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Purpose: Biomarkers can aid in perioperative risk stratification. While preoperative copeptin has been associated with adverse events, intraoperative information is lacking and this association may rather reflect a baseline risk. Knowledge about correlations between postoperative copeptin measurements and clinically relevant outcomes is scarce. We examined the association of perioperative copeptin concentrations with postoperative all-cause mortality and/or major adverse cardiac and cerebrovascular events (MACCE) at 12 months and 30 days as well as with perioperative myocardial injury (PMI). Methods: We conducted a prospective observational cohort study of adults undergoing noncardiac surgery with intermediate to high surgical risk in Basel, Switzerland, and Düsseldorf, Germany from February 2016 to December 2020. We measured copeptin and cardiac troponin before surgery, immediately after surgery (0 hr) and once between the second and fourth postoperative day (POD 2–4). Results: A primary outcome event of a composite of all-cause mortality and/or MACCE at 12 months occurred in 48/502 patients (9.6%). Elevated preoperative copeptin (> 14 pmol·L−1), immediate postoperative copeptin (> 90 pmol·L−1), and copeptin on POD 2–4 (> 14 pmol·L−1) were associated with lower one-year MACCE-free and/or mortality-free survival (hazard ratio [HR], 2.89; 95% confidence interval [CI], 1.62 to 5.2; HR, 2.07; 95% CI, 1.17 to 3.66; and HR, 2.47; 95% CI, 1.36 to 4.46, respectively). Multivariable analysis continued to show an association for preoperative and postoperative copeptin on POD 2–4. Furthermore, elevated copeptin on POD 2–4 showed an association with 30-day MACCE-free survival (HR, 2.15; 95% CI, 1.18 to 3.91). A total of 64 of 489 patients showed PMI (13.1%). Elevated preoperative copeptin was not associated with PMI, while immediate postoperative copeptin was modestly associated with PMI. Conclusion: The results of the present prospective observational cohort study suggest that perioperative copeptin concentrations can help identify patients at risk for all-cause mortality and/or MACCE. Other identified risk factors were revised cardiac risk index, body mass index, surgical risk, and preoperative hemoglobin. Trial registration: ClinicalTrials.gov (NCT02687776); first submitted 9 February 2016.

Graphical AbstractASA, American society of anesthesiology; AUC, area under the receiver operating characteristics curve; Hb, haemoglobin; Na, potassium; RCRI, revised cardiac risk index

Postoperative hypoalbuminaemia is frequent after cardiac surgery with the use of cardiopulmonary bypass (CPB) and can result from intraoperative blood loss, dilution, increased inflammatory response or postoperative capillary leak amongst other reasons [1].

Hintergrund: Über 200 Mio. nichtkardiochirurgische Operationen werden weltweit jährlich durchgeführt. Etwa 5 % der Patienten erleiden im Verlauf kardiovaskuläre Komplikationen. Der Risikostratifizierung sowie der Früherkennung solcher Ereignisse kommt daher eine große Bedeutung zu. Zielsetzung: Diese Übersichtsarbeit soll dazu dienen, einen Überblick über die aktuell verfügbaren Biomarker zu geben, die in diesem Kontext genutzt werden können. Dabei sollen sowohl etablierte Biomarker, wie Troponin oder BNP, aber auch neuere zur Verfügung stehende Biomarker, wie z. B. Copeptin oder Presepsin, näher vorgestellt werden. Methoden: Narrative Übersichtsarbeit. Ergebnisse und Schlussfolgerung: Trotz konsistenter Datenlage zur starken Assoziation zwischen perioperativen Troponin- und BNP-Bestimmungen und postoperativen kardiovaskulären Ereignissen und Mortalität besteht derzeit noch eine große Diskrepanz zwischen diesen Erkenntnissen und ihrer Anwendung in der klinischen Praxis. Grund dafür ist insbesondere der ausstehende Nachweis eines Überlebensvorteils durch diesen Ansatz der Risikoevaluation. Basierend auf den vorliegenden Daten könnte aber auch das alleinige Wissen um das erhöhte perioperative Risiko dazu führen, dass betroffene Patienten ein erhöhtes Maß an Aufmerksamkeit bekommen, beispielsweise im Rahmen der präoperativen kardialen Evaluation, bei der Wahl des intra- bzw. postoperativen Monitorings oder bezüglich der postoperativen Abklärung der Notwendigkeit einer Sekundärprophylaxe. Ob dies schließlich auch zu einer Verbesserung des Outcomes führen kann, muss in zukünftigen Studien noch untersucht werden. Mehrere neue kardiale Biomarker befinden sich derweil in der Evaluationsphase.

Yearly, more than 200 million people worldwide undergo noncardiac surgery, of whom about 5% will develop cardiovascular complications. Prevention, early recognition, and prompt treatment of these adverse cardiovascular events is therefore an important concern in perioperative medicine. The present narrative review aims to provide an overview and critical analysis of the currently available evidence on the role of biomarkers in perioperative cardiac risk assessment and monitoring of perioperative cardiac events before and after noncardiac surgery.

Background: Orthotopic heart transplantation (HTX) is the gold standard to treat end-stage heart failure. Numerous risk stratification tools have been developed in the past years. However, their clinical utility is limited by their poor discriminative ability. High sensitivity troponin T (hsTnT) is the most specific biomarker to detect myocardial cell injury. However, its prognostic relevance after HTX is not fully elucidated. Thus, this study evaluated the predictive value of postoperative hsTnT for 1-year survival and days alive and out of hospital (DAOH) after HTX. Methods: This retrospective cohort study included patients who underwent HTX at the University Hospital Duesseldorf, Germany between 2011 and 2021. The main exposure was hsTnT concentration at 48 h after HTX. The primary endpoints were mortality and DAOH within 1 year after surgery. Receiver operating characteristic (ROC) curve analysis, logistic regression model and linear regression with adjustment for risk index for mortality prediction after cardiac transplantation (IMPACT) were performed. Results: Out of 231 patients screened, 212 were included into analysis (mean age 55 ± 11 years, 73% male). One-year mortality was 19.7% (40 patients) and median DAOH was 298 days (229–322). ROC analysis revealed strongest discrimination for mortality by hsTnT at 48 h after HTX [AUC = 0.79 95% CI 0.71–0.87]. According to Youden Index, the cutoff for hsTnT at 48 h and mortality was 1640 ng/l. After adjustment for IMPACT score multivariate logistic and linear regression showed independent associations between hsTnT and mortality/DAOH with odds ratio of 8.10 [95%CI 2.99–21.89] and unstandardized regression coefficient of −1.54 [95%CI −2.02 to −1.06], respectively. Conclusion: Postoperative hsTnT might be suitable as an early prognostic marker after HTX and is independently associated with 1-year mortality and poor DAOH.

ObjectiveRecently, daytime variation in perioperative myocardial injury (PMI) has been observed in patients undergoing cardiac surgery. We aim at investigating whether daytime variation also occurs in patients undergoing non-cardiac surgery.MethodsIn a prospective diagnostic study, we evaluated the presence of daytime variation in PMI in patients at increased cardiovascular risk undergoing non-cardiac surgery, as well as its possible impact on the incidence of acute myocardial infarction (AMI), and death during 1-year follow-up in a propensity score–matched cohort. PMI was defined as an absolute increase in high-sensitivity cardiac troponin T (hs-cTnT) concentration of ≥14 ng/L from preoperative to postoperative measurements.ResultsOf 1641 patients, propensity score matching defined 630 with similar baseline characteristics, half undergoing non-cardiac surgery in the morning (starting from 8:00 to 11:00) and half in the afternoon (starting from 14:00 to 17:00). There was no difference in PMI incidence between both groups (morning: 50, 15.8% (95% CI 12.3 to 20.3); afternoon: 52, 16.4% (95% CI 12.7 to 20.9), p=0.94), nor if analysing hs-cTnT release as a quantitative variable (median morning group: 3 ng/L (95% CI 1 to 7 ng/L); median afternoon group: 2 ng/L (95% CI 0 to 7 ng/L; p=0.16). During 1-year follow-up, the incidence of AMI was 1.2% (95% CI 0.4% to 3.2%) among morning surgeries versus 4.1% (95% CI 2.3% to 6.9%) among the afternoon surgeries (corrected HR for afternoon surgery 3.44, bootstrapped 95% CI 1.33 to 10.49, p log-rank=0.03), whereas no difference in mortality emerged (p=0.70).ConclusionsAlthough there is no daytime variation in PMI in patients undergoing non-cardiac surgery, the incidence of AMI during follow-up is increased in afternoon surgeries and requires further study.Clinical trial registrationNCT02573532;Results.

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Supplemental Digital Content is available in the text.Published ahead of print May 19, 2017.

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