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).

Repair of abdominal aortic aneurysms (AAA) is a major vascular surgery that carries risk of myocardial injury following non-cardiac 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.

MEDLINE, WOS, and Scopus were searched for studies assessing MINS after AAA repair. The incidence of MINS in EVAR and OAR was pooled by random-effects meta-analysis, with sources of heterogeneity being explored. Assessment of studies' quality was performed using NHLBI Study Quality Assessment and RoB 2 Tool.

Sixteen studies were included, with a total of 25,649 participants. Two were RCTs, while the remaining were cohorts. Age ranged from 65.8-75.5 and percentage of male participants between 78%-96.6%. The pooled incidence of MINS ranged from 0.4%-18.7% for EVAR and 1.8%-46.8% for OAR. Meta-analytical incidence of MINS after EVAR was 12.5% [95%CI 6.2-18.7%] in cohort studies and 0.9% [95%CI 0.4-1.4%] in multicentre 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 multicentre database studies, and 32.4% [95%CI 18.1-46.8%] in RCTs, all with high heterogeneity (I2=96.8%, 86.6%, and 71.3%).

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.

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.

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.

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.

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).

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.

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.

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.

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.

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.

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.

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]).

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.

clinicaltrials.gov, no. NCT00512109 (main VISION study).

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.

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.

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.

A cross-sectional study.

Meizhou People's Hospital.

Adult patients under general anaesthesia and with MINS.

The preoperative TyG index, calculated using triglyceride (TG) and fasting blood glucose (FBG) levels.

The occurrence of MINS, defined using postoperative troponin measurements.

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.

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.

ChiCTR2400082834.

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.

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.

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.

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.

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.

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.

Ten industry-relevant and insightful takeaways are identified that span stakeholders and key performance indicators.

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.

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).

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.

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.

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.

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).

single center, single-blinded randomized controlled trial.

University hospital operating room.

150 patients undergoing lung surgery with single lung ventilation were included.

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.

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).

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).

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Optimised use of kidney function information might improve cardiac risk prediction in noncardiac surgery.

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.

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.

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.

ClinicalTrials.gov NCT00512109 (VISION) and NCT01082874 (POISE-2).

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.

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.

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.

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).

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.

Time elapsed between a prior NSTEMI and surgery.

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.

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).

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.

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.

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.

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).

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

ClinicalTrials.gov identifier NCT06042491. Protocol, V.1.2, dated 6 June 2024.

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.

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.

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.

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.

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.

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.

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.

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.

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).

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.

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.

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 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.

Australia New Zealand Clinical Trials Registry (ACTRN12623000342617).

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).

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.

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.

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.

chictr.org.cn (ChiCTR2200063193); prospectively registered 1 September 2022.

To evaluate whether major adverse cardiac events (MACE) continue to be a major causative factor for mortality after noncardiac surgery.

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.

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%).

MACE was not the leading cause of death both intraoperatively and postoperatively.

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.

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.

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.

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.

NCT04436016.

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.

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.

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.

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.

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.

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.

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).

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%.

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.