile upper reference limit) may play a relevant role in cardiovascular risk assessment both in the general population and in patients with cardiovascular or extra-cardiac disease. International guidelines recommend the use of standardized clinical algorithms based on temporal changes in circulating cTnI and cTnT levels measured by high-sensitivity (hs) methods to detect myocardial injury progressing to acute myocardial infarction. Some recent studies have shown that some point-of-care assays for cTnI with hs performance ensure a faster diagnostic turnaround time and thus significantly reduce the length of stay of patients admitted to emergency departments with chest pain. However, several confounding factors need to be considered in this setting. A novel approach may be the combined assessment of laboratory methods (including hs-cTn assay) and other clinical data, possibly using machine learning methods. In the present document of the Italian Study Group on Cardiac Biomarkers, the authors aimed to discuss these new trends regarding the analytical, pathophysiological and clinical issues related to the measurement of cardiac troponins using hs-cTnI and hs-cTnT methods.
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Affiliation(s)
- Aldo Clerico
- Scuola Superiore Sant'Anna e Fondazione CNR - Regione Toscana G. Monasterio, Pisa, Italy
| | | | - Alberto Aimo
- Scuola Superiore Sant'Anna e Fondazione CNR - Regione Toscana G. Monasterio, Pisa, Italy
| | | | - Claudio Passino
- Scuola Superiore Sant'Anna e Fondazione CNR - Regione Toscana G. Monasterio, Pisa, Italy
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3
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Pilakouta Depaskouale MA, Archonta SA, Moutafidou SΚ, Paidakakos NA, Dimakopoulou AN, Matsota PK. Effectiveness of hypotension prediction index software in reducing intraoperative hypotension in prolonged prone-position spine surgery: a single-center clinical trial. J Clin Monit Comput 2025:10.1007/s10877-025-01303-0. [PMID: 40410627 DOI: 10.1007/s10877-025-01303-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2024] [Accepted: 04/29/2025] [Indexed: 05/25/2025]
Abstract
Intraoperative hypotension (IOH) is associated with morbidity and mortality. The Hypotension Prediction Index (HPI), a machine learning-based tool, offers the opportunity for a proactive approach by predicting hypotensive events. This single center, single blind randomized clinical trial aimed to evaluate the hypothesis that an HPI software-guided approach to IOH management during prone position spine surgery could reduce its incidence compared to our standard care practices. 85 adult patients undergoing spine fusion surgery in the prone position were enrolled. Patients were randomized with a 1:1 allocation ratio. Participants were blinded to their group allocation. In the intervention group, the HPI software was actively used to guide IOH management. In the control group, HPI software readings were blinded, and standard care was administered. The primary outcome was the comparison of time-weighted average (TWA) of IOH between the two groups. Secondary outcomes included a comparison of the incidence of postoperative in-hospital events related to IOH between groups. 77 patients were included in the final analysis (39 in the intervention group), as 8 patients were excluded due to technical issues. No statistically significant difference was found between the intervention and control groups in the TWA of IOH (0.10 mmHg [0.05, 0.23] vs. 0.15 mmHg [0.09, 0.37], p-value 0.088). However, the total duration of hypotensive events per patient was significantly lower in the intervention group (4 min [0.5, 12.2] vs. 11.2 min [2.6, 20.1]; p-value 0.019). Postoperative complication rates did not differ significantly between the two groups. HPI-guided management did not significantly reduce the TWA of IOH compared to standard care in patients undergoing prone-position spine surgery. Complication rates were similar between the two groups.Clinical Trial Registration: This trial was registered with ClinicalTrials.gov (registration number: NCT05341167).
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Affiliation(s)
- Myrto A Pilakouta Depaskouale
- 2nd Department of Anesthesiology, School of Medicine, National and Kapodistrian University of Athens, "Attikon" Hospital, Athens, Greece.
- Department of Anesthesiology, Athens General Hospital "Georgios Gennimatas", Athens, Greece.
| | - Stela A Archonta
- Department of Anesthesiology, Athens General Hospital "Georgios Gennimatas", Athens, Greece
| | - Sofia Κ Moutafidou
- Department of Anesthesiology, Athens General Hospital "Georgios Gennimatas", Athens, Greece
| | - Nikolaos A Paidakakos
- Department of Neurosurgery, Athens General Hospital "Georgios Gennimatas", Athens, Greece
| | - Antonia N Dimakopoulou
- Department of Anesthesiology, Athens General Hospital "Georgios Gennimatas", Athens, Greece
| | - Paraskevi K Matsota
- 2nd Department of Anesthesiology, School of Medicine, National and Kapodistrian University of Athens, "Attikon" Hospital, Athens, Greece
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Francisco-Azevedo J, Romana-Dias L, Ribeiro H, Dias-Neto M, Rocha-Neves J. Incidence of Myocardial Injury in Patients Submitted to Abdominal Aortic Aneurysm Repair: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2025; 120:57-76. [PMID: 40349833 DOI: 10.1016/j.avsg.2025.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2025] [Revised: 05/01/2025] [Accepted: 05/01/2025] [Indexed: 05/14/2025]
Abstract
BACKGROUND Repair of abdominal aortic aneurysms (AAAs) is a major vascular surgery that carries risk of myocardial injury following noncardiac surgery (MINS). MINS occurs in approximately 20% of patients and affects patient outcomes, but its incidence remains unclear in this subset of patients. This systematic review aims to determine the incidence of MINS in patients undergoing AAA repair. METHODS MEDLINE, Web of Science, and Scopus were searched for studies assessing MINS after AAA repair. The incidence of MINS in endovascular aortic repair (EVAR) and open aortic repair (OAR) was pooled by random-effects meta-analysis, with sources of heterogeneity being explored. Assessment of studies' quality was performed using National Heart, Lung, and Blood Institute Study Quality Assessment and RoB 2 Tool. RESULTS Sixteen studies were included, with a total of 25,649 participants. Two were randomized controlled trials, while the remaining were cohorts. Age ranged from 65.8-75.5 and percentage of male participants between 78% and 96.6%. The pooled incidence of MINS ranged from 0.4% to 18.7% for EVAR and 1.8-46.8% for OAR. Meta-analytical incidence of MINS after EVAR was 12.5% (95% confidence interval [CI] 6.2-18.7%) in cohort studies and 0.9% (95% CI 0.4-1.4%) in multicenter database studies, both with severe heterogeneity (I2 = 91.0% and 79.1%). For OAR, the incidence was 30.6% (95% CI 19.5-41.7%) in cohort studies, 3.2% (95% CI 1.8-4.6%) in multicenter database studies, and 32.4% (95% CI 18.1-46.8%) in randomized controlled trials, all with high heterogeneity (I2 = 96.8%, 86.6%, and 71.3%). CONCLUSION MINS incidence was significant, and results indicate a possible difference between EVAR and OAR, but the significant heterogeneity found indicates a need for additional research with consistent methodology and definitions. Registered at PROSPERO (reference: CRD42024507346).
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Affiliation(s)
| | - Lara Romana-Dias
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Unidade Local de Saúde de São João, Porto, Portugal
| | - Hugo Ribeiro
- Faculty of Medicine of the University of Porto, Porto, Portugal; Community Palliative Care Support Team Gaia, Vila Nova de Gaia, Portugal; Faculty of Medicine of University of Coimbra, Coimbra, Portugal; Centre for Innovative Biomedicine and Biotechnology, Coimbra, Portugal
| | - Marina Dias-Neto
- Department of Angiology and Vascular Surgery, Unidade Local de Saúde de São João, Porto, Portugal; UnIC@RISE-Health, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal; RISE-Health, Departamento de Biomedicina-Unidade de Anatomia, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - João Rocha-Neves
- UnIC@RISE-Health, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal; RISE-Health, Departamento de Biomedicina-Unidade de Anatomia, Faculdade de Medicina, Universidade do Porto, Porto, Portugal; Department of Biomedicine, Unity of Anatomy, Faculty of Medicine of the University of Porto, Porto, Portugal
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Zeng C, Gao Y, Lan B, Wang J, Ma F. Metabolic reprogramming in cancer therapy-related cardiovascular toxicity: Mechanisms and intervention strategies. Semin Cancer Biol 2025; 113:39-58. [PMID: 40349808 DOI: 10.1016/j.semcancer.2025.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2025] [Revised: 04/20/2025] [Accepted: 05/07/2025] [Indexed: 05/14/2025]
Abstract
Cancer therapy-related cardiovascular toxicity (CTR-CVT) poses a major challenge in managing cancer patients, contributing significantly to morbidity and mortality among survivors. CTR-CVT includes various cardiovascular issues, such as cardiomyopathy, myocardial ischemia, arrhythmias, and vascular dysfunction, which significantly impact patient prognosis and quality of life. Metabolic reprogramming, characterized by disruptions in glucose, lipid, and amino acid metabolism, represents a shared pathophysiological feature of cancer and cardiovascular diseases; however, the precise mechanisms underlying CTR-CVT remain inadequately understood. In recent years, strategies targeting metabolic pathways have shown promise in reducing cardiovascular risks while optimizing cancer treatment efficacy. This review systematically summarizes metabolic reprogramming characteristics in both cancer and cardiovascular diseases, analyzes how anticancer therapies induce cardiovascular toxicity through metabolic alterations, and explores emerging therapeutic strategies targeting metabolic dysregulation. By integrating current research advancements, this review aims to enhance the understanding of CTR-CVT and provide groundwork for the development of safer and more effective cancer approaches.
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Affiliation(s)
- Cheng Zeng
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China.
| | - Ying Gao
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310000, China.
| | - Bo Lan
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China.
| | - Jiani Wang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China.
| | - Fei Ma
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China.
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Kirkopoulos A, M'Pembele R, Roth S, Stroda A, Larmann J, Gillmann HJ, Kotfis K, Ganter MT, Bolliger D, Filipovic M, Guzzetti L, Mauermann E, Ionescu D, Spadaro S, Szczeklik W, De Hert S, Beck-Schimmer B, Howell SJ, Lurati Buse GA. Outcomes in patients with chronic heart failure undergoing non-cardiac surgery: a secondary analysis of the METREPAIR international cohort study. Anaesthesia 2025. [PMID: 40230320 DOI: 10.1111/anae.16607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2025] [Indexed: 04/16/2025]
Abstract
INTRODUCTION Heart failure is a frequent comorbidity in patients undergoing non-cardiac surgery and an acknowledged risk factor for postoperative mortality. The associations between stable chronic heart failure and postoperative outcomes have not been explored extensively. The aim of this study was to determine associations between stable chronic heart failure and its peri-operative management and postoperative outcomes after major non-cardiac surgery. METHODS This is a secondary analysis of MET-REPAIR, an international prospective cohort study including patients undergoing non-cardiac surgery aged ≥ 45 y with increased cardiovascular risk. Main exposures were stable chronic heart failure and availability of a pre-operative transthoracic echocardiogram. The primary endpoint was the incidence of postoperative major adverse cardiovascular events at 30 days. Secondary endpoints included 30-day mortality and severe in-hospital complications. Multivariable logistic regression models were calculated. RESULTS Of 15,158 included patients, 3880 (25.6%) fulfilled the diagnostic criteria for stable chronic heart failure, of whom 1397 (36%) were female. Chronic heart failure was associated with increased risk of postoperative 30-day major adverse cardiovascular events (OR 2.04, 95%CI 1.59-2.60), 30-day mortality (OR 1.50, 95%CI 1.17-1.92) and in-hospital complications (OR 1.47, 95%CI 1.30-1.66). Transthoracic echocardiography was performed in 1267 (32.7%) patients with heart failure; 146 (11.5%) patients with heart failure presented with a left ventricular ejection fraction < 40%. Reduced ejection fraction was associated with major adverse cardiovascular events (OR 2.0, 95%CI 1.01-3.81). DISCUSSION Stable chronic heart failure is independently associated with major adverse cardiovascular events, mortality and severe postoperative complications when measured 30 days after non-cardiac surgery.
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Affiliation(s)
- Anna Kirkopoulos
- Anesthesiology Department, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - René M'Pembele
- Anesthesiology Department, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Sebastian Roth
- Anesthesiology Department, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Alexandra Stroda
- Anesthesiology Department, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Jan Larmann
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Hans-Joerg Gillmann
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Katarzyna Kotfis
- Department of Anesthesiology, Intensive Care and Pain Management, Pomeranian Medical University, Szczecin, Poland
| | - Michael T Ganter
- Department of Anesthesiology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Daniel Bolliger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Miodrag Filipovic
- Division of Perioperative Intensive Care Medicine, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Luca Guzzetti
- Anesthesia and Intensive Care Department, University Hospital, Varese, Italy
| | - Eckhard Mauermann
- Department of Anesthesiology, Zurich City Hospital, Zurich, Switzerland
| | - Daniela Ionescu
- Department of Anaesthesia and Intensive Care I, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Savino Spadaro
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Stefan De Hert
- Department of Anaesthesiology and Peri-operative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Beatrice Beck-Schimmer
- Institute of Anaesthesiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Simon J Howell
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Giovanna A Lurati Buse
- Anesthesiology Department, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
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Neiva de Paula-Garcia W, De Hert S. Pharmacologic agents for perioperative cardioprotection in noncardiac surgery. Curr Opin Anaesthesiol 2025:00001503-990000000-00288. [PMID: 40241429 DOI: 10.1097/aco.0000000000001494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2025]
Abstract
PURPOSE OF THE REVIEW This review will discuss the current pharmacologic strategies for mitigation of perioperative myocardial. State-of-the-art benefits and harms of pharmacologic interventions to delineate knowledge gaps in current guidelines and clinical practice will be presented. RECENT FINDINGS Beta-blockers are known to reduce major adverse cardiac events but inappropriate preoperative initiation results in adverse outcomes. Renin-Angiotensin-Aldosteron System (RAAS) inhibitors once universally discontinued before surgery are now under reconsideration as continuation seems not to be associated with increased risk. Statins continue to be the cornerstone due to their pleiotropic effect. Continuation of aspirin is supported perioperatively if the bleeding risk due to surgery is low to moderate. A few studies have investigated a strategy of strict intraoperative blood pressure control but failed to observe a meaningful effect on outcome. Whether prompt intensification of treatment in case of diagnosis of myocardial injury after noncardiac surgery improves outcome remains to be established. Since the MANAGE trial, no new studies have prospectively addressed this question. SUMMARY New data have questioned previous ideas and suggest a more nuanced, personalized approach to perioperative management. Accordingly, future studies should address refinement in risk stratification, optimization of pharmacologic strategies, and the development of novel therapies in attempting to enhance outcomes in high-risk surgical populations.
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Affiliation(s)
| | - Stefan De Hert
- Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
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El-Gabalawy R, Sommer JL, Sareen J, Mackenzie CS, Devereaux PJ, Penner K, Srinathan S. Preoperative psychological distress is associated with mortality within 1 year of non-cardiac surgery. Gen Hosp Psychiatry 2025; 95:25-31. [PMID: 40252258 DOI: 10.1016/j.genhosppsych.2025.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2025] [Revised: 04/04/2025] [Accepted: 04/10/2025] [Indexed: 04/21/2025]
Abstract
OBJECTIVE To characterize the association between preoperative psychological distress and postoperative complications at 30 days and mortality at 1 year in a non-cardiac surgery sample. METHOD Data were taken from a subsample of the VISION cohort study (n = 997; 2011-2012). Participants were scheduled to undergo major non-cardiac surgery under general or regional anesthesia. Participants self-reported past 30-day psychological distress on the day of surgery using the Kessler-6 (K6) Scale. Complications were assessed via interviews and/or chart reviews. Multivariable logistic regressions characterized the relationship between preoperative psychological distress and postoperative complications. Models were fitted for sociodemographics, surgery type, preoperative medical morbidity, and smoking. RESULTS Among participants with a completed K6 (n = 938), 7.9 % experienced mortality within 1 year. After controlling for age, ethnicity, sex, surgery type, preoperative medical morbidity, and smoking, higher levels of preoperative psychological distress were associated with 30 day complications such as myocardial infarction, non-fatal cardiac arrest, leg/arm deep vein thrombosis/ pulmonary embolism, new acute renal failure, pneumonia, and congestive heart failure (AOR3 (3rd model), 1.12, [95 % CI, 1.02-1.22, p < 0.05]) and 1-year mortality (AOR3, 1.09, [95 % CI, 1.02-1.18, p < 0.05]). Sensitivity analyses demonstrate that the latter association was being driven by symptoms of depression (AOR3, 1.17 [95 % CI 1.04-1.33, p < 0.05]) but not anxiety (AOR2, 0.94 [95 % CI, 0.61-1.62, p > 0.05]). CONCLUSION Elevated preoperative distress increased the risk of 30-day complications and mortality at 1 year. These results underscore the need for future research to examine if supporting patients' mental health during the perioperative period can mitigate risk. CLINICAL TRIAL REGISTRATION clinicaltrials.gov, no. NCT00512109 (main VISION study).
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Affiliation(s)
- Renée El-Gabalawy
- Department of Clinical Health Psychology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, Canada; Department of Psychology, Faculty of Arts, University of Manitoba, Canada; Department of Psychiatry, Max Rady College of Medicine, University of Manitoba, Canada; CancerCare Manitoba, Canada.
| | - Jordana L Sommer
- Department of Clinical Health Psychology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Psychology, Faculty of Arts, University of Manitoba, Canada
| | - Jitender Sareen
- Department of Psychiatry, Max Rady College of Medicine, University of Manitoba, Canada
| | - Corey S Mackenzie
- Department of Psychology, Faculty of Arts, University of Manitoba, Canada
| | - P J Devereaux
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Kailey Penner
- Department of Clinical Health Psychology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sadeesh Srinathan
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Canada
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Kork F, Liang Y, Ginde AA, Yuan X, Rossaint R, Liu H, Evers AS, Eltzschig HK. Impact of perioperative organ injury on morbidity and mortality in 28 million surgical patients. Nat Commun 2025; 16:3366. [PMID: 40204694 PMCID: PMC11982547 DOI: 10.1038/s41467-025-58161-2] [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: 05/07/2024] [Accepted: 03/13/2025] [Indexed: 04/11/2025] Open
Abstract
Perioperative organ injury contributes to morbidity and mortality of surgical patients. This cohort study included all elective and emergent surgeries in Germany over 4 years to address the impact of perioperative organ injuries on outcomes. We analyzed 28,350,953 cases. In-hospital mortality was 1.4% (n = 393,157), and 4.4% of cases (n = 1,245,898) experienced perioperative organ injury. Perioperative organ injury was associated with 9-fold higher odds of death and prolonged hospital stay by 11.2 days. Acute kidney injury had the highest incidence (2.0%) and was associated with 25.0% mortality. While delirium had the second highest incidence (1.5%), it was associated with the lowest mortality (10.8%). This was followed by acute myocardial infarction (incidence 0.6%, mortality 15.6%), stroke (incidence 0.6%, mortality 13.1%), pulmonary embolism (incidence 0.3%, mortality 20.0%), liver injury (incidence 0.1%, mortality 68.7%), and acute respiratory distress syndrome (incidence 0.1%, mortality 44.7%). These findings help prioritize interventions for preventing or treating individual types of perioperative organ injury.
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Affiliation(s)
- Felix Kork
- Department of Anesthesiology, Medical Faculty, RWTH Aachen University, Aachen, Germany.
| | - Yafen Liang
- Department of Anesthesiology, Critical Care and Pain Medicine, McGovern Medical School, the University of Texas Health Science Center at Houston, Houston, TX, USA.
- Center for OUTCOMES RESEARCH and Department of Anesthesiology, UTHealth, Houston, TX, USA.
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Xiaoyi Yuan
- Department of Anesthesiology, Critical Care and Pain Medicine, McGovern Medical School, the University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Rolf Rossaint
- Department of Anesthesiology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Hongfang Liu
- Department of Health Data Science and Artificial Intelligence, McWilliams School of Biomedical Informatics, the University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Alex S Evers
- Department of Anesthesiology, Washington University, School of Medicine in St. Louis, St. Louis, MO, USA
| | - Holger K Eltzschig
- Department of Anesthesiology, Critical Care and Pain Medicine, McGovern Medical School, the University of Texas Health Science Center at Houston, Houston, TX, USA.
- Center for OUTCOMES RESEARCH and Department of Anesthesiology, UTHealth, Houston, TX, USA.
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Katov L, Huggle W, Teumer Y, Buss A, Diofano F, Bothner C, Öchsner W, Rottbauer W, Weinmann-Emhardt K. Gender-Specific Differences in Sedation-Associated Outcomes During Complex Electrophysiological Procedures. Healthcare (Basel) 2025; 13:844. [PMID: 40218141 PMCID: PMC11988496 DOI: 10.3390/healthcare13070844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2025] [Revised: 04/03/2025] [Accepted: 04/05/2025] [Indexed: 04/14/2025] Open
Abstract
Background: Interventional electrophysiology is a rapidly advancing field, with sedation essential for patient comfort and immobility during complex electrophysiological procedures (EPS). However, sedatives and analgesics can cause respiratory depression and hypotension. Gender-specific differences (GDs) are often overlooked in medical research, as protocols and dosages are typically based on male subjects, potentially compromising treatment safety and efficacy for women. This study examines GDs in CO2 levels, respiratory rate, arterial blood pressure (ABP), and anesthetic requirements during deep sedation for EPS. Methods: This prospective study at Ulm University Heart Center included 702 patients (405 men and 297 women) treated under deep sedation between August 2019 and October 2023. Standard monitoring included an electrocardiogram (ECG) with heart rate, non-invasive ABP, oxygen saturation (SpO2), and a frequent venous blood gas analysis (vBGA). The primary composite endpoint was GDs in SpO2 dips below 90% and pathological vBGA changes. Results: The primary composite endpoint was reached by 177 women (59.6%) and 213 men (52.6%), showing no significant difference (p = 0.102). Women had a 1,6-fold higher risk of experiencing SpO2 dips below 90% (p = 0.001). Additionally, women had 1.7 times higher hypoxia rates (p < 0.001) and were 1.5 times more likely to have a mean ABP below 65 mmHg (p < 0.001). On average, they received 65.3 mg less total propofol than men (p = 0.005) and a higher midazolam dose per kilogram of body weight (p < 0.001). Conclusions: Although the primary composite endpoint showed no significant GDs, secondary outcomes highlight the need to consider gender-specific sedation adjustments, particularly for women. This study underscores the need for personalized sedation management and patient monitoring regarding GDs.
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Affiliation(s)
- Lyuboslav Katov
- Department of Cardiology, Ulm University Heart Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany; (L.K.); (W.H.); (Y.T.); (A.B.); (F.D.); (C.B.); (W.R.)
| | - Weronika Huggle
- Department of Cardiology, Ulm University Heart Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany; (L.K.); (W.H.); (Y.T.); (A.B.); (F.D.); (C.B.); (W.R.)
| | - Yannick Teumer
- Department of Cardiology, Ulm University Heart Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany; (L.K.); (W.H.); (Y.T.); (A.B.); (F.D.); (C.B.); (W.R.)
| | - Alexandra Buss
- Department of Cardiology, Ulm University Heart Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany; (L.K.); (W.H.); (Y.T.); (A.B.); (F.D.); (C.B.); (W.R.)
| | - Federica Diofano
- Department of Cardiology, Ulm University Heart Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany; (L.K.); (W.H.); (Y.T.); (A.B.); (F.D.); (C.B.); (W.R.)
| | - Carlo Bothner
- Department of Cardiology, Ulm University Heart Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany; (L.K.); (W.H.); (Y.T.); (A.B.); (F.D.); (C.B.); (W.R.)
| | - Wolfgang Öchsner
- Department of Anesthesiology and Intensive Care Medicine, Ulm University Medical Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany;
| | - Wolfgang Rottbauer
- Department of Cardiology, Ulm University Heart Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany; (L.K.); (W.H.); (Y.T.); (A.B.); (F.D.); (C.B.); (W.R.)
| | - Karolina Weinmann-Emhardt
- Department of Cardiology, Ulm University Heart Center, Albert-Einstein-Allee 23, 89081 Ulm, Germany; (L.K.); (W.H.); (Y.T.); (A.B.); (F.D.); (C.B.); (W.R.)
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11
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Zhou Y, Chen W, Liang F, Zhong L, Liao Y, Zhong Y. Association between the preoperative triglyceride-glucose index and myocardial injury following non-cardiac surgery: a cross-sectional study. BMJ Open 2025; 15:e091978. [PMID: 40157728 PMCID: PMC11956314 DOI: 10.1136/bmjopen-2024-091978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Accepted: 03/17/2025] [Indexed: 04/01/2025] Open
Abstract
OBJECTIVE An elevated triglyceride-glucose (TyG) index positively correlates with adverse cardiovascular events. However, its association with myocardial injury after non-cardiac surgery (MINS) remains unclear. This study aimed to examine the association between the preoperative TyG index and MINS. DESIGN A cross-sectional study. SETTING Meizhou People's Hospital. PARTICIPANTS Adult patients under general anaesthesia and with MINS. MAIN EXPOSURE MEASURE The preoperative TyG index, calculated using triglyceride (TG) and fasting blood glucose (FBG) levels. MAIN OUTCOME MEASURE The occurrence of MINS, defined using postoperative troponin measurements. RESULTS 889 patients were included, with an 8.3% incidence of MINS (74/889). The median TyG index was 8.57 (8.13, 9.02). TyG exhibited higher discriminatory ability for MINS than TG and FBG, with an area under the curve of 0.624, 0.544 and 0.500, respectively. Fully adjusted logistic regression indicated that an elevated TyG index was independently associated with MINS (OR 1.75, 95% CI 1.21 to 2.52; p=0.003). A multivariate restricted cubic spline suggested a linear relationship between TyG and MINS (p value for non-linearity=0.059). Subgroup analyses showed results consistent with the primary analysis, with no significant interaction effects between subgroups. CONCLUSION An elevated preoperative TyG index is independently associated with an increased incidence of MINS. Monitoring the TyG index perioperatively may improve the management of patients at risk for MINS. TRIAL REGISTRATION NUMBER ChiCTR2400082834.
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Affiliation(s)
- Yuanjun Zhou
- Department of Anaesthesiology, Meizhou People's Hospital, Meizhou, Guangdong, China
| | - Weiming Chen
- Department of Medical Data, Meizhou People's Hospital, Meizhou, Guangdong, China
| | - Fei Liang
- Department of Medical Data, Meizhou People's Hospital, Meizhou, Guangdong, China
| | - Liping Zhong
- Department of Anaesthesiology, Meizhou People's Hospital, Meizhou, Guangdong, China
| | - Yilin Liao
- Department of Anaesthesiology, Meizhou People's Hospital, Meizhou, Guangdong, China
| | - Yuting Zhong
- Department of Anaesthesiology, Meizhou People's Hospital, Meizhou, Guangdong, China
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12
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Zhou Y, Chen W, Liang F, Zhong L, Liao Y, Zhong Y. Intraoperative hemodynamic imbalance quantification: clinical validation of heart rate to mean blood pressure ratio in predicting myocardial injury after noncardiac surgery. BMC Cardiovasc Disord 2025; 25:229. [PMID: 40155827 PMCID: PMC11951704 DOI: 10.1186/s12872-025-04650-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2025] [Accepted: 03/10/2025] [Indexed: 04/01/2025] Open
Abstract
BACKGROUND The effects of isolated heart rate (HR) and mean blood pressure (MBP) on myocardial injury after noncardiac surgery (MINS) have been investigated, but the combined impact of intraoperative HR and MBP remains unclear. This study aimed to assess the influence of the heart rate-mean arterial pressure ratio (HMR) on MINS to optimize hemodynamic management. METHODS This retrospective cohort study included adult patients who underwent general anesthesia and postoperative troponin measurements at Meizhou People's Hospital. The primary exposure was the time-weighted area above the HMR threshold (1.0) (TWAAT-HMR > 1.0), and the primary outcome was MINS within one postoperative day. The diagnostic performance of TWAAT-HMR > 1.0, the time-weighted area under MBP < 60 mmHg, and the time-weighted area above HR > 100 bpm was evaluated using Receiver Operating Characteristic (ROC) analysis. Logistic regression and restricted cubic splines (RCS) were used to assess the association between HMR and MINS. Sensitivity analyses were conducted to confirm the robustness of the findings, and subgroup analyses examined potential interactions with age, sex, and body mass index. RESULTS Among 699 patients, the incidence of MINS was 9.4%. TWAAT-HMR > 1.0 demonstrated superior predictive accuracy for MINS compared to time-weighted areas under/above MBP and HR (AUC: 0.708 vs. 0.646 and 0.640, respectively). TWAAT-HMR > 1.0 was identified as an independent risk factor for MINS (odds ratio [OR] = 1.71, 95% confidence interval [CI] 1.35-2.17, p < 0.001). RCS analysis showed a linear increase in MINS risk with rising HMR (p for non-linearity = 0.507). Sensitivity and subgroup analyses supported the primary findings. CONCLUSION Elevated HMR is associated with a higher risk of MINS in adults undergoing general anesthesia. HMR monitoring may serve as a valuable parameter for optimizing perioperative hemodynamic management.
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Affiliation(s)
- Yuanjun Zhou
- Department of Anesthesiology, Meizhou People's Hospital, 63 Huangtang Road, Meijiang District, Meizhou, Guangdong, China
| | - Weiming Chen
- Department of Medical Data, Meizhou People's Hospital, 63 Huangtang Road, Meijiang District, Meizhou, Guangdong, China
| | - Fei Liang
- Department of Medical Data, Meizhou People's Hospital, 63 Huangtang Road, Meijiang District, Meizhou, Guangdong, China
| | - Liping Zhong
- Department of Anesthesiology, Meizhou People's Hospital, 63 Huangtang Road, Meijiang District, Meizhou, Guangdong, China
| | - Yilin Liao
- Department of Anesthesiology, Meizhou People's Hospital, 63 Huangtang Road, Meijiang District, Meizhou, Guangdong, China
| | - Yuting Zhong
- Department of Anesthesiology, Meizhou People's Hospital, 63 Huangtang Road, Meijiang District, Meizhou, Guangdong, China.
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13
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Strain C, Ravalico T. Electric Trends of Laboratory Medicine: Five Years of Growth, Visibility, and Opportunity. J Appl Lab Med 2025; 10:440-454. [PMID: 39866154 DOI: 10.1093/jalm/jfae152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 10/08/2024] [Indexed: 01/28/2025]
Abstract
BACKGROUND Laboratory medicine has and continues to undergo significant transformation. This paper reviews top trends associated with laboratory medicine using insights, evidence, and outcomes derived from the UNIVANTS of Healthcare ExcellenceTM award program. METHODS Seventy-two judge-approved best practices of measurably better healthcare were assessed for trends and insights related to outcomes and opportunities for highlighting the value of laboratory medicine. RESULTS Ten industry-relevant and insightful takeaways are identified that span stakeholders and key performance indicators. CONCLUSION With evidence that spans 5 years, the findings not only substantiate the critical value of laboratory medicine, but reveal trends associated with award-winning teams, proven integrated clinical care initiatives, and the measurement of their associated outcomes.
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Affiliation(s)
- Colleen Strain
- Core Diagnostics, Scientific and Medical Affairs, Abbott, Mississauga, ON, Canada
- UNIVANTS of Healthcare Excellence Awards, Chicago, IL, United States
| | - Tricia Ravalico
- UNIVANTS of Healthcare Excellence Awards, Chicago, IL, United States
- Core Diagnostics, Scientific and Medical Affairs, Abbott, Dallas, TX, United States
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14
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Shen L, Jin Y, Pan AX, Wang K, Ye R, Lin Y, Anwar S, Xia W, Zhou M, Guo X. Machine learning-based predictive models for perioperative major adverse cardiovascular events in patients with stable coronary artery disease undergoing noncardiac surgery. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2025; 260:108561. [PMID: 39708562 DOI: 10.1016/j.cmpb.2024.108561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 11/17/2024] [Accepted: 12/07/2024] [Indexed: 12/23/2024]
Abstract
BACKGROUND AND OBJECTIVE Accurate prediction of perioperative major adverse cardiovascular events (MACEs) is crucial, as it not only aids clinicians in comprehensively assessing patients' surgical risks and tailoring personalized surgical and perioperative management plans, but also for information-based shared decision-making with patients and efficient allocation of medical resources. This study developed and validated a machine learning (ML) model using accessible preoperative clinical data to predict perioperative MACEs in stable coronary artery disease (SCAD) patients undergoing noncardiac surgery (NCS). METHODS We collected data from 9171 adult SCAD patients who underwent NCS and extracted 64 preoperative variables. First, the optimal data imputation, resampling, and feature selection methods were compared and selected to deal with missing data values and imbalances. Then, nine independent machine learning models (logistic regression (LR), support vector machine, Gaussian Naive Bayes (GNB), random forest, gradient boosting decision tree (GBDT), extreme gradient boosting (XGBoost), light gradient boosting machine, categorical boosting (CatBoost), and deep neural network) and a stacking ensemble model were constructed and compared with the validated Revised Cardiac Risk Index's (RCRI) model for predictive performance, which was evaluated using the area under the receiver operating characteristic curve (AUROC), the area under the precision-recall curve (AUPRC), calibration curve, and decision curve analysis (DCA). To reduce overfitting and enhance robustness, we performed hyperparameter tuning and 5-fold cross-validation. Finally, the Shapley additive interpretation (SHAP) method and a partial dependence plot (PDP) were used to determine the optimal ML model. RESULTS Of the 9,171 patients, 514 (5.6 %) developed MACEs. 24 significant preoperative features were selected for model development and evaluation. All ML models performed well, with AUROC above 0.88 and AUPRC above 0.39, outperforming the AUROC (0.716) and AUPRC (0.185) of RCRI (P < 0.001). The best independent model was XGBoost (AUROC = 0.898, AUPRC = 0.479). The calibration curve accurately predicted the risk of MACEs (Brier score = 0.040), and the DCA results showed that XGBoost had a high net benefit for predicting MACEs. The top-ranked stacking ensemble model, consisting of CatBoost, GBDT, GNB, and LR, proved to be the best (AUROC 0.894, AUPRC 0.485). We identified the top 20 most important features using the mean absolute SHAP values and depicted their effects on model predictions using PDP. CONCLUSIONS This study combined missing-value imputation, feature screening, unbalanced data processing, and advanced machine learning methods to successfully develop and verify the first ML-based perioperative MACEs prediction model for patients with SCAD, which is more accurate than RCRI and enables effective identification of high-risk patients and implementation of targeted interventions to reduce the incidence of MACEs.
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Affiliation(s)
- Liang Shen
- Department of Information Technology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - YunPeng Jin
- Department of Cardiovascular Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - AXiang Pan
- Department of Information Technology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Kai Wang
- Department of Cardiovascular Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - RunZe Ye
- Department of Cardiovascular Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - YangKai Lin
- Department of Cardiovascular Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Safraz Anwar
- Department of Cardiovascular Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - WeiCong Xia
- Department of Cardiovascular Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Min Zhou
- Department of Information Technology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China.
| | - XiaoGang Guo
- Department of Cardiovascular Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China.
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15
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Zahid JA, Gögenur M, Ekeloef S, Gögenur I. Major Adverse Cardiovascular Events After Colorectal Cancer Surgery, Oncological Outcomes, and Long-term Mortality: A Nationwide Retrospective Propensity Score-Matched Cohort Study. ANNALS OF SURGERY OPEN 2025; 6:e560. [PMID: 40134485 PMCID: PMC11932607 DOI: 10.1097/as9.0000000000000560] [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] [Received: 12/03/2024] [Accepted: 02/05/2025] [Indexed: 03/27/2025] Open
Abstract
Objective To investigate the occurrence of major adverse cardiovascular events (MACE) following colorectal cancer (CRC) surgery and its association with long-term mortality and oncological outcomes. Background Cardiovascular complications after noncardiac surgery are a leading cause of perioperative mortality. However, limited knowledge exists on how these complications impact on long-term mortality. Methods This retrospective cohort study used data from 4 nationwide Danish health registries and included all patients undergoing elective surgery with curative intent for CRC between 2001 and 2019. Patients experiencing MACE, defined as acute myocardial infarction, stroke, new-onset heart failure, or nonfatal cardiac arrest, within 30 days of surgery were matched with those who did not using 1:1 propensity score matching (PSM). The outcomes were all-cause mortality within 1, 3, or 5 years of surgery, as well as 5-year cancer recurrence and disease-free survival. Results Out of 39,747 patients, 900 (2.3%) had MACE. PSM resulted in 809 pairs of matched patients. Within 1 year of surgery, 110 (13.6%) patients with MACE and 2063 (5.4%) without MACE died (PSM-adjusted hazard ratio [HR] = 1.36; 95% confidence interval [CI] = 1.02-1.83). Within 3 years, 248 (30.6%) patients with MACE and 6268 (16.5%) without MACE died (PSM-adjusted HR = 1.32; 95% CI = 1.07-1.62). Within 5 years, 333 (41.1%) patients with MACE and 9232 (24.3%) without MACE died (PSM-adjusted HR = 1.25; 95% CI = 1.04-1.50). For recurrence and disease-free survival, no statistically significant differences were observed. Conclusions MACE within 30 days of CRC surgery is associated with higher overall long-term mortality. Investigating causality and preventive measures is urgent in this group.
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Affiliation(s)
- Jawad Ahmad Zahid
- From the Department of Surgery, Center for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Mikail Gögenur
- From the Department of Surgery, Center for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Sarah Ekeloef
- From the Department of Surgery, Center for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Ismail Gögenur
- From the Department of Surgery, Center for Surgical Science, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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16
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Habicher M, Denn SM, Schneck E, Akbari AA, Schmidt G, Markmann M, Alkoudmani I, Koch C, Sander M. Perioperative goal-directed therapy with artificial intelligence to reduce the incidence of intraoperative hypotension and renal failure in patients undergoing lung surgery: A pilot study. J Clin Anesth 2025; 102:111777. [PMID: 39954384 DOI: 10.1016/j.jclinane.2025.111777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 12/19/2024] [Accepted: 02/08/2025] [Indexed: 02/17/2025]
Abstract
STUDY OBJECTIVE The aim of this study was to investigate whether goal-directed treatment using artificial intelligence, compared to standard care, can reduce the frequency, duration, and severity of intraoperative hypotension in patients undergoing single lung ventilation, with a potential reduction of postoperative acute kidney injury (AKI). DESIGN single center, single-blinded randomized controlled trial. SETTING University hospital operating room. PATIENTS 150 patients undergoing lung surgery with single lung ventilation were included. INTERVENTIONS Patients were randomly assigned to two groups: the Intervention group, where a goal-directed therapy based on the Hypotension Prediction Index (HPI) was implemented; the Control group, without a specific hemodynamic protocol. MEASUREMENTS The primary outcome measures include the frequency, duration of intraoperative hypotension, furthermore the Area under MAP 65 and the time-weighted average (TWA) of MAP of 65. Other outcome parameters are the incidence of AKI and myocardial injury after non-cardiac surgery (MINS). MAIN RESULTS The number of hypotensive episodes was lower in the intervention group compared to the control group (0 [0-1] vs. 1 [0-2]; p = 0.01), the duration of hypotension was shorter in the intervention group (0 min [0-3.17] vs. 2.33 min [0-7.42]; p = 0.01). The area under the MAP of 65 (0 mmHg * min [0-12] vs. 10.67 mmHg * min [0-44.16]; p < 0.01) and the TWA of MAP of 65 (0 mmHg [0-0.08] vs. 0.07 mmHg [0-0.25]; p < 0.01) were lower in the intervention group. The incidence of postoperative AKI showed no differences between the groups (6.7 % vs.4.2 %; p = 0.72). There was a trend to lower incidence of MINS in the intervention group (17.1 % vs. 31.8 %; p = 0.07). A tendency towards reduced postoperative infection was seen in the intervention group (16.0 % vs. 26.8 %; p = 0.16). CONCLUSIONS The implementation of a treatment algorithm based on HPI allowed us to decrease the duration and severity of hypotension in patients undergoing lung surgery. It did not result in a significant reduction in the incidence of AKI, however we observed a tendency towards lower incidence of MINS in the intervention group, along with a slight reduction in postoperative infections.
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Affiliation(s)
- Marit Habicher
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Rudolf-Buchheim-Street 7, 35392 Giessen, Germany.
| | - Sara Marie Denn
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Rudolf-Buchheim-Street 7, 35392 Giessen, Germany.
| | - Emmanuel Schneck
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Rudolf-Buchheim-Street 7, 35392 Giessen, Germany.
| | - Amir Ali Akbari
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Rudolf-Buchheim-Street 7, 35392 Giessen, Germany.
| | - Götz Schmidt
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Rudolf-Buchheim-Street 7, 35392 Giessen, Germany.
| | - Melanie Markmann
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Rudolf-Buchheim-Street 7, 35392 Giessen, Germany.
| | - Ibrahim Alkoudmani
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Rudolf-Buchheim Street 7, 35392 Giessen, Germany.
| | - Christian Koch
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Rudolf-Buchheim-Street 7, 35392 Giessen, Germany.
| | - Michael Sander
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Rudolf-Buchheim-Street 7, 35392 Giessen, Germany.
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Valadkhani A, Gupta A, Cauli G, Nordström JL, Rohi A, Tufexis P, Hällsjö Sander C, Jacobsson M, Bell M. Diastolic Versus Systolic or Mean Intraoperative Hypotension as Predictive of Perioperative Myocardial Injury in a White-Box Machine-Learning Model. Anesth Analg 2025; 141:00000539-990000000-01189. [PMID: 39977341 PMCID: PMC12140561 DOI: 10.1213/ane.0000000000007379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2024] [Indexed: 02/22/2025]
Abstract
BACKGROUND Intraoperative hypotension (IOH) and tachycardia are associated with perioperative myocardial injury (PMI), and thereby increased postoperative mortality. Patients undergoing vascular surgery are specifically at risk of developing cardiac complications. This study aimed to explore the association between different thresholds for IOH and tachycardia, and PMI. It also aimed to explore which threshold for IOH and tachycardia best predicts PMI. METHODS In this single-center prospective observational study, high-sensitivity cardiac troponin T was measured preoperatively and at 4, 24, and 48 hours after vascular surgery. Absolute and relative thresholds were used to define intraoperative systolic, mean, and diastolic arterial hypotension, measured every 15 seconds by invasive arterial pressure monitoring and heart rate using the Philips IntelliVue X3 monitor. Decision tree machine-learning (ML) models were used to explore which thresholds for IOH and tachycardia best predict PMI. Clinical utility and transparency were prioritized over maximizing the performance of the ML model and therefore a white-box model was used. RESULTS In all, 498 patients were included in the study. Ninety-nine patients (20%) had PMI. Significant associations were found between IOH and PMI using both absolute and relative thresholds for systolic, mean, and diastolic arterial pressure. Absolute thresholds based on diastolic arterial pressure had the strongest correlation with PMI and yielded greater statistical significance. The threshold that was most predictive of PMI was an absolute diastolic arterial pressure <44 mm Hg. The prediction model with the absolute threshold of diastolic arterial pressure <44 mm Hg had a macro average F1 score of 0.67 and a weighted average F1 score of 0.76. No association was found between tachycardia and PMI. CONCLUSIONS We found that an absolute, not relative, IOH threshold based on diastolic arterial pressure, and not systolic or mean arterial pressure, or tachycardia, was most predictive of PMI.
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Affiliation(s)
- Arman Valadkhani
- From Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital, Stockholm, Sweden
- Department of Pharmacology and Physiology, Karolinska Institutet, Stockholm, Sweden
| | - Anil Gupta
- From Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital, Stockholm, Sweden
- Department of Pharmacology and Physiology, Karolinska Institutet, Stockholm, Sweden
| | - Giordano Cauli
- Department of Biomedical Engineering and Health Systems, KTH Royal Institute of Technology
| | - Johan L. Nordström
- From Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital, Stockholm, Sweden
| | - Ayda Rohi
- From Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital, Stockholm, Sweden
| | - Panos Tufexis
- Department of Pharmacology and Physiology, Karolinska Institutet, Stockholm, Sweden
| | - Caroline Hällsjö Sander
- From Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital, Stockholm, Sweden
- Department of Pharmacology and Physiology, Karolinska Institutet, Stockholm, Sweden
| | - Martin Jacobsson
- Department of Biomedical Engineering and Health Systems, KTH Royal Institute of Technology
| | - Max Bell
- From Department of Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital, Stockholm, Sweden
- Department of Pharmacology and Physiology, Karolinska Institutet, Stockholm, Sweden
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18
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Wittmann M, Dinc T, Kunsorg A, Marcucci M, Ruetzler K. Preventing, identifying and managing myocardial injury after non cardiac surgery - a narrative review. Curr Opin Anaesthesiol 2025; 38:17-24. [PMID: 39670630 DOI: 10.1097/aco.0000000000001454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2024]
Abstract
PURPOSE OF REVIEW There is mounting and convincing evidence that patients with postoperative troponin elevation, with or without any clinical symptoms, are at higher risk for both, short- and long-term morbidity and mortality. Myocardial injury after noncardiac surgery (MINS) is a relatively newly described syndrome, and the pathogenesis is not fully understood yet. MINS is now an established syndrome and multiple guidelines address potential etiologies, triggers, as well as preventive and management strategies. RECENT FINDINGS Surveillance in high-risk patients is required, as most MINS would otherwise be missed. There is no reliable and established preventive strategy, but several potentially avoidable triggers like hypotension, pain and anemia have been identified. Managing patients with MINS postoperatively includes minimizing triggers (such as hemodynamic abnormalities and anemia) that can continue the damage. Long-term pharmacologic strategies include beta-blockers, statins, antiplatelet agents, and anticoagulation. SUMMARY MINS affects up to 20% of surgical patients, remains clinically mostly silent, but is associated with elevated morbidity and mortality. A multidisciplinary approach, that includes involvement of anesthesiologists, for the prevention, diagnosis, and treatment of MINS is recommended.
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Affiliation(s)
- Maria Wittmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Tugce Dinc
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Andrea Kunsorg
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Maura Marcucci
- Population Health Research Institute, Hamilton, Canada
- Clinical Epidemiology and Research Centre, Humanitas University & IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Kurt Ruetzler
- Center for OUTCOMES RESEARCH and Department of Anesthesiology, UTHealth, Houston, Texas
- Division of Multispecialty Anesthesiology, Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
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19
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Heikkilä E, Katajamäki T, Salminen M, Irjala K, Viljanen A, Koivula MK, Pulkki K, Viitanen M, Vahlberg T, Viikari L. High-sensitivity cardiac troponin T and N-terminal b-type natriuretic propeptide are associated with cardiac and all-cause mortality in older adults - A population-based ten-year follow-up study. Clin Chim Acta 2025; 567:120116. [PMID: 39732415 DOI: 10.1016/j.cca.2024.120116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2024] [Revised: 12/24/2024] [Accepted: 12/25/2024] [Indexed: 12/30/2024]
Abstract
BACKGROUND Cardiac troponin T (cTnT) and N-terminal B-type natriuretic propeptide (proBNP) are mainly used as biomarkers to diagnose specific conditions of the heart, but they also have predictive ability. Our aim was to study their associations with cardiovascular and all-cause mortality in an older population in non-acute conditions. METHODS A population-based study with a ten-year follow-up. The data comes from a community-based representative sample of an older population with 1260 participants (participation rate 82 %). Associations were analyzed using Cox proportional hazard models. RESULTS Altogether, 467 (37%) subjects died during the 10-year follow-up period, and 149 of those of a cardiovascular disease. Both elevated cTnT and proBNP concentrations were statistically significantly associated with cardiovascular and all-cause mortality in older adults. CONCLUSIONS Our study shows that older population with higher cTnT and proBNP concentrations have an increased risk of cardiovascular and all-cause mortality. Acknowledging the elevated risk may aid in targeting follow-up, prevention, and treatment adequately and more individually.
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Affiliation(s)
- Elisa Heikkilä
- Faculty of Medicine, Department of Clinical Chemistry, University of Turku, Turku, Finland; Southwest Finland Wellbeing Services County, Turku University Hospital, Laboratory Division, Turku, Finland.
| | - Taina Katajamäki
- Faculty of Medicine, Department of Clinical Chemistry, University of Turku, Turku, Finland; Southwest Finland Wellbeing Services County, Turku University Hospital, Laboratory Division, Turku, Finland
| | - Marika Salminen
- Faculty of Medicine, Department of General Practice, University of Turku and Turku University Hospital, Turku, Finland; Southwest Finland Wellbeing Services County, Turku University Hospital Services, Geriatric Medicine, 20521 Turku, Finland
| | - Kerttu Irjala
- Faculty of Medicine, Department of Clinical Chemistry, University of Turku, Turku, Finland
| | - Anna Viljanen
- The wellbeing services county of Southwest Finland, Academic health and social services centre, Postgraduate educational team in general practice, Turku, Finland; Faculty of Medicine, Department of Clinical Medicine, Unit of Geriatric Medicine, University of Turku and Turku University Hospital, 20700 Turku, Finland
| | - Marja-Kaisa Koivula
- HUS Diagnostic Center, Clinical Chemistry, Helsinki University Hospital, Helsinki, Finland; Faculty of Medicine, Clinical Chemistry and Haematology, University of Helsinki, Helsinki, Finland
| | - Kari Pulkki
- HUS Diagnostic Center, Clinical Chemistry, Helsinki University Hospital, Helsinki, Finland; Faculty of Medicine, Clinical Chemistry and Haematology, University of Helsinki, Helsinki, Finland
| | - Matti Viitanen
- Faculty of Medicine, Department of Clinical Medicine, Unit of Geriatric Medicine, University of Turku and Turku University Hospital, 20700 Turku, Finland
| | - Tero Vahlberg
- Faculty of Medicine, Department of Biostatistics, University of Turku and Turku University Hospital, Turku, Finland
| | - Laura Viikari
- Southwest Finland Wellbeing Services County, Turku University Hospital Services, Geriatric Medicine, 20521 Turku, Finland; Faculty of Medicine, Department of Clinical Medicine, Unit of Geriatric Medicine, University of Turku and Turku University Hospital, 20700 Turku, Finland
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20
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Roshanov PS, Walsh MW, Garg AX, Cuerden M, Lam NN, Hildebrand AM, Lee VW, Mrkobrada M, Leslie K, Chan MTV, Borges FK, Wang CY, Xavier D, Sessler DI, Szczeklik W, Meyhoff CS, Srinathan SK, Sigamani A, Villar JC, Chow CK, Polanczyk CA, Patel A, Harrison TG, Fielding-Singh V, Cata JP, Parlow J, de Nadal M, Devereaux PJ. Preoperative estimated glomerular filtration rate to predict cardiac events in major noncardiac surgery: a secondary analysis of two large international studies. Br J Anaesth 2025; 134:297-307. [PMID: 39753401 PMCID: PMC11775841 DOI: 10.1016/j.bja.2024.10.039] [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: 05/13/2024] [Revised: 10/18/2024] [Accepted: 10/22/2024] [Indexed: 01/31/2025] Open
Abstract
BACKGROUND Optimised use of kidney function information might improve cardiac risk prediction in noncardiac surgery. METHODS In 35,815 patients from the VISION cohort study and 9219 patients from the POISE-2 trial who were ≥45 yr old and underwent nonurgent inpatient noncardiac surgery, we examined (by age and sex) the association between continuous nonlinear preoperative estimated glomerular filtration rate (eGFR) and the composite of myocardial injury after noncardiac surgery, nonfatal cardiac arrest, or death owing to a cardiac cause within 30 days after surgery. We estimated contributions of predictive information, C-statistic, and net benefit from eGFR and other common patient and surgical characteristics to large multivariable models. RESULTS The primary composite occurred in 4725 (13.2%) patients in VISION and 1903 (20.6%) in POISE-2; in both studies cardiac events had a strong, graded association with lower preoperative eGFR that was attenuated by older age (Pinteraction<0.001 for VISION; Pinteraction=0.008 for POISE-2). For eGFR of 30 compared with 90 ml min-1 1.73 m-2, relative risk was 1.49 (95% confidence interval 1.26-1.78) at age 80 yr but 4.50 (2.84-7.13) at age 50 yr in female patients in VISION. This differed modestly (but not meaningfully) in men in VISION (Pinteraction=0.02) but not in POISE-2 (Pinteraction=0.79). eGFR contributed the most predictive information and mean net benefit of all predictors in both studies, most C-statistic in VISION, and third most C-statistic in POISE-2. CONCLUSIONS Continuous preoperative eGFR is among the best cardiac risk predictors in noncardiac surgery of the large set examined. Along with its interaction with age, preoperative eGFR would improve risk calculators. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT00512109 (VISION) and NCT01082874 (POISE-2).
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Affiliation(s)
- Pavel S Roshanov
- Department of Medicine, Western University, London, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada; Outcomes Research Consortium, Houston, TX, USA.
| | - Michael W Walsh
- Population Health Research Institute, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Amit X Garg
- Department of Medicine, Western University, London, ON, Canada
| | | | - Ngan N Lam
- Division of Transplantation and Nephrology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ainslie M Hildebrand
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Vincent W Lee
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | - Marko Mrkobrada
- Department of Medicine, Western University, London, ON, Canada
| | - Kate Leslie
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Matthew T V Chan
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Flavia K Borges
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Chew Yin Wang
- Department of Anesthesiology, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Denis Xavier
- St John's Medical College, Bangalore, Karnataka, India; Division of Clinical Research and Training, St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore, Karnataka, India
| | - Daniel I Sessler
- Outcomes Research Consortium, Department of Anesthesiology, Critical Care and Pain Medicine, University of Texas, Houston, TX, USA
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Małopolska, Poland
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | | | - Alben Sigamani
- Numen Health, Bengaluru, Karnataka, India; Carmel Research, Bengaluru, Karnataka, India
| | - Juan Carlos Villar
- Centro de Investigaciones, Fundación Cardioinfantil - Instituto de Cardiología, Bogotá, Colombia; Facultad de Ciencias de la Salud, Universidad Autónoma de Bucaramanga, Bucaramanga, Santander, Colombia
| | - Clara K Chow
- Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
| | - Carísi A Polanczyk
- Graduate Program in Epidemiology and Cardiovascular Science, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; Institute for Health Technology Assessment, Porto Alegre, Rio Grande do Sul, Brazil
| | - Ameen Patel
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Tyrone G Harrison
- Department of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Vikram Fielding-Singh
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, University of Texas - MD Anderson Cancer Center, Houston, TX, USA
| | - Joel Parlow
- Department of Anesthesiology and Perioperative Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Miriam de Nadal
- Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - P J Devereaux
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
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21
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Valadkhani A, Bell M. Use of glomerular filtration rate to estimate perioperative cardiac risk. Br J Anaesth 2025; 134:263-265. [PMID: 39880489 DOI: 10.1016/j.bja.2024.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2024] [Revised: 11/25/2024] [Accepted: 11/25/2024] [Indexed: 01/31/2025] Open
Abstract
Preoperative estimated glomerular filtration rate is an inexpensive but useful tool in predicting cardiovascular perioperative complications. Estimated glomerular filtration rate, especially considering its interaction with age, might act as a proxy for severity of cardiovascular disease. Further studies regarding the predictive power of estimated glomerular filtration rate to identify patients at risk of perioperative cardiovascular complications are essential.
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Affiliation(s)
- Arman Valadkhani
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden; Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Max Bell
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden; Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.
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22
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Boghean A, Guțu C, Firescu D. Perioperative Risk: Short Review of Current Approach in Non Cardiac Surgery. J Cardiovasc Dev Dis 2025; 12:24. [PMID: 39852302 PMCID: PMC11765857 DOI: 10.3390/jcdd12010024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2024] [Revised: 12/24/2024] [Accepted: 01/03/2025] [Indexed: 01/26/2025] Open
Abstract
The rate of major surgery is constantly increasing worldwide, and approximately 85% are non-cardiac surgery. More than half of patients over 45 years presenting for non-cardiac surgical interventions have cardiovascular risk factors, and the most common: chronic coronary syndrome and history of stroke. The preoperative cardiovascular risk is determined by the comorbidities, the clinical condition before the intervention, the urgency, duration or type. Cardiovascular risk scores are necessary tools to prevent perioperative cardiovascular morbidity and mortality and the most frequently used are Lee/RCRI (Revised Cardiac Risk Index), APACHE II (Acute Physiology and Chronic Health Evaluation), POSSUM (Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity), The American University of Beirut (AUB)-HAS2. To reduce the perioperative risk, there is a need for an appropriate preoperative risk assessment, as well as the choice of the type and timing of surgical intervention. Quantification of surgical risk as low, intermediate, and high is useful in identifying the group of patients who are at risk of complications such as myocardial infarction, thrombosis, arrhythmias, heart failure, stroke or even death. Currently there are not enough studies that can differentiate the risk according to gender, race, elective versus emergency procedure, the value of cardiac biomarkers.
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Affiliation(s)
- Andreea Boghean
- Faculty of Medicine and Pharmacy, University “Dunărea de Jos” Galați, 800008 Galati, Romania;
| | - Cristian Guțu
- Faculty of Medicine and Pharmacy, University “Dunărea de Jos” Galați, 800008 Galati, Romania;
- Emergency Military Hospital “Dr. Aristide Serfioti” Galați, 800150 Galati, Romania
| | - Dorel Firescu
- Faculty of Medicine and Pharmacy, University “Dunărea de Jos” Galați, 800008 Galati, Romania;
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23
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Glance LG, Joynt Maddox KE, Thomas S, Sorbero MJ, Fleisher LA, Lustik SJ, Lander HL, Shang J, Stone PW, Eaton MP, Gloff MS, Dick AW. Time Since Prior NSTEMI and Major Adverse Cardiovascular and Cerebrovascular Events After Noncardiac Surgery. JAMA Surg 2025; 160:45-54. [PMID: 39475957 PMCID: PMC11581740 DOI: 10.1001/jamasurg.2024.4683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 08/22/2024] [Indexed: 11/24/2024]
Abstract
Importance Delaying elective noncardiac surgery after a recent acute myocardial infarction is associated with better outcomes, but current American Heart Association recommendations are based on data that are more than 20 years old. Objective To examine the association between the time since a non-ST-segment elevation myocardial infarction (NSTEMI) and the risk of postoperative major adverse cardiovascular and cerebrovascular events (MACCE). Design, Setting, and Participants This cross-sectional study examined Medicare claims data between 2015 and 2020 for patients 67 years or older who had major noncardiac surgery. Data were analyzed from September 21, 2023, to February 1, 2024. Exposure Time elapsed between a prior NSTEMI and surgery. Main Outcomes and Measures MACCE (30-day mortality, in-hospital myocardial infarction, heart failure, or stroke) and all-cause 30-day mortality. Multivariable logistic regression was used to estimate the association between outcomes and time since a prior NSTEMI. Results The sample included 5 227 473 surgeries. The mean (SD) age was 75.7 (6.6) years; 2 981 239 (57.0%) were female, and 2 246 234 (43%) were male. There were 42 278 patients (0.81%) with a previous NSTEMI. Compared with patients without a prior NSTEMI, patients with an NSTEMI within 30 days of elective surgery had higher odds of MACCE, regardless of whether they had undergone coronary revascularization (adjusted odds ratio [aOR], 2.15; 95% CI, 1.09-4.23; P = .03) or not (aOR, 2.04; 95% CI, 1.31-3.16; P = .001). The odds of postoperative MACCE leveled off after 30 days in patients who had undergone any coronary revascularization procedure (and after 90 days in patients with drug-eluting stents) and then increased after 180 days (any revascularization at 181-365 days: aOR, 1.46; 95% CI, 1.25-1.71; P < .001; patients with drug-eluting stents at 181-365 days: aOR, 1.73; 95% CI, 1.42-2.12; P < .001). The odds of MACCE did not level off for patients who did not have revascularization. Findings for all-cause 30-day mortality were similar to those for MACCE, except that the odds of mortality in patients with previous NSTEMI who had revascularization leveled off after 60 days in elective surgeries and 90 days for nonelective surgeries (elective 30-day: aOR, 2.88; 95% CI, 1.30-6.36; P = .009; elective 61- to 90-day: aOR, 1.03; 95% CI, 0.57-1.86; P = .92; nonelective 30-day: aOR, 1.91; 95% CI, 1.52-2.40; P < .001; nonelective 91- to 120-day: aOR, 1.00; 95% CI, 0.73-1.37; P = .99). Conclusions and Relevance This study found that among older patients undergoing noncardiac surgery who had revascularization, the odds of postoperative MACCE and mortality leveled off between 30 and 90 days and then increased after 180 days. The odds did not level off for patients who did not have revascularization. Delaying elective noncardiac surgery to occur between 90 and 180 days after an NSTEMI may be reasonable for patients who have had revascularization.
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Affiliation(s)
- Laurent G. Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
| | - Karen E. Joynt Maddox
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
- Center for Advancing Health Services, Policy & Economics Research, Washington University in St Louis, St Louis, Missouri
| | - Sabu Thomas
- Department of Cardiology, University of Rochester School of Medicine, Rochester, New York
| | | | - Lee A. Fleisher
- Department of Anesthesiology, Department of Anesthesiology, University of Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Stewart J. Lustik
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Heather L. Lander
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Jingjing Shang
- Columbia School of Nursing, Center for Health Policy, New York, New York
| | - Patricia W. Stone
- Columbia School of Nursing, Center for Health Policy, New York, New York
| | - Michael P. Eaton
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Marjorie S. Gloff
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
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Luney MS, White SM, Moppett IK. Hip Fracture Intervention Study for Prevention of Hypotension Trial: a Pilot Randomized Controlled Trial. A A Pract 2025; 19:e01891. [PMID: 39760415 PMCID: PMC11761058 DOI: 10.1213/xaa.0000000000001891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2024] [Indexed: 01/07/2025]
Abstract
BACKGROUND Hypotension during anesthesia for surgery for hip fracture is common and associated with myocardial injury, stroke, acute kidney injury, and delirium. We hypothesized that maintaining intraoperative blood pressure close to patients' preoperative values would reduce these complications compared to usual care. METHODS A pilot feasibility patient- and assessor-blinded parallel group randomized controlled trial. People with unilateral hip fracture aged ≥70 years with capacity to give consent before surgery were eligible. Participants were allocated at random before surgery to either tight blood pressure control (systolic blood pressure ≥80% preoperative baseline and mean arterial blood pressure ≥75 mm Hg) or usual care. Feasibility outcomes were protocol adherence, primary outcome data completeness, and recruitment rate. The composite primary outcome was myocardial injury, stroke, acute kidney injury or delirium within 7 days of surgery. RESULTS Seventy-six participants were enrolled, and 12 withdrew before randomization. Sixty-four participants were randomized, 30 were allocated to control, and 34 to intervention. There was no crossover, all 64 participants received their allocated treatment, primary outcome was known for all participants. The composite primary outcome occurred in 14 of 30 participants in the control group compared with 23 of 34 participants in the intervention group (P = .09), relative risk 1.45 (95% confidence interval [CI], 0.93-2.27). CONCLUSIONS A randomized controlled trial of tight intraoperative blood pressure control compared to usual care to reduce major postoperative complications after fractured neck of femur surgery is possible. However, the data would suggest a large sample size would be required for a definitive trial.
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Affiliation(s)
- Matthew S. Luney
- From the Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Stuart M. White
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Iain K. Moppett
- Anaesthesia and Critical Care Section, Academic Unit of Injury, Inflammation and Repair, University of Nottingham, Nottingham, UK
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25
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Cicek V, Babaoglu M, Saylik F, Yavuz S, Mazlum AF, Genc MS, Altinisik H, Oguz M, Korucu BC, Hayiroglu MI, Cinar T, Bagci U. A New Risk Prediction Model for the Assessment of Myocardial Injury in Elderly Patients Undergoing Non-Elective Surgery. J Cardiovasc Dev Dis 2024; 12:6. [PMID: 39852284 PMCID: PMC11765956 DOI: 10.3390/jcdd12010006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2024] [Revised: 11/27/2024] [Accepted: 12/06/2024] [Indexed: 01/26/2025] Open
Abstract
Background: Currently, recommended pre-operative risk assessment models including the revised cardiac risk index (RCRI) are not very effective in predicting postoperative myocardial damage after non-elective surgery, especially for elderly patients. Aims: This study aimed to create a new risk prediction model to assess myocardial injury after non-cardiac surgery (MINS) in elderly patients and compare it with the RCRI, a well-known pre-operative risk prediction model. Materials and Methods: This retrospective study included 370 elderly patients who were over 65 years of age and had non-elective surgery in a tertiary hospital. Each patient underwent detailed physical evaluations before the surgery. The study cohort was divided into two groups: patients who had MINS and those who did not. Results: In total, 13% (48 out of 370 patients) of the patients developed MINS. Multivariable analysis revealed that creatinine, lymphocyte, aortic regurgitation (moderate-severe), stroke, hemoglobin, ejection fraction, and D-dimer were independent determinants of MINS. By using these parameters, a model called "CLASHED" was developed to predict postoperative MINS. The ROC analysis comparison demonstrated that the new risk prediction model was significantly superior to the RCRI in predicting MINS in elderly patients undergoing non-elective surgery (AUC: 0.788 vs. AUC: 0.611, p < 0.05). Conclusions: Our study shows that the new risk preoperative model successfully predicts MINS in elderly patients undergoing non-elective surgery. In addition, this new model is found to be superior to the RCRI in predicting MINS.
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Affiliation(s)
- Vedat Cicek
- Machine & Hybrid Intelligence Lab, Department of Radiology, Northwestern University, Chicago, IL 60611, USA;
| | - Mert Babaoglu
- Sultan II. Abdulhamid Han Training and Research Hospital, Department of Cardiology, Health Sciences University, 34668 Istanbul, Turkey; (M.B.); (S.Y.); (H.A.); (M.O.)
| | - Faysal Saylik
- Van Training and Research Hospital, Department of Cardiology, Health Sciences University, 65300 Van, Turkey;
| | - Samet Yavuz
- Sultan II. Abdulhamid Han Training and Research Hospital, Department of Cardiology, Health Sciences University, 34668 Istanbul, Turkey; (M.B.); (S.Y.); (H.A.); (M.O.)
| | - Ahmet Furkan Mazlum
- Sultan II. Abdülhamid Han Training and Research Hospital, Department of General Surgery, Health Sciences University, 34668 Istanbul, Turkey; (A.F.M.); (M.S.G.)
| | - Mahmut Salih Genc
- Sultan II. Abdülhamid Han Training and Research Hospital, Department of General Surgery, Health Sciences University, 34668 Istanbul, Turkey; (A.F.M.); (M.S.G.)
| | - Hatice Altinisik
- Sultan II. Abdulhamid Han Training and Research Hospital, Department of Cardiology, Health Sciences University, 34668 Istanbul, Turkey; (M.B.); (S.Y.); (H.A.); (M.O.)
| | - Mustafa Oguz
- Sultan II. Abdulhamid Han Training and Research Hospital, Department of Cardiology, Health Sciences University, 34668 Istanbul, Turkey; (M.B.); (S.Y.); (H.A.); (M.O.)
| | - Berke Cenktug Korucu
- Department of Internal Medicine, Rutgers\Robert Wood Johnson Barnabas Health, Jersey City Medical Center, Jersey City, NJ 07302, USA;
| | - Mert Ilker Hayiroglu
- Department of Cardiology, Dr. Siyami Ersek Cardiovascular and Thoracic Surgery Research and Training Hospital, 34668 Istanbul, Turkey;
| | - Tufan Cinar
- School of Medicine, University of Maryland, Baltimore, MD 21201, USA;
| | - Ulas Bagci
- Machine & Hybrid Intelligence Lab, Department of Radiology, Northwestern University, Chicago, IL 60611, USA;
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26
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Kondashevskaya MV, Aleksankina VV, Artemyeva KA, Kasabov KA, Kaktursky LV. Metabolic Changes in Myocardium and Skeletal Muscles of C57BL/6 Mice after Noncardiac Surgery. DOKLADY BIOLOGICAL SCIENCES : PROCEEDINGS OF THE ACADEMY OF SCIENCES OF THE USSR, BIOLOGICAL SCIENCES SECTIONS 2024; 519:279-285. [PMID: 39302517 DOI: 10.1134/s0012496624600283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Revised: 06/20/2024] [Accepted: 06/30/2024] [Indexed: 09/22/2024]
Abstract
Approximately 10% of patients without cardiovascular disorders suffer myocardial injury and have a 10% risk of death within 30 days after noncardiac surgery. Preoperative stress increases the risk of myocardial injury after noncardiac surgery (MINS). The mechanisms of MINS are poorly understood. Lack of physical activity and the development of weakness and fatigue are consequences of many noncardiac surgery types. The relationship between surgery and changes in the morphofunctional state of muscles in the postoperative period is still unclear now. The study showed for the first time that metabolic and hormonal changes caused by preoperative stress + surgery or surgery alone underlie MINC in the postoperative period in C57BL/6 mice. Minor increases in triglyceride-glucose (TyG) index were for the first time identified as indicative of ischemic/hypoxic damage to the myocardium and skeletal muscles. More research is necessary to perform to better understand the effects of preoperative stress and noncardiac surgery on the myocardium and muscle performance, as well as the risks and benefits of perioperative treatment.
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Affiliation(s)
- M V Kondashevskaya
- Avtsyn Institute of Human Morphology, Petrovsky National Research Center of Surgery, Moscow, Russia.
| | - V V Aleksankina
- Avtsyn Institute of Human Morphology, Petrovsky National Research Center of Surgery, Moscow, Russia
| | - K A Artemyeva
- Avtsyn Institute of Human Morphology, Petrovsky National Research Center of Surgery, Moscow, Russia
| | - K A Kasabov
- Avtsyn Institute of Human Morphology, Petrovsky National Research Center of Surgery, Moscow, Russia
| | - L V Kaktursky
- Avtsyn Institute of Human Morphology, Petrovsky National Research Center of Surgery, Moscow, Russia
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27
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Li W, Liu Y, Gu X. Catecholamine Vasopressors and the Risk of Atrial Fibrillation After Noncardiac Surgery: A Prospective Observational Study. Drug Des Devel Ther 2024; 18:5193-5202. [PMID: 39568780 PMCID: PMC11577261 DOI: 10.2147/dddt.s474818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Accepted: 11/01/2024] [Indexed: 11/22/2024] Open
Abstract
Background Catecholamine vasopressors are commonly used for intra- or post-operative hypotension for cardiac surgery, which have a side effect of new-onset atrial fibrillation (AF) and myocardial ischemia. However, it is not entirely clear whether catecholamine vasopressors increase the risk of new-onset AF after noncardiac surgery. Aim The aim of this study was to analyze the association between the use of catecholamine vasopressors and the risk of developing new-onset AF after noncardiac surgery. Methods In this prospective trial, available data from eligible elderly individuals receiving noncardiac surgery at a single center from November 2022 to January 2024 were gathered. Propensity score matching (PSM) was used to balance patient baseline characteristics and to control for confounders. To determine the association between catecholamine vasopressors and the risk of new-onset AF, univariate and multivariate logistic regression analyses were performed. Results A total of 6000 subjects were included in this study (mean [SD] age, 70.73 [6.37] years; 910 [50.9%] males). After PSM, the patients were stratified into catecholamine vasopressor (n = 357) and comparator groups (n = 1432). A total of 18/357 patients in the catecholamine vasopressor group developed AF, and 25/1432 patients in the comparator group developed AF (incidence rate, 5.0% vs 1.7%). Compared with the comparator group, the catecholamine vasopressor group had an increased risk of new-onset AF (aOR, 2.77; 95% CI, 1.28-5.89). Some sensitivity analyses also revealed consistent findings of increased new-onset AF risk associated with catecholamine vasopressor treatment. Conclusion The findings from this study suggest that catecholamine vasopressor treatment is associated with an increased risk of new-onset AF and may help physicians select a modest medication for patients while also assessing the risk of new-onset AF.
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Affiliation(s)
- Weichao Li
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
- Department of Anesthesiology, Affiliated Qingyuan Hospital (Qingyuan People's Hospital), Guangzhou Medical University, QingYuan, Guangdong, People's Republic of China
| | - YuYan Liu
- Department of Anesthesiology, Affiliated Qingyuan Hospital (Qingyuan People's Hospital), Guangzhou Medical University, QingYuan, Guangdong, People's Republic of China
| | - Xunhu Gu
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
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28
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Dovzhanskiy DI, Bischoff MS, Passek K, Böckler D. Results of a German nationwide survey on perioperative cardiac management in vascular surgery. Langenbecks Arch Surg 2024; 409:345. [PMID: 39531062 PMCID: PMC11557624 DOI: 10.1007/s00423-024-03523-5] [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: 08/13/2024] [Accepted: 10/21/2024] [Indexed: 11/16/2024]
Abstract
Because of the lack of specific recommendations concerning cardiac risk stratification before vascular surgery, appropriate decisions remain individual. The aim of the present study was to evaluate the perioperative cardiac management in vascular surgery in Germany. METHODS This article is based on a survey from 2018 of heads of German vascular surgical departments or units regarding their experience with perioperative cardiac management. The questionnaire asked about the experience with preoperative cardiac evaluation and its extension, awareness of perioperative myocardial ischemia, the art of postoperative monitoring and the routine use of the best medical treatment. RESULTS In total, 62% of responders agreed that perioperative myocardial ischemia is a relevant postoperative problem in their clinic after open abdominal aortic surgery, while 47% stated the same after vascular surgery (VS) like carotid endarterectomy, peripheral arterial surgery or EVAR. Preoperative cardiological evaluations are performed routinely by 87% of responders before open abdominal aortic surgery and by 42% before VS. Preoperative cardiac evaluation included cardiac echography in 92% and stress diagnostics (stress echography, stress ECG) in 38%. Routine preoperative cardiac catheterisation is performed in 4% before OAS and only 0.5% before VS. In addition, 79% of participants initiate acetylsalicylic acid routinely and 68% use statins preoperatively. The serum troponin diagnostic test in asymptomatic patients was routinely applied by 19% of responders after OAS and by 6% after VS. CONCLUSION Perioperative myocardial ischemia is considered a relevant problem, primarily after aortic surgery. The preoperative cardiac stress diagnostics among vascular surgeons does not seem to be sufficiently widespread. The preoperative initiation of acetylsalicylic acid and statins is not routine in 30% of hospitals.
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Affiliation(s)
- Dmitriy I Dovzhanskiy
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Moritz S Bischoff
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Karola Passek
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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McIsaac DI, Tandon P, Kidd G, Branje K, Hladkowicz E, Hallet J, Wijeysundera DN, Lee S, McNeely ML, Taljaard M, Gillis C. STRIVE pilot trial: a protocol for a multicentre pragmatic internal pilot randomised controlled trial of Structured TRaining to Improve fitness in a Virtual Environment (STRIVE) before surgery. BMJ Open 2024; 14:e093710. [PMID: 39510784 PMCID: PMC11552010 DOI: 10.1136/bmjopen-2024-093710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2024] [Accepted: 10/24/2024] [Indexed: 11/15/2024] Open
Abstract
INTRODUCTION Home-based, virtually-supported care models may represent the most efficient and scalable approach to delivering prehabilitation services. However, virtual approaches to prehabilitation are understudied. This manuscript describes the protocol for an internal pilot randomised controlled trial of a virtually-delivered, multimodal prehabilitation intervention. METHODS AND ANALYSIS We will conduct a pragmatic, individual patient, internal pilot randomised controlled trial of home-based, virtually supported, multimodal prehabilitation compared with standard perioperative care in adults undergoing elective, inpatient thoracic, abdominal, pelvic and vascular surgery at five Canadian hospitals. Participants will be partially blinded; clinicians and outcome assessors will be fully blinded. The intervention consists of 3-12 weeks of a home-based, multimodal (exercise, nutrition and psychosocial support) prehabilitation programme supported through an online platform. The primary feasibility outcomes and their progression targets are (1) monthly recruitment of>6 participants at each centre, (2) intervention adherence of>75%, (3) retention of>90% of participants at the patient-reported primary outcome point of 30-days after surgery and (4) elicitation of patient, clinician and researcher-identified barriers to our pragmatic trial. A sample size of 144 participants will be adequate to estimate recruitment, adherence and retention rates with acceptable precision. All participants will be followed to either death or up to 1 year. As an internal pilot, if no substantive changes to the trial or intervention design are required, pilot participant outcome data will migrate, unanalysed by allocation, to the future full-scale trial. ETHICS AND DISSEMINATION Ethical approval has been granted by Clinical Trials Ontario (Project ID: 4479) and our ethics review board (Protocol Approval #20230399-01T). Results will be disseminated through presentations at scientific conferences, peer-reviewed publications, partner organisations and engagement of social and traditional media. TRIAL REGISTRATION NUMBER ClinicalTrials.gov identifier NCT06042491. Protocol, V.1.2, dated 6 June 2024.
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Affiliation(s)
- Daniel I McIsaac
- Anaesthesiology and Pain Medicine, Ottawa Hospital Research Institute Clinical Epidemiology Programme, Ottawa, Ontario, Canada
| | - Puneeta Tandon
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Gurlavine Kidd
- Patient Partner, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Karina Branje
- Department of Anaesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Emily Hladkowicz
- Departments of Anaesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Julie Hallet
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Susan Lee
- Department of Anesthesiology, Pharmacology, and Therapeutics, UBC Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Margaret L McNeely
- Physical Therapy, University of Alberta, Edmonton, Alberta, Canada
- Supportive Care, Cancer Care Alberta, Edmonton, Alberta, Canada
| | - Monica Taljaard
- Clinical Epidemiology Programme, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Chelsia Gillis
- School of Human Nutrition, McGill University, Montreal, Québec, Canada
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Thompson A, Fleischmann KE, Smilowitz NR, de Las Fuentes L, Mukherjee D, Aggarwal NR, Ahmad FS, Allen RB, Altin SE, Auerbach A, Berger JS, Chow B, Dakik HA, Eisenstein EL, Gerhard-Herman M, Ghadimi K, Kachulis B, Leclerc J, Lee CS, Macaulay TE, Mates G, Merli GJ, Parwani P, Poole JE, Rich MW, Ruetzler K, Stain SC, Sweitzer B, Talbot AW, Vallabhajosyula S, Whittle J, Williams KA. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 150:e351-e442. [PMID: 39316661 DOI: 10.1161/cir.0000000000001285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2024]
Abstract
AIM The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery. METHODS A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.
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Affiliation(s)
| | | | | | - Lisa de Las Fuentes
- Former ACC/AHA Joint Committee on Clinical Practice Guidelines member; current member during the writing effort
| | | | | | | | | | | | | | | | - Benjamin Chow
- Society of Cardiovascular Computed Tomography representative
| | | | | | | | | | | | | | | | | | | | | | - Purvi Parwani
- Society for Cardiovascular Magnetic Resonance representative
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Thompson A, Fleischmann KE, Smilowitz NR, de Las Fuentes L, Mukherjee D, Aggarwal NR, Ahmad FS, Allen RB, Altin SE, Auerbach A, Berger JS, Chow B, Dakik HA, Eisenstein EL, Gerhard-Herman M, Ghadimi K, Kachulis B, Leclerc J, Lee CS, Macaulay TE, Mates G, Merli GJ, Parwani P, Poole JE, Rich MW, Ruetzler K, Stain SC, Sweitzer B, Talbot AW, Vallabhajosyula S, Whittle J, Williams KA. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 84:1869-1969. [PMID: 39320289 DOI: 10.1016/j.jacc.2024.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2024]
Abstract
AIM The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery. METHODS A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.
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Lyu Z, Ji Y, Ji Y. Association between stress hyperglycemia ratio and postoperative major adverse cardiovascular and cerebrovascular events in noncardiac surgeries: a large perioperative cohort study. Cardiovasc Diabetol 2024; 23:392. [PMID: 39488717 PMCID: PMC11531114 DOI: 10.1186/s12933-024-02467-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Accepted: 10/10/2024] [Indexed: 11/04/2024] Open
Abstract
BACKGROUND There has been a concerning rise in the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) following noncardiac surgeries (NCS), significantly impacting surgical outcomes and patient prognosis. Glucose metabolism abnormalities induced by stress response under acute medical conditions may be a risk factor for postoperative MACCE. This study aims to explore the association between stress hyperglycemia ratio (SHR) and postoperative MACCE in patients undergoing general anesthesia for NCS. METHODS There were 12,899 patients in this perioperative cohort study. The primary outcome was MACCE within 30 days postoperatively, defined as angina, acute myocardial infarction, cardiac arrest, arrhythmia, heart failure, stroke, or in-hospital all-cause mortality. Kaplan-Meier curves visualized the cumulative incidence of MACCE. Cox proportional hazard models were utilized to assess the association between the risk of MACCE and different SHR groups. Restricted cubic spline analyses were conducted to explore potential nonlinear relationships. Additionally, exploratory subgroup analyses and sensitivity analyses were performed. RESULTS A total of 592 (4.59%) participants experienced MACCE within 30 days after surgery, and 1,045 (8.10%) within 90 days. After adjusting for confounding factors, compared to the SHR T2 group, the risk of MACCE within 30 days after surgery increased by 1.34 times (95% CI 1.08-1.66) in the T3 group and by 1.35 times (95% CI 1.08-1.68) in the T1 group respectively. In the non-diabetes group, the risk of MACCE within 30 days after surgery increased by 1.60 times (95% CI 1.21-2.12) in the T3 group and by 1.61 times (95% CI 1.21-2.14) in the T1 group respectively, while no statistically significant increase in risk was observed in the diabetes group. Similar results were observed within 90 days after surgery in the non-diabetes group. Additionally, a statistically significant U-shaped nonlinear relationship was observed in the non-diabetes group (30 days: P for nonlinear = 0.010; 90 days: P for nonlinear = 0.008). CONCLUSION In this large perioperative cohort study, we observed that both higher and lower SHR were associated with an increased risk of MACCE within 30 and 90 days after NCS, especially in patients without diabetes. These findings suggest that SHR potentially plays a key role in stratifying cardiovascular and cerebrovascular risk after NCS.
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Affiliation(s)
- Zhihan Lyu
- Department of General Medicine, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, No. 639 Zhizaoju Road, Shanghai, 200011, China.
| | - Yunxi Ji
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuhang Ji
- School of Big Data and Artificial Intelligence, Chizhou University, Chizhou, Anhui, China
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Nicholls M, Anderson N, Jarden R, Selak V, Frampton C, Dalziel SR. Investigating the impact of a multicomponent positive participatory organisational intervention on burnout in New Zealand emergency department staff: a prospective, multisite, before and after, mixed methods study. BMJ Open 2024; 14:e087328. [PMID: 39477263 PMCID: PMC11529577 DOI: 10.1136/bmjopen-2024-087328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 09/18/2024] [Indexed: 11/03/2024] Open
Abstract
INTRODUCTION The well-being of healthcare workers (HCWs) is critical to providing excellent care. Recent evidence concerns the well-being of emergency department (ED) HCWs in New Zealand, with high levels of burnout found in a 2020 survey. This threat to providing high-quality acute care warrants improvement interventions. The causes of burnout are complex and multifactorial, the solutions are not straightforward. METHODS AND ANALYSIS A prospective, multisite, before and after, mixed methods study assessing a multicomponent intervention, adaptable to local context, that targets three organisation levels (the individual, the group and the system levels) and meaningfully involves frontline HCWs may reduce HCW burnout and improve HCW well-being. Individual HCWs will choose from three individual-level psychological interventions and participate in those most appropriate for them. Local champions will decide which group-level intervention their ED will use. The system-level intervention will build capacity and capability for quality improvement (QI) with QI training and the establishment of a Quality Improvement Learning System. This system-level intervention has several important features that may ultimately empower HCWs to contribute to improving the quality of ED healthcare.We will enrol nine EDs, from which there will be at least 900 HCW participants. EDs will be enrolled in three waves from March 2023 to April 2024, with interventions taking place in each ED over 12 months.Methods of assessment will include baseline and repeat survey measures of burnout and well-being. Process evaluation at each ED will provide details of context, the intervention and the fidelity of the implementation. ETHICS AND DISSEMINATION Ethics committee approval was provided, with locality approval at each site.Individual site feedback will be provided to each ED and executive leadership. Dissemination of findings will be through publication in peer-reviewed journals, presentation at national and international scientific meetings and through national healthcare quality bodies. TRIAL REGISTRATION NUMBER Australia New Zealand Clinical Trials Registry (ACTRN12623000342617).
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Affiliation(s)
- Mike Nicholls
- Department of Paediatrics, Faculty of Medicine and Health Sciences, The University of Auckland, Auckland, New Zealand
- Adult Emergency Department, Te Toka Tumai Auckland City Hospital, Auckland, New Zealand
| | - Natalie Anderson
- Adult Emergency Department, Te Toka Tumai Auckland City Hospital, Auckland, New Zealand
- School of Nursing, The University of Auckland, Auckland, New Zealand
| | - Rebecca Jarden
- Nursing, The University of Melbourne Melbourne School of Health Sciences, Melbourne, Victoria, Australia
| | - Vanessa Selak
- Epidemiology & Biostatistics, University of Auckland, Auckland, New Zealand
| | - Chris Frampton
- Department of Medicine, Christchurch School of Medicine and Health Sciences, University of Otago, Christchurch, New Zealand
| | - Stuart R Dalziel
- Cure Kids Chair of Child Health Research; Departments of Surgery and Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
- Children's Emergency Department, Starship Children's Health, Auckland, New Zealand
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Xu CY, An MZ, Hou YR, Zhou QH. Effect of dexmedetomidine on postoperative high-sensitivity cardiac troponin T in patients undergoing video-assisted thoracoscopic surgery: a prospective, randomised controlled trial. BMC Pulm Med 2024; 24:500. [PMID: 39390494 PMCID: PMC11465541 DOI: 10.1186/s12890-024-03325-x] [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: 12/21/2023] [Accepted: 10/04/2024] [Indexed: 10/12/2024] Open
Abstract
BACKGROUND One-lung ventilation and intrathoracic operations during thoracoscopic surgery often result in intraoperative hypoxaemia and haemodynamic fluctuations, resulting in perioperative myocardial injury. Dexmedetomidine, an alpha-2 (α-2) agonist, has demonstrated myocardial protection. We hypothesize that the routine intravenous administration of dexmedetomidine could reduce the extent of myocardial injury during video-assisted thoracoscopic surgery (VATS). METHODS The study included patients aged ≥ 45 years, classified as American Society of Anesthesiologists physical status I-III, who underwent general anesthesia for video-assisted thoracoscopic surgery. The patients were randomly assigned to either the intervention group, receiving general anesthesia with dexmedetomidine, or the control group, receiving general anesthesia without dexmedetomidine. Patients in the intervention group received a loading dose of dexmedetomidine (0.5 µg·kg-1) before anesthesia induction, followed by a continuous infusion (0.5 µg·kg-1·h-1) until the completion of the surgery. Placebos (saline) were administered for the control group to match the treatment. The primary outcome assessed was the high-sensitivity cardiac troponin T on postoperative day 1. Additionally, the incidence of myocardial injury after noncardiac surgery (MINS) was noted. RESULTS A total of 110 participants completed this study. The median [interquartile range (IQR)] concentration of hs-cTnT on postoperative day 1 was lower in the intervention group compared with the control group (7 [6-9] vs. 8 [7-11] pg·ml-1; difference in medians,1 pg·ml-1; 95% confidence interval [CI], 0 to 2; P = 0.005). Similarly, on postoperative day 3, the median [IQR] concentration of hs-cTnT in the intervention group was also lower than that in the control group (6 [5-7] vs. 7 [6-9]; difference in medians,1 pg·ml-1; 95%CI, 0 to 2; P = 0.011). Although the incidence of MINS was not statistically significant (the intervention group vs. the control group, 3.8% vs. 9.1%, P = 0.465), there was a decreasing trend in the incidence of MINS in the intervention group. CONCLUSION The administration of perioperative dexmedetomidine in patients ≥ 45 years undergoing video-assisted thoracoscopic surgery could lower the release of postoperative hs-cTnT without reducing incidence of myocardial injury. TRIAL REGISTRATION chictr.org.cn (ChiCTR2200063193); prospectively registered 1 September 2022.
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Affiliation(s)
- Cheng-Yun Xu
- Department of Anesthesiology and Pain Medicine, Affiliated Hospital of Jiaxing University, No.1882, South Central Road, Jiaxing City, Zhejiang Province, China
| | - Ming-Zi An
- Department of Anesthesiology and Pain Medicine, Affiliated Hospital of Jiaxing University, No.1882, South Central Road, Jiaxing City, Zhejiang Province, China
| | - Yue-Ru Hou
- Department of Anesthesiology and Pain Medicine, Affiliated Hospital of Jiaxing University, No.1882, South Central Road, Jiaxing City, Zhejiang Province, China
| | - Qing-He Zhou
- Department of Anesthesiology and Pain Medicine, Affiliated Hospital of Jiaxing University, No.1882, South Central Road, Jiaxing City, Zhejiang Province, China.
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Hughes C, Ackland G, Shelley B. Perioperative myocardial injury. BJA Educ 2024; 24:352-360. [PMID: 39484008 PMCID: PMC11522720 DOI: 10.1016/j.bjae.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2024] [Indexed: 11/03/2024] Open
Affiliation(s)
- C. Hughes
- University of Glasgow, Glasgow, Scotland
| | - G. Ackland
- Queen Mary University of London, London, UK
| | - B. Shelley
- University of Glasgow, Glasgow, Scotland
- Golden Jubilee National Hospital, Glasgow, Scotland
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Nuttall GA, Merren MP, Naranjo J, Portner ER, Ambrose AR, Rihal CS. Perioperative Mortality: A Retrospective Cohort Study of 75,446 Noncardiac Surgery Patients. Mayo Clin Proc Innov Qual Outcomes 2024; 8:435-442. [PMID: 39263428 PMCID: PMC11387539 DOI: 10.1016/j.mayocpiqo.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/20/2024] [Accepted: 07/01/2024] [Indexed: 09/13/2024] Open
Abstract
Objective To evaluate whether major adverse cardiac events (MACE) continue to be a major causative factor for mortality after noncardiac surgery. Patients and Methods We performed retrospective study of 75,410 adult noncardiac surgery patients at Mayo Clinic Rochester, between January 1, 2016, and May 4, 2018. Electronic medical records were reviewed and data collected on all deaths within 30 days (n=692 patients) of surgery. The incidence of death due to MACE was calculated. Results Postoperative MACE occurred in 150 patients (21.4 events per 10,000 patients; 95% CI, 18.2-25.2 events per 10,000 patients) with most occurring within 3 days of surgery (n=113). Postoperative MACE events were associated with atrial fibrillation with rapid rate response in 25 patients (16.7%), sepsis in 15 patients (10%), and bleeding in 15 patients (10%). There were 12 intraoperative deaths of which 9 were due to exsanguination (75%) and the remaining 3 (25%) due to cardiac arrest. Of the 56 deaths on the first 24 hours after surgery, 7 were due to hemorrhage, 17 due to cardiovascular causes, 20 due to sepsis, and 7 due to neurologic disease. The leading cause of total death over 30 days postoperatively was sepsis (28%), followed by malignancy (27%), cardiovascular disease (12%) neurologic disease (12%), and hemorrhage (5%). Conclusion MACE was not the leading cause of death both intraoperatively and postoperatively.
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Affiliation(s)
- Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Michael P Merren
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Julian Naranjo
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Erica R Portner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Amanda R Ambrose
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
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White MJ, Zaccaria I, Ennahdi-Elidrissi F, Putzu A, Dimassi S, Luise S, Diaper J, Mulin S, Baudat AD, Gil-Wey B, Elia N, Walder B, Bollen Pinto B. Personalised perioperative dosing of ivabradine in noncardiac surgery: a single-centre, randomised, placebo-controlled, double-blind feasibility pilot trial. Br J Anaesth 2024; 133:738-747. [PMID: 38960832 DOI: 10.1016/j.bja.2024.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 05/28/2024] [Accepted: 05/29/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND Perioperative myocardial injury after noncardiac surgery is associated with postoperative mortality. Heart rate (HR) is an independent risk factor for perioperative myocardial injury. In this pilot trial we tested the feasibility of a randomised, placebo-controlled trial of personalised HR-targeted perioperative ivabradine. METHODS This was a single-centre, randomised, placebo-controlled, double-blind, parallel group, feasibility pilot trial conducted at Geneva University Hospitals. We included patients ≥75 yr old or ≥45 yr old with cardiovascular risk factors planned for intermediate- or high-risk surgery. Patients were randomised to receive ivabradine (2.5, 5.0, or 7.5 mg) or placebo according to their HR, twice daily, from the morning of surgery until postoperative day 2. Primary outcomes were appropriate dosage and blinding success rates. RESULTS Between October 2020 and January 2022, we randomised 78 patients (recruitment rate of 1.3 patients week-1). Some 439 of 444 study drug administrations were adequate (99% appropriate dosage rate). The blinding success rate was 100%. There were 137 (31%) administrations of Pill A (placebo in both groups for HR ≤70 beats min-1). Nine (11.5%) patients had a high-sensitive cardiac troponin T elevation ≥14 ng L-1 between any two measurements. The number of bradycardia episodes was eight in the placebo group and nine in the ivabradine group. CONCLUSIONS This pilot study demonstrates the feasibility of, and provides guidance for, a future trial testing the efficacy of personalised perioperative ivabradine. Future studies should include patients at higher risk of cardiac complications. CLINICAL TRIAL REGISTRATION NCT04436016.
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Affiliation(s)
- Marion J White
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Isabelle Zaccaria
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Florence Ennahdi-Elidrissi
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Alessandro Putzu
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Saoussen Dimassi
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Stéphane Luise
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - John Diaper
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Stéphanie Mulin
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Aurélie D Baudat
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Béatrice Gil-Wey
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Nadia Elia
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland; Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Bernhard Walder
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland; Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Bernardo Bollen Pinto
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland; Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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Ali S, Roubos S, Hoeks SE, Verbrugge SJC, Koopman-van Gemert AWMM, Stolker RJ, van Lier F. Perioperative transfusion study (PETS): Does a liberal transfusion protocol improve outcome in high-risk cardiovascular patients undergoing non-cardiac surgery? A randomised controlled pilot study. Transfus Med 2024; 34:398-404. [PMID: 38890740 DOI: 10.1111/tme.13058] [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: 03/25/2024] [Revised: 05/07/2024] [Accepted: 06/10/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Small studies have shown that patients with advanced coronary artery disease might benefit from a more liberal blood transfusion strategy. The goal of this pilot study was to test the feasibility of a blood transfusion intervention in a group of vascular surgery patients who have elevated cardiac troponins in rest. METHODS We conducted a single-centre, randomised controlled pilot study. Patients with a preoperative elevated high-sensitive troponin T undergoing non-cardiac vascular surgery were randomised between a liberal transfusion regime (haemoglobin >10.4 g/dL) and a restrictive transfusion regime (haemoglobin 8.0-9.6 g/dL) during the first 3 days after surgery. The primary outcome was defined as a composite endpoint of all-cause mortality, myocardial infarction or unscheduled coronary revascularization. RESULTS In total 499 patients were screened; 92 were included and 50 patients were randomised. Postoperative haemoglobin was different between the intervention and control group; 10.6 versus 9.8, 10.4 versus 9.4, 10.9 versus 9.4 g/dL on day one, two and three respectively (p < 0.05). The primary outcome occurred in four patients (16%) in the liberal transfusion group and in two patients (8%) in control group. CONCLUSION This pilot study shows that the studied transfusion protocol was able to create a clinically significant difference in perioperative haemoglobin levels. Randomisation was possible in 10% of the screened patients. A large definitive trial should be possible to provide evidence whether a liberal transfusion strategy could decrease the incidence of postoperative myocardial infarction in high risk surgical patients.
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Affiliation(s)
- Samir Ali
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Steven Roubos
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Sanne E Hoeks
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Serge J C Verbrugge
- Department of Anaesthesiology, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | | | - Robert Jan Stolker
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Felix van Lier
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Mazzolai L, Teixido-Tura G, Lanzi S, Boc V, Bossone E, Brodmann M, Bura-Rivière A, De Backer J, Deglise S, Della Corte A, Heiss C, Kałużna-Oleksy M, Kurpas D, McEniery CM, Mirault T, Pasquet AA, Pitcher A, Schaubroeck HAI, Schlager O, Sirnes PA, Sprynger MG, Stabile E, Steinbach F, Thielmann M, van Kimmenade RRJ, Venermo M, Rodriguez-Palomares JF. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J 2024; 45:3538-3700. [PMID: 39210722 DOI: 10.1093/eurheartj/ehae179] [Citation(s) in RCA: 134] [Impact Index Per Article: 134.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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Kumar M, Wilkinson K, Li YH, Masih R, Gandhi M, Saadat H, Culmone J. Association of a Novel Electronic Form for Preoperative Cardiac Risk Assessment With Reduction in Cardiac Consultations and Testing: Retrospective Cohort Study. JMIR Perioper Med 2024; 7:e63076. [PMID: 39269754 PMCID: PMC11437228 DOI: 10.2196/63076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2024] [Revised: 08/02/2024] [Accepted: 08/06/2024] [Indexed: 09/15/2024] Open
Abstract
BACKGROUND Preoperative cardiac risk assessment is an integral part of preoperative evaluation; however, there is significant variation among providers, leading to inappropriate referrals for cardiology consultation or excessive low-value cardiac testing. We implemented a novel electronic medical record (EMR) form in our preoperative clinics to decrease variation. OBJECTIVE This study aimed to investigate the impact of the EMR form on the preoperative utilization of cardiology consultation and cardiac diagnostic testing (echocardiograms, stress tests, and cardiac catheterization) and evaluate postoperative outcomes. METHODS A retrospective cohort study was conducted. Patients who underwent outpatient preoperative evaluation prior to an elective surgery over 2 years were divided into 2 cohorts: from July 1, 2021, to June 30, 2022 (pre-EMR form implementation), and from July 1, 2022, to June 30, 2023 (post-EMR form implementation). Demographics, comorbidities, resource utilization, and surgical characteristics were analyzed. Propensity score matching was used to adjust for differences between the 2 cohorts. The primary outcomes were the utilization of preoperative cardiology consultation, cardiac testing, and 30-day postoperative major adverse cardiac events (MACE). RESULTS A total of 25,484 patients met the inclusion criteria. Propensity score matching yielded 11,645 well-matched pairs. The post-EMR form, matched cohort had lower cardiology consultation (pre-EMR form: n=2698, 23.2% vs post-EMR form: n=2088, 17.9%; P<.001) and echocardiogram (pre-EMR form: n=808, 6.9% vs post-EMR form: n=591, 5.1%; P<.001) utilization. There were no significant differences in the 30-day postoperative outcomes, including MACE (all P>.05). While patients with "possible indications" for cardiology consultation had higher MACE rates, the consultations did not reduce MACE risk. Most algorithm end points, except for active cardiac conditions, had MACE rates <1%. CONCLUSIONS In this cohort study, preoperative cardiac risk assessment using a novel EMR form was associated with a significant decrease in cardiology consultation and testing utilization, with no adverse impact on postoperative outcomes. Adopting this approach may assist perioperative medicine clinicians and anesthesiologists in efficiently decreasing unnecessary preoperative resource utilization without compromising patient safety or quality of care.
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Affiliation(s)
- Mandeep Kumar
- Pre-Admission Testing Center, Perioperative Medicine, Hartford HealthCare, Hartford, CT, United States
- University of Connecticut, Storrs, CT, United States
- Hartford HealthCare Medical Group, Hartford, CT, United States
| | | | - Ya-Huei Li
- Research Program, Hartford HealthCare, Hartford, CT, United States
| | - Rohit Masih
- Hartford HealthCare Medical Group, Hartford, CT, United States
| | - Mehak Gandhi
- Hartford HealthCare Medical Group, Hartford, CT, United States
| | - Haleh Saadat
- Integrated Anesthesia Associates-Fairfield Division, Hartford Healthcare, Hartford, CT, United States
- Frank H Netter MD School of Medicine, Quinnipiac University, North Haven, CT, United States
| | - Julie Culmone
- Pre-Admission Testing Center, Perioperative Medicine, Hartford HealthCare, Hartford, CT, United States
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Alatassi R, Somerville LE, Vasarhelyi EM, Lanting BA, MacDonald SJ, Howard JL. Evaluation of the Effectiveness of Canadian Cardiovascular Society Guidelines in Minimizing Cardiac Events After Total Hip Arthroplasty. J Arthroplasty 2024; 39:S67-S72. [PMID: 38830433 DOI: 10.1016/j.arth.2024.05.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 05/26/2024] [Accepted: 05/27/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND The aim of the study was to analyze the Canadian Cardiovascular Society (CCS) guidelines for routine postoperative troponin testing after elective total hip arthroplasty (THA) to reduce the mortality rate resulting from myocardial injury. The purpose of this study was to assess the prognostic relevance of implementing these guidelines to minimize cardiac events in patients undergoing elective THA. METHODS Patients who underwent THA surgery in 2020 were included in the study. The inclusion criteria were elective THA patients aged ≥45 years, while emergency, revision, and simultaneous bilateral THA surgeries were excluded. The patients were categorized into 4 groups based on the CCS guidelines. RESULTS The study included 669 patients who had an average age of 67 years. There were 43 patients (6.4%), who experienced a rise in troponin levels ≥30 ng/L and developed myocardial injury after noncardiac surgery. Among these patients, 8 developed cardiac complications, and one experienced a serious cardiac event that resulted in death. Notably, there was a significant increase in the length of hospital stay for patients who received the postoperative screening protocol. CONCLUSIONS The implementation of the CCS guidelines for routine postoperative troponin testing in elective THA surgery did not significantly decrease the rate of cardiac events or mortality.
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Affiliation(s)
- Raheef Alatassi
- Division of Orthopedic Surgery, Department of Surgery, London Health Sciences Centre, University Hospital, London, Ontario, Canada
| | - Lyndsay E Somerville
- Division of Orthopedic Surgery, Department of Surgery, London Health Sciences Centre, University Hospital, London, Ontario, Canada
| | - Edward M Vasarhelyi
- Division of Orthopedic Surgery, Department of Surgery, London Health Sciences Centre, University Hospital, London, Ontario, Canada
| | - Brent A Lanting
- Division of Orthopedic Surgery, Department of Surgery, London Health Sciences Centre, University Hospital, London, Ontario, Canada
| | - Steven J MacDonald
- Division of Orthopedic Surgery, Department of Surgery, London Health Sciences Centre, University Hospital, London, Ontario, Canada
| | - James L Howard
- Division of Orthopedic Surgery, Department of Surgery, London Health Sciences Centre, University Hospital, London, Ontario, Canada
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Obada B, Georgeanu V, Iliescu M, Popescu A, Petcu L, Costea DO. Clinical outcomes of total hip arthroplasty after femoral neck fractures vs. osteoarthritis at one year follow up-A comparative, retrospective study. INTERNATIONAL ORTHOPAEDICS 2024; 48:2301-2310. [PMID: 38970678 PMCID: PMC11347475 DOI: 10.1007/s00264-024-06242-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 06/21/2024] [Indexed: 07/08/2024]
Abstract
PURPOSE The objective of the study is to determine if there was a difference in medical complications and in-hospital mortality among the patients who underwent THA for femoral neck fracture relative to same procedure for elective patients with coxarthrosis. METHODS We compared characteristics and short-term outcomes during the rehabilitative postsurgical period. We included all patients older than 45 years who underwent THA for primary/secondary hip arthritis and displaced femoral neck fractures type Garden III and IV. Clinical examination, functional outcome and radiographic evaluation were performed during follow-up. Patients were evaluated at the following time points: preoperatively, postoperatively at three days, six weeks, 12 weeks and one year and we registered Visual Analogue Scale (VAS) pain score, Harris Hip Score (HHS), the Western Ontario McMaster Osteoarthritis Index (WOMAC), internal and external rotation of the hip and operated limb length compared with the opposite. RESULTS There is no significant statistically differences between the two groups regarding the preoperative comorbidities. The frequencies of patients experiencing in-hospital and 30-day postoperative complications were generally low and same in groups we studied. The mean quantity of surgical blood loos during the operation was significantly higher in the hip fracture group compared with elective patient group with OA (340.09 ± 86.03 vs 309.43 ± 102.52). With respect to postoperative recovery the patients with THA after FNF were mobilized by active walking a little bit faster as the patient with OA (2.77 ± 1.18 days vs 3.1 ± 1.14 days). The average inpatient hospital length of stay after THA for OA was 11.07 days compared to 13.41 days following a THA for FNF. CONCLUSION Our study showed that THA for treatment of an acute fracture of the femoral neck in an elderly patient can provide results comparable to those of patients who received THA for OA and we found that the results are similar.
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Affiliation(s)
- Bogdan Obada
- Orthopaedic Traumatology Clinic, Ovidius" University of Constanta, Constanta, Romania.
| | - Vlad Georgeanu
- Orthopaedic Traumatology Clinic, UMF "Carol Davila, Bucharest, Romania
| | - Madalina Iliescu
- Medical Rehabilitation Clinic, Ovidius" University of Constanta, Constanta, Romania
| | | | - Lucian Petcu
- Ovidius" University of Constanta, Constanta, Romania
| | - Dan Ovidiu Costea
- General Surgery Clinic, Ovidius" University of Constanta, Constanta, Romania
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Aakre EK, Aakre KM, Flaatten H, Hufthammer KO, Ranhoff AH, Jammer I. High-Sensitivity Cardiac Troponin T and Frailty Predict Short-Term Mortality in Patients ≥75 Years Undergoing Emergency Abdominal Surgery: A Prospective Observational Study. Anesth Analg 2024; 139:313-322. [PMID: 39008976 DOI: 10.1213/ane.0000000000006845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2024]
Abstract
BACKGROUND An elevated cardiac troponin concentration is a prognostic factor for perioperative cardiac morbidity and mortality. In elderly patients undergoing emergency abdominal surgery, frailty is a recognized risk factor, but little is known about the prognostic value of cardiac troponin in these vulnerable patients. Therefore, we investigated the prognostic significance of elevated high-sensitivity cardiac troponin T (hs-cTnT) concentration and frailty in a cohort of elderly patients undergoing emergency abdominal surgery. METHODS We included consecutive patients ≥75 years of age who presented for emergency abdominal surgery, defined as abdominal pathology requiring surgery within 72 hours, in a university hospital in Norway. Patients who underwent vascular procedures or palliative surgery for inoperable malignancies were excluded. Preoperatively, frailty was assessed using the Clinical Frailty Scale (CFS), and blood samples were measured for hs-cTnT. We evaluated the predictive power of CFS and hs-cTnT concentrations using receiver operating characteristic (ROC) curves and Cox proportional hazard regression with 30-day mortality as the primary outcome. Secondary outcomes included (1) a composite of 30-day all-cause mortality and major adverse cardiac event (MACE), defined as myocardial infarction, nonfatal cardiac arrest, or coronary revascularization; and (2) 90-day mortality. RESULTS Of the 210 screened and 156 eligible patients, blood samples were available in 146, who were included. Troponin concentration exceeded the 99th percentile upper reference limit (URL) in 83% and 89% of the patients pre- and postoperatively. Of the participants, 53% were classified as vulnerable or frail (CFS ≥4). The 30-day mortality rate was 12% (18 of 146). Preoperatively, a threshold of hs-cTnT ≥34 ng/L independently predicted 30-day mortality (hazard ratio [HR] 3.14, 95% confidence interval [CI], 1.13-9.45), and the composite outcome of 30-day mortality and MACE (HR 2.58, 95% CI, 1.07-6.49). In this model, frailty (continuous CFS score) also independently predicted 30-day mortality (HR 1.42, 95% CI, 1.01-2.00) and 30-day mortality or MACE (HR 1.37, 95% CI, 1.02-1.84). The combination of troponin and frailty, 0.14 × hs-cTnT +4.0 × CFS, yielded apparent superior predictive power (area under the receiver operating characteristics curve [AUC] 0.79, 95% CI, 0.68-0.88), compared to troponin concentration (AUC 0.69, 95% CI, 0.55-0.83) or frailty (AUC 0.69, 95% CI, 0.57-0.82) alone. CONCLUSIONS After emergency abdominal surgery in elderly patients, increased preoperative troponin concentration and frailty were independent predictors of 30-day mortality. The combination of increased troponin concentration and frailty seemed to provide better prognostic information than troponin or frailty alone. These results must be validated in an independent sample.
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Affiliation(s)
- Elin Kismul Aakre
- From the Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Kristin Moberg Aakre
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Medical Biochemistry and Pharmacology
| | - Hans Flaatten
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | | | | | - Ib Jammer
- From the Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
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Bukhari S, Leth MF, Laursen CCW, Larsen ME, Tornøe AS, Eriksen VR, Hovmand AEK, Jakobsen JC, Maagaard M, Mathiesen O. Risks of serious adverse events with non-steroidal anti-inflammatory drugs in gastrointestinal surgery: A systematic review with meta-analysis and trial sequential analysis. Acta Anaesthesiol Scand 2024; 68:871-887. [PMID: 38629348 DOI: 10.1111/aas.14425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 03/19/2024] [Accepted: 03/21/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly recommended for perioperative opioid-sparing multimodal analgesic treatments. Concerns regarding the potential for serious adverse events (SAEs) associated with perioperative NSAID treatment are especially relevant following gastrointestinal surgery. We assessed the risks of SAEs with perioperative NSAID treatment in patients undergoing gastrointestinal surgery. METHODS We conducted a systematic review of randomised clinical trials assessing the harmful effects of NSAIDs versus placebo, usual care or no intervention in patients undergoing gastrointestinal surgery. The primary outcome was an incidence of SAEs. We systematically searched for eligible trials in five major databases up to January 2024. We performed risk of bias assessments to account for systematic errors, trial sequential analysis (TSA) to account for the risks of random errors, performed meta-analyses using R and used the Grading of Recommendations Assessment, Development and Evaluation framework to describe the certainty of evidence. RESULTS We included 22 trials enrolling 1622 patients for our primary analyses. Most trials were at high risk of bias. Meta-analyses (risk ratio 0.78; 95% confidence interval [CI] 0.51-1.19; I2 = 4%; p = .24; very low certainty of evidence) and TSA indicated a lack of information on the effects of NSAIDs compared to placebo on the risks of SAEs. Post-hoc beta-binomial regression sensitivity analyses including trials with zero events showed a reduction in SAEs with NSAIDs versus placebo (odds ratio 0.73; CI 0.54-0.99; p = .042). CONCLUSION In adult patients undergoing gastrointestinal surgery, there was insufficient information to draw firm conclusions on the effects of NSAIDs on SAEs. The certainty of the evidence was very low.
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Affiliation(s)
- Shaheer Bukhari
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Morten F Leth
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Christina C W Laursen
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Mia E Larsen
- Department of Anesthesiology, Nykøbing Falster Hospital, Nykøbing Falster, Denmark
| | - Anders S Tornøe
- Department of Anesthesiology, Nordland Hospital Trust, Bodø, Norway
| | - Vibeke R Eriksen
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Alfred E K Hovmand
- Department of Anesthesiology, University Hospital Northern Norway, Tromsø, Norway
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Mathias Maagaard
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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Körner L, Riddersholm S, Torp-Pedersen C, Houlind K, Bisgaard J. Is General Anesthesia for Peripheral Vascular Surgery Correlated with Impaired Outcome in Patients with Cardiac Comorbidity? A Closer Look into the Nationwide Danish Cohort. J Cardiothorac Vasc Anesth 2024; 38:1707-1715. [PMID: 38789284 DOI: 10.1053/j.jvca.2024.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/27/2024] [Accepted: 03/20/2024] [Indexed: 05/26/2024]
Abstract
OBJECTIVE General anesthesia (GA) may impair outcome after vascular surgery. The use of anticoagulant medication is often used in patients with cardiac comorbidity. Regional anesthesia (RA) requires planning of discontinuation before neuraxial blockade(s) in this subgroup. This study aimed to describe the effect of anesthesia choice on outcome after vascular surgery in patients with known cardiac comorbidity. DESIGN Retrospective cohort study. SETTING Danish hospitals. PARTICIPANTS 6302 patients with known cardiac comorbidity, defined as ischemic heart disease, valve disease, pulmonary vascular disease, heart failure, and cardiac arrhythmias, undergoing lower extremity vascular surgery between 2005 and 2017. INTERVENTIONS GA versus RA. MEASUREMENTS AND MAIN RESULTS Data were extracted from national registries. GA was defined as anesthesia with mechanical ventilation. Multivariable regression models were used to describe the incidence of postoperative complications as well as 30-day mortality, hypothesizing that better outcomes would be seen after RA. The rate of RA decreased from 48% in 2005 to 20% in 2017. The number of patients with 1 or more complications was 9.7% vs 6.2% (p < 0.001), and 30-day mortality was 6.0% vs 3.4% (p < 0.001) after GA. After adjusting for baseline differences, the odds ratio (OR) was significantly lower for medical complications (cardiac, pulmonary, renal, new dialysis, intensive care unit and other medical complications; OR, 0.97; 95% confidence interval [CI], 0.95-0.98) and 30-day mortality (OR 0.98; 95% CI, 0.97-0.99) after RA. CONCLUSIONS RA may be associated with a better outcome than GA after lower extremity vascular surgery in patients with a cardiac comorbidity. Prioritizing RA, despite the inconvenience of discontinuing anticoagulants, may be recommended.
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Affiliation(s)
- Luisa Körner
- Department of Anesthesiology, Aalborg University Hospital, Aalborg, Denmark.
| | - Signe Riddersholm
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Kim Houlind
- Department of Vascular Surgery, Lillebælt Hospital, Kolding, Denmark
| | - Jannie Bisgaard
- Department of Anesthesiology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Dovzhanskiy DI, Bischoff MS, Jäckel P, Boeckler D. [Diagnosis and Management of Perioperative Myocardial Ischemia after Elective Aortic Aneurysm Surgery]. Zentralbl Chir 2024; 149:391-397. [PMID: 35915925 DOI: 10.1055/a-1880-1586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Perioperative myocardial ischemia (PMI) is a serious postoperative complication. Aortic operations represent an especially high-risk surgery concerning cardiac complications. This aim of this study was to analyse the clinical features of PMI after elective aortic aneurysm surgery. PATIENTS AND METHODS This study is a retrospective analysis of 863 patients who underwent elective aortic aneurysm surgery between 2005 and 2012 in the Department of Vascular and Endovascular Surgery of Heidelberg University Hospital with regard to PMI. The PMI diagnosis was based on a positive serum troponin diagnostic test. We evaluated the clinical course, time point of the diagnosis and features of diagnostics to characterise PMI. Moreover, we analysed the treatment options and management of the patients' discharge. RESULTS Thirty-one patients (3.6% of 863) with PMI after elective aortic aneurysm surgery were identified. Of these, 21 patients (67.7%) underwent open surgery and 10 patients (32.3%) received endovascular treatment. PMI was diagnosed in 24 patients (77%) during the first 3 days. More than half of these patients (16/31) were clinically asymptomatic. Electrocardiogram did not show pathological findings in 24 cases (77.4%). The first troponin measurement was not elevated in eight patients (25.8%). Drug therapy alone was used in 17 cases (54.8%) of PMI, coronary catheterisation was performed in 12 patients (38.7%) and two patients (6.5%) received aortocoronary bypass. Fourteen patients (45.1%) were discharged home and another 14 patients (44.1%) were transferred to another hospital or to a rehabilitation institution. Two patients died because of multi-organ failure. CONCLUSION PMI is not a rare complication after elective aortic surgery. The diagnosis of PMI can be challenging because of occult symptoms especially in a perioperative setting. Due to the potentially serious consequences, cardiac enzyme diagnostics should be initiated immediately if there is suspicion of PMI or routinely in defined at-risk patients after aortic surgery.
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Affiliation(s)
- Dmitriy I Dovzhanskiy
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinik Heidelberg, Heidelberg, Deutschland
| | - Moritz S Bischoff
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinik Heidelberg, Heidelberg, Deutschland
| | - Petra Jäckel
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinik Heidelberg, Heidelberg, Deutschland
| | - Dittmar Boeckler
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinik Heidelberg, Heidelberg, Deutschland
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Barker AB, Melvin RL, Godwin RC, Benz D, Wagener BM. Machine Learning Predicts Unplanned Care Escalations for Post-Anesthesia Care Unit Patients during the Perioperative Period: A Single-Center Retrospective Study. J Med Syst 2024; 48:69. [PMID: 39042285 PMCID: PMC11266221 DOI: 10.1007/s10916-024-02085-9] [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: 11/30/2023] [Accepted: 07/06/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND Despite low mortality for elective procedures in the United States and developed countries, some patients have unexpected care escalations (UCE) following post-anesthesia care unit (PACU) discharge. Studies indicate patient risk factors for UCE, but determining which factors are most important is unclear. Machine learning (ML) can predict clinical events. We hypothesized that ML could predict patient UCE after PACU discharge in surgical patients and identify specific risk factors. METHODS We conducted a single center, retrospective analysis of all patients undergoing non-cardiac surgery (elective and emergent). We collected data from pre-operative visits, intra-operative records, PACU admissions, and the rate of UCE. We trained a ML model with this data and tested the model on an independent data set to determine its efficacy. Finally, we evaluated the individual patient and clinical factors most likely to predict UCE risk. RESULTS Our study revealed that ML could predict UCE risk which was approximately 5% in both the training and testing groups. We were able to identify patient risk factors such as patient vital signs, emergent procedure, ASA Status, and non-surgical anesthesia time as significant variable. We plotted Shapley values for significant variables for each patient to help determine which of these variables had the greatest effect on UCE risk. Of note, the UCE risk factors identified frequently by ML were in alignment with anesthesiologist clinical practice and the current literature. CONCLUSIONS We used ML to analyze data from a single-center, retrospective cohort of non-cardiac surgical patients, some of whom had an UCE. ML assigned risk prediction for patients to have UCE and determined perioperative factors associated with increased risk. We advocate to use ML to augment anesthesiologist clinical decision-making, help decide proper disposition from the PACU, and ensure the safest possible care of our patients.
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Affiliation(s)
- Andrew B Barker
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 901 19th Street South, PBMR 302, Birmingham, AL, 35294, United States of America
| | - Ryan L Melvin
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Ryan C Godwin
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - David Benz
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Brant M Wagener
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, 901 19th Street South, PBMR 302, Birmingham, AL, 35294, United States of America.
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Xi S, Wang B, Su Y, Lu Y, Gao L. Predicting perioperative myocardial injury/infarction after noncardiac surgery in patients under surgical and medical co-management: a prospective cohort study. BMC Geriatr 2024; 24:540. [PMID: 38907213 PMCID: PMC11193176 DOI: 10.1186/s12877-024-05130-x] [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: 12/30/2023] [Accepted: 06/06/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Perioperative myocardial injury/infarction (PMI) following noncardiac surgery is a frequent cardiac complication. This study aims to evaluate PMI risk and explore preoperative assessment tools of PMI in patients at increased cardiovascular (CV) risk who underwent noncardiac surgery under the surgical and medical co-management (SMC) model. METHODS A prospective cohort study that included consecutive patients at increased CV risk who underwent intermediate- or high-risk noncardiac surgery at the Second Medical Center, Chinese PLA General Hospital, between January 2017 and December 2022. All patients were treated with perioperative management by the SMC team. The SMC model was initiated when surgical intervention was indicated and throughout the entire perioperative period. The incidence, risk factors, and impact of PMI on 30-day mortality were analyzed. The ability of the Revised Cardiac Risk Index (RCRI), frailty, and their combination to predict PMI was evaluated. RESULTS 613 eligible patients (mean [standard deviation, SD] age 73.3[10.9] years, 94.6% male) were recruited consecutively. Under SMC, PMI occurred in 24/613 patients (3.9%). Patients with PMI had a higher rate of 30-day mortality than patients without PMI (29.2% vs. 0.7%, p = 0.00). The FRAIL Scale for frailty was independently associated with an increased risk for PMI (odds ratio = 5.91; 95% confidence interval [CI], 2.34-14.93; p = 0.00). The RCRI demonstrated adequate discriminatory capacity for predicting PMI (area under the curve [AUC], 0.78; 95% CI, 0.67-0.88). Combining frailty with the RCRI further increased the accuracy of predicting PMI (AUC, 0.87; 95% CI, 0.81-0.93). CONCLUSIONS The incidence of PMI was relatively low in high CV risk patients undergoing intermediate- or high-risk noncardiac surgery under SMC. The RCRI adequately predicted PMI. Combining frailty with the RCRI further increased the accuracy of PMI predictions, achieving excellent discriminatory capacity. These findings may aid personalized evaluation and management of high-risk patients who undergo intermediate- or high-risk noncardiac surgery.
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Affiliation(s)
- Shaozhi Xi
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No.28 Fu Xing Road, Beijing, 100853, China
| | - Bin Wang
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No.28 Fu Xing Road, Beijing, 100853, China
| | - Yanhui Su
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No.28 Fu Xing Road, Beijing, 100853, China
| | - Yan Lu
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No.28 Fu Xing Road, Beijing, 100853, China.
| | - Linggen Gao
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No.28 Fu Xing Road, Beijing, 100853, China.
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Jin Y, Shen L, Ye R, Zhou M, Guo X. Development and validation of a novel score for predicting perioperative major adverse cardiovascular events in patients with stable coronary artery disease undergoing noncardiac surgery. Int J Cardiol 2024; 405:131982. [PMID: 38521511 DOI: 10.1016/j.ijcard.2024.131982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/01/2024] [Accepted: 03/17/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND A model developed specifically for stable coronary artery disease (SCAD) patients to predict perioperative major adverse cardiovascular events (MACE) has not been previously reported. METHODS The derivation cohort consisted of 5780 patients with SCAD undergoing noncardiac surgery at the First Affiliated Hospital of Zhejiang University School of Medicine, from January 1, 2013 until May 31, 2021. The validation cohort consisted of 2677 similar patients from June 1, 2021 to May 31, 2023. The primary outcome was a composite of MACEs (death, resuscitated cardiac arrest, myocardial infarction, heart failure, and stroke) intraoperatively or during hospitalization postoperatively. RESULTS Six predictors, including Creatinine >90 μmol/L, Hemoglobin <110 g/L, Albumin <40 g/L, Leukocyte >10 ×109/L, high-risk Surgery (general abdominal or vascular), and American Society of Anesthesiologists (ASA) class (III or IV), were selected in the final model (CHALSA score). Each patient was assigned a CHALSA score of 0, 1, 2, 3, or > 3 according to the number of predictors present. The incidence of perioperative MACEs increased steadily across the CHALSA score groups in both the derivation (0.5%, 1.4%, 2.9%, 6.8%, and 23.4%, respectively; p < 0.001) and validation (0.3%, 1.5%, 4.1%, 9.2%, and 29.2%, respectively; p < 0.001) cohorts. The CHALSA score had a higher discriminatory ability than the revised cardiac risk index (C statistic: 0.827 vs. 0.695 in the validation dataset; p < 0.001). CONCLUSIONS The CHALSA score showed good validity in an external dataset and will be a valuable bedside tool to guide the perioperative management of patients with SCAD undergoing noncardiac surgery.
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Affiliation(s)
- Yunpeng Jin
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China; Department of Cardiology, The Fourth Affiliated Hospital of School of Medicine, International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu 322000, China
| | - Liang Shen
- Department of Information Technology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Runze Ye
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Min Zhou
- Department of Information Technology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Xiaogang Guo
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China.
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50
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Noordzij PG, Ruven HJ, Reniers T, Idema RN, Thio MS, Cremer OL, Hollema N, Smit KN, Vernooij LM, Dijkstra IM, Rettig TC. Cohort profile of BIGPROMISE: a perioperative biobank of a high-risk surgical population. BMJ Open 2024; 14:e078307. [PMID: 38862228 PMCID: PMC11168131 DOI: 10.1136/bmjopen-2023-078307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 05/24/2024] [Indexed: 06/13/2024] Open
Abstract
PURPOSE Postoperative complications increase mortality, disability and costs. Advanced understanding of the risk factors for postoperative complications is needed to improve surgical outcomes. This paper discusses the rationale and profile of the BIGPROMISE (biomarkers to guide perioperative management and improve outcome in high-risk surgery) cohort, that aims to investigate risk factors, pathophysiology and outcomes related to postoperative complications. PARTICIPANTS Adult patients undergoing major surgery in two tertiary teaching hospitals. Clinical data and blood samples are collected before surgery, at the end of surgery and on the first, second and third postoperative day. At each time point a panel of cardiovascular, inflammatory, renal, haematological and metabolic biomarkers is assessed. Aliquots of plasma, serum and whole blood of each time point are frozen and stored. Data on severe complications are prospectively collected during 30 days after surgery. Functional status is assessed before surgery and after 120 days using the WHO Disability Assessment Schedule (WHODAS) 2.0. Mortality is followed up until 2 years after surgery. FINDINGS TO DATE The first patient was enrolled on 8 October 2021. Currently (1 January 2024) 3086 patients were screened for eligibility, of whom 1750 (57%) provided informed consent for study participation. Median age was 66 years (60; 73), 28% were female, and 68% of all patients were American Society of Anaesthesiologists (ASA) physical status class 3. Most common types of major surgery were cardiac (49%) and gastro-intestinal procedures (26%). The overall incidence of 30-day severe postoperative complications was 16%. FUTURE PLANS By the end of the recruitment phase, expected in 2026, approximately 3000 patients with major surgery will have been enrolled. This cohort allows us to investigate the role of pathophysiological perioperative processes in the cause of postoperative complications, and to discover and develop new biomarkers to improve risk stratification for adverse postoperative outcomes. TRIAL REGISTRATION NUMBER NCT05199025.
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Affiliation(s)
- Peter G Noordzij
- Department of Anaesthesiology, Intensive Care and Pain management, St. Antonius Hospital, Nieuwegein, Netherlands
- Department of Anaesthesiology, Intensive Care and Emergency Medicine, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Henk Jt Ruven
- Department of Clinical Chemistry, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Ted Reniers
- Department of Anaesthesiology, Intensive Care and Pain management, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Rene N Idema
- Department of Clinical Chemistry, Amphia Hospital, Breda, Netherlands
| | - Maaike Sy Thio
- Department of Anaesthesiology and Intensive Care, Amphia Hospital, Breda, Netherlands
| | - Olaf L Cremer
- Department of Intensive Care Medicine, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Nynke Hollema
- Department of Anaesthesiology, Intensive Care and Pain management, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Kyra N Smit
- Department of Clinical Chemistry, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Lisette M Vernooij
- Department of Anaesthesiology, Intensive Care and Pain management, St. Antonius Hospital, Nieuwegein, Netherlands
- Department of Anaesthesiology, Intensive Care and Emergency Medicine, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Ineke M Dijkstra
- Department of Clinical Chemistry, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Thijs Cd Rettig
- Department of Anaesthesiology and Intensive Care, Amphia Hospital, Breda, Netherlands
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