scholarly journals Preoperative assessment of cardiovascular risk in patients undergoing noncardiac surgery: the Orion study

2020 ◽  
Vol 90 (1) ◽  
Author(s):  
Giampaolo Scorcu ◽  
Annarita Pilleri ◽  
Paolo Contu ◽  
Pompilio Faggiano ◽  
Roberto Floris ◽  
...  
Keyword(s):  
Risk Score ◽  
Risk Index ◽  
Preoperative Assessment ◽  
Predictive Performance ◽  
Roc Curves ◽  
Cardiac Risk ◽  
Cardiovascular Complications ◽  
Noncardiac Surgery ◽  
Derivation Cohort ◽  
Risk Indices

In patients undergoing noncardiac surgery risk indices can estimate patients’ perioperative risk of major cardiovascular complications. The indexes currently in use were derived from observational studies that are now outdated with respect to the current clinical context. We undertook a prospective, observational, cohort study to derive, validate, and compare a new risk index with established risk indices. We evaluated 7335 patients (mean age 63±13 years) who underwent noncardiac surgery. Based on prospective data analysis of 4600 patients (derivation cohort) we developed an Updated Cardiac Risk Score (UCRS), and validated the risk score on 2735 patients (validation cohort). Four variables (i.e. the UCRS) were significantly associated with the risk of a major perioperative cardiovascular events: high-risk surgery, preoperative estimate glomerular filtration rate <30 ml/min/1.73 m2, age ≥75 years, and history of heart failure. Based on the UCRS we created risk classes 1,2,3 and 4 and their corresponding 30-day risk of a major cardiovascular complication was 0.8% [95% confidence interval (CI) 0.5-1.7], 2.5 (95% CI 1.6-5.6), 8.7 (95% CI 5.2-18.9) and 27.2 (95% CI 11.8-50.3), respectively. No significant differences were found between the derivation and validation cohorts. Receiver operating characteristic (ROC) curves demonstrate a high predictive performance of the new index, with greater power to discriminate between the various classes of risk than the indexes currently used. The high predictive performance and simplicity of the UCRS make it suitable for wide-scale use in preoperative cardiac risk assessment of patients undergoing noncardiac surgery.

Abstract 12444: Outcomes After Starting Beta-Blockade Within a Clinically Sensible Period Before Major Elective Noncardiac Surgery

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Duminda N Wijeysundera ◽  
Dennis T Ko ◽  
Harindra C Wijeysundera ◽  
Lingsong Yun ◽  
W. Scott Beattie
Keyword(s):  
Cohort Study ◽  
Beta Blockers ◽  
Risk Index ◽  
Cardiac Risk ◽  
Population Based ◽  
Noncardiac Surgery ◽  
Beta Blockade ◽  
Matched Cohort ◽  
Post Surgery ◽  
Median Daily Dose

INTRODUCTION: Guidelines recommend that perioperative beta-blockade be started days to weeks before surgery. Nonetheless, all randomized trials except for the controversial DECREASE trials started treatment ≤1 day before surgery, while most observational studies did not distinguish between long-term beta-blockade versus beta-blockers started for perioperative reasons. We thus conducted a population-based cohort study of the effectiveness of beta-blockade started within a clinically sensible period (8-60 days) before surgery. METHODS: Following research ethics approval, we conducted a cohort study of patients (≥66 years) who underwent major elective noncardiac surgery from 2003 and 2012 in Ontario, Canada. Propensity-score methods were used to form a matched cohort that reduced important differences between patients who started beta-blockers 8-60 days before surgery versus controls (no beta-blockers within 1 year before surgery). We measured the association of beta-blockade with 30-day (death, MI, stroke) and 1-year (death) outcomes post-surgery. Subgroup analyses were performed based on Revised Cardiac Risk Index class and history of prior CAD. RESULTS: The cohort included 4268 beta-blocked patients and 154,357 controls. Metoprolol (median daily dose 50 mg) was prescribed to 36% of beta-blocked patients, atenolol (median 25 mg) to 26%, and bisoprolol (median 5 mg) to 37%. In the matched cohort (n=8492), beta-blockade was not associated with death (RR 0.96; CI 0.70-1.32), MI (RR 0.92; CI 0.72-1.17), and stroke (RR 1.31; CI 0.68-2.52) at 30-days, or death at 1-year (Figure). Associations with outcomes did not differ significantly across subgroups. CONCLUSIONS: Outcomes were not altered in patients who start perioperative beta-blockade within a clinically sensible period before surgery. A large randomized trial is needed to determine if the continued use of perioperative beta-blockade in clinical practice is justified.

scholarly journals The Use of Lee and Co-Workers’ Index to Assist a Risk Adjusted Audit of Perioperative Cardiac Outcome

2008 ◽  
Vol 36 (2) ◽  
pp. 167-173 ◽  
Author(s):  
P. J. Moran ◽  
T. Ghidella ◽  
G. Power ◽  
A. S. Jenkins ◽  
D. Whittle
Keyword(s):  
Risk Factors ◽  
High Risk ◽  
Positive Result ◽  
Cardiac Event ◽  
Risk Index ◽  
Cardiac Risk ◽  
Noncardiac Surgery ◽  
Frequent Use ◽  
Cardiac Outcome ◽  
The Impact

Lee and co-workers’ revised cardiac risk index was used to study the perioperative cardiac outcome of 296 patients. The index uses a history of ischaemic heart disease, congestive cardiac failure, diabetes treated with insulin, a creatinine greater than 180 μmol/l, cerebrovascular disease and high risk surgery as the risk factors involved in predicting a perioperative cardiac event. It was derived on the basis of data from patients over the age of 50 years undergoing elective, noncardiac surgery with an expected inpatient stay of two or more days. The presence of one, two and three or more risk factors predicted a risk of a major cardiac event of 1.3% (95% confidence interval [CI] 0.7 to 2.1), 3.6% (95% CI 2.1 to 5.6) and 9% (95% CI 5.5 to 13.8) respectively in Lee's derivation group of 2,893 patients. In our audit of 296 patients we observed a cardiac event rate of 0.8% (95% CI 0 to 2.3%), 6.7% (95% CI 1.6 to 10%) and 2% (95% CI 0 to 5.9%), in patients with one, two and three or more risk factors respectively. The more frequent use of ECGs and troponin levels in the routine postoperative care of high risk patients undergoing major noncardiac surgery is recommended on the basis of the frequency of a positive result and the impact of a positive result on a patient's management.

scholarly journals Postoperative atrial fibrillation as a risk factor for cardiovascular complications in non-cardiac surgery

2020 ◽  
Vol 19 (4) ◽  
pp. 2540
Author(s):  
O. N. Dzhioeva ◽  
O. M. Drapkina
Keyword(s):  
Atrial Fibrillation ◽  
Cardiac Surgery ◽  
Perioperative Complications ◽  
Risk Index ◽  
Clinical Importance ◽  
Cardiac Risk ◽  
Cardiovascular Complications ◽  
Improvement Program ◽  
Deliberate Hypotension ◽  
Number Of Patients

Reducing mortality due to cardiovascular complications (CVC) after non-cardiac surgery is one of the priority tasks of modern healthcare. According to the literature data, it is the CVC that are leading cause of perioperative mortality in non-cardiac surgery. Atrial fibrillation (AF) is a common complication after surgery. It is believed that in most cases the AF is potentiated by a combination of factors. It is intraoperative triggers, such as deliberate hypotension, anemia, injury, and pain, that can directly contribute to development of arrhythmia. However, heart rate monitoring after non-cardiac surgery is performed in only a small number of patients, so in most cases, arrhythmias remain unreported. The Revised Cardiac Risk Index (RCRI) and theAmericanCollegeof Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Surgical Risk Calculator are the current tools for assessing perioperative cardiovascular risk. Postoperative AF is not included in any CVC risk stratification system. The presented review systematizes the data that postoperative AF is closely associated with perioperative complications and in some cases it may be the only marker of these complications.  It has been shown that AF detection is of great clinical importance in both high-risk patients and, especially, in patients with a low risk of potential complications in non-cardiac surgery.

scholarly journals Posthospital Cardiovascular Complications in Patients after Non-Cardiac Surgery

2021 ◽  
Vol 18 (4) ◽  
pp. 62-72
Author(s):  
D. A. Sokolov ◽  
P. A. Lyuboshevsky ◽  
I. N. Staroverov ◽  
I. A. Kozlov
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
Cardiac Surgery ◽  
Chronic Heart Failure ◽  
Cardiac Risk ◽  
Cardiovascular Complications ◽  
Cardiac Events ◽  
Risk Indices ◽  
Medium Risk ◽  
Potential Risk Factors

The objective: to analyze the incidence and spectrum of cardiovascular complications within 12 months after noncardiac surgery, as well as to assess the association of preoperative values of various cardiac risk indices (CRI) and other potential risk factors with the actual development of complications.Subjects and Methods. We analyzed data of medical records and telephone interviews of 141 patients aged 65 [60-71] years who had undergone non-cardiac surgery a year before the interview The operations were low risk in 13.5% of observations, medium risk in 64.5%, and high risk in 22%. A retrospective calculation of the Revised CRI (RCRI), Individual CRI (Khoronenko CRI), and the American College of Surgeons Perioperative Risk for Myocardial Infarction or Cardiac Arrest (MICA) was performed.Results. Cardiac events (myocardial infarction, decompensation of chronic heart failure, new arrhythmias, stroke, and/or the need to prescribe or escalate the dose of cardiovascular drugs and/or hospitalization for cardiac indications, and/or death from cardiovascular diseases) within 12 months after elective noncardiac surgeries were detected in 27.7% of cases, and in 2.1% of patient's death occurred due to cardiac disorders. Predictors of cardiac events were concomitant ischemic heart disease (OR = 2.777; 95% CI 1.286-5.966; p = 0.0093) and chronic heart failure (OR = 2.900; 95% CI 1.224-6.869; p = 0, 0155), RCRI (OR = 1.886; 95% CI 1.2-8-2.944; p = 0.005), Khoronenko CRI (OR = 3254.3; 95% CI 64.33-164,638; p = 0.0001), MICA (OR = 1.628; 95% CI 1.156-2.292; p = 0.005), creatininemia on the first postoperative day (OR = 1.023; 95% CI 1.010-1.061; p = 0.005), and propensity for bradycardia during surgery (OR = 0.945; 95% CI 0.908-0.983; p = 0.005). Combined analysis of Khoronenko's CRI and postoperative creatininemia provided a very good model: area under the ROC-curve - 0.823 (95% CI 0.728-0.641; p = 0.0002).Conclusion. All studied CRIs can be used to predict posthospital cardiac events; however, the most promising is a joint assessment of Khoronenko's CRI and postoperative creatinemia.

scholarly journals Postoperative Myocardial Injury in Patients Classified as Low Risk Preoperatively Is Associated With a Particularly Increased Risk of Long‐Term Mortality After Noncardiac Surgery

2021 ◽  
Author(s):  
Sunil K. Vasireddi ◽  
Erica Pivato ◽  
Enrique Soltero‐Mariscal ◽  
Raghuram Chava ◽  
Laurence O. James ◽  
...  
Keyword(s):  
Risk Index ◽  
Cardiac Risk ◽  
Noncardiac Surgery ◽  
Low Risk ◽  
Preoperative Risk ◽  
Improvement Program ◽  
Troponin Elevation ◽  
American College Of Surgeons ◽  
All Cause Mortality

Background Prior studies have shown an association between myocardial injury after noncardiac surgery (MINS) and all‐cause mortality in patients following noncardiac surgery. However, the association between preoperative risk assessments, Revised Cardiac Risk Index and American College of Surgeons National Surgical Quality Improvement Program, and postoperative troponin elevations and long‐term mortality is unknown. Methods and Results A retrospective chart review identified 548 patients who had a troponin I level drawn within 14 days of noncardiac surgery that required an overnight hospital stay. Patients aged 40 to 80 years with at least 2 cardiovascular risk factors were included, while those with trauma, pulmonary embolism, and neurosurgery were excluded. Kaplan–Meier survival and odds ratio (OR) with sensitivity/specificity analysis were performed to assess the association between preoperative risk and postoperative troponin elevation and all‐cause mortality at 1 year. Overall, 69%/31% were classified as low‐risk/high‐risk per the Revised Cardiac Risk Index and 66%/34% per American College of Surgeons National Surgical Quality Improvement Program. Comparing the low‐risk versus high‐risk groups, preoperative risk assessment was not associated with either postoperative troponin elevation or 1‐year mortality. MINS portended a 1‐year mortality of OR, 3.9 (95% CI, 2.44–6.33) in the total population. Patients classified as low risk preoperatively with MINS had the highest risk of 1‐year mortality (OR, 9.6; 95% CI, 4.27–24.38), with a low prevalence of statin use. Conclusions Current preoperative risk stratification tools do not prognosticate the risk of postoperative troponin elevation and all‐cause mortality at 1 year. Interestingly, patients classified as low risk preoperatively with MINS had a markedly higher 1‐year mortality risk compared with the general population, and most of them are not taking a statin. Our results suggest that evaluating preoperatively low‐risk patients for MINS presents an opportunity for prognostication, risk reclassification, and initiating therapies such as statins to mitigate long‐term risk.

Abstract 14637: Influence of Age on Perioperative Major Adverse Cardiovascular Events and Mortality Risks in Elective Non-cardiac Surgery

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Peter W Hansen ◽  
Gunnar H Gislason ◽  
Mads Emil Joergensen ◽  
Lars Køber ◽  
Per F Jensen ◽  
...  
Keyword(s):  
Cardiovascular Events ◽  
Elective Surgery ◽  
Risk Index ◽  
Cardiac Risk ◽  
Cardiovascular Death ◽  
Cardiovascular Complications ◽  
Advanced Age ◽  
Major Adverse Cardiovascular Events ◽  
Logistic Regression Models ◽  
The Impact

Background and Aims: Advanced age increases risk of perioperative cardiovascular complications and might therefore pose reluctance to subject elderly patients to surgery. We examined the impact of high age on perioperative major adverse cardiovascular events (MACE) and mortality in a nationwide cohort of patients undergoing elective surgery. Methods: All Danish patients aged ≥20 years undergoing non-cardiac, elective surgery in 2005-2011 were identified from nationwide administrative registers. Risks of 30-day MACE (non-fatal ischemic stroke, non-fatal myocardial infarction, or cardiovascular death) and all-cause mortality were analysed by multivariable logistic regression models (adjusted for major comorbidities, revised cardiac risk index, cardiovascular pharmacotherapy, body mass index, and surgery type). Results: A total of 386,818 procedures were included; mean age 56 years (min-max 20-104), 44% women. In total 1,297 (0.34%) had perioperative MACE and 1,449 (0.37%) died. Odds ratios increased with higher age for both MACE and mortality (Figure). Each 10-year higher age was associated with odds ratio 1.87 (1.78-1.98) for MACE, and 1.86 (1.77-1.95) for mortality. In total of 19,849 procedures were performed in patients 81-90 years of age, and 1,662 on patients ≥90 years. The crude MACE and mortality rates were 331 (1.7%) and 388 (2.0%) among 81-90 years old, and 50 (3.0%) and 67 (4.6%) for those aged ≥90 years. Conclusion: The risk of mortality and major adverse cardiovascular events within 30 days after surgery increased linearly with advanced age. However, despite advanced age the absolute event rates were relatively modest and below 5% even for people aged ≥90 years.

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