Perioperative Cardiac Events Research Articles

Predictors of Perioperative Outcomes in Chronic Limb-threatening Ischemia Patients

Background: Revascularization in chronic limb-threatening ischemia (CLTI) patients carries a risk of perioperative events. Scoring systems such as the Society for Vascular Surgery vascular quality initiative mortality prediction score (VQI MPS) for 30 days and 2-year mortality and revised cardiac risk index (RCRI) for perioperative major adverse cardiac events (MACE) have been validated to risk stratify patients. Both scoring systems had not been previously validated in an Indian cohort. Aims and Objectives: This study was conducted to validate both scoring systems and to identify predictors of perioperative adverse events. The primary objective was the validation of scoring systems based on observed peri-operative 30-day mortality and MACE. The secondary objective was to identify risk factors that affected these outcomes. Materials and Methods: Data of subsequent CLTI patients who underwent open or endovascular revascularization in a single centre between 2018 and 2024 were retrieved from a prospectively maintained database and retrospectively analysed. Patients who were lost to follow-up or had incomplete data were excluded from the study. MACE was defined as any acute coronary syndrome, pulmonary oedema, or cardiac-related death. Validity of VQI MPS and RCRI was calculated using receiver-operating curves. Predictors of outcome were analysed by univariate analysis and logistic regression. Results: One hundred forty-six patients were analysed and risk-stratified based on VQI MPS and RCRI. The mean age was 68 ± 9 years with 31.5% females. About 88.4% (n = 129/146), 9.6% (n = 14/146), and 2% (n = 3/146) were categorized into low, medium, and high risk as per VQI MPS and 19 (13.05%), 59 (40.4%), 49 (33.5%), and 19 (13.05%) patients were categorized into Class 1, II, III, IV and above according to RCRI, respectively. Both scoring systems accurately risk-stratified procedures into different strata. Seven (4.79%) patients died within 30 day of procedure and 10 (6.84%) patients had MACE. There was a statistical difference between the predicted versus observed 30-day mortality and MACE. The discriminatory power of VQI MPS and RCRI were poor with c statistic of 0.664 for VQI MPS and 0.518 for RCRI. Univariate analysis showed that congestive heart failure (CHF) was the only factor that affected 30-day mortality and perioperative MACE. Conclusion: VQI MPS and RCRI did not accurately predict perioperative outcomes in CLTI patient undergoing revascularization in an Indian population. CHF was found to be the only predictor of perioperative mortality and MACE.

Differences in Postoperative Disposition by Kidney Disease Severity: A Population-Based Cohort Study.

People with advanced kidney disease undergo more non-cardiac operations compared to the general population, with a higher risk of perioperative cardiac events and death. However, little is known about the associations between severity of preoperative kidney dysfunction with postoperative length of hospitalization and discharge disposition; these were the focus of this study. Population-based retrospective cohort. Adults from Alberta, Canada undergoing inpatient major noncardiac surgery between April 2005 and February 2019. Categorical preoperative outpatient estimated glomerular filtration rate (eGFR) or kidney failure status. Length of stay (LOS), days alive at home after surgery within 30 and 90 days, and discharge disposition location. Associations were estimated with unadjusted and adjusted generalized estimating equation models. 927,560 inpatient surgeries in 666,770 people (55.9% female, median age 57.4 years) were identified. People receiving dialysis had the longest LOS (11 days [95% CI 6, 29), 2 times greater than that among people with normal kidney function (adjusted incidence rate ratio [IRR] 2.21 [95% CI 2.10, 2.32]). This group also had the fewest days alive at home within the first 30 days after surgery, with an IRR of 0.69 (95% CI 0.67, 0.70) compared to people with normal eGFR. The majority of people (82.8%) were discharged home without nursing support after surgery, though people receiving dialysis were discharged to a facility with 24-hour nursing care nearly 4 times more often. There were graded increases in risks of these outcomes with lower levels of kidney function. Many people did not have preoperative kidney function assessed, reflecting standard clinical practice in the general population. After major surgery, people with kidney disease spend more time recovering in hospital and have less independence from post-discharge nursing supports than otherwise similar patients who have normal or near normal kidney function. These differences were more pronounced for those with the most severe stages of kidney disease.

Association and predictive ability between significant perioperative cardiovascular adverse events and stress glucose rise in patients undergoing non-cardiac surgery

BackgroundThe predictive importance of the stress hyperglycemia ratio (SHR), which is composed of admission blood glucose (ABG) and glycated hemoglobin (HbA1c), has not been fully established in noncardiac surgery. This study aims to evaluate the association and predictive capability the SHR for major perioperative adverse cardiovascular events (MACEs) in noncardiac surgery patients.MethodsIndividuals who underwent noncardiac surgical procedures between 2011 and 2020, including both diabetic and non-diabetic patients, were identified in the perioperative medicine database (INSPIRE 1.1) and classified into tertiles based on their SHR. The connection between the SHR and the risk of MACEs was studied using Cox proportional hazards regression analysis, then restricted cubic spline (RCS) was employed to assess the association’s form. Additionally, the SHR’s incremental predictive utility for MACEs was assessed by the C-statistic, continuous net reclassification improvement (NRI), and integrated discrimination improvement (IDI), thereby quantifying the enhancement in predictive accuracy brought by incorporating the SHR into existing risk models. Feature importance and predictive models were generated utilizing the Boruta algorithm and machine learning approaches.ResultsA total of 5609 patients were enrolled. With an upwards shift in SHR vertices, the rate of perioperative MACEs and cardiac death event steadily rose. The RCS analysis for perioperative MACEs and cardiac death event both indicated J-shaped associations. Inflection points occurred at SHR = 0.81 for MACEs and SHR = 0.97 for cardiac death. The model’s fit improved significantly, with a continuous NRI of 0.067 (95% CI: 0.025–0.137, P < 0.001) and an IDI of 0.305 (95% CI: 0.155–0.430, P < 0.001). When SHR was added as a categorical variable (> 0.81), the C-statistic increased to 0.785 (95% CI: 0.756–0.814) with a ΔC-statistic of 0.035 (P = 0.009), a continuous NRI of 0.007 (95% CI: 0.000-0.021, P = 0.016), and an IDI of 0.076 (95% CI -0.024-0.142, P = 0.092). In the Boruta algorithm, variables identified as important features in the green area were incorporated into the machine learning models development.ConclusionsThe SHR was related with an increased risk of perioperative MACEs in patients following noncardiac surgery, highlighting its potential as a useful and reliable predictive tool for assessing the risk of perioperative MACEs.Graphical

Visual coronary artery calcium assessment on routine chest CT can readily and cheaply identify liver transplant recipients with a low cardiac risk

Abstract Background Peri- and postoperative cardiac complications play an important role in survival of patients after liver transplantation (LT). However, the optimal approach for cardiac risk prediction in these patients has been debated on. LT recipients routinely receive non-gated computed tomography (CT) of the abdomen and chest to follow-up on their liver diseases. This study analyzed whether performance of coronary artery calcium (CAC) assessment on freely available scans can enhance cardiac risk stratification of LT recipients. Methods Consecutive LT recipients from 2008-2023 were included and analyzed retrospectively. CAC was scored visually on non-gated CT on a semi-quantitative ordinal scale and stratified in two groups according to CAC severity. Peri-operative (≤90 days) and post-operative all-cause mortality and cardiac events were analyzed. Furthermore, all-cause mortality and cardiac events were analyzed and compared between the groups with a Kaplan Meier curve and Cox proportional hazard regression. Results A total of 149 patients were included with a median age of 58 years. The median follow-up time was 5 years. The majority (74%) of patients had no or mild CAC. None of these patients died perioperatively due to cardiac causes, or experienced peri-operative cardiac events. The post-operative 10-year survival of LT recipients with no or mild calcifications was significantly better (p&amp;lt;0.01) than patients with severe CAC. The 10-year cardiac event-free survival was significantly better in patients with no or mild CAC (p&amp;lt;0.01) and the incidence increased &amp;gt;4-fold from only 4% in patients with no-mild CAC to 18% in patients with severe CAC. Of interest, severe CAC was a significant predictor of cardiac events (HR 4.6, p=0.02), while classical cardiovascular risk factors e.g. diabetes were not. Conclusion CAC assessment on routinely available non-gated CT can readily enhance peri- and postoperative cardiac risk stratification of LT recipients, as it identifies a selection of low-risk individuals for having peri- and post-operative cardiac events and all-cause mortality. Thereby, reducing test burden for the patients and saving healthcare expenses.

Potential mechanisms of metabolic reprogramming induced by ischemia-reperfusion injury in diabetic myocardium.

This study aimed to explore metabolic reprogramming in diabetic myocardium subjected to ischemia-reperfusion injury (I/RI) and potential mechanisms. Increased vulnerability after I/RI in diabetic myocardium is a major cause of the high prevalence of perioperative adverse cardiac events, and the specific alterations in energy metabolism after I/RI in diabetic myocardium and the impact on increased vulnerability are not fully understood. Metabolomic methods were used to explore the differences and characteristics of metabolites in the heart tissues of four groups, and then, single-cell RNA sequencing (ScRNA-seq) was used to explore the potential mechanism of metabolic reprogramming. It was found that the fatty acid metabolism of db/db mouse I/RI (DMI) showed a significant upward trend, especially the metabolites of ultra-long and medium-long-chain fatty acids; the metabolic flow analysis found that the U-13C glucose M + 6 was significantly higher in the C57BL mouse sham operation (NM) group than in the db/db mouse sham operation (DM) group, and in the C57BL mouse I/RI (NMI) than in the DMI group. Compared with the NMI group, the intermediate metabolites of glycolysis and tricarboxylic acid (TCA) cycle were significantly reduced in the DMI group; all comparisons were statistically significant (p < 0.05), indicating that the glucose uptake of diabetic myocardetis, the ability of glucose glycolysis after I/RI, and the contribution of glucose to TCA were significantly reduced. The results of ScRNA-seq revealed that the number of Cluster 0 myocardial isoforms was significantly increased in diabetic myocardium, and the differential genes were mainly enriched in fatty acid metabolism, and the PPARA signaling pathway was found to be over-activated and involved in the regulation of metabolic reprogramming of diabetic myocardial I/RI. Metabolic reprogramming of diabetic myocardial I/RI may be the main cause of increased myocardial vulnerability. The number of myocardial subtype Cluster 0 increased significantly, and PPARA PPARA is a ligand-activated receptor of the nuclear hormone receptor family that plays a central regulatory role in lipid metabolism.signaling pathway activation may be a potential mechanism for reprogramming metabolism in diabetic myocardium.

Role of Dobutamine Stress Echocardiography in the Evaluation of Patients Undergoing Noncardiac Surgeries in the Contemporary Era

Abstract Objective: Dobutamine stress echocardiography (DSE) is a widely used diagnostic modality for preoperative cardiac risk assessment in patients undergoing major noncardiac surgeries. However, its role in facilitating safe noncardiac surgery in the contemporary era needs to be evaluated. Materials and Methods: A total of 1283 participants (mean age – 63.8 years and 54.9% males) undergoing DSE for preoperative cardiac evaluation before nonemergent, noncardiac, major surgeries were included. DSE findings were recorded, and the Revised Cardiac Risk Index or Lee’s score was also calculated. The patients were followed up for in-hospital adverse cardiac events. Results: DSE showed evidence of inducible myocardial ischemia in 19 (1.5%) patients, whereas Lee’s score was elevated (&gt;3) in 43 (3.4%) patients. The overall in-hospital event rate was 0.7%. Among 1264 patients with normal DSE, 5 (0.4%) had a perioperative cardiac event (negative predictive value 99.6%). Of the 19 patients with abnormal DSE, all underwent coronary angiography which was abnormal in 16 patients. Of these 16 patients, 4 had a perioperative cardiac event. A Lee’s score value &gt;3 had a sensitivity of 68.4% (95% confidence interval [CI] - 43.5–87.4), specificity of 97.6% (95% CI - 96.6–98.4), positive predictive value of 30.2% (95% CI - 21.4–40.9), and negative predictive value of 99.5% (95% CI - 99.1–99.8) for predicting abnormal DSE. Conclusion: Our study reinforces the clinical utility of DSE in facilitating major, nonemergent, noncardiac surgeries in a contemporary setting in India. A normal DSE had a very high negative predictive value for an adverse cardiac event, whereas an abnormal DSE identified the population at high risk for perioperative cardiac events requiring appropriate risk mitigation strategies.

The predictive value of coronary computed tomography angiography-derived fractional flow reserve for perioperative cardiac events in lung cancer surgery.

As a non-invasive coronary functional examination, coronary computed tomography angiography (CCTA)-derived fractional flow reserve (CT-FFR) showed predictive value in several non-cardiac surgeries. This study aimed to evaluate the predictive value of CT-FFR in lung cancer surgery. We retrospectively collected 227 patients from January 2017 to June 2022 and used machine learning-based CT-FFR to evaluate the stable coronary artery disease (CAD) patients undergoing lung cancer surgery. The major adverse cardiac event (MACE) was defined as perioperative myocardial injury (PMI), myocardial infarction, heart failure, atrial and ventricular arrhythmia with hemodynamic disorder, cardiogenic shock and cardiac death. The multivariate logistic regression analysis was performed to identify risk factors for MACE and PMI. The discriminative capacity, goodness-of-fit, and reclassification improvement of prediction model were determined before and after the addition of CT-FFR≤0.8. The incidence of MACE was 20.7% and PMI was 15.9%. CT-FFR significantly outperformed CCTA in terms of accuracy for predicting MACE (0.737 vs 0.524). In the multivariate regression analysis, CT-FFR≤0.8 was an independent risk factor for both MACE [OR=10.77 (4.637, 25.016), P<0.001] and PMI [OR=8.255 (3.372, 20.207), P<0.001]. Additionally, we found that the performance of prediction model for both MACE and PMI improved after the addition of CT-FFR. CT-FFR can be used to assess the risk of perioperative MACE and PMI in patients with stable CAD undergoing lung cancer surgery. It adds prognostic information in the cardiac evaluation of patients undergoing lung cancer surgery.

QTc prolongation after aneurysmal subarachnoid hemorrhage might be associated with worse neurologic outcome in patients receiving microsurgical clipping or embolization of the intracranial aneurysms: a retrospective observational study

PurposeQT interval prolongation is one of the most common electrocardiographic (ECG) abnormalities in patients with aneurysmal subarachnoid hemorrhage (aSAH). Whether corrected QT interval (QTc) prolongation is associated with perioperative cardiac events and dismal neurological outcome in mid to long-term follow-up in patients after aSAH is insufficiently studied and remains controversial.MethodsWe retrospectively studied the adult (≥ 18 years) patients admitted to our institution between Jan 2018 and Dec 2020 for aSAH who underwent intracranial aneurysm clipping or embolization. The patients were divided into 2 groups (normal and QTc prolongation groups) according to their QTc. To minimize the confounding bias, a propensity score matching (PSM) analysis was performed to compare the neurologic outcomes between patients with normal QTc and QTc prolongation.ResultsAfter screening, 908 patients were finally included. The patients were divided into 2 groups: normal QTc groups (n = 714) and long QTc group (n = 194). Female sex, hypokalemia, posterior circulation aneurysm, and higher Hunt-Hess grade were associated with QTc prolongation. In multiple regression analysis, older age, higher hemoglobin level, posterior circulation aneurysm, and higher Hunt-Hess grade were identified to be associated with worse outcome during 1-year follow-up. Before PSM, patients with QTc prolongation had higher rate of perioperative cardiac arrest or ventricular arrhythmias. After PSM, there was no statistical difference between normal and QTc prolongation groups in perioperative cardiac events. However, patients in the QTc prolongation group still had worse neurologic outcome during 1-year follow-up.ConclusionsQTc prolongation is associated with worse outcome in patients following SAH, which is independent of perioperative cardiac events.

Retrospective cohort analysis on perioperative adverse cardiac events in patients with Parkinson disease undergoing deep brain stimulation

Retrospective cohort analysis on perioperative adverse cardiac events in patients with Parkinson disease undergoing deep brain stimulation

Perioperative adverse cardiac events in maxillofacial surgery: A systematic review and meta-analysis.

Maxillofacial surgeries, including procedures to the face, oral cavity, jaw, and head and neck, are common in adults. However, they impose a risk of adverse cardiac events (ACEs). While ACEs are well understood for other non-cardiac surgeries, there is a paucity of data about maxillofacial surgeries. This systematic review and meta-analysis report the incidence and presentation of perioperative ACEs during maxillofacial surgery. We included primary studies that reported on perioperative ACEs in adults. To standardise reporting, ACEs were categorised as 1. heart rate and rhythm disturbances, 2. blood pressure disturbances, 3. ischaemic heart disease and 4. heart failure and other complications. The primary outcome was ACE presentation and incidence during the perioperative period. Secondary outcomes included the surgical outcome according to the Clavien-Dindo classification and trigeminocardiac reflex involvement. STATA version 17.0 and MetaProp were used to delineate proportion as effect size with a 95% confidence interval (CI). Twelve studies (34,227 patients) were included. The incidence of perioperative ACEs was 2.58% (95% CI 1.70, 3.45, I2 = 96.17%, P = 0.001). Heart rate and rhythm disturbances resulted in the greatest incidence at 3.84% among the four categories. Most commonly, these ACEs resulted in intensive care unit admission (i.e. Clavien-Dindo score of 4). Despite an incidence of 2.58%, ACEs can disproportionately impact surgical outcomes. Future research should include large-scale prospective studies that may provide a better understanding of the contributory factors and long-term effects of ACEs in patients during maxillofacial surgery.

Temporal trends and risk factors of perioperative cardiac events in patients over 80years old with coronary artery disease undergoing noncardiac surgery: a high-volume single-center experience, 2014-2022.

Temporal trends and risk factors of perioperative cardiac events (PCEs) in patients over 80years old with coronary artery disease (CAD) undergoing noncardiac surgery are still unclear. We retrospectively reviewed 1478 patients over 80years old, with known CAD undergoing selective noncardiac surgery in a single center (2014-2022). Patients were divided into three equal time groups based on the discharge date (2014-2016, 2017-2019, and 2020-2022), with 367, 473, and 638 patients in Groups 1-3, respectively. Perioperative clinical variables were extracted from the electronic medical records database. The primary outcome was the occurrence of PCEs intraoperatively or during hospitalization postoperatively, defined as any of the following events: myocardial infarction, heart failure, nonfatal cardiac arrest, and death. PCEs occurred in 180 (12.2%) patients. Eight independent risk factors were associated with PCEs, including four clinical factors (body mass index < 22kg/m2, history of myocardial infarction, history of heart failure, and general anesthesia) and four preoperative laboratory results (hemoglobin < 110g/L, albumin < 40g/L, creatinine > 120μmol/L, and potassium <3.6mmol/L). Significant rising trends were seen over the 9-year study period in the incidence of PCEs and independent risk factors including history of myocardial infarction, history of heart failure, general anesthesia, preoperative hemoglobin < 110g/L, preoperative albumin < 40g/L, and preoperative creatinine > 120μmol/L (P for trend <0.05). The incidence and independent risk factors of PCEs in patients over 80years old with CAD undergoing noncardiac surgery showed significant rising trends over the last 9-year period.

Slowly moving the needle away from Fistula First

ObjectiveIn 2019, the management of end-stage kidney disease (ESKD) shifted away from “Fistula First” (FF) to “ESKD Life-Plan: Patient Life-Plan First then Access Needs.” Indeed, some patients exhibit such excessive comorbidity that even relatively minor vascular surgery may be complicated. The purpose of this study was to retrospectively assess complications and mortality (and delineate operative futility) in patients undergoing arteriovenous fistula (AVF) creation in the FF era. MethodsConsecutive AVFs created in a single institution before 2021 were retrospectively reviewed. Operative futility was defined as never-accessed fistula, no initiation of dialysis, failure of access maturation (despite secondary intervention), hemodialysis access-induced distal ischemia requiring ligation, early loss of secondary patency, and/or patient mortality within the first 6 postoperative months. ResultsA total of 401 AVFs were created including radial-cephalic (44%), brachial-cephalic (41%), and brachial-basilic (15%) constructions. Patients exhibited a mean age of 69 ± 15 years; 63% were male, and most (74%) were already being hemodialyzed at the time of fistula creation. Forty-five patients (11%) suffered a cardiac event, and five patients died (1%) within 90 days of their access surgery. Perioperative cardiac events were significantly more common after age 80 (19% vs 8%; P = .004); age >80 years was an independent predictor of major 90-day complications (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.04-3.39; P = .036) and the sole independent predictor of major morbidity defined as cardiopulmonary complications, stroke, or death within the first year (OR, 2.01; 95% CI, 1.24-3.25; P = .004). Operative futility was encountered in 52% of the cohort (n = 208 patients): 40% (n = 160) of primary AVFs failed to mature despite assistance, 19% (n = 77) had lost secondary patency by 6 months, 13% of patients (n = 53) were never started on dialysis after access creation, 4% (n = 16) were dead by 6 months, 2% of AVFs (n = 10) matured but were never accessed, and 2% (n = 9) required ligation for hemodialysis access-induced distal ischemia. Not surprisingly, the sole independent protector against operative futility was that catheter-based dialysis had been established prior to AVF creation (OR, 0.36; 95% CI, 0.22-0.59; P < .01). ConclusionsApproximately 50% of primary AVF operations performed in the aggressive FF era were deemed futile. Octogenarians were particularly prone to futility and complications during this era. A paradigm shift, from FF to an “ESKD Life-Plan” will, hopefully, more thoughtfully match vascular access strategies to individual patient needs.

Intravascular lithotripsy: A novel option for severe calcification of coronary artery.

Severe coronary artery calcification is associated with low success rate of interventional operation, perioperative adverse cardiac events, and poor prognosis, which is a major problem faced by operators. The existing therapy methods all have inherent limitations, such as unsatisfactory balloon crossability, inadequate balloon dilation, and so on. The emergence of intravascular lithotripsy (IVL) has brought the dawn of the treatment of calcified lesions by using unfocused acoustic pressure waves to fracture calcification in situ. And IVL is the only technology capable of targeting deep calcification. IVL may have great clinical application values and potential prospects. Based on the existing clinical evidence of IVL and traditional treatment ways, this review discusses the safety and efficacy of IVL. Combined with clinical practice, the precautions and coping strategies of IVL are analyzed. And the review improves the management algorithm of coronary calcification. IVL has extremely high safety and effectiveness for severe coronary calcification compared with other ways, and structural improvements of IVL will further expand its value. The emergence of IVL could set off a revolution in the treatment of coronary artery calcification.

Surgical strategies and outcomes for myocardial bridges coexisting with other cardiac conditions

BackgroundMyocardial bridges are congenital coronary artery anomalies. There are still many controversies surrounding surgical treatment strategies for myocardial bridges combined with other heart disorders. The purpose of this study was to evaluate the surgical treatment strategies and outcomes in patients with these conditions.MethodsBetween March 2004 and October 2021, our institution witnessed 77 patients diagnosed with myocardial bridging who underwent surgical intervention. According to the myocardial bridge and combined heart disorder, four groups were identified: 1. isolated LAD supra-arterial myotomy group, 2. LAD CABG and(or not) myotomy group, 3. LAD supra-arterial myotomy and grafting of other branches group, and 4. LAD supra-arterial myotomy and other cardiac surgery group. The perioperative outcomes, symptoms, life quality, mortality, and major adverse cardiac events (MACEs) were analyzed.ResultsThere were no deaths during hospitalization and no rethoractomy for postoperative bleeding or major adverse cardiac events (MACEs). The follow-up period ranged from 2 months to 199.2 months (55.61 ± 10.21) months, the 10-year cumulative survival rates for the four groups of patients were 95.0%, 100%, 100% and 74.1%, and the 10-year freedom rates from the MACEs were 83.9%, 92.0%, 87.5% and 76.2%, respectively.ConclusionsSupra-arterial myotomy is preferred in patients with isolated myocardial bridge, and acceptable results can be achieved by choosing supra-arterial myotomy in combination with CABG or other cardiac surgery simultaneously for patients with myocardial bridges and other heart disorders.

Analysis of Cardiac Events and the Subsequent Impact for Geriatric Patients Undergoing Hip Fracture Surgeries.

Perioperative complications, particularly cardiac events, compromised surgical outcomes for geriatric patients. This retrospective study intended to investigate the occurrence and subsequent impact of cardiac events for geriatric patients undergoing hip fracture surgeries. We collected 607 patients undergoing hip fracture surgeries from January 2017 to December 2022 that received transthoracic echocardiography (TTE) pre-operatively to screen for cardiac abnormalities. Except for demographic characteristics, the researchers recorded fracture type, surgical method, American Society of Anesthesiologists (ASA) class, anesthesia type, perioperative cardiac events, and in-hospital mortality. Statistical analysis was performed using SPSS 22.0 statistics software. Throughout the whole course of the study, 16 postoperative cardiac events occurred. The cardiac events included ten arrhythmias, three acute myocardial infarctions, two heart failures, and one sudden death. Notably, 12 of 16 patients with cardiac events presented with abnormal findings on TTE, except 15 of them had a history of cardiac disease. This study disclosed 93.7% of cardiac events developed in patients with a history of cardiovascular disease. Among patients that experienced cardiac events, 75% of patients had abnormal echocardiographic findings. Pre-operative transthoracic echocardiography deserves a recommendation for geriatric patients with histories of cardiac diseases undergoing hip fracture surgeries to detect the risk of developing cardiac events earlier.

Increased Preoperative Stress Test Utilization is Not Associated With Reduced Adverse Cardiac Events in Current US Surgical Practice.

To measure the frequency of preoperative stress testing and its association with perioperative cardiac events. There is persistent variation in preoperative stress testing across the United States. It remains unclear whether more testing is associated with reduced perioperative cardiac events. We used the Vizient Clinical Data Base to study patients who underwent 1 of 8 elective major surgical procedures (general, vascular, or oncologic) from 2015 to 2019. We grouped centers into quintiles by frequency of stress test use. We computed a modified revised cardiac risk index (mRCRI) score for included patients. Outcomes included in-hospital major adverse cardiac events (MACEs), myocardial infarction (MI), and cost, which we compared across quintiles of stress test use. We identified 185,612 patients from 133 centers. The mean age was 61.7 (±14.2) years, 47.5% were female, and 79.4% were White. Stress testing was performed in 9.2% of patients undergoing surgery, and varied from 1.7% at lowest quintile centers, to 22.5% at highest quintile centers, despite similar mRCRI comorbidity scores (mRCRI>1: 15.0% vs 15.8%; P =0.068). In-hospital MACE was less frequent among lowest versus highest quintile centers (8.2% vs 9.4%; P <0.001) despite a 13-fold difference in stress test use. Event rates were similar for MI (0.5% vs 0.5%; P =0.737). Mean added cost for stress testing per 1000 patients who underwent surgery was $26,996 at lowest quintile centers versus $357,300 at highest quintile centers. There is substantial variation in preoperative stress testing across the United States despite similar patient risk profiles. Increased testing was not associated with reduced perioperative MACE or MI. These data suggest that more selective stress testing may be an opportunity for cost savings through a reduction of unnecessary tests.

Perioperative adverse cardiac events and mortality after non-cardiac surgery: a multicenter study.

Perioperative adverse cardiac events (PACE), a composite of myocardial infarction, coronary revascularization, congestive heart failure, arrhythmic attack, acute pulmonary embolism, cardiac arrest, and stroke during 30-day postoperative period, is associated with long-term mortality, but with limited clinical evidence. We compared long-term mortality with PACE using data from nationwide multicenter electronic health records. Data from 7 hospitals, converted to Observational Medical Outcomes Partnership Common Data Model, were used. We extracted records of 277,787 adult patients over 18 years old undergoing non-cardiac surgery for the first time at the hospital and had medical records for more than 180 days before surgery. We performed propensity score matching and then an aggregated meta‑analysis. After 1:4 propensity score matching, 7,970 patients with PACE and 28,807 patients without PACE were matched. The meta‑analysis showed that PACE was associated with higher one-year mortality risk (hazard ratio [HR]: 1.33, 95% CI [1.10, 1.60], P = 0.005) and higher three-year mortality (HR: 1.18, 95% CI [1.01, 1.38], P = 0.038). In subgroup analysis, the risk of one-year mortality by PACE became greater with higher-risk surgical procedures (HR: 1.20, 95% CI [1.04, 1.39], P = 0.020 for low-risk surgery; HR: 1.69, 95% CI [1.45, 1.96], P < 0.001 for intermediate-risk; and HR: 2.38, 95% CI [1.47, 3.86], P = 0.034 for high-risk). A nationwide multicenter study showed that PACE was significantly associated with increased one-year mortality. This association was stronger in high-risk surgery, older, male, and chronic kidney disease subgroups. Further studies to improve mortality associated with PACE are needed.

Utility of Preoperative Brain Natriuretic Peptide and Cardiac Troponin I in Predicting Perioperative Major Adverse Cardiovascular Events in Elderly Patients Undergoing Noncardiac Surgery

Abstract Background: Major adverse cardiovascular events (MACEs) are frequently encountered in patients undergoing noncardiac surgeries. This study evaluated the utility of cardiac troponin I (cTnI) and brain natriuretic peptide (BNP) to predict MACE in elderly patients (aged ≥60 years) undergoing noncardiac surgeries. Methods: This comparative cross-sectional study was carried out at a tertiary care center in India between November 2016 and August 2018. A total of 136 consecutive patients (aged ≥60 years) presenting for noncardiac surgeries under general/spinal/regional anesthesia in the departments of surgery, orthopedics, or gynecology were included in the study. Patients with chronic kidney disease stages 4 and 5 and those receiving hemodialysis or peritoneal dialysis for renal failure were excluded from the study. Peripheral blood samples for BNP and cTnI were obtained within 24 h preoperatively. The primary endpoint was the occurrence of MACE, defined as the composite of cardiac death, nonfatal myocardial infarction, heart failure, arrhythmias, and cardiac arrest at 6 days postsurgery. Results: The mean age of patients was 69.41 ± 7.56 years. Females comprised 54.1% of the study population. During the perioperative period and follow-up of 6 days, 12 MACE were recorded. Preoperative cTnI levels alone or both cTnI and BNP together (cTnI levels &gt;0.07 ng/mL and BNP levels &gt;40 pg/mL) increased significantly in the patients who experienced MACE (P &lt; 0.05). The area under receiver operating characteristics curve for cTnI and BNP for predicting perioperative cardiac events was 0.817 (95% confidence interval [CI] 0.646–0.988; P &lt; 0.001) and 0.520 (95% CI 0.337–0.704; P = 0.817), respectively. Conclusions: In elderly patients undergoing noncardiac surgeries, a preoperative assessment of BNP and cTnI may help in the assessment of MACE.

Transient asystole associated with vasovagal reflex in an oral surgery patient: A case report

The perioperative cardiac events may be brought about by a relative imbalance of autonomic activities due to excessive psychological and physical stress. The present case study focuses on the asystole that can occur as a serious cardiac adverse event associated with vasovagal reflex likely to be triggered by venipuncture for securing an intravenous line during dental care. In addition, we describe and discuss herein the management of intravenous sedation for a dental phobic patient who experienced the vasovagal reflex involved in an unexpected transient asystole. The patient with vasovagal reflex episodes in daily life, who had no past medical history relevant to cardiovascular disorders, was scheduled for dental extraction under intravenous sedation. Immediately after peripheral intravenous catheterization, she complained of discomfort and nausea, and a II-lead electrocardiogram revealed asystole following bradycardia associated with vasovagal reflex. Oxygenation and intravenous fluid loading in the supine position with elevation of the lower extremities restored sinus rhythm and normal hemodynamics without the intervention of cardiopulmonary resuscitation. With administration of intravenous atropine and betamethasone as premedication, she was uneventfully treated in stress-free psychosomatic conditions under optimal sedation with midazolam without any signs of cardiovascular disorders. After administration of flumazenil, the patient satisfactorily recovered from sedation without re-sedation. The present case suggests that an asystole associated with vasovagal reflex can be triggered by venipuncture for intravenous catheterization during dental anxiety likely to affect the imbalance between sympathetic and parasympathetic activities.

Abstract 10982: A Novel Index of Coronary Artery Calcium Derived From Preoperative Non-Gated Chest Computed Tomography Correlates With Traditional Estimates of Perioperative Risk

Introduction: Cardiovascular events are feared complications of non-cardiac surgery. Prior studies demonstrate associations between coronary artery calcium (CAC) from ECG-gated computed tomography (CT) imaging and perioperative major adverse cardiac events. We sought to evaluate correlations between an index of CAC severity from preoperative non-gated CT imaging and traditional estimates of perioperative risk. Methods We identified consecutive adults age ≥45 years who underwent in-hospital, major non-cardiac surgery across a large urban health system between 2016 and 2020 and had non-gated (contrast or non-contrast) chest CT imaging performed within 1 year prior to surgery. Patients with prior coronary revascularization or heart valve surgery were excluded. CAC severity in each coronary artery was assessed and graded from absent to severe using a 0-3 scale by physicians blinded to clinical data. An index of CAC was computed as the sum of the scores for each coronary artery. The Revised Cardiac Risk Index (RCRI) was determined for each patient. Correlations between the CAC index and RCRI were assessed using Spearman Correlation Coefficient (𝜌;). Results A total of 2,560 patients met inclusion criteria - mean age 68.1 ± 12.3 years, 49.8% female, 60% white (Figure 1A). The median pre-operative RCRI score was 1 [IQR 0-1, range 0-6] (Figure 1B). A majority of patients (64.3%) had non-contrast chest CT imaging. The median CAC index was 1 [IQR 0-3, range 0-9] (Figure 1C). A correlation between the CAC index and RCRI (Coefficient (𝜌;): 0.209, p&lt;0.001) was observed, with stepwise increases in the CAC index when stratified by pre-operative RCRI (Figure 1D). Conclusions A pragmatic, novel index of CAC derived from existing non-gated chest CT imaging correlates with pre-operative RCRI. As the RCRI is a validated preoperative risk stratification tool, this finding demonstrates the potential to leverage pre-existing, non-gated CT imaging to inform preoperative risk assessment.