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1. Impact of Arterial Procedures on Coagulation and Fibrinolysis - A Pilot Study

Author

Kamil Jurand Polok, Jacek Górka, Jakub Fronczek, Karolina Górka, Bogusz Kaczmarek, Teresa Iwaniec, Paweł Iwaszczuk, Jacek Musiał, and Wojciech Szczeklik

Subjects
Blood, Coagulation/Anticoagulation, Fibrin/Fibrosis/Fibrinolysis, Vascular Surgical Procedures, Surgery, RD1-811, Diseases of the circulatory (Cardiovascular) system, RC666-701
Abstract

Abstract Objective: The main goal of our study was to assess the impact of vascular procedures on the activity of hemostatic and fibrinolytic pathways. Methods: We enrolled 38 patients with ≥ 45 years old undergoing surgery for abdominal aortic aneurysm or peripheral artery disease under general or regional anesthesia and who were hospitalized at least one night after the procedure. Patients undergoing carotid artery surgery and those who had acute bypass graft thrombosis, cancer, renal failure defined as estimated glomerular filtration rate < 30 ml/min/1.73m2, venous thromboembolism three months prior to surgery, or acute infection were excluded from the study. We measured levels of markers of hemostasis (factor VIII, von Willebrand factor:ristocetin cofactor [vWF:CoR], antithrombin), fibrinolysis (D-dimer, tissue plasminogen activator [tPA], plasmin-antiplasmin complexes), and soluble cluster of differentiation 40 ligand (sCD40L) before and 6-12h after vascular procedure. Results: Significant differences between preoperative and postoperative levels of factor VIII (158.0 vs. 103.3, P

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2. Perioperative covert stroke in patients undergoing non-cardiac surgery (NeuroVISION): a prospective cohort study

Author

Philip J. Devereaux, Feryal Saad, Wojciech Szczeklik, Nikesh R. Adunuri, Manoj J. Raval, Tony Gin, Demetrios J. Sahlas, Matthew T. V. Chan, Jonathan Kumar, Shrikant I. Bangdiwala, Quazi Ibrahim, Shun Fu Lee, Ingrid Copland, Bogusz Kaczmarek, PT Phang, Maite Fuentes, Luciano A. Sposato, Shirley Pettit, Steven Yang, Robert D. Sanders, Pui San Loh, Monidipa Dasgupta, Simon Ch Yu, William K.K. Wu, Jessica Spence, Ronit Agid, Michael D. Hill, Sarah Apolcer, Sara Hussain, Alexander Khaw, Divya Sadana, Heidi Lindroth, Scott Tsai, Carl J. Brown, Victor Ortiz-Soriano, Vincent Mok, Yee Lein Siow, Timothy G. Short, Douglas M Campbell, Chew Yin Wang, Mun Thing Liew, Flávia Kessler Borges, Amelia Trombetta, Stephanie Handsor, Norlisah Ramli, Ahmer A. Karimuddin, Mukul Sharma, Salim Yusuf, Marko Mrkobrada, David Cowan, Arun Mensinkai, Germán Málaga, Gordon H. Guyatt, Alben Sigamani, Eric E. Smith, Manas Sharma, Deborah M. Siegal, Jennifer Mandzia, Daniel I. Sessler, David Torres, Lenimol Thomas, Sara Simpson, John M. Murkin, Ellen Waymouth, and Adam A Dmytriw

Subjects
Male, medicine.medical_specialty, 030204 cardiovascular system & hematology, 03 medical and health sciences, 0302 clinical medicine, Emergence Delirium, Postoperative Complications, Risk Factors, medicine, Humans, Cognitive Dysfunction, 030212 general & internal medicine, Prospective Studies, Cognitive decline, Prospective cohort study, Perioperative Period, Stroke, Aged, business.industry, Absolute risk reduction, Montreal Cognitive Assessment, General Medicine, Perioperative, Odds ratio, medicine.disease, Magnetic Resonance Imaging, Elective Surgical Procedures, Case-Control Studies, Emergency medicine, Delirium, Female, medicine.symptom, business
Abstract

Summary Background In non-surgical settings, covert stroke is more common than overt stroke and is associated with cognitive decline. Although overt stroke occurs in less than 1% of adults after non-cardiac surgery and is associated with substantial morbidity, we know little about perioperative covert stroke. Therefore, our primary aim was to investigate the relationship between perioperative covert stroke (ie, an acute brain infarct detected on an MRI after non-cardiac surgery in a patient with no clinical stroke symptoms) and cognitive decline 1 year after surgery. Methods NeuroVISION was a prospective cohort study done in 12 academic centres in nine countries, in which we assessed patients aged 65 years or older who underwent inpatient, elective, non-cardiac surgery and had brain MRI after surgery. Two independent neuroradiology experts, masked to clinical data, assessed each MRI for acute brain infarction. Using multivariable regression, we explored the association between covert stroke and the primary outcome of cognitive decline, defined as a decrease of 2 points or more on the Montreal Cognitive Assessment from preoperative baseline to 1-year follow-up. Patients, health-care providers, and outcome adjudicators were masked to MRI results. Findings Between March 24, 2014, and July 21, 2017, of 1114 participants recruited to the study, 78 (7%; 95% CI 6–9) had a perioperative covert stroke. Among the patients who completed the 1-year follow-up, cognitive decline 1 year after surgery occurred in 29 (42%) of 69 participants who had a perioperative covert stroke and in 274 (29%) of 932 participants who did not have a perioperative covert stroke (adjusted odds ratio 1·98, 95% CI 1·22–3·20, absolute risk increase 13%; p=0·0055). Covert stroke was also associated with an increased risk of perioperative delirium (hazard ratio [HR] 2·24, 95% CI 1·06–4·73, absolute risk increase 6%; p=0·030) and overt stroke or transient ischaemic attack at 1-year follow-up (HR 4·13, 1·14–14·99, absolute risk increase 3%; p=0·019). Interpretation Perioperative covert stroke is associated with an increased risk of cognitive decline 1 year after non-cardiac surgery, and perioperative covert stroke occurred in one in 14 patients aged 65 years and older undergoing non-cardiac surgery. Research is needed to establish prevention and management strategies for perioperative covert stroke. Funding Canadian Institutes of Health Research; The Ontario Strategy for Patient Oriented Research support unit; The Ontario Ministry of Health and Long-Term Care; Health and Medical Research Fund, Government of the Hong Kong Special Administrative Region, China; and The Neurological Foundation of New Zealand.

Published
2019

3. Impact of Arterial Procedures on Coagulation and Fibrinolysis - A Pilot Study

Author

Jakub Fronczek, Paweł Iwaszczuk, Bogusz Kaczmarek, Wojciech Szczeklik, Teresa Iwaniec, Kamil Polok, Karolina Górka, Jacek Górka, and Jacek Musiał

Subjects
Male, lcsh:Diseases of the circulatory (Cardiovascular) system, medicine.medical_treatment, Pilot Projects, 030204 cardiovascular system & hematology, 0302 clinical medicine, Reference Values, Risk Factors, Coagulation/Anticoagulation, Postoperative Period, education.field_of_study, biology, Fibrinolysis, Antithrombin, General Medicine, Middle Aged, Blood Coagulation Factors, Abdominal aortic aneurysm, Treatment Outcome, Blood, Coagulation, Preoperative Period, Cardiology, Original Article, Female, Cardiology and Cardiovascular Medicine, Vascular Surgical Procedures, medicine.drug, medicine.medical_specialty, Population, lcsh:Surgery, Enzyme-Linked Immunosorbent Assay, Statistics, Nonparametric, Peripheral Arterial Disease, 03 medical and health sciences, Von Willebrand factor, Internal medicine, medicine, Humans, education, Blood Coagulation, Aged, business.industry, lcsh:RD1-811, Vascular surgery, medicine.disease, lcsh:RC666-701, Hemostasis, biology.protein, Surgery, Fibrin/Fibrosis/Fibrinolysis, business, Biomarkers, Aortic Aneurysm, Abdominal
Abstract

Objective: The main goal of our study was to assess the impact of vascular procedures on the activity of hemostatic and fibrinolytic pathways. Methods: We enrolled 38 patients with ≥ 45 years old undergoing surgery for abdominal aortic aneurysm or peripheral artery disease under general or regional anesthesia and who were hospitalized at least one night after the procedure. Patients undergoing carotid artery surgery and those who had acute bypass graft thrombosis, cancer, renal failure defined as estimated glomerular filtration rate < 30 ml/min/1.73m2, venous thromboembolism three months prior to surgery, or acute infection were excluded from the study. We measured levels of markers of hemostasis (factor VIII, von Willebrand factor:ristocetin cofactor [vWF:CoR], antithrombin), fibrinolysis (D-dimer, tissue plasminogen activator [tPA], plasmin-antiplasmin complexes), and soluble cluster of differentiation 40 ligand (sCD40L) before and 6-12h after vascular procedure. Results: Significant differences between preoperative and postoperative levels of factor VIII (158.0 vs. 103.3, P

Published
2019

4. Dabigatran in patients with myocardial injury after non-cardiac surgery (MANAGE) : an international, randomised, placebo-controlled trial

Author

P J Devereaux, Emmanuelle Duceppe, Gordon Guyatt, Vikas Tandon, Reitze Rodseth, Bruce M Biccard, Denis Xavier, Wojciech Szczeklik, Christian S Meyhoff, Jessica Vincent, Maria Grazia Franzosi, Sadeesh K Srinathan, Jason Erb, Patrick Magloire, John Neary, Mangala Rao, Prashant V Rahate, Navneet K Chaudhry, Bongani Mayosi, Miriam de Nadal, Pilar Paniagua Iglesias, Otavio Berwanger, Juan Carlos Villar, Fernando Botto, John W Eikelboom, Daniel I Sessler, Clive Kearon, Shirley Pettit, Mukul Sharma, Stuart J Connolly, Shrikant I Bangdiwala, Purnima Rao-Melacini, Andreas Hoeft, Salim Yusuf, P.J. Devereaux, Shrikant I. Bangdiwala, Stuart Connolly, John Eikelboom, Janice Pogue, Daniel I. Sessler, Sara Di Diodato, Zora Gasic, Louise J. Mastrangelo, Sarah H. Molnar, Jennifer L. Swanson, Makayla L. Tosh, Jennifer R. Wells, Rafael Diaz, Clara K. Chow, Beatriz Gonzales, Skarlet Vásquez, Petr Jansky, Radovan Dušek, Christian S. Meyhoff, Pierre Coriat, Maria Wittmann, Gerald Yonga, Nandini Mathur, Elena Seletti, German Malaga, Bernadette A. Tumanan-Mendoza, Maria Pamela A. Tagle, Bruce M. Biccard, Pablo Alonso-Coello, Ekaterine Popova, Martin Shields, Yannick Le Manach, Paul Moayyedi, Sander van Zanten, Edith Fleischmann, Amit Garg, Kamilu Karaye, Edward McFalls, Alben Sigamani, Emilie Belley-Côté, Grzegorz Biedroń, Flavia Borges, Steffan Frosi Stella, Christian Haarmark Nielsen, Darryl P. Leong, Jessica Spence, Allen Tran, Katarzyna Wawrzycka-Adamczyk, Stephen S. Yang, Terence Yung, D. George Wyse, Davy Cheng, David E. Johnstone, George A. Wells, Philip Joseph, Ameen Patel, Krysten Gregus, Kelly Lawrence, Lindsay Doharris, David Conen, Jason Cheung, Jim Douketis, Douglas Wright, Spencer Wikkerink, William Dechert, Mohamed Panju, Khalid Azzam, Theodore Rapanos, Tomas Van Helder, Anjali Shroff, Jacqueline Hare, Biniam Kidane, Thang Nguyen, Larissa Leydier, Vanessa Bayaraa, Joel Parlow, Deborah A. DuMerton, Amar Thakrar, Jessica Shelley, Benoit Deligne, Roberta Daila Carling, Marko Mrkobrada, George K. Dresser, Michael J. Jacka, David Hornstein, Gerrit B. Winkelaar, Zoeb Hussain Haider, Pravina Prashant Lanjewar, Valsamma Varughese, Rajneesh Calton, Hemani Ahuja, Preetha George, Ambika Sharma, Keyur Sureshchandra Bhatt, Dhaval Odhavajibhai Mangukiya, Karshan Vira Nandaniya, Viral Vasantrai Parekh, Ashok Bhaskaran Pillai, Vidya P. Menon, Sanjay Channappa Desai, Ravinder Singh Sidhu, Sandeep Kumar Gupta, Robbie K. George, T.R. Gurunath, Leanne W. Drummond, Alexandra M. Torborg, Belinda S. Küsel, Prebashini Naidoo, Datshana P. Naidoo, Chantal Rajah, Zane Farina, Richard Peter von Rahden, Simphiwe Gumede, Chishala Chishala, Ettienne Coetzee, Robert A. Dyer, Johan Diedericks, Piotr Bielański, Bogusz Kaczmarek, Dorota Studzińska, Maciej Zaniewski, Marek Józef Libura, Tomasz Mikołaj Zacharias-Nalichowski, Aurelia A.S. Sega, Jakub Salwa, Mateusz Kózka, Jacek Górka, Anna Wludarczyk, Ilona Nowak-Kózka, Paweł Szczepan Grudzień, Jaroslaw W. Gucwa, Michał Piotr Słowiaczek, Paweł P.D. Dobosz, Ismail Gögenur, Jens Ravn Eriksen, Tine Borup, Tove Kirkegaard, Dan Isbye, Asger Sonne, Lars S. Rasmussen, Sofie Pedersen, Hannibal Troensegaard, Camilla L. Duus, Benedikte M. Halle, Ossian N. Gundel, Katrine F. Bernholm, Kristian Rønsholt Martinsen, Søren Pedersen, Theis S. Itenov, Elena Camio, Carles Vázquez, Silvia Matarin, Esther Cano, Jesús Álvarez-García, Inmaculada India, Aránzazu González-Osuna, Marc Vives, Elena Rosselló, Ana B. Serrano, Maurizio Turiel, Lorenzo Drago, Chiara Colombo, Federica Marra, Lucio Mos, Franco Arteni, Rosalba Lembo, Alessandro Ortalda, Simonetta Passarani, Zhirajr Mokini, Estevao Lanna Figueiredo, Gustavo Fonseca Werner, Joao Luiz Petriz, Lilia Nigro Maia, Ricardo R. Bergo, Dalton Bertolim Precoma, José Francisco Kerr Saraiva, Oscar Gomez Vilamajo, Eduardo Allegrini, Mariano Benzadón, Maria Leonor Parody, Ernesto A. Duronto, Adrián C. Ingaramo, Gustavo Adolfo Parra, Danny Novoa, Scott A. Miller, Sabu Thomas, Sudhakar P. Karlapudi, Mohamad H. Bourji, Subhash Banerjee, Anita Gupta, Isaac O. Opole, Michal Fischer, Victor Lecaros Mendoza, Eugenio Borja Reyes, Richard J. Pierson, Martin O. Shields, Vincent Piriou, Kai Zacharowski, Aida Rotta-Rotta, Main Paper, Sadeesh K. Srinathan, Prashant Rahate, Navneet Chaudhry, Bogani Mayosi, and Mike Sharma

Subjects
Male, medicine.medical_specialty, Myocardial Infarction, Placebo-controlled study, Hemorrhage, 030204 cardiovascular system & hematology, Placebo, Antithrombins, Dabigatran, law.invention, Peripheral Arterial Disease, 03 medical and health sciences, 0302 clinical medicine, Randomized controlled trial, 030202 anesthesiology, law, Internal medicine, medicine, Humans, Perioperative Period, Stroke, Aged, Aged, 80 and over, business.industry, Hazard ratio, Proton Pump Inhibitors, Thrombosis, Venous Thromboembolism, General Medicine, Perioperative, Placebo Effect, medicine.disease, Troponin, Clinical trial, Treatment Outcome, Female, business, Omeprazole, medicine.drug
Abstract

Summary Background Myocardial injury after non-cardiac surgery (MINS) increases the risk of cardiovascular events and deaths, which anticoagulation therapy could prevent. Dabigatran prevents perioperative venous thromboembolism, but whether this drug can prevent a broader range of vascular complications in patients with MINS is unknown. The MANAGE trial assessed the potential of dabigatran to prevent major vascular complications among such patients. Methods In this international, randomised, placebo-controlled trial, we recruited patients from 84 hospitals in 19 countries. Eligible patients were aged at least 45 years, had undergone non-cardiac surgery, and were within 35 days of MINS. Patients were randomly assigned (1:1) to receive dabigatran 110 mg orally twice daily or matched placebo for a maximum of 2 years or until termination of the trial and, using a partial 2-by-2 factorial design, patients not taking a proton-pump inhibitor were also randomly assigned (1:1) to omeprazole 20 mg once daily, for which results will be reported elsewhere, or matched placebo to measure its effect on major upper gastrointestinal complications. Research personnel randomised patients through a central 24 h computerised randomisation system using block randomisation, stratified by centre. Patients, health-care providers, data collectors, and outcome adjudicators were masked to treatment allocation. The primary efficacy outcome was the occurrence of a major vascular complication, a composite of vascular mortality and non-fatal myocardial infarction, non-haemorrhagic stroke, peripheral arterial thrombosis, amputation, and symptomatic venous thromboembolism. The primary safety outcome was a composite of life-threatening, major, and critical organ bleeding. Analyses were done according to the intention-to-treat principle. This trial is registered with ClinicalTrials.gov, number NCT01661101. Findings Between Jan 10, 2013, and July 17, 2017, we randomly assigned 1754 patients to receive dabigatran (n=877) or placebo (n=877); 556 patients were also randomised in the omeprazole partial factorial component. Study drug was permanently discontinued in 401 (46%) of 877 patients allocated to dabigatran and 380 (43%) of 877 patients allocated to placebo. The composite primary efficacy outcome occurred in fewer patients randomised to dabigatran than placebo (97 [11%] of 877 patients assigned to dabigatran vs 133 [15%] of 877 patients assigned to placebo; hazard ratio [HR] 0·72, 95% CI 0·55–0·93; p=0·0115). The primary safety composite outcome occurred in 29 patients (3%) randomised to dabigatran and 31 patients (4%) randomised to placebo (HR 0·92, 95% CI 0·55–1·53; p=0·76). Interpretation Among patients who had MINS, dabigatran 110 mg twice daily lowered the risk of major vascular complications, with no significant increase in major bleeding. Patients with MINS have a poor prognosis; dabigatran 110 mg twice daily has the potential to help many of the 8 million adults globally who have MINS to reduce their risk of a major vascular complication. Funding Boehringer Ingelheim and Canadian Institutes of Health Research.

Published
2018

5. Myocardial Injury after Noncardiac Surgery

Author

Pierre Coriat, Patricia Cruz, Bogusz Kaczmarek, Gabriel Cusati, Wendy Lim, Saeed Darvish-Kazim, Rupert Pearse, Finlay A. McAlister, Cheryl Ramballi, Robert C M Stephens, R.M. Pearse, Jeff Weitz, Germán Málaga, Alexander Y. Fu, Eleanor McAlees, Alberto Varela, Maria Palencia, James Zacharias, Ryan J. J. Amadeo, Bruce M Biccard, Janet Woods, Catherine M. Clase, Patrick S Finnegan, Laura Gallego Paredes, Alistair Hall, Mariana Vargas Furtado, Alben Sigamani, José Villamor, Alex Torborg, Maria De Los Angeles Lazo, Tony Gin, Pavel S Roshanov, Carmen Fernández, Andrea Kurz, Hertzel C. Gerstein, Stephen Li, R.N. Rodseth, P. Naidoo, Mitchell Winemaker, Parminder Raina, Gordon Y.S. Choi, Lalita Afzal, Richard Mizera, Sean M. Bagshaw, Marta Januszewska, Yannick LeManach, Sultana Furruqh, Robert J. Sapsford, Peter Lovrics, B M Biccard, Cecilia Martínez, Faisal Siddiqui, J. Mooney, Carisi Anne Polanczyk, Ina Ismiarti Shariffuddin, Mark Crowther, Elizabeth Ling, Adrià Font, Mark Soth, Maria Stella Chaparro, Maria José Membrillo, Ekaterina Popova, Denis Monneret, Richard P. Whitlock, Amit Garg, Andrew Archbold, Vascular Events In Noncardiac Surgery Patients Cohort Evaluation (Vision) Investigators, M Leuwer, Vincent W. Lee, Zhuo Sun, Patricia Piñeiro, César A. Jardim, Clare D. Ramsey, Krit Panjasawatwong, James Paul, David W. Gibson, Philip St John, Peter Nagele, Jose Amalth do Espirirto Santo, Pablo Alonso-Coello, Jacek Musial, Jacques G. Tittley, Fernando Botto, Georges Daas, Hou Yee Lai, Ana Gutierrez del Arroyo, Edmunds Reineks, Martin Leuwer, Clive Kearon, Jane Blood, Mari Luz Maestre, Neesh Pannu, Marta De Antonio, Ameen Patel, Aida Rotta-Rotta, Noorjahan Haneem Md Hashim, Amal Bessissow, Hélio Penna Guimarães, Norman Buckley, Mateusz Kózka, Maria José Ferré, Gerard Urrútia, Lydia C.W. Lit, Matthew T. V. Chan, Philip J. Devereaux, Ushananthini Ki, Jesús Alvarez García, Shaveta Mala, Juan Carlos Villar, Andrew McKay, Silvia Moreira Ayub Ferreira, Angeles de Miguel, Gordon H. Guyatt, David Orozco, A. Rushton, Michael J Jacka, Holger J Schünemann, Diane Heels-Ansdell, Guillaume Paré, Stephen Hill, Amit X Garg, Hooman Honar, Pervez Sultan, Miquel Santaló, Zubin Punthakee, Sihe Wang, Katia R. M. Leite, Holger Schünemann, Hilary P Grocott, Aram Shahinyan, Sebastian Ribas, Jackie Bosch, Amanda Smith, Giovanna Luratibuse, Joseph Cherian, Maciej Chwała, Heather McDonald, Rey R. Acedillo, Manuel Muñoz, Sally Benton, Michael Walsh, Vikas Tandon, Shirley Pettit, Javier D Loza-Herrera, Paul M. O'Bryne, Joanne Fletcher, Richard Halliwell, Clara K Chow, Jacek Górka, Michelle M. Graham, Alvaro Castañeda, Ainslie Hildebrand, Patrick Magloire, Skarlett Vásquez, Gareth L Ackland, P. George, Sergio Mazzadi, Susannah Howard, Simon J. Howell, Rubeshan Naidoo, William Orovan, Megan Kalin, Anna Reyes, Anthony Adili, Frederick A. Spencer, Laurel Thorlacius, Jehonathan H. Pinthus, Michaela Lobley, Justin DeBeer, Theroshnie Kisten, Dean Gopalan, John W. Eikelboom, Eliana Vieira Santucci, Derek R. Townsend, Raúl Gonzalez, Tomas VanHelder, Sean McMurtry, Susana Díaz, Catherine Royer, Hussein Cassimjee, James D. Douketis, Ahsun Khan, V Vasanthan, Chew Yin Wang, Sadeesh Srinathan, A. Wahab Undok, Deven Reddy, Paola Muti, Paul Jackson, Javier Ganame, Danielle MacNeil, Pilar Paniagua, Graham S. Hillis, Wojciech Szczeklik, Azim S. Gangji, Stephen D. Walter, Andrew Worster, Matthew B. McQueen, Sadeesh K Srinathan, Otavio Berwanger, Cameron Egan, Aine Mugabi, Neil MacDonald, Erica Aranha Suzumura, Matthew J. McQueen, Reitze N. Rodseth, Maria Del Barrio, Peter A. Kavsak, Cristina Ibanez Esteve, David Szalay, Olga L. Cortés, Fidel Reyes, John Whittle, Gracie Ong, Troy S. Wildes, Ngan N. Lam, Karen Raymer, C. Williams, G.L. Ackland, Enrico Vizza, Salim Yusuf, Wan Azman Ahmad, Radhika Dhanpal, Barbara Sokołowska, David Cain, Andre Lamy, Alexandre Biasi Cavalcanti, Marko Mrkobrada, James Hankinson, Emmanuelle Duceppe, Julian Scott, Maria Tiboni, Tomasz Mrowiecki, Vanessa Valderrama-Victoria, Paweł Iwaszczuk, Robert Sapsford, Andrew Wragg, Atiya Faruqui, Edyta Niebrzegowska, Mohit Bhandari, Teresa Del Castillo, Jean Pierre Goarin, Marko Simunovic, Omid Salehian, Smitha Almeida, Ingeborg Welters, Lehana Thabane, D.L. Skinner, Tej Sheth, Alvin S.B. Tan, Ignacio Garutti, Daniel I. Sessler, Sabu Thomas, Sarah D. McDonald, Trevor W R Lee, Marzida Mansor, Julian H. Barth, Nikki Dewhirst, Xavier Pelaez, Valsa Abraham, Jill Rudkowski, Sanjit S. Jolly, Azad Hassan Abdul Razack, Marcin Raczek, Duane J. Funk, Deborah J. Cook, Martin O'Donnell, and Denis Xavier

Subjects
medicine.medical_specialty, biology, Troponin T, business.industry, Hazard ratio, Infarction, Perioperative, medicine.disease, Troponin, Surgery, Anesthesiology and Pain Medicine, Internal medicine, medicine, biology.protein, Cardiology, Myocardial infarction, Prospective cohort study, business, Cohort study
Abstract

Background: Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study’s four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS. Methods: In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated “abnormal” laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria. Results: An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors’ diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96–5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6–41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom. Conclusion: Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.

Published
2014

6. Myocardial Injury after Noncardiac Surgery: A Large, International, Prospective Cohort Study Establishing Diagnostic Criteria, Characteristics, Predictors, and 30-day Outcomes

Author

Fernando, Botto, Pablo, Alonso-Coello, Matthew T V, Chan, Juan Carlos, Villar, Denis, Xavier, Sadeesh, Srinathan, Gordon, Guyatt, Patricia, Cruz, Michelle, Graham, C Y, Wang, Otavio, Berwanger, Rupert M, Pearse, Bruce M, Biccard, Valsa, Abraham, German, Malaga, Graham S, Hillis, Reitze N, Rodseth, Deborah, Cook, Carisi A, Polanczyk, Wojciech, Szczeklik, Daniel I, Sessler, Tej, Sheth, Gareth L, Ackland, Martin, Leuwer, Amit X, Garg, Yannick, Lemanach, Shirley, Pettit, Diane, Heels-Ansdell, Giovanna, Luratibuse, Michael, Walsh, Robert, Sapsford, Holger J, Schünemann, Andrea, Kurz, Sabu, Thomas, Marko, Mrkobrada, Lehana, Thabane, Hertzel, Gerstein, Pilar, Paniagua, Peter, Nagele, Parminder, Raina, Salim, Yusuf, P J, Devereaux, Matthew J, McQueen, Mohit, Bhandari, Jackie, Bosch, Norman, Buckley, Clara K, Chow, Richard, Halliwell, Stephen, Li, Vincent W, Lee, John, Mooney, Mariana V, Furtado, Erica, Suzumura, Eliana, Santucci, Katia, Leite, Jose Amalth do Espirirto, Santo, Cesar A P, Jardim, Alexandre Biasi, Cavalcanti, Helio Penna, Guimaraes, Michael J, Jacka, Finlay, McAlister, Sean, McMurtry, Derek, Townsend, Neesh, Pannu, Sean, Bagshaw, Amal, Bessissow, Emmanuelle, Duceppe, John, Eikelboom, Javier, Ganame, James, Hankinson, Stephen, Hill, Sanjit, Jolly, Andre, Lamy, Elizabeth, Ling, Patrick, Magloire, Guillaume, Pare, Deven, Reddy, David, Szalay, Jacques, Tittley, Jeff, Weitz, Richard, Whitlock, Saeed, Darvish-Kazim, Justin, Debeer, Peter, Kavsak, Clive, Kearon, Richard, Mizera, Martin, O'Donnell, Matthew, McQueen, Jehonathan, Pinthus, Sebastian, Ribas, Marko, Simunovic, Vikas, Tandon, Tomas, Vanhelder, Mitchell, Winemaker, Sarah, McDonald, Paul, O'Bryne, Ameen, Patel, James, Paul, Zubin, Punthakee, Karen, Raymer, Omid, Salehian, Fred, Spencer, Stephen, Walter, Andrew, Worster, Anthony, Adili, Catherine, Clase, Mark, Crowther, James, Douketis, Azim, Gangji, Paul, Jackson, Wendy, Lim, Peter, Lovrics, Sergio, Mazzadi, William, Orovan, Jill, Rudkowski, Mark, Soth, Maria, Tiboni, Rey, Acedillo, Amit, Garg, Ainslie, Hildebrand, Ngan, Lam, Danielle, Macneil, Pavel S, Roshanov, Sadeesh K, Srinathan, Clare, Ramsey, Philip St, John, Laurel, Thorlacius, Faisal S, Siddiqui, Hilary P, Grocott, Andrew, McKay, Trevor W R, Lee, Ryan, Amadeo, Duane, Funk, Heather, McDonald, James, Zacharias, Olga Lucía, Cortés, Maria Stella, Chaparro, Skarlett, Vásquez, Alvaro, Castañeda, Silvia, Ferreira, Pierre, Coriat, Denis, Monneret, Jean Pierre, Goarin, Cristina Ibanez, Esteve, Catherine, Royer, Georges, Daas, Gordon Y S, Choi, Tony, Gin, Lydia C W, Lit, Alben, Sigamani, Atiya, Faruqui, Radhika, Dhanpal, Smitha, Almeida, Joseph, Cherian, Sultana, Furruqh, Lalita, Afzal, Preetha, George, Shaveta, Mala, Holger, Schünemann, Paola, Muti, Enrico, Vizza, G S Y, Ong, Marzida, Mansor, Alvin S B, Tan, Ina I, Shariffuddin, V, Vasanthan, N H M, Hashim, A Wahab, Undok, Ushananthini, Ki, Hou Yee, Lai, Wan Azman, Ahmad, Azad H A, Razack, Vanessa, Valderrama-Victoria, Javier D, Loza-Herrera, Maria, De Los Angeles Lazo, Aida, Rotta-Rotta, Barbara, Sokolowska, Jacek, Musial, Jacek, Gorka, Pawel, Iwaszczuk, Mateusz, Kozka, Maciej, Chwala, Marcin, Raczek, Tomasz, Mrowiecki, Bogusz, Kaczmarek, Bruce, Biccard, Hussein, Cassimjee, Dean, Gopalan, Theroshnie, Kisten, Aine, Mugabi, Prebashini, Naidoo, Rubeshan, Naidoo, Reitze, Rodseth, David, Skinner, Alex, Torborg, Gerard, Urrutia, Mari Luz, Maestre, Miquel, Santaló, Raúl, Gonzalez, Adrià, Font, Cecilia, Martínez, Xavier, Pelaez, Marta, De Antonio, Jose Marcial, Villamor, Jesús Alvarez, García, Maria José, Ferré, Ekaterina, Popova, Ignacio, Garutti, Carmen, Fernández, Maria, Palencia, Susana, Díaz, Teresa, Del Castillo, Alberto, Varela, Angeles, de Miguel, Manuel, Muñoz, Patricia, Piñeiro, Gabriel, Cusati, Maria, Del Barrio, Maria José, Membrillo, David, Orozco, Fidel, Reyes, Robert J, Sapsford, Julian, Barth, Julian, Scott, Alistair, Hall, Simon, Howell, Michaela, Lobley, Janet, Woods, Susannah, Howard, Joanne, Fletcher, Nikki, Dewhirst, C, Williams, A, Rushton, I, Welters, M, Leuwer, Rupert, Pearse, Gareth, Ackland, Ahsun, Khan, Edyta, Niebrzegowska, Sally, Benton, Andrew, Wragg, Andrew, Archbold, Amanda, Smith, Eleanor, McAlees, Cheryl, Ramballi, Neil, Macdonald, Marta, Januszewska, Robert, Stephens, Anna, Reyes, Laura Gallego, Paredes, Pervez, Sultan, David, Cain, John, Whittle, Ana Gutierrez, Del Arroyo, Zhuo, Sun, Patrick S, Finnegan, Cameron, Egan, Hooman, Honar, Aram, Shahinyan, Krit, Panjasawatwong, Alexander Y, Fu, Sihe, Wang, Edmunds, Reineks, Jane, Blood, Megan, Kalin, David, Gibson, and Troy, Wildes

Subjects
Male, Myocardial Ischemia, surgical technique, Article, Cohort Studies, Age Distribution, Postoperative Complications, Troponin T, Humans, preoperative care, human, Prospective Studies, outcome assessment, Aged, Hardware_MEMORYSTRUCTURES, troponin T, ComputingMilieux_THECOMPUTINGPROFESSION, predictive value, Research Diagnostic Criteria, heart muscle injury, Middle Aged, Prognosis, major clinical study, mortality, clinical feature, Patient Outcome Assessment, peroperative complication, priority journal, Surgical Procedures, Operative, prognosis, purl.org/pe-repo/ocde/ford#3.02.09 [https]
Abstract

Background: Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study's four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS. Methods: In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated abnormal laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria. Results: An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors' diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96-5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6-41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom. Conclusion: Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.

Published
2014

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