Are the Incidences of Cardiac Events During Noncardiac Surgery in Japan the Same as in the United States and Europe?

BACKGROUND/OBJECTIVE: Risk-stratification tools for cardiac complications after noncardiac surgery based on preoperative risk factors are used to inform postoperative management. However, there is limited evidence on whether risk stratification can be improved by incorporating data collected intraoperatively, particularly for low-risk patients. METHODS: We conducted a retrospective cohort study of adults who underwent noncardiac surgery between 2014 and 2018 at four hospitals in the United States. Logistic regression with elastic net selection was used to classify in-hospital major adverse cardiovascular events (MACE) using preoperative and intraoperative data (“perioperative model”). We compared model performance to standard risk stratification tools and professional society guidelines that do not use intraoperative data. RESULTS: Of 72,909 patients, 558 (0.77%) experienced MACE. Those with MACE were older and less likely to be female. The perioperative model demonstrated an area under the receiver operating characteristic curve (AUC) of 0.88 (95% CI, 0.85-0.92). This was higher than the Lee Revised Cardiac Risk Index (RCRI) AUC of 0.79 (95% CI, 0.74-0.84; P < .001 for AUC comparison). There were more MACE complications in the top decile (n = 1,465) of the perioperative model’s predicted risk compared with that of the RCRI model (n = 58 vs 43). Additionally, the perioperative model identified 2,341 of 7,597 (31%) patients as low risk who did not experience MACE but were recommended to receive postoperative biomarker testing by a risk factor–based guideline algorithm. CONCLUSIONS: Addition of intraoperative data to preoperative data improved prediction of cardiovascular complication outcomes after noncardiac surgery and could potentially help reduce unnecessary postoperative testing.

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Temporal Trends in Risk of Future Cardiac Events among Stroke Survivors in the United States

International Journal of Stroke ◽

10.1111/j.1747-4949.2011.00701.x ◽

2012 ◽

Vol 7 (3) ◽

pp. 207-212 ◽

Cited By ~ 2

Author(s):

Amytis Towfighi ◽

Daniela Markovic ◽

Bruce Ovbiagele

Keyword(s):

United States ◽

Temporal Trends ◽

The United States ◽

Stroke Survivors ◽

Cardiac Events

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Angina and Its Management

Journal of Cardiovascular Pharmacology and Therapeutics ◽

10.1177/1074248416679733 ◽

2016 ◽

Vol 22 (3) ◽

pp. 199-209 ◽

Cited By ~ 12

Author(s):

Robert A. Kloner ◽

Bernard Chaitman

Keyword(s):

United States ◽

Sodium Current ◽

The United States ◽

Pharmacologic Therapy ◽

Channel Blockers ◽

Cardiac Events ◽

Transmyocardial Revascularization ◽

Adverse Cardiac Events ◽

Revascularization Procedures ◽

Pharmacologic Agents

Angina pectoris is defined as substernal chest pain, pressure, or discomfort that is typically exacerbated by exertion and/or emotional stress, lasts greater than 30 to 60 seconds, and is relieved by rest and nitroglycerin. There are approximately 10 million people in the United States who have angina, and there are over 500 000 cases diagnosed per year. Several studies now show that angina itself is a predictor of major adverse cardiac events. In addition, angina is a serious morbidity that impedes quality of life and should be treated. In the United States, pharmacologic therapy for angina includes β-blockers, nitrates, calcium channel blockers, and the late sodium current blocker ranolazine. In other countries, additional pharmacologic agents include trimetazidine, ivabradine, nicorandil, fasudil, and others. Revascularization is indicated in certain high-risk individuals and also has been shown to improve angina. However, even after revascularization, a substantial percentage of patients return with recurrent or continued angina, requiring newer and better therapies. Treatment for refractory angina not amenable to usual pharmacologic therapies or revascularization procedures, includes enhanced external counterpulsation, transmyocardial revascularization, and stem cell therapy. Angina continues to be a significant cause of morbidity. Therapy should be geared not only to treating the risk factors for atherosclerotic disease and improving survival but should also be aimed at eliminating or reducing the occurrence of angina and improving the ability of patients to be active.

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Preoperative Evaluation and Management Before Major Noncardiac Surgery

The Brigham Intensive Review of Internal Medicine ◽

10.1093/med/9780199358274.003.0094 ◽

2014 ◽

pp. 995-1004

Author(s):

Adam C. Schaffer ◽

Sylvia C. W. McKean

Keyword(s):

Cardiac Disease ◽

Preoperative Evaluation ◽

The United States ◽

Noncardiac Surgery ◽

Elevated Risk ◽

Cardiac Events ◽

Medical Clearance ◽

Estimated Risk ◽

Preoperative Risk Stratification

There are more than 10 million major noncardiac surgical procedures performed in the United States per year, and this number is expected to grow as the population ages. The problem of perioperative cardiac events among patients undergoing noncardiac surgery is significant. The estimated risk of myocardial infarction (MI) in patients undergoing noncardiac surgery is 1.1% among unselected patients and 3.1% among patients at elevated risk of cardiac disease. The task of the internist providing preoperative evaluation of patients is not to provide medical “clearance.” Instead, the role of the internist is, in addition to answering any specific questions posed by the requesting physician, to provide a thorough assessment of the patient's cardiovascular and other risks for the procedure. This risk assessment can assist in the balancing of risks and benefits that influences whether the surgeon decides to go forward with the procedure. The consulting internist must also provide specific suggestions regarding further testing that may be indicated for preoperative risk stratification and, most importantly, recommendations for measures that can be taken to mitigate the identified risks.

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Sudden Cardiac Death not Related to Coronary Atherosclerosis

Toxicologic Pathology ◽

10.1080/01926230500519824 ◽

2006 ◽

Vol 34 (1) ◽

pp. 52-57 ◽

Cited By ~ 13

Author(s):

Elena Ladich ◽

Renu Virmani ◽

Allen Burke

Keyword(s):

United States ◽

Cardiovascular Diseases ◽

Sudden Cardiac Death ◽

Cardiac Disease ◽

Cardiac Death ◽

Coronary Atherosclerosis ◽

The United States ◽

Cardiac Diseases ◽

Cardiac Events ◽

Myocardial Diseases

Sudden cardiac death (SCD) accounts for approximately 300,000 cardiac events in the United States each year, representing an overall incidence of 0.1–0.2% per year. Although the vast majority of these may be attributed to coronary atherosclerosis, a wide variety of nonatherosclerotic-related cardiac diseases have been associated with SCD. This review highlights three general categories of cardiac disease not related to atherosclerosis: the cardiomyopathies, inflammatory myocardial diseases, and ion channel disorders. The important role played by genetics in some of these cardiovascular diseases is presented as well as toxic and drug-related etiologies.

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Abstract 154: A Comparison of Carotid Artery Stent Placement Performed Within and Outside Clinical Trials in the United States

Stroke ◽

10.1161/str.43.suppl_1.a154 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Haitham M Hussein ◽

Saqib A Chaudhry ◽

Shahram Majidi ◽

Rakesh Khatri ◽

Gustavo J Rodriguez ◽

...

Keyword(s):

United States ◽

Clinical Trial ◽

Clinical Trials ◽

Hospital Mortality ◽

Stent Placement ◽

The United States ◽

Cardiac Events ◽

Hospital Outcomes ◽

End Point ◽

National Cohort

Background: A discrepancy between characteristics of patients treated with carotid angioplasty and stent placement (CAS) within and outside clinical trials, particularly characteristics with direct impact on clinical outcome, may lead to reduction in anticipated benefit. Objective: To identify differences in demographic and clinical characteristics and outcomes related to CAS in patients treated within clinical trials and those treated outside clinical trials in a large national cohort. Methods: We determined the frequency of CAS performed within and outside clinical trials and associated in-hospital outcomes using data from the Nationwide Inpatient Survey (NIS) data files from 2005 to 2008. All the in-hospital outcomes were analyzed after adjusting for potential confounders using multivariate analysis. Results: Of the 47,899 patients who underwent CAS, 16,078 (1%) underwent the procedure as part of a clinical trial. The mean age of the patients was significantly lower in patients treated with CAS as part of a clinical trial than those treated with CAS outside a clinical trial. The proportion of women and non-whites was lower among patients treated with CAS as part of a clinical trial. The in-hospital mortality was two folds higher among patients treated with CAS outside clinical trial (1.12% versus 0.53%, p=0.0.0005). The rate of composite end-point of stroke, cardiac events, and death was significantly higher among patients treated with CAS outside clinical trials (p=0.02). After adjusting for age, gender, presence of hypertension, diabetes mellitus, renal failure, congestive heart failure, and hospital teaching status, CAS performed as part of clinical trial was associated with lower rates of in-hospital mortality (OR 0.349, 95% CI 0.219-0.555)(p<0.0001) and composite end point of stroke, cardiac events, and death (OR 0.349, 95% CI 0.219-0.555)(p<0.0001) . Conclusions: Our results suggests that CAS performed as part of clinical trial was associated with lower rates of in-hospital mortality and composite end point of stroke, cardiac events, and death in United States. These findings highlight the need for strategies that ensure appropriate adoption of CAS to ensure that the benefits observed in clinical trials can be replicated in general practice.

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