Preoperative Cardiovascular Risk Research Articles

Perioperative Risk: Short Review of Current Approach in Non Cardiac Surgery

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.

Effectiveness of the 5As Model-Based Transitional Care Program among Chinese Patients with Type B Aortic Dissection Post-TEVAR: A Randomized Controlled Trial.

Thoracic aortic endovascular repair (TEVAR) is the primary treatment for Stanford type B aortic dissection (type B AD). However, patients often encounter significant difficulties post-TEVAR that endanger their safety when transitioning from hospital- to home-based care. Moreover, information on the ideal transitional care for patients with type B AD post-TEVAR is scarce in China. This single-masked randomized clinical trial aimed to assess the effectiveness of the Assess, Advise, Agree, Assist, and Arrange (5As) model-based transitional care in improving discharge preparation level and transitional care quality post-TEVAR among patients with type B AD in China. This study was conducted at a hospital in China between January 2021 and October 2021. Patients with type B AD were randomly divided into intervention and control groups. Participants in the intervention group received the 5As model-based transitional nursing care. The 5As model is an evidence-based intervention strategy comprising: (1) Assess: assessing the preoperative cardiovascular risk behavior of patients with AD. (2) Advise: making suggestions according to the risk behaviors of the patients. (3) Agree: reaching a consensus on goals and action plans by making decisions with the patients and their families. (4) Assist: assisting patients in solving obstacles to implementing health plans. (5) Arrange: arranging follow-up visits according to the actual situation of the patients and guiding them in adhering to a schedule. The control group received the usual nursing care for the same duration and number of follow-up visits. A trained research nurse collected all the baseline data of the patients on admission, assessed discharge readiness level (using the Readiness for Hospital Discharge Scale) on the day of discharge, and collected transitional quality of care (by the Care Transition Measure-15) data on day 30 after discharge. Overall, 72 patients with type B AD were recruited. Discharge readiness level and transitional care quality in the intervention group were significantly superior to those in the control group. This study showed that the 5As model-based transitional care program can effectively promote discharge readiness and transitional care quality of patients with type B AD post-TEVAR. The Chinese Clinical Trial Registry Center: ChiCTR2200060797 (https://www.chictr.org.cn/showproj.html?proj=167403).

Association between self-reported functional capacity measures and postoperative myocardial injury in patients undergoing noncardiac surgeries.

Self-reported functional capacity measures have an uncertain role in the pre-operative cardiovascular risk stratification. This substudy aimed to evaluate whether self-reported metabolic equivalent (MET) could improve the prediction of postoperative myocardial injury (MI) over other well-established cardiovascular risk factors. This is a post hoc analysis of an international multicenter prospective cohort study. We recruited patients ≥45 years old who had elective elevated-risk noncardiac surgery in 45 centers across 17 countries between June 2017 and April 2020. The primary outcome was MI defined according to the Fourth Universal Definition of Myocardial Infarction. We measured the proportion of new prognostic information added by self-reported MET using multivariable logistic regression. In total, 860 (41.3%) patients suffered MI. In patients without systematic troponin surveillance, the odds ratio for MI with each 1-point increment in MET equaled 1.03 (95% confidence interval [CI], 0.99-1.07). The new prognostic information, according to the likelihood ratio adequacy index, accounted for 1.5%. Sensitivity analysis, including centers with >90% of patients with routine high-sensitivity troponin T monitoring, showed that MET added 21.8% of new information to the baseline model, and each additional point was associated with a lower risk of MI (odds ratio, 0.86; 95% CI, 0.81-0.91). In elevated-risk noncardiac surgery, self-reported functional capacity measures do not significantly improve the prediction of MI; however, they add new prognostic information in centers with routine perioperative troponin monitoring.

Most preoperative stress tests fail to comply with practice guideline indications and do not reduce cardiac events.

There is wide variation in stress test utilization before major vascular surgery and adherence to practice guidelines is unclear. We defined rates of stress test compliance at our institution and led a quality improvement initiative to improve compliance with American Heart Association (ACC/AHA) guidelines. We implemented a stress testing order set in the electronic medical record at one tertiary hospital. We reviewed all patients who underwent elective, major vascular surgery in the 6 months before (Jan 1, 2022 - Jul 1, 2022) and 6 months after (Aug 1, 2022 - Jan 31, 2023) implementation. We studied stress test guideline compliance, changes in medical or surgical management, and major adverse cardiac events (MACE). Before order set implementation, 37/122 patients (30%) underwent stress testing within the past year (29 specifically ordered preoperatively) with 66% (19/29) guideline compliance. After order set implementation, 50/173 patients (29%) underwent stress testing within the past year (41 specifically ordered preoperatively) with 80% (33/41) guideline compliance. In the pre- and postimplementation cohorts, stress testing led to a cardiovascular medication change or preoperative coronary revascularization in 24% (7/29) and 27% (11/41) of patients, and a staged surgery or less invasive anesthetic strategy in 14% (4/29) and 4.9% (2/41) of patients, respectively. All unindicated stress tests were surgeon-ordered and none led to a change in management. There was no change in MACE after order set implementation. Electronic medical record-based guidance of perioperative stress testing led to a slight decrease in overall stress testing and an increase in guideline-compliant testing. Our study highlights a need for improved preoperative cardiovascular risk assessment prior to major vascular surgery, which may eliminate unnecessary testing and more effectively guide perioperative decision-making.

Comparison of Hospital Stay After Open Abdominal Aortic Aneurysm Repair With or Without Enhanced Recovery Protocol

Enhanced recovery after surgery (ERAS) is a protocol of evidence based practices applied in major surgery. Open aortic aneurysm repair is major surgery in terms of complications and mortality. This study aimed to compare early outcomes of ERAS with a traditional post-operative protocol in patients undergoing elective open aortic surgery. This retrospective cohort study was conducted between 2018 - 2022 in two tertiary vascular surgery centres. The ERAS program was routinely implemented in one centre, while the other one used a standard peri-operative protocol. The primary outcome was post-operative length of stay (pLOS). Secondary outcomes were 30 day mortality rate, complications, re-interventions, and re-hospitalisations. Propensity score weighting was used to balance the two groups by comorbidities. Inverse probability of treatment weight (IPTW) was used to estimate the average treatment effect on the treated patients. A total of 198 patients were enrolled: 128 in the ERAS group (EG) and 70 in the standard group (SG). Mean age was 70.8 ± 6.7 years in EG and 71.1 ± 6.7 in SG (p= 0.39). No significant differences were observed in pre-operative cardiovascular risk factors. The median pLOS was 5 days (IQR 3, 6) in the EG group and 8 days (IQR 6, 11) in the SG group (p < 0.001). No differences in terms of mortality, re-operations, and re-hospitalisations were observed. The IPTW analyses showed a 40% reduction in pLOS and a significant reduction in major complications in EG (OR 0.41, 95% CI 0.26-0.66; p < 0.001). A 45% increase in pLOS in patients with chronic obstructive pulmonary disease was found in both groups. Enhanced recovery after surgery is safe and feasible for elective open aortic surgery and is associated with earlier hospital discharge without differences in terms of mortality and lower complication rates compared with a standard protocol. Chronic obstructive pulmonary disease is a major risk factor for an increase in pLOS. The ERAS protocol is promising in terms of resource utilisation.

Existing Nongated CT Coronary Calcium Predicts Operative Risk in Patients Undergoing Noncardiac Surgeries (ENCORES).

Preoperative cardiovascular risk stratification before noncardiac surgery is a common clinical challenge. Coronary artery calcium scores from ECG-gated chest computed tomography (CT) imaging are associated with perioperative events. At the time of preoperative evaluation, many patients will not have had ECG-gated CT imaging, but will have had nongated chest CT studies performed for a variety of noncardiac indications. We evaluated relationships between coronary calcium severity estimated from previous nongated chest CT imaging and perioperative major clinical events (MCE) after noncardiac surgery. We retrospectively identified consecutive adults age ≥45 years who underwent in-hospital, major noncardiac surgery from 2016 to 2020 at a large academic health system composed of 4 acute care centers. All patients had nongated (contrast or noncontrast) chest CT imaging performed within 1 year before surgery. Coronary calcium in each vessel was retrospectively graded from absent to severe using a 0 to 3 scale (absent, mild, moderate, severe) by physicians blinded to clinical data. The estimated coronary calcium burden (ECCB) was computed as the sum of scores for each coronary artery (0 to 9 scale). A Revised Cardiac Risk Index was calculated for each patient. Perioperative MCE was defined as all-cause death or myocardial infarction within 30 days of surgery. A total of 2554 patients (median age, 68 years; 49.7% women; median Revised Cardiac Risk Index, 1) were included. The median time interval from nongated chest CT imaging to noncardiac surgery was 15 days (interquartile range, 3-106 days). The median ECCB was 1 (interquartile range, 0-3). Perioperative MCE occurred in 136 (5.2%) patients. Higher ECCB values were associated with stepwise increases in perioperative MCE (0: 2.9%, 1-2: 3.7%, 3-5: 8.0%; 6-9: 12.6%, P<0.001). Addition of ECCB to a model with the Revised Cardiac Risk Index improved the C-statistic for MCE (from 0.675 to 0.712, P=0.018), with a net reclassification improvement of 0.428 (95% CI, 0.254-0.601, P<0.0001). An ECCB ≥3 was associated with 2-fold higher adjusted odds of MCE versus an ECCB <3 (adjusted odds ratio, 2.11 [95% CI, 1.42-3.12]). Prevalence and severity of coronary calcium obtained from existing nongated chest CT imaging improve preoperative clinical risk stratification before noncardiac surgery.

Impact of Diabetes Duration and Control on the Extent and Severity of Coronary Artery Disease in Egyptian Patients: Evaluation by Coronary CT Angiography

Abstract Background Diabetes mellitus (DM) has reached epidemic proportions worldwide and approximately 40% of diabetics die due to ischemic heart disease, 15% from other forms of heart disease, principally congestive heart failure, and about 10% from stroke. The role of DM in CAD progression is now universally accepted. Aim of the Work To explore the association between diabetes duration and control on the extent of coronary artery disease (CAD) using coronary computed tomography angiography (CCTA). Patients and Methods This study is a cross sectional observational study that included 100 diabetic patients who were eligible for CT coronary angiography. They were evaluated in the diabetic outpatient clinic of the internal affairs ministry Hospitals for symptoms suggestive of CAD or for preoperative cardiovascular system risk stratification. CT coronary angiography was performed in all patients, and CACS was calculated using Agatston score. CCTA was analyzed for the site and severity of stenosis. For each patient, the number of diseased vessels was calculated through the assignment of one, two, and three or left main (LM) coronary artery vessels. Results The prevalence of atherosclerotic coronary artery disease among diabetics in the studied population was 78%, moderate to severe degree of obstructive lesions was found in 81% of them as detected by CTCA. Coronary calcification was found in 65% of diabetic patients. Coronary calcium score showed a significant positive correlation with age (p-value =0.002), HB1c level and the Triglycerides, cholesterol and LDL levels. The severity of atherosclerotic coronary artery disease was significantly associated with dyslipidemia. On the other hand, the extent of coronary affection was associated with the duration of diabetes. Among the studied subjects, the LAD was the most frequently affected artery (60% of patients). Low risk diabetics (zero calcium and no atherosclerotic plaques) had a mean duration of DM &amp;lt; 10 years with controlled lipid profile. Conclusion Based on the results of the current study, we can draw several conclusions. Diabetic patients are at risk for significant CAD with or without calcium burden. Extensive significant CAD is associated with long standing diabetes. Uncontrolled diabetes mellitus and the presence of dyslipidemia augment the process of atherosclerosis and the severity of the disease. Younger patients with controlled diabetes and lipid profile have a more favorable coronary anatomy profile and a favorable outcome. The LAD is the artery of predilection in diabetics. Abbreviations ASCVD: Atherosclerotic cardiovascular disease; BP: Blood pressure; CABG: Coronary artery bypass graft; CAD: Coronary artery disease; CCTA: Coronary computed tomography angiography; CVD: Cardiovascular disease; DM: Diabetes mellitus; HDL-c: High density lipoprotein cholesterol; HS: Highly significant; IQR: Inter-quartile range; LAD: Left anterior descending; LCX: Left circumflex; LDL-c: Low density lipoprotein cholesterol; LM: Left main; MDCT: Multidetector coronary CT angiography; MSCT: Multi-slice computed tomography; NS: Non significant; PCI: Percutaneous coronary intervention; RCA: Right coronary artery; S: Significant; TC: Total cholesterol; TG: Triglycerides

NT-proBNP level as a substitute for myocardial perfusion scan in preoperative cardiovascular risk assessment in noncardiac surgery

BackgroundPreoperative cardiovascular risk assessment is one of the main principles before noncardiac surgeries. Cardiac stress imaging, such as myocardial perfusion scan (MPS), is a proposed cardiovascular risk evaluation method according to the latest guidelines. Yet, its efficacy, along with the cost-effectiveness of the method, has been questioned in previous studies. Our study aims to evaluate the utility of N-terminal pro-b-type natriuretic peptide (NT-proBNP) level measurement in predicting postoperative cardiovascular complications in candidates who have undergone an MPS before surgery and compare the results.MethodsA cohort of 80 patients with a revised cardiac risk index score of one or more who were scheduled for moderate to high-risk noncardiac surgeries and met the criteria to undergo an MPS for risk assessment were included in the study. All of them underwent an MPS one week before surgery. Their preoperative NT-proBNP, troponin levels, and electrocardiograms were obtained one day before surgery and again on day three postoperative. The predictive efficacy of NT-proBNP levels and MPS were compared.ResultsSeventy-eight patients underwent surgery, three of which exhibited a rise in troponin level, six showed changes on electrocardiogram, and pulmonary edema was detected in one, three days after surgery. There was no mortality in our patients. The sensitivity and specificity of the MPS for predicting postoperative cardiovascular complications were 100% and 66%, respectively. MPS also had a positive predictive value of 20% and a negative predictive value of 100% in our study. A 332.5 pg/ml cut-off value for NT-proBNP level yielded a sensitivity of 100%, specificity of 79.2%, positive predictive value of 40%, and negative predictive value of 100%.ConclusionsOur study reveals the incremental specificity and positive predictive value of NT-proBNP level measurement in preoperative cardiovascular risk evaluation compared to MPS. Given the low feasibility, high costs, and disappointing predictive value of MPS, preoperative NT-proBNP level assessment can be substituted. This method can assist anesthesiologists and surgeons with precisely detecting at-risk patients resulting in taking proper measures to reduce the morbidity and mortality of the proposed patients before and during surgeries.

Cardiovascular risk management in the peri-operative setting.

Peri-operative cardiovascular events occur in up to 3% of patients undergoing non-cardiac surgery. Accurate cardiovascular risk assessment is important in the peri-operative setting, as it allows informed and shared decisions regarding the appropriateness of proceeding with surgery, guides surgical and anaesthetic approaches, and may influence the use of preventive medications and post-operative cardiac monitoring. Quantitative risk assessment may also inform a reconsideration of choosing a more limited lower risk type of surgery, or conservative management. Pre-operative cardiovascular risk assessment starts with clinical assessment and should include an estimate of functional capacity. Specialised cardiac investigations are rarely indicated specifically to assess pre-operative cardiovascular risk. The decision regarding cardiac investigations is influenced by the nature, extent and urgency of surgery. The strategy of performing pre-operative revascularisation to improve post-operative outcomes is not evidence-based and recent international guidelines recommend against this.

Preoperative Management of Diabetic Patients Undergoing Abdominal Surgery

Introduction: The management of diabetic patients undergoing abdominal surgery presents a multifaceted challenge that demands a comprehensive and tailored approach to ensure optimal perioperative outcomes Objectives: The basic aim of the study is to find the preoperative management of diabetic patients undergoing abdominal surgery Material and methods: A retrospective analysis was conducted, utilizing medical records from a cohort of 200 diabetic patients who had undergone various abdominal surgical procedures at Khyber Teaching Hospital Peshawar between August 2018 to March 2019. Ethical approval was obtained from the Institutional Review Board (IRB) prior to the commencement of data collection.Electronic medical records were meticulously reviewed to gather comprehensive patient information. Relevant demographic data, including age, gender, and body mass index (BMI), were documented. Preoperative glycemic status, measured through fasting blood glucose levels, HbA1c levels, and medication regimens, were recorded. Patient comorbidities, particularly cardiovascular conditions, were identified, and details of preoperative cardiovascular risk assessments were documented. Practical Implication: The prevalence of postoperative complications emphasizes the need for comprehensive management. These findings underscore the significance of holistic approaches to ensure safer surgeries and improved patient well-being. Conclusion: It is concluded that glycemic control, collaborative cardiovascular risk assessment, nutritional optimization, and patient education play pivotal roles in enhancing surgical outcomes. The prevalence of postoperative complications emphasizes the need for comprehensive management. Keywords: Diabetic, abdominal surgery, postoperative complications, nutritional optimization, cardiovascular risk, Nutritional Optimization

Cardiac Evaluation of Patients with Diabetes Mellitus Before Noncardiac Surgery

Up to 40% of patients undergoing elective surgeries have underlying diabetes mellitus (DM), and therefore an elevated risk of perioperative adverse cardiovascular outcomes. Preoperative cardiovascular risk assessment and therapeutic optimization are warranted in all patients with DM. This is an updated review on preoperative evaluation of cardiac risk in patients with DM undergoing surgery and strategies to minimize the risk. This article summarizes the current evidence and recommendations for cardiac evaluation in DM before noncardiac surgery. Preoperative risk estimation includes risk stratification of the proposed surgery and estimating the risk in the patient using available risk calculators such as the Revised Cardiac Risk Index and assessment of the functional status of the patient in terms of metabolic equivalents of tasks. Preoperative cardiac investigations such as electrocardiogram, echocardiography, stress testing, or cardiac biomarkers should be done in high-risk surgeries, and in certain subsets of patients undergoing low- or intermediate-risk surgeries. Additional testing and preoperative optimization are warranted in patients with heart failure and reduced or preserved ejection fraction, those with cardiac autonomic neuropathy, hypertension with or without end-organ damage, and patients undergoing transplant surgery, all of which are discussed in the current review.

Cardiovascular Profile And Risk of Patients During Non-Cardiovascular Surgery Scheduled at Sylvanus Olympio University Hospital in Lome

Objective: To describe the cardiovascular profile and the preoperative cardiovascular risk stratification prior to scheduled non-cardiac surgeries at CHU SO. Materials and methods: This is a retrospective and descriptive study on the records of patients received in consultation in the Cardiology and anesthesia departments of the CHU-SO of Lomé from March 2014 to October 2019. Results: A total of 220 patient records were selected. The mean age was 57.1±14.4. In 81% of cases, these are minor predictors; intermediate predictors are found in 9.1% of cases and in 1.4% they are major factors. Patients were classified as ASA1 (50.0%), ASA 2 (39.1%), ASA 3 (9.6%), and ASA4 (41.3%). As age increased, patients had a major predictor factor or were classified as ASA3 and ASA4. The predictors of minor operative risk were hypertension (70.3%) followed by age correlated with sex (48.2%) in men, metabolic syndrome (21.8%), and left ventricular hypertrophy (LVH) (21.0 %). Intermediate predictors were dominated by diabetes (9.1%), chronic myocardial ischemia (6.8%), and RI (4.5%). Patients with diabetes (9.1%) or morbid obesity (7.7%) were classified as ASA3 Heart failure (1.4%) and renal failure (4.5%) classified patients as ASA4. Conclusion: The predictors of cardiovascular risk for NCS are multiple and are observed in the same patients. The overall operative risk is moderate to medium.

The association of pre-transplant atrial fibrillation with in-hospital outcomes in patients undergoing orthotopic liver transplantation: A propensity score matching analysis.

In this study, we sought to evaluate the prevalence and association of pre-transplant atrial fibrillation (AF) on 30-day postoperative outcomes in patients undergoing orthotopic liver transplant (OLT). The National Inpatient Sample Database was queried from 2011 to 2017 for relevant ICD-9 and ICD-10 procedural and diagnostic codes. Baseline characteristics and in-hospital outcomes were compared in patients who underwent OLT with AF and those without. Among 45,357 patients who underwent OLT, women made up 35.8% of the overall population. The prevalence of AF before transplant was 2932 (6.5%) with a trend towardincreasing prevalence, with an average annual change rate of 4.19%. Applying propensity score matching to control for potential confounding factors, there was no association between pre-transplant AF and in-hospital mortality in patients undergoing OLT, however there was a higher incidence of perioperative complications including: acute kidney injury, ventricular tachycardia, major bleeding, blood product transfusion, and septic shock. In patients undergoing OLT, pre-transplant AF is increasing in prevalence and appears to be associated with similar in-hospital mortality but worse perioperative outcomes. Greater emphasis should be placed on AF in the preoperative cardiovascular risk stratification of patients undergoing OLT.

Osteoporotic hip fracture-Comorbidities and factors associated with in-hospital mortality in the elderly: A nine-year cohort study in Brazil.

The aim of the study was to identify factors associated with the causes of in-hospital morbidity and mortality in an elderly Brazilian population due to osteoporotic hip fractures. Retrospective cohort study involving a population over 60 years of age admitted to hospital due to osteoporotic hip fractures and followed up from hospitalization to outcome (discharge or mortality) from 2010 to 2018, in a public hospital in Brasília, the capital of Brazil. Multivariate analysis was performed using the Poisson regression model with a robust variance, observing the hierarchical model proposed and the receiver operating characteristic (ROC) curve to obtain the cutoff point for mortality incidence in relation the total length of hospital stay. Significance level was set as p < 0.05. The analyses were conducted using the SAS 9.4 software. The mean hospital mortality rate among the 402 patients involved was 18.4%, and the associations made with the outcome mortality were per relevance: respiratory infection, age over 90 years, high preoperative cardiovascular risk, chronic obstructive pulmonary disease (COPD) as comorbidity, serum hemoglobin level ≤ 10 and other infections. Mortality also showed association with longer total length of hospital stay, as well as with prolonged postoperative period. Hip fractures in the elderly due to osteoporosis indicate a relationship between the sicker profile of the aging elderly population and the prevalence of chronic diseases strongly associated with in-hospital infections, contributing to increased mortality. There were fewer early interventions, and mortality was also associated with prolonged postoperative period. The aim of this study was not to compare independent variables with each other, but suggests the relationship between the presence of comorbidities, which predisposes to the development of infections, directly linked to mortality.

Association of Intraoperative and Perioperative Transfusions with Postoperative Cardiovascular Events and Mortality After Infrainguinal Revascularization

Patients undergoing open or endovascular infrainguinal revascularization are at an elevated risk for postoperative cardiovascular complications due to high rates of comorbidities and the physiologic stress of surgery. Transfusions are known to be associated with adverse events but knowledge of specific risks associated with transfusion timing, product type, and long-term outcomes while accounting for preoperative cardiovascular risk factors is not well understood in this population. This study aimed to characterize the association of intraoperative and perioperative transfusion, anemia, and cardiovascular risk factors with cardiovascular events and mortality in patients undergoing infrainguinal revascularization. A single-center retrospective study was performed on 564 infrainguinal revascularization procedures, including both open (n=250) and endovascular (n=314) approaches (2016-2020). Comprehensive clinical data were collected including patient demographics, cardiovascular risk factors, preoperative hemoglobin, and detailed transfusion data. Multivariable logistic regression tested the association of transfusions with composite 30-day outcomes of cardiac complications (postoperative myocardial infarction [postop-MI], congestive heart failure, or dysrhythmia) and with major adverse cardiovascular events (MACE-postop-MI or death). Kaplan-Meier analysis and Cox proportional hazard modeling examined the association of transfusions, anemia, and cardiovascular risk factors with mortality up to 1year. Intraoperative transfusion was performed in 15% of cases and 13% underwent transfusion in the early postoperative period. Intraoperative transfusion was associated with higher Revised Cardiac Risk Index (RCRI), lower preoperative hemoglobin, increased blood loss, and open procedures (all P<0.05). Within each RCRI score, intraoperative transfusion was associated with 2-4-fold increased MACE at 30days. Intraoperative packed red blood cells transfusion and early postoperative packed red blood cells transfusion was associated with more than 2-fold adjusted odds of any cardiovascular complication and intraoperative transfusion was also associated with MACE (all P<0.05). Intraoperative transfusion was associated with mortality at 1year on unadjusted analysis, but after adjustment for RCRI, age, and preoperative hemoglobin, only RCRI scores of 2 and 3+ and preoperatively hemoglobin remained significant risk factors for mortality. Intraoperative and early perioperative transfusions are strongly associated with worse cardiovascular outcomes after infrainguinal revascularization. These findings may have a prognostic value for further risk stratifying patients perioperatively at a high risk for complications. However, prospective studies are needed to elucidate whether optimizing transfusion strategies mitigates these risks.

Effect of age and gender on pre-operative cardiovascular risk assessment

BackgroundThe AUB-HAS2 Cardiovascular Risk Index is a recently published tool for pre-operative cardiovascular evaluation. It is based on six data elements: history of heart disease, symptoms of angina or dyspnea, age ≥ 75 years, hemoglobin < 12 mg/dl, vascular surgery, and emergency surgery. The objective of this study is to study the effect of age and gender on the performance of the AUB-HAS2 Index in pre-operative cardiovascular risk assessment.MethodsThe study population consisted of 1,167,414 non-cardiac surgeries registered in the ACS NSQIP database. The population was stratified by age (≥ 40 and < 40 years old) and by gender (men and women). Each patient was given an AUB-HAS2 score of 0, 1, 2, 3, or > 3 based on the number of data elements s/he has. The outcome measure was all-cause mortality, myocardial infarction (MI), or stroke at 30 days after surgery.ResultsThe overall 30-day event rate was higher in patients ≥ 40 years compared to those < 40 years (2.5% vs 0.3%, P < 0.0001) and in men compared to women (2.7% vs 1.8%, P < 0.0001). In both age and gender subgroups, there was a gradual and significant increase in the outcome measure (death, MI, or stroke) as the AUB-HAS2 score increased: from ≤ 0.5% in those with a score of 0 to more than 15% in those with a score > 3 (P < 0.0001). The AUB-HAS2 Index was able to stratify risk in all subgroups into low, intermediate, and high (P < 0.0001). Receiver operating characteristic curves showed the AUB-HAS2 Index has very good discriminatory power in both age (area under the curve (AUC) of 0.81 and 0.78) and gender (AUCs of 0.79 and 0.84) subgroups.ConclusionThis study extends the validation of the newly derived AUB-HAS2 Cardiovascular Risk Index to different age and gender subgroups with very good discriminative power.

Abstract P1-14-04: Cardiotoxicity of adjuvant trastuzumab chemotherapy in women with early-stage breast cancer under 50 years of age based on analysis of Japanese insurance claims data

Abstract Background: Adjuvant chemotherapy with anti-HER2 therapy has markedly improved the postoperative life expectancy of women with HER2-positive breast cancer, but cardiotoxicity remains a challenge. Although East Asians, especially premenopausal women, have a lower incidence of cardiovascular disease attributable to traditional risk factors, it is unclear whether the same ethnic factors apply to cancer treatment-related cardiovascular disease. The purpose of this study is to detect rare but serious adverse events to provide real-world evidence for cardio-oncology. Materials and Methods: Women under 50 years of age who underwent their first surgery between January 2010 and December 2019 were extracted from JMDC, a national-level insurance claims database collected under Japan's universal health insurance system. Patients with a history of heart failure and those with less than six months records before surgery were excluded. Patients with both codes for diagnosis (breast cancer: C50) and surgery (K476) on the same receipt were defined as early breast cancer. Adjuvant chemotherapy was defined as anti-HER2, including trastuzumab (L01XC03), lapatinib (L01XE07), pertuzumab (L01XC13), or trastuzumab emtansine (L01XC14), prescribed within six months before or after surgery. Patients with a new episode of heart failure (Diagnosis: echocardiography 160072510, 160072610 or BNP 160162350, 160181250. Treatment: diuretics C03, beta-blockers C07, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers C09) were defined as cancer treatment-related cardiovascular disease (CTRCD). Results: Of the 11,594,000 subscribers in JMDC, 7,663 were eligible. The anti-HER2 group (n=863 (11%), median duration 13 months [IQR: 12-13]) was compared with the non-HER2 group ( n=6,800 (89%) ). Age 43 [39-46] vs 45 [41-47], anthracycline 602 (69.8%) vs 1,550 ( 22.8%), radiotherapy 496 (57.5%) vs 3,763 (55.3%), and tamoxifen 544 (63.0%) vs 4,809 (70.7%). Preoperative cardiovascular risk factors were diabetes 60 (0.9%) vs 7 (0.6%), hypertension 37 (4.2%) vs 157 (2.3%), dyslipidemia 17 (2.0%) vs 93 (1.4%). Preoperative echocardiography was 436 (50.5%) vs 1,282 (18.9%). CTRCD within 18 months postoperatively was 25 (2.9%) vs. 39 (0.6%), with an odds ratio of 5.2 [95% CI: 3.1-8.6]. Logistic regression analysis showed that the odds ratios for CTRCD were HER2: 3.0 [1.7-5.1], anthracycline: 3.4 [1.9-5.9], radiotherapy: 1.2 [0.7-2.0], tamoxifen: 1.4 [0.8-2.4], hypertension: 4.8 [2.3-10.2], :hyperlipidemia 1.5 [0.4-6.4], respectively. Conclusion: Real-world data indicate that premenopausal East Asians have a higher incidence of cardiac events with anti-HER2 therapy despite fewer cardiovascular risk factors. In addition, only about half of the patients underwent pretreatment cardiac function assessment as recommended in the guidelines. Citation Format: Akihiko Shimomura, Hiroshi Ohtsu, Chikako Shimizu, Kazuhiro Sase. Cardiotoxicity of adjuvant trastuzumab chemotherapy in women with early-stage breast cancer under 50 years of age based on analysis of Japanese insurance claims data [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-14-04.

Efficacy of Pre-Operative Cardiovascular Risk Assessment with MPI in Patient Having an Elective Vascular Surgery

Efficacy of Pre-Operative Cardiovascular Risk Assessment with MPI in Patient Having an Elective Vascular Surgery

Chronic kidney disease and risk of postoperative cardiovascular events in elderly patients receiving hip fracture surgery

IntroductionThe long-term risk of cardiovascular events caused by chronic kidney disease (CKD) is well described in the general population. Less is known concerning the risk of postoperative cardiovascular events in geriatric hip fracture patients with CKD. MethodsThis study involved patients at least 65 years of age who received surgery for acute hip fracture between January 2000 and April 2016. We identified CKD patients with a baseline diagnosis of CKD or an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 at admission. Each CKD patient was matched, for age, gender, fracture type, and year of admission, with 4 control non-CKD patients. The primary endpoint was a compositepostoperative cardiovascular events, including pulmonary embolism, angina pectoris, myocardial infarction, heart failure, arrhythmia, stroke, and death. Conditional logistic regression was used to evaluate the association between CKD and the outcome after adjusting for potential confounders including age, gender, fracture type, body mass index, preexisting comorbidities, history of cardiovascular events, and the Charlson Comorbidity Index (CCI). ResultsThree hundred and seventy-five CKD patients were matched with 1,438 non-CKD patients. The mean age of the CKD patients was 81.9 ± 7.0 (mean ± SD), 69.9% were females, and 59.2% had an intertrochanteric fracture. Compared to non-CKD patients, CKD patients had a higher proportion of preexisting comorbidities, including hypertension, coronary heart disease, heart failure, and type 2 diabetes (all p < 0.05). The risk of postoperative cardiovascular events was 125.3 per 1000 persons (95%CI, 91.8–158.8) in CKD patients and 64.7 per 1000 persons (95%CI, 52.0–77.4) in non-CKD patients. A 1.96-fold risk of cardiovascular events after hip fracture surgery was found in CKD patients than those without CKD (adjusted OR, 1.96; 95%CI, 1.23–3.12). ConclusionPatients with CKD were more likely to have cardiovascular events after hip fracture surgery than those without CKD. Appropriate preoperative cardiovascular risk assessment and corresponding preventive and therapeutic measures should be given to this vulnerable population to mitigate such complications.

Towards the quantification of perioperative cardiovascular risk in the African context: A sub-analysis of the South African Surgical Outcomes Study and the African Surgical Outcomes Study.

The burden of cardiovascular disease in patients requiring non-cardiac surgery in Africa is not known. These patients are at increased risk for postoperative cardiovascular complications. In this sub-study, to use data on comorbidities and surgical outcomes from two large observational studies, the South African Surgical Outcomes Study (SASOS) and the African Surgical Outcomes Study (ASOS), to investigate the prevalence of cardiovascular disease in elective surgical patients and the risk of postoperative cardiovascular complications in this population. SASOS and ASOS were both prospective, observational cohort studies that collected data over 1 week in each participating centre. The primary outcome was in-hospital postoperative complications, which included prespecified and defined cardiovascular complications. We defined the cardiovascular disease burden of patients aged ≥45 years presenting for surgery (main objective), determined the relative risk of developing postoperative cardiovascular complications (secondary objective) and assessed the utility of the Revised Cardiac Risk Index (RCRI) for preoperative cardiovascular risk stratification of elective, non-cardiac surgical patients in Africa (third objective). The primary outcome analysis of 3 045 patients showed that patients with major cardiac complications were significantly older, with a higher prevalence of hypertension, coronary artery disease or congestive cardiac failure, and had undergone major surgery. In-hospital mortality for the cohort was 1.2%. The substantial burden of cardiovascular disease in patients presenting for non-cardiac surgery in Africa is shown in the principal findings of this study. The RCRI has moderate discrimination for major cardiac complications and major adverse cardiac events in African patients undergoing non-cardiac surgery.