Major Cardiac Events in Patients Admitted to Intensive Care After Vascular Noncardiac Surgery: A Retrospective Cohort

2019 ◽  
Vol 23 (3) ◽  
pp. 293-299 ◽  
Author(s):  
Pedro Videira Reis ◽  
Ana Isabel Lopes ◽  
Diana Leite ◽  
João Moreira ◽  
Leonor Mendes ◽  
...  
Keyword(s):  
High Risk ◽  
Characteristic Curve ◽  
Risk Index ◽  
Previous History ◽  
Predictive Ability ◽  
Cardiac Risk ◽  
Noncardiac Surgery ◽  
Intermediate Risk ◽  
Cardiac Events ◽  
Predictive Capacity

Introduction. Patients proposed to vascular noncardiac surgery (VS) have several comorbidities associated with major adverse cardiac events (MACE). We evaluated incidence, predictors, and outcomes, and compared different scores to predict MACE after VS. Methods. We included all patients admitted from 2006 to 2013. Perioperative MACE included cardiac arrhythmias, myocardial infarction (MI), cardiogenic pulmonary edema (CPE), acute heart failure (AHF), and cardiac arrest (CA). Lee Revised Cardiac Risk Index (RCRI), Vascular Quality Initiative (VQI-CRI), Vascular Study Group of New England (VSG-CRI), and South African Vascular Surgical (SAVS-CRI) Cardiac Risk Indexes were calculated and analyzed. We performed multivariate logistic regression to assess independent predictors with calculation of odds ratio (OR) and 95% confidence interval (CI). To reduce overfitting, we used leave-one-out cross-validation approach. The Predictive ability of scores was tested using area under receiver operating characteristic curve (AUROC). Results. A total of 928 patients were included. We observed 81 MACE (28 MI, 22 arrhythmias, 10 CPE, 9 AHF, 12 CA) in 60 patients (6.5%): 3.3% in intermediate-risk surgery and 9.8% in high-risk surgery. Previous history of coronary artery disease (OR = 3.2, CI = 1.8-5.7), atrial fibrillation (OR = 5.1, CI = 2.4-11.0), insulin-treated diabetes mellitus (OR = 3.26, CI = 1.51-7.06), mechanical ventilation (OR = 2.75, CI = 1.41-4.63), and heart rate (OR = 1.02, CI = 1.01-1.03) at admission were considered independent risk factors in multivariate analysis. The AUROC of our model was 0.79, compared with RCRI (0.66), VSG-CRI (0.69), VQI-CRI (0.71), and SAVS-CRI (0.73). Conclusions. Observed MACE were within predicted range (1% to 5% after intermediate-risk surgery and >5% after high-risk surgery). SAVS-CRI and VQI-CRI had slightly better predictive capacity than VSG-CRI or RCRI.

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 Improving Identification of Patients at Low Risk for Major Cardiac Events After Noncardiac Surgery Using Intraoperative Data

2020 ◽  
Vol 15 (10) ◽  
pp. 581-587
Author(s):  
Amol S Navathe ◽  
Victor J Lei ◽  
Lee A Fleisher ◽  
ThaiBinh Luong ◽  
Xinwei Chen ◽  
...  
Keyword(s):  
Risk Stratification ◽  
Characteristic Curve ◽  
Risk Index ◽  
Model Performance ◽  
The United States ◽  
Noncardiac Surgery ◽  
Low Risk ◽  
Major Adverse Cardiovascular Events ◽  
Cardiac Complications ◽  
Cardiac Events

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.

Abstract 15582: Patterns of Statin Initiation in Patients Undergoing Intermediate to High Risk Non-Cardiac Surgery

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Elisabetta Patorno ◽  
Shirley Wang ◽  
Sebastian Schneeweiss ◽  
Jun Liu ◽  
Brian Bateman
Keyword(s):  
Cardiac Surgery ◽  
High Risk ◽  
Vascular Surgery ◽  
Elective Surgery ◽  
Risk Index ◽  
Cardiac Risk ◽  
Cardiac Events ◽  
Initiation Rate ◽  
Cardiac Risk Index ◽  
Recent Estimate

Background: Starting from early to mid 2000s a growing body of literature has been produced on the potential role of statins in reducing perioperative cardiac events in patients undergoing non-cardiac surgery. However, evidence remains inconsistent and little is known regarding the use of perioperative statins in clinical practice. Objectives: To examine pattern of statin initiation among patients undergoing non-cardiac elective surgery in the US. Methods: Using data from a large US healthcare insurer, we identified patients ≥18 years who underwent moderate- to high-risk non-cardiac elective surgery and initiated statins within 30-days before surgery. We assessed trends of statin initiation over time and predictors of initiation. To ensure statin initiation was precipitated by non-cardiac surgery vs. alternative indications, we also assessed the effect of temporal proximity to surgery on initiation in a matched analysis. Results: Of 460,154 patients undergoing surgery between 2003-2012, 5,628 (1.2%) initiated a statin before surgery. Initiation rate increased from 0.8% in 2003 to 1.5% in 2012 (p = .0004). The increase was more pronounced among patients with revised cardiac risk index (RCRI) score ≥2 and patients undergoing vascular surgery, with initiation rates equal to 7.2% and 14.9% respectively by the end of 2012. Proximity to surgery was predictive of statin initiation (p < .0001). Significant predictors of initiation were older age, male sex, revised cardiac risk index (RCRI) score ≥1, vascular or orthopedic surgery. At the most recent estimate, patients undergoing vascular surgery and with a RCRI score ≥2 had initiation rates equal to 19.9%. Conclusions: The rate of statin initiation progressively increased from 2003 to 2012, particularly among patients with higher RCRI score and undergoing major vascular surgery. Research is needed to further define the risks and benefits of initiation of statins prior to surgery.

scholarly journals Patient Selection for Routine Troponin Monitoring After Noncardiac Surgery

2021 ◽  
Author(s):  
Corien S. A. Weersink ◽  
Judith A. R. van Waes ◽  
Remco B. Grobben ◽  
Hendrik M. Nathoe ◽  
Wilton A. van Klei
Keyword(s):  
High Risk ◽  
Troponin I ◽  
Elective Surgery ◽  
Risk Index ◽  
Regression Tree ◽  
Cardiac Risk ◽  
Noncardiac Surgery ◽  
Classification And Regression Tree ◽  
Regression Tree Analysis ◽  
Number Needed To Screen

Background Myocardial 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 Results This 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. Conclusions To 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.

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.

Gene scoring model to predict recurrence in low- and intermediate-risk uterine endometrial cancer: Establishment of uterine print.

2013 ◽  
Vol 31 (15_suppl) ◽  
pp. 5590-5590
Author(s):  
Tatsuyuki Chiyoda ◽  
Yoichi M Ito ◽  
Fumio Kataoka ◽  
Wataru Yamagami ◽  
Hiroyuki Nomura ◽  
...  
Keyword(s):  
Gene Expression ◽  
High Risk ◽  
Expression Profiles ◽  
Characteristic Curve ◽  
High Risk Group ◽  
Internal Controls ◽  
Rank Test ◽  
Test Cases ◽  
Intermediate Risk ◽  
Scoring Model

5590 Background: Endometrial cancers (ECs) classified as low-, intermediate-, and high-risk, based on clinical and pathological features (CPF: Lurain, 2007) associated with 5%, 15%, and 25% risk of recurrence, respectively. The need for adjuvant chemotherapy in intermediate-risk patients is controversial. We examined whether gene expression profiling can more accurately predict the prognosis of ECs, excluding the CPF-based high-risk group. Methods: Tumor specimens were obtained from 136 ECs including 14 recurrences, excluding high-risk cases. Gene expression profiles were achieved using a custom array consisting of 85 genes associated with EC recurrence and 20 internal controls that were previously screened. We established the gene scoring model (GSM) for recurrence by the logistic regression model in randomly selected 68 ECs including 7 recurrences, and evaluated the accuracy of GSM in other 68 ECs including 7 recurrences. This process was repeated 100 times. We calculated the mean accuracy of GSM and compared it with the accuracy of CPF. We also compared GSM and CPF with respect to progression-free survival (PFS) by use of the log-rank test. Results: Median age of all cases was 58 (29-86) years, and stage, histologic grade, and risk classification based on CPF were as follows: (I, 107; II, 15; III, 14), (G1, 69; G2, 57; G3, 10), and (low, 67; intermediate, 69). The median follow-up period was 1830 (1626-3444) days. The GSM was established based on the expression of 4 genes (PRCC, SPC25, PXDN, and LBXCOR1) and 10 internal controls. The area under the receiver operating characteristic curve of GSM to predict recurrence was 0.87 in 68 test cases. Based on the CPF, 68 cases were classified as 30 low-risk and 38 intermediate-risk, and the sensitivity and specificity of CPF was 86% and 48% each in the 68 test cases. When sensitivity of GSM was fixed at 86%, specificity of 67% was achieved, and 68 cases were classified as 42 risk (-) and 26 risk (+). PFS was significantly related with GSM (p = 0.006); however, it was not related with CPF (p = 0.09). Conclusions: GSM can predict the prognosis of ECs (low- and intermediate-risk) more precisely than CPF.

Predictive role of capillaroscopic skin ulcer risk index in systemic sclerosis: a multicentre validation study

2011 ◽  
Vol 71 (1) ◽  
pp. 67-70 ◽  
Author(s):  
M Sebastiani ◽  
A Manfredi ◽  
G Vukatana ◽  
S Moscatelli ◽  
L Riato ◽  
...  
Keyword(s):  
Systemic Sclerosis ◽  
High Risk ◽  
Characteristic Curve ◽  
Risk Index ◽  
Large Population ◽  
Area Under The Curve ◽  
Skin Ulcer ◽  
Digital Ulcers ◽  
Specificity And Sensitivity

IntroductionThe early detection of systemic sclerosis (SSc) patients at high risk of developing digital ulcers could allow preventive treatment, with a reduction of morbidity and social costs. In 2009, a quantitative score, the capillaroscopic skin ulcer risk index (CSURI), calculated according to the formula ‘D×M/N2’, was proposed, which was highly predictive of the appearance of scleroderma digital ulcers within 3 months of capillaroscopic evaluation.ObjectivesThis multicentre study aims to validate the predictive value and reproducibility of CSURI in a large population of SSc patients.MethodsCSURI was analysed in 229 unselected SSc patients by nailfold videocapillaroscopy (NVC). All patients were re-evaluated 3 months later with regard to the persistence and/or appearance of new digital ulcers.Results57 of 229 patients presented with digital ulcers after 3 months. The receiver operating characteristic curve analysis showed an area under the curve of 0.884 (95% CI 0.835 to 0.922), with specificity and sensitivity of 81.4% (95% CI 74.8 to 86.89) and 92.98% (95% CI 83.0 to 98.0), respectively, at the cut-off value of 2.96. The reproducibility of CSURI was validated on a random sample of 81 patients, with a κ-statistic measure of interrater agreement of 0.8514.ConclusionsThe role of CSURI was confirmed in detecting scleroderma patients with a significantly high risk of developing digital ulcers within the first 3 months from NVC evaluation. CSURI is the only method validated to predict the appearance of digital ulcers and its introduction into routine clinical practice might help optimise the therapeutic strategy of these harmful SSc complications.

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