In-hospital Cardiac Events Research Articles

Results of percutaneous coronary intervention for chronic total occlusions of coronary arteries: a single center report

Percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) is associated with lower rates of procedural success and higher complication rates compared with PCIs in non-CTO lesions. The purpose of this study was to analyze the relationship between lesion characteristics and procedural success rates and in-hospital outcomes after PCI for CTO with novel equipment. We evaluated the prospectively entered data of 63 consecutive patients undergoing PCI for CTO at our institute between August 2009 and June 2012. A total of 63 patients (mean age: 64±11, 71% male) with one CTO lesion each underwent PCI. There were 46 patients (mean age: 63±10, 70% male) in the CTO success group and 17 patients (mean age: 65±13, 76.5% male) in the CTO failure group. Successful revascularization was achieved in 73% of patients. We used antegrade approach in 61 cases and retrograde approach in 2 cases. Our predominant strategy was single-wire technique, which was used in 54 cases (85.7%), followed by parallel-wire technique in 7 cases (11.1%). Moderate-to-severe tortuosity (odds ratio [OR]: 9.732, 95% confidence interval [CI]: 1.783-53.115, p=0.009) and occlusion duration (OR: 1.536, 95% CI: 1.178-2.001, p=0.002) were independent predictors of procedural failure in the multivariate analysis. No in-hospital major cardiac events occurred. We have reported a study with a relatively high success rate of PCI with very low procedural and in-hospital complications. Moderate-to-severe tortuosity was observed as the most challenging problem despite the utilisation of novel equipment and techniques for CTO recanalization.

Effect of Early Statin Treatment in Patients with Cardiogenic Shock Complicating Acute Myocardial Infarction

Background and ObjectivesThe benefit of early statin treatment following acute myocardial infarction (MI) complicated with cardiogenic shock (CS) has not been well studied. We sought to assess the effect of early statin therapy in patients with CS complicating acute MI.Subjects and MethodsWe studied 553 statin-naive patients with acute MI and CS (Killip class IV) who underwent revascularization therapy between November 2005 and January 2008 at 51 hospitals in the Korea Acute Myocardial Infarction Registry. Patients were divided into 2 groups: those who received statins during hospitalization (n=280) and those who did not (n=273). The influence of statin treatment on a 12-month clinical outcome was examined using a matched-pairs analysis (n=200 in each group) based on the propensity for receiving statin therapy during hospitalization.ResultsBefore adjustment, patients receiving statin, compared to those not receiving statin, had a more favorable clinical profile, were less likely to suffer procedural complications, and more likely to receive adequate medical therapy. Patients receiving statin had lower unadjusted in-hospital mortality and composite rate of mortality, MI, and repeat revascularization at 12 months, which remained significantly lower after adjustment for patient risk, procedural characteristics, and treatment propensity.ConclusionIn CS patients with acute MI undergoing revascularization therapy, early statin treatment initiated during hospitalization was associated with lower rates of in-hospital death and 12-month adverse cardiac events.

Early Cardiac Arrest in Patients Hospitalized With Pneumonia: A Report From the American Heart Association's Get With the Guidelines-Resuscitation Program

Pneumonia is the leading infectious cause of death. Early deterioration and death commonly result from progressive sepsis, shock, respiratory failure, and cardiac complications. Recent data suggest that cardiac arrest may also be common, yet few previous studies have addressed this. Accordingly, we sought to characterize early cardiac arrest in patients who are hospitalized with coexisting pneumonia. We performed a retrospective analysis of a multicenter cardiac arrest database, with data from > 500 North American hospitals. We included in-hospital cardiac arrest events that occurred in community-dwelling adults with pneumonia within the first 72 h after hospital admission. We compared patient and event characteristics for patients with and without pneumonia. For patients with pneumonia, we also compared events according to event location. We identified 4,453 episodes of early cardiac arrest in patients who were hospitalized with pneumonia. Among patients with preexisting pneumonia, only 36.5% were receiving mechanical ventilation and only 33.3% were receiving infusions of vasoactive drugs prior to cardiac arrest. Only 52.3% of patients on the ward were receiving ECG monitoring prior to cardiac arrest. Shockable rhythms were uncommon in all patients with pneumonia (ventricular tachycardia or fibrillation, 14.8%). Patients on the ward were significantly older than patients in the ICU. In patients with preexisting pneumonia, cardiac arrest may occur in the absence of preceding shock or respiratory failure. Physicians should be alert to the possibility of abrupt cardiopulmonary collapse, and future studies should address this possibility. The mechanism may involve myocardial ischemia, a maladaptive response to hypoxia, sepsis-related cardiomyopathy, or other phenomena.

Outcomes and practice patterns in patients undergoing lower extremity bypass

The appropriate application of endovascular intervention vs bypass for both critical limb ischemia (CLI) and intermittent claudication (IC) remains controversial, and outcomes from large, contemporary series are critical to help inform treatment decisions. Therefore, we sought to define the early and 1-year outcomes of lower extremity bypass (LEB) in a large, multicenter regional cohort, and analyze trends in the use of LEB with or without prior endovascular interventions. The Vascular Study Group of New England database was used to identify all infrainguinal LEB procedures performed between 2003 and 2009. The primary study endpoint was 1-year amputation-free survival (AFS). Secondary endpoints included in-hospital mortality and morbidity, including major adverse cardiac events. Trend analyses were conducted to identify annual trends in the proportion of LEBs performed for an indication of IC, in-hospital outcomes, including mortality and morbidity, and 1-year outcomes, including AFS. Analyses were performed on the entire cohort and then stratified by indication. Between 2003 and 2009, 2907 patients were identified who underwent LEBs (72% for CLI; 28% for IC). The proportion that underwent LEB for IC increased significantly over the study period (from 19% to 31%; P < .0001). There was a significant increase over time in the proportion of LEBs performed after a previous endovascular intervention among both CLIs (from 11% to 24%; P < .0001) and ICs (from 13% to 23%; P = .02). Neither in-hospital mortality nor cardiac event rates changed significantly among either group. There was no significant change in 1-year AFS in patients with IC (97% in 2003 and 98% in 2008; P for trend .63) or in patients with CLI (73% in 2003 and 81% in 2008; P = .10). Over the last 7 years, significant changes in patient selection for LEBs have occurred in New England. The proportion of LEBs performed for ICs as opposed to CLIs has increased. Patients are much more likely to have undergone prior endovascular interventions before undergoing a bypass. In-hospital and 1-year outcomes after LEB for both IC and CLI have remained excellent with no significant changes in AFS.

Prognostic Power of Pre- and Postoperative B-Type Natriuretic Peptide Levels in Patients Undergoing Abdominal Aortic Surgery

The first aim of the present study was to evaluate the pre- and postoperative B-type natriuretic peptide (BNP) levels in patients undergoing surgery for repair of an infrarenal abdominal aortic aneurysm (AAA) and analyze their power as a predictor of in-hospital cardiac events. The second aim was to evaluate the association among pre- and postoperative BNP levels, postoperative patient complications, and length of hospital stay. Prospective observational study. A university hospital. Forty-five patients undergoing elective surgery for an abdominal aortic aneurysm. The plasma BNP level was assessed just before surgery and then on postoperative day 1. Cardiac troponin I levels were measured postoperatively on arrival to the intensive care unit (time 0) and then 12, 48, and 72 hours later. The preoperative BNP concentration in patients who developed an acute myocardial infarction was 209 (IQR 84-346) pg/mL compared with 74 (IQR 28-142) pg/mL in those who did not. The difference between groups was statistically significant (p = 0.04). The Spearman correlation showed that postoperative BNP levels correlated significantly with preoperative BNP levels (r = 0.73, p = 0.0001), length of hospital stay (r = 0.35, p = 0.04), and troponin I concentration at 0 hour (r = 0.42, p = 0.02), 12 hours (r = 0.51, p = 0.0052), and 48 hours (r = 0.40, p = 0.033). In contrast, preoperative BNP levels correlated with troponin I at only 12 hours (r = 0.34, p = 0.02). Postoperative BNP levels were influenced significantly by transfusions (p = 0.035) and cross-clamping times (p = 0.038). The present results confirm the high negative predictive value of preoperative BNP levels; and postoperative BNP levels showed a better correlation with postoperative troponin levels, blood transfusion, and postoperative cardiac events.

N-Terminal Pro-Brain Natriuretic Peptide and Angiotensin-Converting Enzyme-2 Levels and Their Association With Postoperative Cardiac Complications After Emergency Orthopedic Surgery

The prognostic usefulness of the cardiac biomarkers N-terminal pro-brain natriuretic peptide (NT-proBNP) and angiotensin-converting enzyme 2 (ACE-2), in predicting adverse cardiac outcomes after orthopedic surgery is not well studied. The aim of our study was to determine the usefulness of perioperative NT-proBNP and ACE-2 for predicting cardiac events after emergency orthopedic surgery. The perioperative NT-proBNP and ACE-2 levels were determined in 187 consecutive patients aged >60 years who underwent orthopedic surgery with 1 year of follow-up for any cardiac complications (defined as acute myocardial infarction, congestive cardiac failure, atrial fibrillation, or major arrhythmia) and death. Of the 187 patients, 20 (10.7%) sustained an in-hospital postoperative cardiac complication. The total all-cause in-hospital and 1-year mortality rate was 1.6% (3 of 187) and 8.6% (16 of 187), respectively. The median preoperative and postoperative NT-proBNP level was greater in patients who sustained an in-hospital cardiac event than in those who had not (386 vs 2,273 pg/ml, p <0.001, and 605 vs 4,316 pg/ml, p <0.001, respectively). Similarly, the postoperative median ACE-2 levels were significantly greater in the patients with an in-hospital cardiac event than in those without (25.3 vs 39.5 pmol/ml/min, p = 0.012). A preoperative NT-proBNP level of ≥741 pg/ml (odds ratio 4.5, 95% confidence interval 1.3 to 15.2, p = 0.017), postoperative troponin elevation (odds ratio 4.9, 95% confidence interval 1.3 to 18.9, p = 0.022), and number of co-morbidities (odds ratio 1.8, 95% confidence interval 1.2 to 2.8, p = 0.009) independently predicted in-hospital cardiac complications on multivariate analysis. The pre- and postoperative NT-proBNP level independently predicted 1-year cardiovascular complications but not the ACE-2 levels. In conclusion, elevated perioperative NT-proBNP predicted in-hospital and 1-year cardiac events in an emergency orthopedic population but the ACE-2 levels did not, which requires additional study for validation.

GRACE Risk Score Predicts Contrast-Induced Nephropathy in Patients With Acute Coronary Syndrome and Normal Renal Function

We evaluated the incidence, clinical predictors, and outcomes of contrast-induced nephropathy (CIN) after coronary angiography in patients with myocardial infarction and normal kidney function. We studied 202 consecutive patients with glomerular filtration rate >60 mL/min/1.73 m(2). The CIN was defined according to 3 definitions: increases in serum creatinine (sCr) ≥25%, ≥0.3 mg/dL, and ≥0.5 mg/dL. The CIN occurred in 56 (27.7%), 42 (20.8%), and 13 (6.4%) patients, respectively. In multivariate analysis, the presence of a high Global Registry of Acute Coronary Events (GRACE) risk score (>140) was an independent predictor of CIN in its milder forms (≥25% and ≥0.3 mg/dL of rise in sCr). Increase in sCr ≥0.3 mg/dL was an independent predictor of bleeding. Increase in sCr ≥0.5 mg/dL was an independent predictor of in-hospital cardiac events (mortality, myocardial infraction [MI], and heart failure). As conclusion, the GRACE score is a useful tool to predict CIN in patients with MI and normal renal function.

The Prognostic Value of Serum Gamma Glutamyl Transferase Activity on Admission in Patients With STEMI Undergoing Primary PCI

We assessed the association between serum gamma glutamyl transferase (GGT) activity with postprimary percutaneous coronary intervention (PCI) coronary flow and in-hospital major advanced cardiac events (MACEs) in patients with ST elevation myocardial infarction (STEMI). Patients with STEMI (n = 425; males 78%; mean age 60 ± 13 years) were enrolled. Patients were divided into 3 GGT tertiles and 2 groups according to thrombolysis in myocardial infarction (TIMI) flow grade. The TIMI flow percentages were similar in the 3 GGT tertiles (32%, 45%, and 42%, respectively, P = .336). Total MACE increased with GGT tertiles (among tertiles, respectively; P < .001). The total MACE was significantly higher in impaired flow group than in normal flow group (23% vs 7%; P < .001). At multivariate analyses, serum GGT activity was an independent predictor of in-hospital MACE (odds ratio [OR] 1.12, 95% confidence interval [CI] 1.01-1.33; P < .001). In conclusion, serum GGT activity is associated with in-hospital MACE in patients with STEMI undergoing primary PCI.

Incidence of treated cardiac arrest in hospitalized patients in the United States*

The incidence and incidence over time of cardiac arrest in hospitalized patients is unknown. We sought to estimate the event rate and temporal trends of adult inhospital cardiac arrest treated with a resuscitation response. Three approaches were used to estimate the inhospital cardiac arrest event rate. First approach: calculate the inhospital cardiac arrest event rate at hospitals (n = 433) in the Get With The Guidelines-Resuscitation registry, years 2003-2007, and multiply this by U.S. annual bed days. Second approach: use the Get With The Guidelines-Resuscitation inhospital cardiac arrest event rate to develop a regression model (including hospital demographic, geographic, and organizational factors), and use the model coefficients to calculate predicted event rates for acute care hospitals (n = 5445) responding to the American Hospital Association survey. Third approach: classify acute care hospitals into groups based on academic, urban, and bed size characteristics, and determine the average event rate for Get With The Guidelines-Resuscitation hospitals in each group, and use weighted averages to calculate the national inhospital cardiac arrest rate. Annual event rates were calculated to estimate temporal trends. Get With The Guidelines-Resuscitation registry. Adult inhospital cardiac arrest with a resuscitation response. The mean adult treated inhospital cardiac arrest event rate at Get With The Guidelines-Resuscitation hospitals was 0.92/1000 bed days (interquartile range 0.58 to 1.2/1000). In hospitals (n = 150) contributing data for all years of the study period, the event rate increased from 2003 to 2007. With 2.09 million annual U.S. bed days, we estimated 192,000 inhospital cardiac arrests throughout the United States annually. Based on the regression model, extrapolating Get With The Guidelines-Resuscitation hospitals to hospitals participating in the American Hospital Association survey projected 211,000 annual inhospital cardiac arrests. Using weighted averages projected 209,000 annual U.S. inhospital cardiac arrests. There are approximately 200,000 treated cardiac arrests among U.S. hospitalized patients annually, and this rate may be increasing. This is important for understanding the burden of inhospital cardiac arrest and developing strategies to improve care for hospitalized patients.

141 Effectiveness of modern techniques and the transradial approach for the recanalization of chronic total occlusions; early canadian experience

141 Effectiveness of modern techniques and the transradial approach for the recanalization of chronic total occlusions; early canadian experience

Retrograde recanalization of chronic total occlusions from the transradial approach; Early canadian experience

Retrograde approach for chronic total occlusions (CTO) improves recanalization success rates. Eight French (Fr) catheters and the femoral approach are advocated. Evaluate whether transradial operators can achieve similar success rates using smaller catheters. This is a single-operator series of 42 consecutive cases performed between January and December 2010, including 13 while demonstrating CTO recanalization. Patients were referred because of complexity of the CTO or after failed attempt. Most frequent indications for recanalization were CCS 3-4 angina (52%) and CCS 1-2 in 21%. Eighteen (43%) patients underwent previous failed attempts. CTO was in the right coronary in 74%, left anterior descending in 24%, and a left main in 1. Most lesions (88%) were ≥20 mm long and 52% were calcified. We used septal collateral channels (CC) in 33 (79%), epicardial CC in 8 (20%), and a saphenous vein graft in one case. Radial access was used in all patients and was bilateral in 37 (88%). Five cases required one radial and one femoral access. Six French guides were used in 91% for the retrograde side and 71% for the antegrade side. Otherwise, 7 Fr guides were used. The Corsair(®) was used in 38 (90%). Procedural success was achieved in 37 (88%), mostly using reverse controlled antegrade-retrograde tracking (60%) or retrograde crossing (29%). The average <24-h Hb drop was 0.75 ± 0.84 g/dl. No in-hospital major cardiac events occurred. Transradial retrograde CTO recanalization is feasible, safe, and still associated with high success rates despite the use of smaller guide catheters.

High-Sensitivity C-Reactive Protein is a Predictor of In-Hospital Cardiac Events in Acute Myocardial Infarction Independently of GRACE Risk Score

High-sensitivity CRP (hsCRP) is being increasingly used as a marker for cardiac risk assessment and as a prognostic tool in acute coronary syndrome. We analyzed the relation between hsCRP values at admission and in-hospital outcomes in 98 consecutive patients with acute myocardial infarction (AMI) undergoing catheterization. Patients with cardiac events had more advanced Killip class, more proportion of depressed left ventricular ejection fraction (LVEF), higher Global Registry of Acute Coronary Events (GRACE) risk score, and higher hsCRP levels. High-sensitivity CRP and GRACE risk score showed a significant positive correlation (r = .320, P = .002). In multivariate analysis, hsCRP resulted as a predictor of worse in-hospital outcomes independently of GRACE risk score (OR 1.122, CI95%:1.005-1.252, P = .040). The hsCRP value showing the maximum likelihood ratio for predicting cardiac events was 1.45 mg/dL. High levels of hsCRP were also associated with development of contrast-induced nephropathy but not with bleeding events.

Effects of glycoprotein IIB/IIIA inhibition on QT dispersion in patients with unstable angina and non-Q-wave myocardial infarction

Acute coronary ischemia augments inhomogeneity in ventricular repolarization, which significantly correlates with ventricular fibrillation. The effects of glycoprotein IIb/IIIa receptor inhibition on QT interval dispersion (QTd), and the effects of QTd changes on in-hospital, 30 day, and long-term cardiac events in patients with unstable angina (UA) and non-Q-wave myocardial infarction (MI) have not been investigated previously. Eighty-three patients presenting with Braunwald class IIIB UA or non-Q-wave MI were randomized to standard therapy (aspirin and unfractionated heparin, 42 patients) or tirofiban therapy: addition to standard therapy (41 patients). QT interval dispersion (QTd) and corrected QTd (QTcd) were measured prior to therapy, and 6, 24, 48, 72, and 96 hours after the initiation of the treatment. In both groups QTd and QTcd were higher than normal limits during the admission, prior to therapy. The first QTd and QTcd were not different between two groups; the remaining values were significantly lower in tirofiban group except the first and last QTd (p values for QTd at 6, 24, 48, 72, and 96 hours are 0.057, 0.045, 0.0006, 0.04, and NS, respectively, and for QTcd, they are 0.017, 0.046, 0.0004, 0.012, and 0.01, respectively). When the first QTd and QTcd compared to the following measurements in each group, the first significant decrease occurred at 6th hour (p = 0.004 for QTd, and 0.004 for QTcd) in tirofiban group, whereas in standard therapy group it was occurred at 48th hour (p = 0.02) for QTd, and 72nd hour (p = 0.019) for QTcd. While the incidence of in-hospital acute MI, recurrent refractory angina, and total major cardiac events were significantly lower in the tirofiban group (p = 0.03, 0.04, and 0.01, respectively) that early QTd recovery observed, the 30 day and long-term incidence of major cardiac events were not different between the two groups. GP IIb/IIIa receptor inhibition in addition to heparin treatment causes a faster recovery of increased QT dispersion, and the early recovery of QTd is associated with a reduction in in-hospital major cardiac events.

Cardiac Arrest in the PACU: An Analysis of Evolving Challenges for Perianesthesia Nursing

Cardiac arrest in the PACU is a rare and poorly described event, with attendant limitations to experiential learning for the perianesthesia nurse. Good outcome from in-hospital cardiac arrest events differs partly because of variability in direct causes and clinical responses. Development of in-house training programs tailored to retain basic and advanced life support skills and enhance perianesthesia nurse responses to PACU arrests are essential to improving outcomes.

B-type natriuretic peptide as a predictor of anterior wall location in patients with non-ST-elevation myocardial infarction

OBJECTIVE:Involvement of the left ventricular anterior wall in ST-elevation myocardial infarction has a worse prognosis compared with other regions. In non-ST-elevation myocardial infarction, noninvasive methods of locating the ischemic myocardial territory have been limited. The objective of this report is therefore to determine what factors are predictive of the anterior location of the ischemic myocardial territory.METHODS:This study included 170 patients with non-ST-elevation myocardial infarction. Clinical, echocardiographic, and laboratory characteristics, including B-type natriuretic peptide measured within 24 hours of hospitalization, and coronary angiographic features were analyzed.RESULTS:The mean age was 64.5 ± 12.3 years, and 112 of the patients were male (66%). The median follow-up was 23 months. The territory involved, as determined from the angiogram, was divided into anterior [n = 80 (47%)] regions and inferior and lateral [n = 90 (53%)] regions. Multivariate analysis showed that B-type natriuretic peptide was the only independent predictor of an anterior wall infarct [OR = 3.70 (95% CI: 1.61 – 8.53); P = 0.002] in non-ST-elevation myocardial infarction patients. Multivariate analysis also showed that B-type natriuretic peptide was an independent predictor of in-hospital cardiac events during index admission [OR = 5.05 (95% CI: 1.49 – 17.12); P = 0.009] and of cardiac events occurring during follow-up [HR = 1.79 (95% CI: 1.05 – 3.04); P = 0.032].CONCLUSIONS:B-type natriuretic peptide was the only factor independently associated with anterior wall involvement in non-ST-elevation myocardial infarction, and the peptide levels upon admission predicted in-hospital and subsequent cardiac events.

Impact of troponin 1 on long‐term mortality after emergency orthopaedic surgery in older patients

To determine the association between post-operative troponin rises and longer term (2-year) mortality after emergency orthopaedic surgery in patients over 60 years of age. One hundred and two patients were recruited in 2006 and had inpatient troponin 1 measurements. These patients were followed up by a telephone call annually for complications. At 2 years, 29.4% (30/102) of patients had died. Twenty-five patients (25/54 or 49.3%) with a troponin rise were dead at 2 years compared with five patients without a troponin rise (5/48 or 10.4%), which was significantly different P < 0.0001. Patients with a higher troponin level (>0.1 µg/L) were more likely to be dead at 2 years compared with those with a lower level of troponin. However, when adjusted for other comorbidities the association between troponin elevation and death at 2 years did not persist. Using Cox regression multivariate analysis, only one factor, sustaining an in-hospital cardiac event odds ratio 4.3 (95% confidence interval 1.8-10.3, P = 0.001), was associated with 2 years all-cause mortality . Furthermore, patients who sustained a symptomatic troponin rise (P < 0.0001) or asymptomatic troponin rise (P = 0.004) were more likely to have died at 2 years compared with those with no troponin rise. Three factors were significantly associated with a cardiac event during the second year: (i) post-operative troponin rise (P = 0.05); (ii) pre-morbid atrial fibrillation (P = 0.04); and (iii) post-operative renal failure (P < 0.001). Elevated post-operative troponin levels are predictive of 1-year but not 2-year mortality in older patients undergoing emergency orthopaedic surgery.

Usefulness of N-Terminal Pro–Brain Natriuretic Peptide to Predict Postoperative Cardiac Complications and Long-Term Mortality After Emergency Lower Limb Orthopedic Surgery

After emergency orthopedic-geriatric surgery, cardiac complications are an important cause of morbidity and mortality. The utility of N-terminal pro-brain natriuretic peptide (NT-pro-BNP) for the prediction of cardiac complications and mortality was evaluated. NT-pro-BNP was tested pre- and postoperatively in 89 patients >60 years of age. They were followed for 2 years for cardiac complications (defined as acute myocardial infarction, congestive cardiac failure, atrial fibrillation or major arrhythmia) or death. Receiver operating characteristic curves were constructed to determine the optimal discriminatory level for cardiac events and death using NT-pro-BNP. Twenty-three patients (25.8%) sustained an in-hospital postoperative cardiac complication. Total all-cause mortality was 3 of 89 (3.4%) in hospital, 21 of 89 (23.6%) at 1 year, and 27 of 89 (30.3%) at 2 years. Median preoperative and postoperative NT-pro-BNP levels were higher in patients who had an in-hospital cardiac event compared to those without (387 vs 1,969 pg/ml, p <0.001; and 676 vs 7,052 pg/ml, p <0.001 respectively). The optimal discriminatory level for preoperative NT-pro-BNP was 842 pg/ml and that for postoperative NT-pro-BNP was 1,401 pg/ml for the prediction of in-hospital cardiac events and 1- and 2-year mortality. Preoperative NT-pro-BNP >/=842 pg/ml (odds ratio 11.6, 95% confidence interval 2.1 to 65.0, p = 0.005) was an independent predictor of in-hospital cardiac complications using multivariate analysis and pre- and postoperative NT-pro-BNP levels were independent predictors of 2-year cardiovascular events. Patients who had preoperative NT-pro-BNP >/=842 pg/ml or postoperative NT-pro-BNP >/=1,401 pg/ml had significantly worse survival using log-rank testing (p <0.001) and these variables independently predicted 2-year mortality. In conclusion, increase pre- and postoperative NT-pro-BNP levels are independent predictors of in-hospital cardiac events and 1- and 2-year mortality in older patients undergoing emergency orthopedic surgery.

B-type natriuretic peptide in patients undergoing orthopaedic surgery: a prospective cohort study

Postoperative cardiac complications pose a substantial risk to patients undergoing orthopaedic surgery. B-type natriuretic peptide (BNP) was determined preoperatively in 270 patients undergoing scheduled orthopaedic surgery. The accuracy of BNP to predict the occurrence of in-hospital cardiac events was evaluated as the primary endpoint. Cardiac events at 1 year of follow-up were considered secondary endpoints. Preoperative BNP levels were significantly higher in the four patients experiencing in-hospital cardiac events than in patients without events [median 306 pg ml(-1) (range 123-3958) vs. 35 pg ml(-1) (range 14-2074), P = 0.01]. In a receiver operating characteristic analysis for the prediction of in-hospital cardiac events, the area under the receiver operating characteristic curve for BNP was 0.86 (95% confidence interval 0.74-0.99). The optimal predictive accuracy was achieved with a BNP threshold of 174 pg ml(-1). Importantly, the combination of BNP and the American Society of Anesthesiologists score further improved this accuracy. Additionally, BNP retained a high predictive accuracy in the subgroup of patients with known cardiac diseases [area under the receiver operating characteristic curve 0.85 (95% confidence interval from 0.65 to <1)]. The area under the receiver operating characteristic curve for the prediction of long-term cardiac events by BNP was 0.71 (95% confidence interval 0.57-0.84). In patients undergoing orthopaedic surgery, preoperative BNP levels can predict short-term and long-term postoperative cardiac events. Despite the paucity of endpoint events observed in this study, our results are in agreement with all prior investigations. BNP used in addition to an American College of Cardiology/American Heart Association guideline-based risk assessment might, therefore, be a useful tool in the preoperative evaluation of patients undergoing orthopaedic surgery.

The Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) predicts cardiac complications more accurately than the Revised Cardiac Risk Index in vascular surgery patients

The Revised Cardiac Risk Index (RCRI) is a widely used model for predicting cardiac events after noncardiac surgery. We compared the accuracy of the RCRI with a new, vascular surgery-specific model developed from patients within the Vascular Study Group of New England (VSGNE). We studied 10,081 patients who underwent nonemergent carotid endarterectomy (CEA; n = 5293), lower extremity bypass (LEB; n = 2673), endovascular abdominal aortic aneurysm repair (EVAR; n = 1005), and open infrarenal abdominal aortic aneurysm repair (OAAA; n = 1,110) within the VSGNE from 2003 to 2008. First, we analyzed the ability of the RCRI to predict in-hospital major adverse cardiac events, including myocardial infarction (MI), arrhythmia, or congestive heart failure (CHF) in the VSGNE cohort. Second, we used a derivation cohort of 8208 to develop a new cardiac risk prediction model specifically for vascular surgery patients. Chi-square analysis identified univariate predictors, and multivariate logistic regression was used to develop an aggregate and four procedure-specific risk prediction models for cardiac complications. Calibration and model discrimination were assessed using Pearson correlation coefficient and receiver operating characteristic (ROC) curves. The ability of the model to predict cardiac complications was assessed within a validation cohort of 1873. Significant predictors were converted to an integer score to create a practical cardiac risk prediction formula. The overall incidence of major cardiac events in the VSGNE cohort was 6.3% (2.5% MI, 3.9% arrhythmia, 1.8% CHF). The RCRI predicted risk after CEA reasonably well but substantially underestimated risk after LEB, EVAR, and OAAA for low- and higher-risk patients. Across all VSGNE patients, the RCRI underestimated cardiac complications by 1.7- to 7.4-fold based on actual event rates of 2.6%, 6.7%, 11.6%, and 18.4% for patients with 0, 1, 2, and >or=3 risk factors. In multivariate analysis of the VSGNE cohort, independent predictors of adverse cardiac events were (odds ratio [OR]) increasing age (1.7-2.8), smoking (1.3), insulin-dependent diabetes (1.4), coronary artery disease (1.4), CHF (1.9), abnormal cardiac stress test (1.2), long-term beta-blocker therapy (1.4), chronic obstructive pulmonary disease (1.6), and creatinine >or=1.8 mg/dL (1.7). Prior cardiac revascularization was protective (OR, 0.8). Our aggregate model was well calibrated (r = 0.99, P < .001), demonstrating moderate discriminative ability (ROC curve = 0.71), which differed only slightly from the procedure-specific models (ROC curves: CEA, 0.74; LEB, 0.72; EVAR, 0.74; OAAA, 0.68). Rates of cardiac complications for patients with 0 to 3, 4, 5, and >or=6 VSG risk factors were 3.1%, 5.0%, 6.8%, and 11.6% in the derivation cohort and 3.8%, 5.2%, 8.1%, and 10.1% in the validation cohort. The VSGNE cardiac risk model more accurately predicted the actual risk of cardiac complications across the four procedures for low- and higher-risk patients than the RCRI. When the VSG Cardiac Risk Index (VSG-CRI) was used to score patients, six categories of risk ranging from 2.6% to 14.3% (score of 0-3 to 8) were discernible. The RCRI substantially underestimates in-hospital cardiac events in patients undergoing elective or urgent vascular surgery, especially after LEB, EVAR, and OAAA. The VSG-CRI more accurately predicts in-hospital cardiac events after vascular surgery and represents an important tool for clinical decision making.

C-reactive protein in unstable angina: clinical and angiographic correlation

ObjectiveTo assess prevalence, in-hospital prognostic significance and angiographic correlation of C-reactive protein (CRP) elevation in patients with unstable angina.DesignProspective observational study.SettingRoyal Hospital, Muscat, Oman.Patients100 patients admitted between July 2008 and...