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Background: Mortality, morbidity, and organ failure are important and common serious harms after surgery. However, there are many candidate measures to describe these outcome domains. Definitions of these measures are highly variable, and validity is often unclear. As part of the International Standardised Endpoints in Perioperative Medicine (StEP) initiative, this study aimed to derive a set of standardised and valid measures of mortality, morbidity, and organ failure for use in perioperative clinical trials. Methods: Three domains of endpoints (mortality, morbidity, and organ failure) were explored through systematic literature review and a three-stage Delphi consensus process using methods consistently applied across the StEP initiative. Reliability, feasibility, and patient-centredness were assessed in round 3 of the consensus process. Results: A high level of consensus was achieved for two mortality time points, 30-day and 1-yr mortality, and these two measures are recommended. No organ failure endpoints achieved threshold criteria for consensus recommendation. The Clavien–Dindo classification of complications achieved threshold criteria for consensus in round 2 of the Delphi process but did not achieve the threshold criteria in round 3 where it scored equivalently to the Post Operative Morbidity Survey. Clavien–Dindo therefore received conditional endorsement as the most widely used measure. No composite measures of organ failure achieved an acceptable level of consensus. Conclusions: Both 30-day and 1-yr mortality measures are recommended. No measure is recommended for organ failure. One measure (Clavien–Dindo) is conditionally endorsed for postoperative morbidity, but our findings suggest that no single endpoint offers a reliable and valid measure to describe perioperative morbidity that is not dependent on the quality of deli-vered care. Further refinement of current measures, or development of novel measures, of postoperative morbidity might improve consensus in this area.

Objectives N-terminal pro-brain natriuretic peptide (NT-proBNP), a standard marker for diagnosis and treatment guidance of heart failure, has previously been investigated in high-risk patients undergoing cardiac and non-cardiac surgery. However, the kinetics of NT-proBNP in healthy patients undergoing non-cardiac surgery are unknown. Design & methods A secondary analysis of a prospective cohort study was conducted. NT-proBNP plasma concentrations were measured preoperatively, 2–6 h, and 18–30 h after surgery in 120 patients, 18–35 years, undergoing elective non-cardiac surgery. Reasons for non-inclusion: history or symptoms of cardiac disease, kidney disease, pulmonary embolism , thrombosis, stroke, diabetes, head or chest trauma , pregnancy, incomplete panel of perioperative NT-proBNP plasma samples. Absolute and relative change of NT-proBNP plasma concentration were calculated. Changes between preoperative, 2–6 h, and 18–30 h (POD 1) NT-proBNP values, and of within-patient change in NT-proBNP were analyzed. Results In 95 patients, NT-proBNP plasma concentrations (median [IQR]) were 8 [5–26] pg/mL at baseline, 17 [5–53] pg/mL 2–6 h, and 42 [11–86] pg/mL 18–30 h after surgery. Absolute and relative NT-proBNP increase after surgery was 32 [5–74] pg/mL and 196% [61 – 592%] compared to baseline. NT-proBNP elevation above the age- and sex-specific reference range was observed in 6/95 (6%) patients prior to surgery and in 39/95 (41%) patients after surgery. Conclusions Even after uncomplicated surgery and postoperative period , NT-proBNP concentrations markedly increase in otherwise healthy adult patients. The aetiology of postoperative NT-proBNP increase is currently unknown and may be multifactorial.

Background Perioperative β-blocker therapy has been associated with increased risk of stroke. However, the association between β-blocker initiation before the day of surgery and the risk of stroke is unknown. The authors hypothesized there would be no association between preoperative β-blocker initiation within 60 days of surgery or chronic β-blockade (more than 60 days) and the risk of stroke in patients undergoing major abdominal surgery. Methods Data on elective major abdominal surgery were obtained from the IBM (USA) Truven Health MarketScan 2005 to 2015 Commercial and Medicare Supplemental Databases. Patients were stratified by β-blocker dispensing exposure: (1) β-blocker–naïve, (2) preoperative β-blocker initiation within 60 days of surgery, and (3) chronic β-blocker dispensing (more than 60 days). The authors compared in-hospital stroke and major adverse cardiac events between the different β-blocker therapy exposures. Results There were 204,981 patients who underwent major abdominal surgery. β-Blocker exposure was as follows: perioperative initiation within 60 days of surgery for 4,026 (2.0%) patients, chronic β-blocker therapy for 45,424 (22.2%) patients, and β-blocker–naïve for 155,531 (75.9%) patients. The unadjusted frequency of stroke for patients with β-blocker initiation (0.4%, 17 of 4,026) and chronic β-blocker therapy (0.4%, 171 of 45,424) was greater than in β-blocker–naïve patients (0.2%, 235 of 155,531; P < 0.001). After propensity score weighting, patients initiated on a β-blocker within 60 days of surgery (odds ratio, 0.90; 95% CI, 0.31 to 2.04; P = 0.757) or on chronic β-blocker therapy (odds ratio, 0.86; 95% CI, 0.65 to 1.15; P = 0.901) demonstrated similar stroke risk compared to β-blocker–naïve patients. Patients on chronic β-blocker therapy demonstrated lower adjusted risk of major adverse cardiac events compared to β-blocker–naïve patients (odds ratio, 0.81; 95% CI, 0.72 to 0.91; P = 0.007), despite higher unadjusted absolute event rate (2.6% [1,173 of 45,424] vs. 0.6% [872 of 155,531]). Conclusions Among patients undergoing elective major abdominal surgery, the authors observed no association between preoperative β-blocker initiation within 60 days of surgery or chronic β-blocker therapy and stroke. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Background Preoperative resting echocardiography is often performed before noncardiac surgery, but indications for preoperative resting echocardiography are limited. This study aimed to investigate appropriateness of preoperative resting echocardiography using the Appropriate Use Criteria for Echocardiography, which encompass indications from the guidelines on perioperative cardiovascular evaluation and management and nonperioperative indications independent of the perioperative period. The authors hypothesized that patients are frequently tested without an appropriate indication. Methods Records of patients in the Truven Health MarketScan Commercial and Medicare Supplemental Databases who underwent a major abdominal surgery from 2005 to 2017 were included. These databases contain de-identified records of health services for more than 250 million patients with primary or Medicare supplemental health insurance coverage through employer-based fee-for-service, point-of-service, or capitated plans. Patients were classified based on the presence of an outpatient claim for resting transthoracic echocardiography within 60 days of surgery. Appropriateness was determined via International Classification of Diseases, Ninth Revision–Clinical Modification, and International Classification of Diseases, Tenth Revision–Clinical Modification principal and secondary diagnosis codes associated with the claims, and classified as “appropriate,” “rarely appropriate,” or “unclassifiable” using the Appropriate Use Criteria for Echocardiography. Results Among 230,535 patients in the authors’ cohort, preoperative resting transthoracic echocardiography was performed in 6.0% (13,936) of patients. There were 12,638 (91%) studies classifiable by the Appropriate Use Criteria for Echocardiography, and 1,298 (9%) were unable to be classified. Among the classifiable studies, 8,959 (71%) were deemed “appropriate,” while 3,679 (29%) were deemed “rarely appropriate.” Surveillance of chronic ischemic heart disease and uncomplicated hypertension accounted for 43% (1,588 of 3,679) of “rarely appropriate” echocardiograms. Conclusions More than one in four preoperative resting echocardiograms were considered “rarely appropriate” according to the Appropriate Use Criteria for Echocardiography. A narrow set of patient characteristics accounts for a large proportion of “rarely appropriate” preoperative resting echocardiograms. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Hidradenitis suppurativa (HS) is a chronic, debilitating skin disease estimated to affect ∼1% of the population, for which few treatment options are available. Risk factors associated with HS include smoking, obesity, and some high penetrance genetic variants. Some rare families have autosomal dominant inheritance. Previous studies have shown that rare loss-of-function variants in genes of the gamma-secretase complex, particularly nicastrin, segregate with autosomal dominant HS in some kindred. However, these gamma-secretase variants do not explain much of the overall genetic risk for HS. We performed targeted DNA sequencing of 21 candidate genes in a cohort of 117 individuals with HS to test for an increased burden of rare genetic variants. Candidates included the genes of the gamma-secretase complex, Notch signaling genes, and PSTPIP1, a known risk factor for PAPA syndrome. We discovered two pathogenic loss-of-function variants in nicastrin that to the best of our knowledge have not been described in HS before. We did not identify significant enrichment of rare missense variants in any gamma-secretase gene, further supporting that loss-of-function in gamma-secretase genes is not a common risk factor. We did, however, identify a statistically significant enrichment of rare variants in the SH3 domain of PSTPIP1. Clinical overlap between HS and PSTPIP1 syndromic features has been noted clinically. Our data suggest that there is shared genetic risk as well, and highlights the need for further population-scale HS genetic research.

Objectives To develop parsimonious models of in-hospital mortality and morbidity risk after perioperative acute myocardial infarction (AMI). Design Retrospective data analysis. Setting National Inpatient Sample (2008-2013), a 20% sample of all non-federal in-patient hospitalizations in the United States. Participants Patients 45 years or older who experienced perioperative AMI during elective admission for noncardiac surgery. Interventions The study used a mixed principal components analysis and multivariate logistic regression to identify risk factors for in-hospital mortality after perioperative AMI. A model incorporating only preoperative risk factors, defined by the Revised Cardiac Risk Index (RCRI), was compared with a “full risk factor” model, incorporating a large set of preoperative AMI risk factors. The risk of post-AMI disposition to an intermediate care or skilled nursing facility, a marker of functional impairment, then was evaluated. Measurements and Main Results In the present study, 15,574 cases of AMI after elective noncardiac surgery were identified (0.42%, corresponding with 78,122 cases nationally), with a 12.4% in-hospital mortality rate. The “RCRI-only” model was the best-fit model of post-AMI in-hospital mortality risk, without loss of predictive accuracy compared with the “full risk factor” model (area under the receiver operator characteristic curve 0.80, 95% confidence interval [CI] [0.77-0.82] v area under the receiver operator characteristic curve 0.81, 95% CI [0.77-0.83], respectively). Post-AMI mortality risk was the highest for perioperative complications, including sepsis (odds ratio 4.95, 95% CI [4.32-5.67]). Conversely, functional impairment was best predicted by the “full-risk factor” model and depended strongly on chronic preoperative comorbidities. Conclusions The RCRI provides a simple but adequate model of preoperative risk factors for in-hospital mortality after perioperative AMI.

Background Myocardial injury after noncardiac surgery (MINS) is common and of prognostic importance. Little is known about MINS in orthopaedic surgery. The diagnostic criterion for MINS was a level of ≥0.03 ng/mL on a non-high-sensitivity troponin T (TnT) assay due to myocardial ischemia. Methods We undertook an international, prospective study of 15,103 patients ≥45 years of age who had inpatient noncardiac surgery; 3,092 underwent orthopaedic surgery. Non-high-sensitivity TnT assays were performed on postoperative days 0, 1, 2, and 3. Among orthopaedic patients, we determined (1) the prognostic relevance of the MINS diagnostic criteria, (2) the 30-day mortality rate for those with and without MINS, and (3) the probable proportion of MINS cases that would go undetected without troponin monitoring because of a lack of an ischemic symptom. Results Three hundred and sixty-seven orthopaedic patients (11.9%) had MINS. MINS was associated independently with 30-day mortality including among those who had had orthopaedic surgery. Orthopaedic patients without and with MINS had a 30-day mortality rate of 1.0% and 9.8%, respectively (odds ratio [OR], 11.28; 95% confidence interval [CI], 6.72 to 18.92). The 30-day mortality rate was increased for patients with MINS who had an ischemic feature (i.e., symptoms, or evidence of ischemia on electrocardiography or imaging) (OR, 18.25; 95% CI, 10.06 to 33.10) and for those who did not have an ischemic feature (OR, 7.35; 95% CI, 3.37 to 16.01). The proportion of orthopaedic patients with MINS who were asymptomatic and in whom the myocardial injury would have probably gone undetected without TnT monitoring was 81.3% (95% CI, 76.3% to 85.4%). Conclusions One in 8 orthopaedic patients in our study had MINS, and MINS was associated with a higher mortality rate regardless of symptoms. Troponin levels should be measured after surgery in at-risk patients because most MINS cases (>80%) are asymptomatic and would go undetected without routine measurements. Level of evidence Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Nitrous oxide (NGlutamate-mediated synaptic transmission was studied in the CA1 region of hippocampal slices from adult albino rats using standard extracellular recording methods. Effects of NAkin to 1 μM ketamine, 30% NThese results indicate that N

Background: Abnormalities in computed tomography myocardial perfusion has been associated with coronary artery disease and major adverse cardiovascular events (MACE). We sought to investigate if subendocardial attenuation using coronary computed tomography angiography predicts MACE 30 days postelective noncardiac surgery. Methods: Using a 17-segment model, coronary computed tomography angiography images were analyzed for subendocardial and transmural attenuation and the corresponding blood pool. The segment with the lowest subendocardial attenuation and transmural attenuation were normalized to the segment with the highest subendocardial and transmural attenuation, respectively (SUB normalized , and TRANS normalized , respectively). We evaluated the independent and incremental value of myocardial attenuation to predict the composite of cardiovascular death or nonfatal myocardial infarction. Results: Of a total of 995 coronary CTA VISION (Coronary Computed Tomographic Angiography and Vascular Events in Noncardiac Surgery Patients Cohort Evaluation Study) patients, 735 had available images and complete data for these analyses. Among these patients, 60 had MACE. Based on Revised Cardiovascular Risk Index, 257, 302, 138, and 38 patients had scores of 0, 1, 2, and ≥3, respectively. On coronary computed tomography angiography, 75 patients had normal coronary arteries, 297 patients had nonobstructive coronary artery disease, 264 patients had obstructive disease, and 99 patients had extensive obstructive coronary artery disease. SUB normalized was an independent and incremental predictor of events in the model that included Revised Cardiovascular Risk Index and coronary artery disease severity. Compared with patients in the highest tertile of SUB normalized , patients in the second and first tertiles had an increased hazards ratio for events (2.23 [95% CI, 1.091–4.551] and 2.36 [95% CI, 1.16–4.81], respectively). TRANS normalized , as a continuous variable, was also found to be a predictor of MACE ( P =0.027). Conclusions: Our study demonstrates that SUB normalized and TRANS normalized are independent and incremental predictors of MACE 30 days after elective noncardiac surgery. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01635309.

We sought to determine if epicardial adipose tissue (EAT) volume is an independent and incremental prognostic marker of 30-day major adverse cardiovascular events (MACE) after elective noncardiac surgery. The Coronary CTA VISION Study enrolled 995 patients ([1][1]), and the primary outcome was a

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Functional capacity assessment is a core component of current perioperative cardiovascular evaluation and management guidelines for noncardiac surgery. The authors investigated the ability of standardized physical function questions to predict whether participants engaged in moderate physical activity as measured by hip accelerometers. Methods Participant responses to physical functioning questions and whether they engaged in moderate physical activity were extracted from the National Health and Nutrition Examination Survey (2003 to 2004 and 2005 to 2006). Physical activity intensity was measured using hip accelerometers. Adult participants with at least one Revised Cardiac Risk Index condition were included in the analysis. Standardized physical function questions were evaluated using a classification and regression tree analysis. Training and test datasets were randomly generated to create and test the analysis. Results Five hundred and twenty-two participants were asked the physical functioning questions and 378 of 522 (72.4%) had a bout of moderate-vigorous activity. Classification and regression tree analysis identified a “no difficulty” response to walking up 10 stairs and the ability to walk two to three blocks as the most sensitive questions to predict the presence of a 2-min bout of moderate activity. Participants with positive responses to both questions had a positive likelihood ratio of 3.7 and a posttest probability greater than 90% of a 2-min bout of moderate-vigorous activity. The sensitivity and specificity of positive responses to physical functioning questions in the pruned tree were 0.97 (95% CI, 0.94 to 0.98) and 0.16 (95% CI, 0.10 to 0.23) for training data, and 0.88 (95% CI, 0.75 to 0.96) and 0.10 (95% CI, 0.00 to 0.45) for the test data. Participants with at least one 2-min bout of moderate activity had a greater percentage of overall daily active time (35.4 ± 0.5 vs. 26.7 ± 1.2; P = 0.001) than those without. Conclusions Standardized physical function questions are highly sensitive but poorly specific to identify patients who achieve moderate physical activity. Additional strategies to evaluate functional capacity should be considered.

Nitrous oxide (N 2 O) is one of the oldest drugs still in use in medicine. Despite its superior pharmacokinetic properties, controversy remains over its continued use in clinical practice, reflecting in part significant improvements in the pharmacology of other anaesthetic agents and developing awareness of its shortcomings. This narrative review describes current knowledge regarding the clinical use of N 2 O based on a systematic and critical analysis of the available scientific literature. The pharmacological properties of N 2 O are reviewed in detail along with current evidence for the indications and contraindications of this drug in specific settings, both in perioperative care and in procedural sedation. Novel potential applications for N 2 O for the prevention or treatment of chronic pain and depression are also discussed. In view of the available evidence, we recommend that the supply of N 2 O in hospitals be maintained while encouraging its economic delivery using modern low flow delivery systems. Future research into its potential novel applications in prevention or treatment of chronic conditions should be pursued to better identify its role place in the developing era of precision medicine.

EDITOR’S PERSPECTIVE What We Already Know about This Topic The incidence of major adverse cardiac events after electroconvulsive therapy is not known What This Article Tells Us That Is New Major adverse cardiac events and death after electroconvulsive therapy are infrequent and occur in about 1 of 50 patients and after about 1 of 200 to 500 electroconvulsive therapy treatments Background Cardiac events after electroconvulsive therapy have been reported sporadically, but a systematic assessment of the risk is missing. The goal of this study was to obtain a robust estimate of the incidence of major adverse cardiac events in adult patients undergoing electroconvulsive therapy. Methods Systematic review and meta-analysis of studies that investigated electroconvulsive therapy and reported major adverse cardiac events and/or mortality. Endpoints were incidence rates of major adverse cardiac events, including myocardial infarction, arrhythmia, pulmonary edema, pulmonary embolism, acute heart failure, and cardiac arrest. Additional endpoints were all-cause and cardiac mortality. The pooled estimated incidence rates and 95% CIs of individual major adverse cardiac events and mortality per 1,000 patients and per 1,000 electroconvulsive therapy treatments were calculated. Results After screening of 2,641 publications and full-text assessment of 284 studies, the data of 82 studies were extracted (total n = 106,569 patients; n = 786,995 electroconvulsive therapy treatments). The most commonly reported major adverse cardiac events were acute heart failure, arrhythmia, and acute pulmonary edema with an incidence (95% CI) of 24 (12.48 to 46.13), 25.83 (14.83 to 45.00), and 4.92 (0.85 to 28.60) per 1,000 patients or 2.44 (1.27 to 4.69), 4.66 (2.15 to 10.09), and 1.50 (0.71 to 3.14) per 1,000 electroconvulsive therapy treatments. All-cause mortality was 0.42 (0.11 to 1.52) deaths per 1,000 patients and 0.06 (0.02 to 0.23) deaths per 1,000 electroconvulsive therapy treatments. Cardiac death accounted for 29% (23 of 79) of deaths. Conclusions Major adverse cardiac events and death after electroconvulsive therapy are infrequent and occur in about 1 of 50 patients and after about 1 of 200 to 500 electroconvulsive therapy treatments.

BACKGROUND: The United States population is aging and projected to undergo an increasing number of general surgical procedures. However, recent trends in the frequency of major abdominal procedures in older adults are currently unknown as improvements in non-operative interventions may obviate the need for major surgery. Thus, we evaluated the trends of major abdominal surgical procedures in older adults in the United States. METHODS: We performed a retrospective cohort study using the National Inpatient Sample from 2002–2014 with trend analysis using National Cancer Institute’s Joinpoint Trend Analysis Software. We identified the average annual percent change (AAPC) in yearly frequency of major abdominal surgical procedures in older adults (≥50 years of age). RESULTS: Our cohort included a total of 3,951,947 survey-weighted discharges that included a major abdominal surgery in adults ≥50 years of age between 2002 and 2014. Of these discharges, 2,529,507 (64.0%) were for elective abdominal surgeries, 2,062,835 (52.0%) were for female patients, and mean (SD) age was 61.4(15.9) years. The frequency of major abdominal procedures (elective and emergent) decreased for adults age 65–74 (AAPC: −1.43, −1.75, −1.11, P85 (AAPC= −3.53; −4.57, −2.48: P

Peri-operative myocardial injury, detected by dynamic and elevated cardiac troponin (cTn) concentrations, is a common complication of noncardiac surgery that is strongly associated with 30-day mortality. Although active screening for peri-operative myocardial injury has been suggested in recent guidelines, clinical implementation remains tentative due to a lack of examples on how to tackle such an interdisciplinary project at a local level. Moreover, consensus on which assay and cTn cut-off values should be used has not yet been reached, and guidance on whom to screen is lacking. In this article, we aim to summarise local examples of successfully implemented cTn screening practices and review the current literature in order to provide information and suggestions for patient selection, organisation of a screening programme, caveats and a potential management pathway.

Background: Adverse cardiovascular events are a leading cause of perioperative morbidity and mortality. The definitions of perioperative cardiovascular adverse events are heterogeneous. As part of the international Standardized Endpoints in Perioperative Medicine initiative, this study aimed to find consensus amongst clinical trialists on a set of standardised and valid cardiovascular outcomes for use in future perioperative clinical trials.Methods: We identified currently used perioperative cardiovascular outcomes by a systematic review of the anaesthesia and perioperative medicine literature (PubMed/Ovid, Embase, and Cochrane Library). We performed a three-stage Delphi consensus-gaining process that involved 55 clinician researchers worldwide. Cardiovascular outcomes were first shortlisted and the most suitable definitions determined. These cardiovascular outcomes were then assessed for validity, reliability, feasibility, and clarity.Results: We identified 18 cardiovascular outcomes. Participation in the three Delphi rounds was 100% (n=19), 71% (n=55), and 89% (n=17), respectively. A final list of nine cardiovascular outcomes was elicited from the consensus: myocardial infarction, myocardial injury, cardiovascular death, non-fatal cardiac arrest, coronary revascularisation, major adverse cardiac events, pulmonary embolism, deep vein thrombosis, and atrial fibrillation. These nine cardiovascular outcomes were rated by the majority of experts as valid, reliable, feasible, and clearly defined.Conclusions: These nine consensus cardiovascular outcomes can be confidently used as endpoints in clinical trials designed to evaluate perioperative interventions with the goal of improving perioperative outcomes.

IMPORTANCE: Cardiac stress testing is often performed prior to noncardiac surgery, although trends in use of preoperative stress testing and the effect of testing on cardiovascular outcomes are currently unknown. OBJECTIVE: To describe temporal trends and outcomes of preoperative cardiac stress testing from 2004 to 2017. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of patients undergoing elective total hip or total knee arthroplasty from 2004 to 2017. Trend analysis was conducted using Joinpoint and generalized estimating equation regression. The study searched IBM MarketScan Research Databases inpatient and outpatient health care claims for private insurers including supplemental Medicare coverage and included patients with a claim indicating an elective total hip or total knee arthroplasty from January 1, 2004, to December 31, 2017. EXPOSURES: Elective total hip or knee arthroplasty. MAIN OUTCOMES AND MEASURES: Trend in yearly frequency of preoperative cardiac stress testing. RESULTS: The study cohort consisted of 801 396 elective total hip (27.9%; n = 246 168 of 801 396) and total knee (72.1%; 555 228 of 801 396) arthroplasty procedures, with a median age of 62 years (interquartile range, 57-70 years) and 58.1% women (n = 465 545 of 801 396). The overall rate of stress testing during the study period was 10.4% (n = 83 307 of 801 396). The rate of stress tests increased 0.65% (95% CI, 0.09-1.21; P = .03) annually from quarter (Q) 1 of 2004 until Q2 of 2006. A joinpoint was identified at Q3 of 2006 (95% CI, 2005 Q4 to 2007 Q4) when preoperative stress test use decreased by −0.71% (95% CI, −0.79% to 0.63%; P

Background The limited applicability of evidence from RCTs in real-word practice is considered a potential bottleneck for evidence-based practice but rarely systematically assessed. Using our failure to recruit patients into a perioperative beta-blocker trial, we set out to analyse the restrictiveness and generalisability of trial eligibility criteria in a real-world cohort. Methods We prospectively included adult patients (≥18 yr) scheduled for elective noncardiac surgery at an academic tertiary care facility who were screened for inclusion in a planned perioperative beta-blocker RCT, which was terminated owing to recruitment failure. The primary outcome was the proportion of screened patients who matched the eligibility criteria of 36 published RCTs included in a large Cochrane meta-analysis on perioperative beta-blocker therapy. The pragmatic/explanatory level of each RCT was assessed using the PRagmatic–Explanatory Continuum Indicator Summary 2 (PRECIS-2) score, which ranges from 9 points (indicating a very explanatory study) to 45 points (indicating a very pragmatic study). Results A total of 2241 patients (54% female, n=1215; 52 [standard deviation, 20] yr) were included for the assessment of trial eligibility between October 2015 and January 2016. Only a small proportion of patients matched the inclusion and exclusion criteria for each of the 36 RCTs, ranging from 53% to 0%. The average proportion of patients who did match the eligibility criteria of all 36 RCTs was 6.5% (n=145; 95% confidence interval, 6.3–6.6). A higher PRECIS-2 score was associated with a higher proportion of matching patients (P Conclusions Trial eligibility criteria in perioperative beta-blocker therapy trials are overly restrictive and not generalisable to a real-world surgical population. Clinical trial registration EudraCT#: 2015-002366-23.

Nitrous oxide at 50% inhaled concentration has been shown to improve depressive symptoms in patients with treatment-resistant major depression (TRMD). Whether a lower concentration of 25% nitrous oxide provides similar efficacy and persistence of antidepressant effects while reducing the risk of adverse side effects is unknown. In this phase 2 clinical trial (NCT03283670), 24 patients with severe TRMD were randomly assigned in a crossover fashion to three treatments consisting of a single 1-hour inhalation with (i) 50% nitrous oxide, (ii) 25% nitrous oxide, or (iii) placebo (air/oxygen). The primary outcome was the change on the Hamilton Depression Rating Scale (HDRS-21). Whereas nitrous oxide significantly improved depressive symptoms versus placebo (P = 0.01), there was no difference between 25 and 50% nitrous oxide (P = 0.58). The estimated differences between 25% and placebo were -0.75 points on the HDRS-21 at 2 hours (P = 0.73), -1.41 points at 24 hours (P = 0.52), -4.35 points at week 1 (P = 0.05), and -5.19 points at week 2 (P = 0.02), and the estimated differences between 50% and placebo were -0.87 points at 2 hours (P = 0.69), -1.93 points at 24 hours (P = 0.37), -2.44 points at week 1 (P = 0.25), and -7.00 points at week 2 (P = 0.001). Adverse events declined substantially with dose (P < 0.001). These results suggest that 25% nitrous oxide has comparable efficacy to 50% nitrous oxide in improving TRMD but with a markedly lower rate of adverse effects.

Here, we present a case where a patient with severe recurrent treatment resistant major depression experienced full remission, which lasted more than one month, after a single nitrous oxide inhalation treatment.

BackgroundThe limited applicability of evidence from randomized controlled trials in real word practice is considered a potential bottleneck for evidence-based practice but rarely systematically assessed. Using our failure to recruit patients into a perioperative beta-blocker trial, we set out to analyse the restrictiveness and generalizability of trial eligibility criteria in a real-world cohort.MethodsWe included adult patients scheduled for elective major non-cardiac surgery at an academic tertiary care facility who were screened for inclusion in a planned perioperative beta-blocker RCT, which was terminated due to recruitment failure. Primary outcome was the proportion of screened patients who matched the eligibility criteria of 36 published RCTs included in a large Cochrane meta-analysis on perioperative beta-blocker therapy. The PRECIS-2 tool was used to assess the pragmatism/explanatory level of each RCT. ResultsA total of 2,241 patients were included for the assessment of trial-eligibility. Overall, eligibility proportions were low and ranged from 53% to 0%. The average proportion of patients who did match the eligibility criteria of all 36 RCTs was 6.5% (n=145, 95% confidence interval 6.3 to 6.6). There was no major criterion causing trial-ineligibility of study patients. A higher PRECIS-2 score was associated with a higher proportion of matching patients (pConclusionsTrial eligibility criteria in perioperative beta-blocker therapy trials are overly restrictive and not generalizable to a real-world population.

Background The diagnosis of myocardial infarction (MI) after noncardiac surgery has traditionally relied on using relatively insensitive contemporary cardiac troponin (cTn) assays. We hypothesized that using a recently introduced novel high-sensitivity cTnT (hscTnT) assay would increase the detection rate of perioperative MI. Methods In this ancillary study of the Vitamins in Nitrous Oxide trial, readjudicated incidence rates of myocardial injury (new isolated cTn elevation) and MI were compared when diagnosed by contemporary cTnI versus hscTnT. We probed various relative (eg, >50%) or absolute (eg, +5 ng/L) hscTnT change metrics. Inclusion criteria for this ancillary study were the presence of a baseline and at least 1 postoperative hscTnT value. Results Among 605 patients, 70 patients (12%) had electrocardiogram changes consistent with myocardial ischemia; 82 patients (14%) had myocardial injury diagnosed by contemporary cTnI, 31 (5.1%) of which had an adjudicated MI. After readjudication, 67 patients (11%) were diagnosed with MI when using hscTnT, a 2-fold increase. Incidence rates of postoperative myocardial injury ranged from 12% (n = 73) to 65% (n = 393) depending on the hscTnT metric used. Incidence rates of MI using various hscTnT change metrics and the presence of ischemic electrocardiogram changes, but without event adjudication, ranged from 3.6% (n = 22) to 12% (n = 74), a >3-fold difference. New postoperative hscTnT elevation, either by absolute or relative hscTnT change metric, was associated with an up to 5-fold increase in 6-month mortality. Conclusions The use of hscTnT compared to contemporary cTnI increases the detection rate of perioperative MI by a factor of 2. Using different absolute or relative hscTnT change metrics may lead to under- or overdiagnosis of perioperative MI.

Background While electroconvulsive therapy is widely regarded as a lifesaving and safe procedure, evidence regarding its effects on myocardial cell injury is sparse. The objective of this investigation was to determine the incidence and magnitude of new cardiac troponin elevation after electroconvulsive therapy using a novel high-sensitivity cardiac troponin I assay. Methods This was a prospective cohort study in adult patients undergoing electroconvulsive therapy in a single academic center (up to three electroconvulsive therapy treatments per patient). The primary outcome was new high-sensitivity cardiac troponin I elevation after electroconvulsive therapy, defined as an increase of high-sensitivity cardiac troponin I greater than 100% after electroconvulsive therapy compared to baseline with at least one value above the limit of quantification (10 ng/l). Twelve-lead electrocardiogram and high-sensitivity cardiac troponin I values were obtained before and 15 to 30 min after electroconvulsive therapy; in a subset of patients, an additional 2-h high-sensitivity cardiac troponin I value was obtained. Results The final study population was 100 patients and a total of 245 electroconvulsive therapy treatment sessions. Eight patients (8 of 100; 8%) experienced new high-sensitivity cardiac troponin I elevation after electroconvulsive therapy with a cumulative incidence of 3.7% (9 of 245 treatments; one patient had two high-sensitivity cardiac troponin I elevations), two of whom had a non–ST-elevation myocardial infarction (incidence 2 of 245; 0.8%). Median high-sensitivity cardiac troponin I concentrations did not increase significantly after electroconvulsive therapy. Tachycardia and/or elevated systolic blood pressure developed after approximately two thirds of electroconvulsive therapy treatments. Conclusions Electroconvulsive therapy appears safe from a cardiac standpoint in a large majority of patients. A small subset of patients with preexisting cardiovascular risk factors, however, may develop new cardiac troponin elevation after electroconvulsive therapy, the clinical relevance of which is unclear in the absence of signs of myocardial ischemia.

Background: Perioperative infection and sepsis are of fundamental concern to perioperative clinicians. However, standardised endpoints are either poorly defined or not routinely implemented. The Standardised Endpoints in Perioperative Medicine (StEP) initiative was established to derive a set of standardised endpoints for use in perioperative clinical trials.Methods: We undertook a systematic review to identify measures of infection and sepsis used in the perioperative literature. A multi-round Delphi consensus process that included more than 60 clinician researchers was then used to refine a recommended list of outcome measures.Results: A literature search yielded 1857 titles of which 255 met inclusion criteria for endpoint extraction. A long list of endpoints, with definitions and timescales, was generated and those potentially relevant to infection and sepsis circulated to the theme subgroup and then the wider StEP-COMPAC working group, undergoing a three-stage Delphi process. The response rates for Delphi rounds 1, 3, and 3 were 89% (n=8), 67% (n=62), and 80% (n=8), respectively. A set of 13 endpoints including fever, surgical site, and organ-specific infections as defined by the US Centres for Disease Control and Sepsis-3 are proposed for future use.Conclusions: We defined a consensus list of standardised endpoints related to infection and sepsis for perioperative trials using an established and rigorous approach. Each endpoint was evaluated with respect to validity, reliability, feasibility, and patient centredness. One or more of these should be considered for inclusion in future perioperative clinical trials assessing infection, sepsis, or both, thereby permitting synthesis and comparison of future results.

Background The recent introduction of high‐sensitivity cardiac troponin (hs‐cTn) assays has allowed clinicians to measure hs‐cTn before and after cardiac stress testing, but the hs‐cTn release pattern and potential utility in identifying inducible myocardial ischemia are unclear. We thus conducted a systematic review and meta‐analysis to improve our understanding of hs‐cTn release associated with exercise and pharmacological stress testing. Methods and Results Studies published between January 2008 and July 2016 that reported hs‐cTn change values (high‐sensitivity cardiac troponin T [hs‐cTnT] or high‐sensitivity cardiac troponin I [hs‐cTnI]) in relation to cardiac stress testing were searched and reviewed by 2 independent screeners. Primary outcomes were pooled estimates of absolute and relative hs‐cTn changes after cardiac stress test, stratified by the presence of inducible myocardial ischemia. This meta‐analysis included 11 studies (n=2432 patients). After exercise stress testing, hs‐cTnT increased by 0.5 ng/L or 11% (6 studies, n=406) and hs‐cTnI by 2.4 ng/L or 41% (4 studies, n=365) in patients with inducible myocardial ischemia versus hs‐cTnT by 1.1 ng/L or 18% (8 studies, n=629; P =0.29) and hs‐cTnI by 1.8 ng/L or 72% (4 studies, n=831; P =0.61) in patients who did not develop inducible myocardial ischemia. After pharmacological stress test, hs‐cTnT changed by −0.1 ng/L or −0.4% (6 studies, n=251) and hs‐cTnI by 2.4 ng/L or 32% (2 studies, n=108) in patients with inducible myocardial ischemia versus hs‐cTnT by 0.7 ng/L or 11% (5 studies, n=443, P =0.44) and hs‐cTnI by 1.7 ng/L or 38% (2 studies, n=116; P =0.62) in patients who did not develop inducible myocardial ischemia. Conclusions hs‐cTn rising patterns after exercise and pharmacological stress testing appear inconsistent and comparably small, and do not appear to be correlated with inducible myocardial ischemia.

N-methyl- d -aspartate receptor (NMDAR) antagonists, including ketamine and nitrous oxide, are currently intensely studied as rapid-acting antidepressant agents. Interestingly, both of these compounds are also drugs of abuse. Intravenous ketamine, a dissociative anesthetic that induces complex downstream effects via NMDARs, rapidly reduces depressive and suicidal symptoms in treatment-resistant depression (TRD), as demonstrated by several trials. Recently, the United States Food and Drug Administration (FDA) approved an intranasal version of ketamine (esketamine) for TRD. The United States Drug Enforcement Agency (DEA) lists ketamine as a Class III scheduled drug (moderate-low potential for physical and psychological abuse). The FDA has established a Risk Evaluation and Management Strategy (REMS) program to ensure proper drug storage, handling, dispensing, and monitoring intranasal esketamine to minimize misuse/abuse opportunities. Nitrous Oxide is a colorless, odorless, gas that has been in medical use for over 150 years. The mechanisms of action of nitrous oxide are not fully understood; however, it is known to act as a non-competitive inhibitor of NMDA-type glutamate receptors. Currently, nitrous oxide is used for inhalational general anesthesia and analgesia for short procedures. Inhaled nitrous oxide is also used recreationally, primarily by teens and young adults, but is not believed to have strong addiction potential. In contrast to ketamine, nitrous oxide is not a controlled substance and can be legally purchased without a prescription. A recent double-blind, prospective, cross-over study demonstrated that nitrous oxide reduced depressive symptoms in a group of severely ill TRD patients. Though this is a promising initial study, further investigation is needed.

Importance The tinnitus research literature suggests thatN-methyl-d-aspartate (NMDA) receptor antagonists may be useful in reducing tinnitus. Nitrous oxide, a member of the NMDA receptor antagonist class, is a widely used general anesthetic and sedative with a proven safety record. Objective To investigate whether nitrous oxide can reduce bothersome tinnitus. Design, Setting, and Participants Randomized, placebo-controlled crossover trial conducted between October 15, 2016, and June 22, 2017. Participants attended 2 interventional sessions separated by at least 14 days and were randomized to receive either placebo first or nitrous oxide first. Participants were followed up through completion of the second arm of the study. The setting was a clinical research unit at an academic medical center. Adults aged 18 to 65 years with subjective, idiopathic, nonpulsatile bothersome tinnitus of 6 months’ duration or longer were recruited from 2 clinical research databases. Seventy-one individuals were screened, of whom 40 were enrolled. Of those enrolled, 37 participants completed all components of the study. Interventions The placebo session consisted of 50% nitrogen and 50% oxygen inhaled for 40 minutes, and the treatment session consisted of 50% nitrous oxide and 50% oxygen inhaled for 40 minutes. Main Outcomes and Measures Tinnitus was assessed before and after intervention, with the change in the Tinnitus Functional Index (TFI) as the primary outcome measure. Secondary outcome measures included the Patients’ Global Impression of Change score and the change in the Global Bothersome Scale score. Results Among 40 participants in this intent-to-treat randomized clinical trial with 20 participants randomly assigned to each group, the mean (SD) age of participants was 52.9 (11.1) years, with equal numbers of male and female participants. The TFI after intervention was a mean (SD) of 1.8 (8.8) points lower than before intervention in the placebo arm and a mean (SD) of 2.5 (11.0) points lower than before intervention in the nitrous oxide arm. The within-participant mean difference in the change in the TFI of the placebo arm compared with the nitrous oxide arm was −1.1 points (95% CI, −5.6 to 3.4 points). The difference between the placebo and nitrous oxide arms was neither clinically meaningful nor statistically significant. Conclusions and Relevance Nitrous oxide was no more effective than placebo for the treatment of subjective, idiopathic tinnitus. Trial Registration ClinicalTrials.gov identifier:NCT03365011

Introduction Exercise (ESE) and dobutamine stress echocardiography (DSE) have high sensitivity and specificity to detect inducible myocardial ischemia in patients with significant coronary artery disease (CAD). High-sensitivity cardiac troponin (hs-cTn) assays detect troponin concentrations in the ng/L range. The aim of this study was to determine the kinetics of hs-cTnT in patients undergoing ESE and DSE and possible association of hs-cTnT with inducible myocardial ischemia. Methods In this prospective study adult patients undergoing ESE/DSE were enrolled. Peripheral blood samples were obtained before, and 30 min, 1, 2, and 4–6 h after completion of ESE/DSE. Hs-cTnT was measured on a Roche Diagnostics Elecsys 2010 analyzer. Results We enrolled 48 patients (33 ESE and 15 DSE); 11 patients (23%) had elevated baseline hs-cTnT concentrations >14 ng/L (99th percentile URL); 31/48 (65%) developed an hs-cTnT increase after ESE/DSE (peak 4–6 h post stress test), but only three patients (all in ESE group) had a positive stress test. Absolute and relative hs-cTnT increases were higher after DSE (median Δhs-cTnT +9.7 ng/L [IQR 4.5, 27.2]; +123% [IQR 49, 271]) compared to ESE (median Δhs-cTnT +2.3 ng/L [IQR 1, 4.9]; +37% [IQR 9.1, 221]). Conclusions One in four patients undergoing ESE/DSE had increased hs-cTnT values prior to stress testing. Hs-cTnT increased above the upper limit of normal occurred commonly after ESE/DSE but was more pronounced after DSE. Increases in hs-cTn did not appear to be associated with inducible myocardial ischemia. These findings may have important implications for the clinical use of hs-cTnT within 6 h after ESE/DSE.

Background: The Standardising Endpoints for Perioperative Medicine group was established to derive an appropriate set of endpoints for use in clinical trials related to anaesthesia and perioperative medicine. Anaesthetic or analgesic technique during cancer surgery with curative intent may influence the risk of recurrence or metastasis. However, given the current equipoise in the existing literature, prospective, randomised, controlled trials are necessary to test this hypothesis. As such, a cancer subgroup was formed to derive endpoints related to research in onco-anaesthesia based on a current evidence base, international consensus and expert guidance.Methods: We undertook a systematic review to identify measures of oncological outcome used in the oncological, surgical, and wider literature. A multiround Delphi consensus process that included up to 89 clinician–researchers was then used to refine a recommended list of endpoints.Results: We identified 90 studies in a literature search, which were the basis for a preliminary list of nine outcome measures and their definitions. A further two were added during the Delphi process. Response rates for Delphi rounds one, two, and three were 88% (n=9), 82% (n=73), and 100% (n=10), respectively. A final list of 10 defined endpoints was refined and developed, of which six secured approval by ≥70% of the group: cancer health related quality of life, days alive and out of hospital at 90 days, time to tumour progression, disease-free survival, cancer-specific survival, and overall survival (and 5-yr overall survival).Conclusion: Standardised endpoints in clinical outcomes studies will support benchmarking and pooling (meta-analysis) of trials. It is therefore recommended that one or more of these consensus-derived endpoints should be considered for inclusion in clinical trials evaluating a causal effect of anaesthesia–analgesia technique on oncological outcomes.

Background The objective of this investigation was to determine the etiology of perioperative acute coronary syndrome with a particular emphasis on thrombosis versus demand ischemia. Methods In this retrospective cohort study, adult patients were identified who underwent coronary angiography for acute coronary syndrome within 30 days of noncardiac surgery at a major tertiary hospital between January 2008 and July 2015. Angiograms were independently reviewed by two interventional cardiologists who were blinded to clinical data and outcomes. Acute coronary syndrome was classified as ST–elevation myocardial infarction, non–ST–elevation myocardial infarction, or unstable angina; myocardial infarctions were adjudicated as type 1 (plaque rupture), type 2 (demand ischemia), or type 4b (stent thrombosis). Results Among 215,077 patients screened, 146 patients were identified who developed acute coronary syndrome: 117 were classified as non–ST–elevation myocardial infarction (80.1%); 21 (14.4%) were classified as ST–elevation myocardial infarction, and 8 (5.5%) were classified as unstable angina. After coronary angiography, most events were adjudicated as demand ischemia (type 2 myocardial infarction, n = 106, 72.6%) compared to acute coronary thrombosis (type 1 myocardial infarction, n = 37, 25.3%) and stent thrombosis (type 4B, n = 3, 2.1%). Absent or only mild, nonobstructive coronary artery disease was found in 39 patients (26.7%). In 14 patients (9.6%), acute coronary syndrome was likely due to stress-induced cardiomyopathy. Aggregate 30-day and 1-yr mortality rates were 7 and 14%, respectively. Conclusions The dominant mechanism of perioperative acute coronary syndrome in our cohort was demand ischemia. A subset of patients had no evidence of obstructive coronary artery disease, but findings were consistent with stress-induced cardiomyopathy.

Nitrous oxide (laughing gas) has shown early promise as a rapidly acting antidepressant in patients with treatment-resistant major depression and is currently investigated in several clinical trials. Because nitrous oxide is rarely administered outside operating rooms or dental practices, most psychiatrists are not familiar with how nitrous oxide is administered in a medical setting and what regulations guide its use. The goal of this brief review was to educate psychiatrists about the basic concepts of nitrous oxide administration and pharmacology. Furthermore, common misconceptions about nitrous oxide will be discussed.

Background It is unclear if isolated postoperative cardiac-troponin elevation, often referred to as myocardial injury, represents a pathological event, as control studies in otherwise healthy adults are lacking. Methods In this single-centre prospective observational cohort study, serial high-sensitivity cardiac troponin T (hscTnT) plasma concentrations were obtained from young, healthy adults undergoing elective orthopaedic surgery at three time points: before operation, 2–6 h, and 18–30 h after surgery. End points were hscTnT increases after surgery: ≥20% (exceeding analytical variability), ≥50% (exceeding short-term biological variability), and ≥85% (exceeding long-term biological variability). The secondary end point was myocardial injury, defined as new postoperative hscTnT elevation >99th % upper reference limit (URL) (women >10 ng litre−1; men >15 ng litre−1). Results Amongst the study population (n=95), no hscTnT increase ≥20% was detected in 68 patients (73%). A hscTnT increase between 20% and 49% was observed in 17 patients (18%), 50–84% in seven patients (7%), and ≥85% in three patients (3%). Twenty patients (21%) had an absolute ΔhscTnT between 0 and 2 ng litre−1, 12 patients (13%) between 2 and 4 ng litre−1, three patients between 4 and 6 ng litre−1, and one patient (1%) between 6 and 8 ng litre−1. Myocardial injury (new hscTnT elevation >99th%) was diagnosed in one patient (1%). The median hscTnT concentrations did not increase after operation, and were 4 (3.9–5, inter-quartile range) ng litre−1 at baseline, 4 (3.9–5) ng litre−1 at 2–6 h after surgery, and 4 (3.9–5) ng litre−1 on postoperative day 1. Conclusions One in four young adult patients without known cardiovascular disease developed a postoperative hscTnT increase, but without exceeding the 99th% URL and without evidence of myocardial ischaemia. These results may have important ramifications for the concept of postoperative myocardial injury, as they suggest that, in some patients, postoperative cardiac-troponin increases may be the result of a normal physiological process in the surgical setting. Clinical trial registration NCT 02394288.

Introduction Accurate estimation of burn size is of critical importance, as it is incorporated in every resuscitation formula. The aim of this study was to investigate total burn surface area (TBSA) accuracy among burn specialists, evaluate the potential impact of incorrect evaluation on variations of resultant fluid resuscitation volumes and to discuss future possibilities to estimate or measure TBSA more precisely. Methods In a poll during two international burn meetings in 2010 and 2011 demonstrating three pictures of patients with different burn wound patterns and sizes we asked participants to estimate the total surface area burned in percentages. We then calculated resultant fluid volume differences based on established resuscitation formulas. Results In the polled 80 participants, the estimations for three patients demonstrated the following differences (DIF = MAX − MIN): for patient 1, 2 and 3 they were 22.5 (25–2.5), 16.5 (20–3.5) and 31.5 (40–8.5) %TBSA, respectively. Based on these differences we calculated the volume differences for patients 1,2 and 3, which were 1080 ml (Cincinnati Formula), 5280 ml (Parkland Formula) and 2016 ml (Cincinnati Formula), respectively. Conclusions The analysis showed high deviations of total body surface area among participants, also resulting in large variations of initial fluid resuscitation volumes. One option to address estimation variances is to perform more accurate assessments; also incorporating new technologies aiding to improve the quality of body surface estimations and related decisions.

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.

Background It is unclear if cardiac troponin values are stable in patients prior to undergoing non-cardiac surgery, or if they tend to rise towards the day of surgery. Methods In this small pilot study (n = 18) among patients with cardiac risk undergoing non-cardiac surgery, we determined if high-sensitivity cardiac troponin I (hscTnI) changes between the preoperative clinic visit and the day of surgery. HscTnI was measured on an Abbott Architect STAT (Abbott Laboratories, USA) platform. Results The mean duration between preoperative clinic visit and day of surgery was 8.7 ± 2.8 (SD) days. Median hscTnI was 3.4 ng/L [2.0–4.8, IQR] at the preoperative visit and 2.8 ng/L [2.3–4.4] on the day of surgery (mean difference − 0.24 ng/L, 95% CI - 0.73 to 0.24 ng/L, p = 0.30). Only one patient had a large change (> 50%) along with symptoms. Discussion Evidence from this small study suggests that cardiac troponin values are stable in most high-risk patients, absent clinical events, within 10 days prior to non-cardiac surgery.