Risk Of Noncardiac Surgery Research Articles

Incidence, characteristics, and outcome of noncardiac surgery following transcatheter aortic valve implantation.

Planning noncardiac surgery after transcatheter aortic valve implantation (TAVI) is challenging. We evaluated the incidence, characteristics, and outcome of noncardiac surgeries in patients who underwent TAVI. We retrieved data from the Prospective Segeberg TAVI registry of all patients who received TAVI between 2007 and 2020. Type, timing, urgency, and risk of noncardiac surgery were assessed. We evaluated the patients' clinical outcomes within 30days following noncardiac surgery that included death, myocardial infarction, bleeding, stroke, and acute heart failure. A composite outcome of all adverse events was proposed to independently predict 30day adverse events. Among 1602 patients, 104 patients (mean age, 79.9 ± 7.14 years; 61 (58.7%) females) underwent 148 noncardiac surgeries after TAVI. More than half of the noncardiac surgeries were considered elective (n = 84, 56.7%). Procedures were categorized into low-risk (n = 27, 18.2%), intermediate-risk (n = 102, 68.9%), and high-risk (n = 19, 12.8%) surgery. The composite outcome of adverse events occurred after 57 noncardiac surgeries (38.5% of all procedures) and after more than half of the surgeries in the high-risk group (n = 11, 57.9%). Major or life-threatening bleeding occurred in 24 noncardiac surgeries (19.1%) and was more frequent in high-risk surgeries than in low- and intermediate-risk surgeries (36.8%, p < 0.047). High-risk category of surgery was independently associated with increased risk of the composite outcome (adjusted OR, 3.99; 95% CI 1.12-14.23; p = 0.033). Noncardiac surgery after TAVI was performed in 6.5% patient of our study cohort. High-risk noncardiac surgeries were associated with increased risk of adverse events.

Aspirin Monotherapy vs No Antiplatelet Therapy in Stable Patients With Coronary Stents Undergoing Low-to-Intermediate Risk Noncardiac Surgery.

Current guidelines recommend the perioperative continuation of aspirin in patients with coronary drug-eluting stents (DES) undergoing noncardiac surgery. However, supporting evidence is limited. This study aimed to compare continuing aspirin monotherapy vs temporarily holding all antiplatelet therapy before noncardiac surgery in patients with previous DES implantation. We randomly assigned patients who had received a DES >1 year previously and were undergoing elective noncardiac surgery either to continue aspirin or to discontinue all antiplatelet agents 5days before noncardiac surgery. Antiplatelet therapy was recommended to be resumed no later than 48 hours after surgery, unless contraindicated. The primary outcome was a composite of death from any cause, myocardial infarction, stent thrombosis, or stroke between 5days before and 30days after noncardiac surgery. A total of 1,010 patients underwent randomization. Among 926 patients in the modified intention-to-treat population (462 patients in aspirin monotherapy group and 464 patients in the no-antiplatelet therapy group), the primary composite outcome occurred in 3 patients (0.6%) in the aspirin monotherapy group and 4 patients (0.9%) in the no antiplatelet group (difference, -0.2 percentage points; 95%CI:-1.3 to 0.9; P > 0.99). There was no stent thrombosis in either group. The incidence of major bleeding did not differ significantly between groups (6.5% vs 5.2%; P=0.39), whereas minor bleeding was significantly more frequent in the aspirin group (14.9% vs 10.1%; P = 0.027). Among patients undergoing low-to-intermediate risk noncardiac surgery >1 year after stent implantation primarily with a DES, in the setting of lower-than-expected event rates, we failed to identify a significant difference between perioperative aspirin monotherapy and no antiplatelet therapy with respect to ischemic outcomes or major bleeding. (Perioperative Antiplatelet Therapy in Patients With Drug-eluting Stent Undergoing Noncardiac Surgery [ASSURE-DES]; NCT02797548).

Screening for Cardiac Abnormalities in Asymptomatic Patients Undergoing low to Intermediate Risk Non-Cardiac Surgery

Abstract Background Perioperative cardiovascular complications are the predominant cause of morbidity and mortality in patients undergoing non cardiac surgery. Major cardiovascular and cerebrovascular complications, including death, myocardial infarction or stroke, occur in approximately 1 of every 33 hospitalizations for non-cardiac surgery. Objective To uncover hidden cardiac problems that may cause complications during and after non- cardiac major surgery. Patients and Methods This observational cross-sectional study was conducted on 250 asymptomatic patients coming to Ain Shams University Hospitals and police hospitals clinics for preoperative assessment to undergo low to intermediate risk non cardiac surgery. Results most of the study group were males (68%) with a mean age of 47 years. Diabetes and hypertension were found in 45% and 41% of patients respectively. Most patients had GIT operations (34%) followed by cataract extraction (14%), orthopedic operation was done in 11% of patients. clinical examination was normal in 98% of patients with 2% had AF and systolic murmur. Significantly abnormal ECG was found in 10% of patients. Preoperative significantly abnormal TTE was detected in 9% of patients. post-operative cardiovascular complications occurred in 7% of patients who had completely normal preoperative clinical, ECG and echocardiographic data. Most of these patients had orthopedic operations and hysterectomy. Conclusion The clinical and predictive value of routine preoperative ECG and echocardiography for major cardiac adverse events is limited especially in low-risk patients groups undergoing low to intermediate risk operations. However, it helps uncovering of hidden conditions that alter patient's plan of treatment. The type of surgery was an important factor for the occurrence of post-operative complications.

Perioperative Risk of Noncardiac Surgery in Patients With Asymptomatic Significant Aortic Stenosis: A 10-Year Retrospective Study.

Aortic stenosis (AS) is a representative geriatric disease, and there is an anticipated rise in the number of patients requiring noncardiac surgeries in patients with AS. However, there is still a lack of research on the primary predictors of noncardiac perioperative complications in patients with asymptomatic significant AS. Among the cohort of noncardiac surgeries under general anesthesia, with an intermediate to high risk of surgery from 2011 to 2019, at Samsung Medical Center, 221 patients were identified to have asymptomatic significant AS. First, to examine the impact of significant AS on perioperative adverse events, the occurrences of major adverse cardiovascular events and perioperative adverse cardiovascular events were compared between patients with asymptomatic significant AS and the control group. Second, to identify the factors influencing the perioperative adverse events in patients with asymptomatic significant AS, a least absolute shrinkage and selection operator regression model was used. There was no significant difference between the control group and the asymptomatic significant AS group in the event rate of major adverse cardiovascular events (4.6% at control group versus 5.5% at asymptomatic significant AS group; P=0.608) and perioperative adverse cardiovascular events (13.8% at control group versus 18.3% at asymptomatic significant AS group; P=0.130). Cardiac damage stage was a significant risk factor of major adverse cardiovascular events and perioperative adverse cardiovascular events. There was no significant difference in major postoperative cardiovascular events between patients with asymptomatic significant AS and the control group. Advanced cardiac damage stage in significant AS is an important factor in perioperative risk of noncardiac surgery.

Detection of Preoperative Cardiac Abnormalities in Asymptomatic Patients Undergoing Low to Intermediate Risk Non-Cardiac Surgery

Detection of Preoperative Cardiac Abnormalities in Asymptomatic Patients Undergoing Low to Intermediate Risk Non-Cardiac Surgery

Novel Russian guidelines for the assessment and modification of cardiovascular risk in non-cardiac surgery

This year, new domestic recommendations for assessing and correcting the risk of cardiac complications during non-cardiac surgery have been published. These guidelines provide simple and practical key messages to facilitate decision-making in real-life clinical practice. The proposed algorithm for the management of patients before non-cardiac operations, focused on integral risk assessment, assessment of functional status and biomarkers. This review provides a summary of perioperative drug therapy, management of the most common CVDs, and focuses on specific care based on the risk of the patient's preexisting clinical conditions. Finally, the document includes practical recommendations for the management of postoperative complications, and also includes a new section on perioperative myocardial infarction/injury.

Abstract 14133: Use of Computed Tomography Coronary Angiography in Pre-Operative Risk Assessment in Non-Cardiac Surgeries

Introduction: Computed Tomography Coronary Angiography (CTCA) has emerged as a promising tool for detecting and evaluating coronary artery diseases (CAD). However, the role of CTCA for risk assessment tool for patients undergoing noncardiac surgeries is unknown. Methods: We searched databases like PubMed and Google Scholar to compile the literature including reviews, meta-analyses, scientific articles, and guidelines, describing the use of CTCA in the diagnosis and evaluation of cardiac risk assessment in noncardiac surgeries. Results: Based on our literature review we found that CTCA is a promising adjunctive tool for preoperative assessment in noncardiac surgeries to evaluate cardiac risk with high sensitivity and negative predictive value. VISION-CTA sub study showed that CTCA combined with Myocardial Perfusion Imaging (MPI) predicts major adverse cardiac events within 30 days of surgery with higher accuracy than either test alone. McCarthy KJ et al found an increase in the proportion of CTCAs performed from before 2018, 2018 to post 2018, (3%, 6.3%, and 26.3% respectively; p &lt;0.001) and obstructive CAD diagnosis using CTCA (0%, 30%, and 51.4% respectively; p = 0.04). Hence supporting a shift to non-invasive CTCA for pre-operative assessment of liver transplant candidates. According to Ahn J et al, CTCA shows 100% sensitivity and 99.3% negative predictive value in predicting major adverse cardiac events and can be used to stratify intermediate risk noncardiac surgery patients. Conclusions: CTCA is a valuable risk assessment tool in patients undergoing noncardiac surgery because of its high sensitivity and negative predictive value. There is a need for further research and guidelines for using CTCA as a risk assessment tool in noncardiac surgeries.

Assessment and modification of cardiovascular risk in non-cardiac surgery. Clinical guidelines 2023

Russian Society of Cardiology (RCS)

Prognostic role of stress-CMR and SPECT-MPI in patients undergoing intermediate-to-high risk non-cardiac surgery

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Data supporting the role of stress test myocardial perfusion imaging (MPI) before non-cardiac surgery (NCS) are sparse and out of date. In particular, there is no specific evidence on the use of stress cardiac magnetic resonance (sCMR) in this setting. The aim of the present study was to evaluate the impact MPI stress test with sCMR and single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) on surgery-related cardiac events. Method In this single-centre retrospective study, we included all patients with CAD or at least two cardiovascular risk factors undergoing intermediate-to-high-risk non-cardiac surgery. After a pre-operative cardiological assessment, including EKG and echocardiography, the indication to perform a pre-operative MPI-stress-test relied on the clinical judgement of the cardiologist. Cardiac events occurring within 30 days from surgery were evaluated. A composite primary endpoint included myocardial infarction, unstable angina, cardiac death, cardiogenic shock and pulmonary oedema. The secondary endpoint was the rate of acute coronary syndromes. Results A total of 1590 patients were included, of whom 669 underwent an MPI stress test strategy (287 sCMR, 382 SPECT-MPI). The rate of 30-day cardiac events was lower in the stress test group vs. the non-stress test group (1.2% vs 3.4%; p 0,006; figure 1). Adopting a stress test strategy showed a significant reduction of composite endpoint (OR: 0.334, IC: 0.155 – 0.766, p 0.009) and acute coronary syndrome (OR: 0.414, IC: 0.174 – 0.984, p 0.046) at multivariable analysis. Stress CMR was non-inferior to SPECT in predicting cardiac events and showed a greater accuracy to predict coronary artery revascularizations (AUC for sCMR: 0.95 with a percentage of myocardial ischemia cut-point of 5.5%; figure 2). Conclusions A stress-test strategy is associated with a lower incidence of cardiac events in high-risk patients candidate to intermediate-to-high-risk non-cardiac surgery. The rate of cardiac complications is similarly predicted by sCMR and SPECT-MPI, although sCMR is more accurate in predicting coronary artery revascularizations.

Preoperative Right Ventricular Echocardiographic Parameters Predict Perioperative Cardiovascular Complications in Patients Undergoing High risk Non-Cardiac Surgery

Background: Every year, 200 million people worldwide have major non-cardiac surgery (NCS), and 10 million people experience a significant cardiac problem during the first 30 days following NCS. Perioperative cardiovascular complications (PCCs), are extremely significant since they contribute to at least one-third of perioperative mortality, lengthen hospital stays, and raise medical expenses.

Pre-operative evaluation in geriatric patients

The population of the United States, as well as developing countries like India, is rapidly ageing. Surgical operations are more common in the elderly than in younger age groups. A comprehensive pre-operative evaluation of these elderly patients is an important component of improving perioperative outcomes. It is very different from the pre-operative assessment in younger patients, which usually encompasses evaluating cardiac risk for non-cardiac surgery and single end-organ functional assessment. Functional and cognitive impairment are additional risk factors associated with poorer outcomes in older patients. Guidelines for pre-operative assessment of elderly surgical patients have been developed by the American College of Surgeons and the American Geriatrics Society.

Prediction of intraoperative hypotension from the linear extrapolation of mean arterial pressure.

Hypotension prediction index (HPI) software is a proprietary machine learning-based algorithm used to predict intraoperative hypotension (IOH). HPI has shown superiority in predicting IOH when compared to the predictive value of changes in mean arterial pressure (ΔMAP) alone. However, the predictive value of ΔMAP alone, with no reference to the absolute level of MAP, is counterintuitive and poor at predicting IOH. A simple linear extrapolation of mean arterial pressure (LepMAP) is closer to the clinical approach. Our primary objective was to investigate whether LepMAP better predicts IOH than ΔMAP alone. Retrospective diagnostic accuracy study. Two tertiary University Hospitals between May 2019 and December 2019. A total of 83 adult patients undergoing high risk non-cardiac surgery. Arterial pressure data were automatically extracted from the anaesthesia data collection software (one value per minute). IOH was defined as MAP < 65 mmHg. Correlations for repeated measurements and the area under the curve (AUC) from receiver operating characteristics (ROC) were determined for the ability of LepMAP and ΔMAP to predict IOH at 1, 2 and 5 min before its occurrence (A-analysis, using the whole dataset). Data were also analysed after exclusion of MAP values between 65 and 75 mmHg (B-analysis). A total of 24 318 segments of ten minutes duration were analysed. In the A-analysis, ROC AUCs to predict IOH at 1, 2 and 5 min before its occurrence by LepMAP were 0.87 (95% confidence interval, CI, 0.86 to 0.88), 0.81 (95% CI, 0.79 to 0.83) and 0.69 (95% CI, 0.66 to 0.71) and for ΔMAP alone 0.59 (95% CI, 0.57 to 0.62), 0.61 (95% CI, 0.59 to 0.64), 0.57 (95% CI, 0.54 to 0.69), respectively. In the B analysis for LepMAP these were 0.97 (95% CI, 0.9 to 0.98), 0.93 (95% CI, 0.92 to 0.95) and 0.86 (95% CI, 0.84 to 0.88), respectively, and for ΔMAP alone 0.59 (95% CI, 0.53 to 0.58), 0.56 (95% CI, 0.54 to 0.59), 0.54 (95% CI, 0.51 to 0.57), respectively. LepMAP ROC AUCs were significantly higher than ΔMAP ROC AUCs in all cases. LepMAP provides reliable real-time and continuous prediction of IOH 1 and 2 min before its occurrence. LepMAP offers better discrimination than ΔMAP at 1, 2 and 5 min before its occurrence. Future studies evaluating machine learning algorithms to predict IOH should be compared with LepMAP rather than ΔMAP.

Stress echocardiography with regadenoson for the assessment of perioperative cardiovascular risk in non-cardiac surgery

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The most commonly used drug in pharmacological stress echocardiography (SE) for perioperative cardiovascular (CV) risk assessment is dobutamine. Its arrhythmogenic potential and the unpredictable hypertensive response in patients with vascular pathology, makes us often resort to other less accessible and more expensive techniques such as Cardio-MRI or SPECT. Regadenoson is emerging as a safe drug in the detection of myocardial ischemia, although its use has not yet been validated in SE. Purpose The objective is to assess the short-medium term prognosis in patients undergoing high-risk noncardiac surgery who undergo SE with regadenoson. Methods A unicentric retrospective observational study. We included a subgroup of 58 patients referred for detection of ischemia prior to high-risk noncardiac surgery who underwent SE with regadenoson during the years 2017-2020. No patient has had cardiological symptoms. The test was considered positive if it presented at least one of the following: wall motion abnormalities, electrocardiographic and/or clinical changes compatible with ischemia. Patients were followed up in the immediate postoperative period (30 days), at 12 months and at 24 months, considering the presence of CV events such as admission for heart failure (HF), chest pain, acute myocardial infarction (AMI) or CV death. It was compared the group with negative (NG) and the group with positive (PG) results. Results 97% of the patients underwent vascular high-risk noncardiac surgery, 3% underwent other surgeries such as kidney transplantation or lung surgery considered high risk in the preanesthetic assessment. Twelve studies (21%) were positive and of these, only 2 patients underwent coronary artery bypass prior to surgery. The only CV event observed in this period was HF: in the NG 3 episodes were observed compared to 1 in the PG (p = 0.82), only in one of the events for HF was coronary angiography done that did not show coronary artery disease. The time to the NG event was a median of 90 [3-600] days versus 180 days in the PG. The cumulative incidence (CI) of events in the NG in the immediate postoperative period (30 days post-surgery) was 2%, annual 4% and biannual 7%. Conclusions A SE test with negative regadenoson prior to high-risk noncardiac surgery presents a low CI of events in the immediate postoperative period and in the short-medium term. Abstract Figure.

Perioperative cardiac risk assessment by anesthesiology residents

Major adverse cardiac events (MACE) occurring during non-cardiac surgery (NCS) are a common cause of morbidity and mortality. An individual preoperative MACE risk stratification during NCS based on the patient-specific risk factors and the surgical risk is highly recommended by learned societies. The aim of our study was to evaluate the perioperative management of cardiac risk in NCS by anesthesiology residents. We conducted a prospective, longitudinal and descriptive study. One hundred anesthesiology residents practicing their residency training in several Tunisian university hospital centers (UHC) were asked to take a survey inspired by The French RICARDO survey. A quarter of residents reported that they never conducted multidisciplinary team meetings (MDTMs) during the preoperative care and that there were no validated protocols elaborated with cardiologists of their departments. The majority (96,3%) requested an ECG according to the patient's age and 33% a resting Transthoracic Echocardiography (TTE) for coronary artery disease risk assessment. A ß-blocker was initiated by 44,4% of residents. Acetylsalicylic acid and clopidogrel were systematically stopped by respectively 7,4% and 51.9% of residents. Intraoperatively, the anesthetic technique was general anesthesia in 52% of cases versus locoregional anesthesia in 48% of cases. Postoperatively, 14,8% required troponins, ECG, continuous monitoring, and cardiologist follow-up. In the case of troponins elevation, 81,5% requested an ECG, and 59% involved cardiologists. Through our work, we found a discrepancy between the recommendations and the anesthetic practices. Better dissemination of guidelines and the development of local standardized protocols for CV risk assessment would be beneficial.

Adverse outcomes after noncardiac surgery in patients with aortic stenosis

Whether aortic stenosis (AS) increases perioperative risk in noncardiac surgery remains controversial. Limited information is available regarding adequate anesthetic techniques for patients with AS. Using the reimbursement claims data of Taiwan’s National Health Insurance, we performed propensity score matching analyses to evaluate the risk of adverse outcomes in patients with or without AS undergoing noncardiac surgery between 2008 and 2013. We also compared the perioperative risk of AS patients undergoing general anesthesia or neuraxial anesthesia. Multivariable logistic regressions were applied to calculate the adjusted odds ratios (aORs) with 95% confidence intervals (CIs) for postoperative mortality and major complications. The matching procedure generated 9741 matched pairs for analyses. AS was significantly associated with 30-day in-hospital mortality (aOR 1.31, 95% CI 1.03–1.67), acute renal failure (aOR 1.42, 95% CI 1.12–1.79), pneumonia (aOR 1.16, 95% CI 1.02–1.33), stroke (aOR 1.14, 95% CI 1.01–1.29), and intensive care unit stay (aOR 1.38, 95% CI 1.27–1.49). Compared with neuraxial anesthesia, general anesthesia was associated with increased risks of acute myocardial infarction (aOR 3.06, 95% CI 1.22–7.67), pneumonia (aOR 1.80, 95% CI 1.32–2.46), acute renal failure (aOR 1.82, 95% CI 1.11–2.98), and intensive care (aOR 4.05, 95% CI 3.23–5.09). The findings were generally consistent across subgroups. AS was an independent risk factor for adverse events after noncardiac surgery. In addition, general anesthesia was associated with greater postoperative complications in AS patients compared to neuraxial anesthesia. This real-world evidence suggests that neuraxial anesthesia should not be contraindicated in patients with AS.

The predictive value of high-sensitive troponin I for perioperative risk in patients undergoing gastrointestinal tumor surgery.

BackgroundThe incidence of cardiovascular events in perioperative period of gastrointestinal tumor surgery cannot be ignored, and studies have shown that level of postoperative troponin is related to the postoperative risk of non-cardiac surgery. However, the relationship between pre-operative troponin levels and perioperative risk of gastrointestinal tumor surgery is unclear. Thus, we aimed to evaluate the value of high-sensitive cardiac troponin I (hs-cTnI) prior to gastrointestinal tumor surgery for perioperative risk assessment.MethodsIn this retrospective cohort study, 1259 patients who underwent gastrointestinal tumor surgery and had been tested for hs-cTnI on admission within 7 days prior to surgery were retrospectively recruited from January 2018 to June 2020. The primary combined endpoint including in-hospital all-cause mortality, acute myocardial infarction, cardiac arrest or ventricular fibrillation and acute decompensated heart failure. The secondary endpoint included total hospital stay and requirement of intensive care treatment.FindingsCompared with patients with normal hs-cTnI, those with elevated hs-cTnI (> 0·028 ng/ml) were more likely to experience the combined endpoint (28·2% versus 2·7%, P < 0·001) and there was also an increasing rate of in mortality in elevated hs-cTnI group (2·4% versus 0·3%, P = 0·057). The length of total hospital stay was significantly longer in patients with elevated hs-cTnI (24·8 ± 16·3 versus 19·5 ± 7·9, P = 0·003) and the number of patients requiring intensive care treatment was also higher (22·6% versus 4·2%, P < 0·001). The area under the ROC curve assessing hs-cTnI in predicting in-hospital mortality was 0·787 [95% confidence interval (CI) 0·612–0·963, P = 0·015] and for combined endpoint was 0·822 [95% CI 0·766–0·879, P < 0·001]. Hs-cTnI > 0·028 ng/ml was associated with significantly higher cardiovascular event rate in patients with the revised cardiac index ≤ 1. The positive likelihood ratio of hs-cTnI (> 0·028 ng/ml) for predicting combined endpoint reaches 10.5 in patients with Lee index = 0. In multivariate logistic analyses, hs-cTnI was one of the best predictors for the combined endpoint [odds ratio (OR) 5·924 (95%CI: 2·869–12·233), P < 0·001].InterpretationHs-cTnI provides powerful prognostic information for patients undergoing gastrointestinal tumor surgery, and therefore provides reliable prognostic information incremental to revised cardiac index.

Reevaluating the Cardiac Risk of Noncardiac Surgery Using the National Surgical Quality Improvement Program

BackgroundAs surgical techniques evolve and patient outcomes improve over time, a renewed analysis of the cardiac risk of noncardiac surgeries is needed. The goal of this study was to investigate and categorize the cardiac risk of elective noncardiac surgeries. MethodsThis was a cohort study of surgical data and outcomes from the 2018 National Surgical Quality Improvement Program Participant Use Data File; 807,413 cases were analyzed after excluding non-elective, emergent, and cardiac surgeries. Postoperative major adverse cardiac events (MACE) were defined as 30-day all-cause mortality, myocardial infarction, or cardiac arrest. According to their 95% confidence intervals (CI) for postoperative MACE, surgeries were categorized as low risk (95% CI <1%), intermediate risk (95% CI above and below 1%), or elevated risk (95% CI ≥1%). Multivariable logistic regression analyses were performed to determine differences in the odds for postoperative MACE for the intermediate- and elevated-risk categories relative to the low-risk category while controlling for several risk factors of prognostic importance. ResultsPostoperative MACE occurred in 4047/807,413 cases (0.50%), including in 1708/667,735 (0.26%) of the low-risk category, in 516/53,499 (0.96%) of the intermediate-risk category, and in 1823/86,179 (2.12%) of the elevated-risk category. The elevated-risk category accounted for 10.7% of total procedures and 45.1% of total postoperative MACE. Compared with the low-risk category, the multivariable adjusted risk of postoperative MACE was increased in the intermediate-risk category (adjusted odds ratio 2.35; 95% CI, 2.12-2.62) and the elevated-risk category (adjusted odds ratio 3.15; 95% CI, 2.92-3.39). Conclusion: Categorization of noncardiac surgeries according to cardiac risk may help to identify populations who are most likely to benefit from preoperative cardiac evaluation when indicated.

Patient Selection for Routine Troponin Monitoring After Noncardiac Surgery.

BackgroundMyocardial infarction is an important complication after noncardiac surgery. Therefore, perioperative troponin surveillance is recommended for patients at risk. The aim of this study was to identify patients at high risk of perioperative myocardial infarction (POMI), in order to aid appropriate selection and to omit redundant laboratory measurements in patients at low risk.Methods and ResultsThis observational cohort study included patients ≥60 years of age who underwent intermediate to high risk noncardiac surgery. Routine postoperative troponin I monitoring was performed. The primary outcome was POMI. Classification and regression tree analysis was used to identify patient groups with varying risks of POMI. In each subgroup, the number needed to screen to identify 1 patient with POMI was calculated. POMI occurred in 216 (4%) patients and other myocardial injury in 842 (15%) of the 5590 included patients. Classification and regression tree analysis divided patients into 14 subgroups in which the risk of POMI ranged from 1.7% to 42%. Using a risk of POMI ≥2% to select patients for routine troponin I monitoring, this monitoring would be advocated in patients ≥60 years of age undergoing emergency surgery, or those undergoing elective surgery with a Revised Cardiac Risk Index class >2 (ie >1 risk factor). The number needed to screen to detect a patient with POMI would be 14 (95% CI 14–14) and 26% of patients with POMI would be missed.ConclusionsTo improve selection of high‐risk patients ≥60 years of age, routine postoperative troponin I monitoring could be considered in patients undergoing emergency surgery, or in patients undergoing elective surgery classified as having a revised cardiac risk index class >2.

Perioperative cardiovascular outcomes among older adults undergoing in-hospital noncardiac surgery.

Older adults undergoing noncardiac surgery have a high risk of major adverse cardiovascular events (MACE). This study aims to estimate the magnitude of increased perioperative risk, and examine national trends in perioperative MACE following in-hospital noncardiac surgery in older adults compared to middle-aged adults. Time-series analysis of retrospective longitudinal data. The United States Agency for Healthcare Research and Quality National Inpatient Sample (NIS). Hospitalizations for major noncardiac surgery among adults age ≥45 years between January 2004 and December 2014. Inpatient perioperative MACE was defined as a composite of in-hospital death, myocardial infarction (MI), and ischemic stroke. In hospital death was determined from the NIS discharge disposition. MI and ischemic stroke were defined by International Classification of Diseases, Ninth Revision codes. Of an estimated 55,349,978 surgical hospitalizations, 26,423,039 (47.7%) were for adults age 45-64, 14,231,386 (25.7%) age 65-74, 10,621,029 (19.2%) age 75-84 years, and 4,074,523 (7.4%) age ≥85 years. MACE occurred in 1,601,022 surgical hospitalizations (2.9%). Adults 65-74 (2.8%; aOR 1.16, 95% CI 1.14-1.17), 75-84 years (4.5%; aOR 1.30, 95% CI 1.28-1.32), and ≥85 years (6.9%; aOR 1.55, 95% CI 1.52-1.57) had greater risk of MACE than those 45-64 years (1.7%). From 2004 to 2014, MACE declined among adults 65-74 (3.1-2.5%, p< 0.001), 75-85 years (4.9-3.9%, p< 0.001), and ≥85 years (7.7-6.1%, p< 0.001), but was unchanged for adults age 45-64. Declines in MACE were driven by decreased MI and mortality despite increased stroke. Older adults accounted for half of hospitalizations, but experienced the majority of MACE. Older adults had greater adjusted odds of MACE than younger individuals. The proportion of perioperative MACE declined over time, despite increases in ischemic stroke. These data highlight risks of noncardiac surgery in older adults that warrant increased attention to improve perioperative outcomes.

The Predictive Value of High-Sensitive Troponin I for Perioperative Risk in Patients Undergoing Gastrointestinal Tumor Surgery

Background: The incidence of cardiovascular events in perioperative period of gastrointestinal tumor surgery cannot be ignored, and studies have shown that postoperative troponin is related to the postoperative risk of non-cardiac surgery. However, the relationship between pre-operative troponin levels and perioperative risk of gastrointestinal tumor surgery is unclear. Thus, we aimed to evaluate the value of high-sensitive cardiac troponin I (hs-cTnI) prior to gastrointestinal tumor surgery for perioperative risk assessment. Methods: 1259 patients who underwent gastrointestinal tumor surgery and had been tested for hs-cTnI on admission within 7 days prior to surgery were retrospectively recruited. The primary endpoint was in-hospital all-cause mortality and the combined endpoint including death, acute myocardial infarction, cardiac arrest and acute decompensated heart failure. The secondary endpoint included total hospital stay and requirement of intensive care treatment. Findings: Compared with patients with normal hs-cTnI (≤0.028ng/ml), those with elevated hs-cTnI were more likely to experience the combined endpoint (28·2% versus 2·7%, P < 0·001) and there was also an increasing rate of in mortality in elevated hs-cTnI group (2·4% versus 0·3%, P = 0·057). The length of total hospital stay was significantly prolonged in patients with elevated hs-cTnI (24·8 ± 16·3 versus 19·5 ± 7·9, P = 0·003) and the number of patients requiring intensive care treatment was also higher (22.6% versus 4.2%, P ＜0·001). The area under the ROC curve assessing hs-cTnI in predicting in-hospital mortality was 0·787 [95% confidence interval (CI) 0·612 - 0·963, P = 0·015] and for combined endpoint was 0·822 [95%CI 0·766 - 0·879, P ＜0·001], which was larger than revised cardiac index. Hs-cTnI＞0·028 ng/ml was associated with higher cardiovascular event rate according to the stratification of the revised cardiac index. In multivariate logistic analyses, hs-cTnI was the strongest independent predictor for the combined endpoint [odds ratio (OR) 7·454 (95%CI: 3·872-14·348); P < 0·001]. Interpretation: High sensitivity troponin I provides powerful prognostic information for patients undergoing gastrointestinal tumor surgery, and therefore provides strong prognostic information incremental to revised cardiac index. Funding: The Fundamental Research Funds for the Central Universities and the National Natural Science Foundation of China. Declaration of Interest: No potential conflict of interest was reported by the authors. Ethics Approval Statement: The study has been approved by the local ethical boards of the sixth affiliated hospital of Sun Yat-sen University.