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Perioperative myocardial damage and cardiac outcome in patients-at-risk undergoing non-cardiac surgery
Linköping University, Department of Medical and Health Sciences, Anesthesiology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Anaesthesiology and Surgical Centre, Department of Anaesthesiology and Intensive Care VHN.
2009 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Despite increasingly sophisticated perioperative management, cardiovascular complications continue to be major challenges for the clinician. As a growing number of elderly patients with known coronary artery disease (CAD) or with risk factors for CAD are undergoing non-cardiac surgery, cardiovascular complications will remain a significant clinical problem in the future.

The overall objective of this thesis was to study the incidence of myocardial damage and perioperative adverse cardiac events, to determine predictors of poor outcome and to assess the effect of a medical intervention in patients at risk undergoing non-cardiac surgery.

The studies in this thesis were conducted on a total of 952 patients undergoing non-cardiac surgery. Studies I and IV were multicenter studies; whereas the patients included in studies II and III underwent non-cardiac surgery at Linkoping University Hospital, Sweden.

The correlation between postoperative myocardial damage and short- and long-term outcome were studied in 546 patients, aged 70 years or older undergoing non-cardiac surgery of at least 30 minutes duration. This study showed a close correlation between postoperative myocardial damage and poor short- as well as long-term outcome. Elevated Troponin T was a strong independent predictor of mortality within one year of surgery. In 186 patients with ASA physical status classification III or IV undergoing non-elective surgery, the incidence of myocardial damage was 33%. In this study preoperative myocardial damage was an independent predictor of major adverse cardiac events in the postoperative period. In 69 patients with ASA physical status classification III & IV undergoing acute hip surgery, we found a close correlation between elevated NT-proBNP value prior to surgery and cardiac complications in the postoperative period. To study the effect of acetylsalicylic acid on postoperative myocardial damage and cardiovascular events, 220 patients at risk were randomized to receive 75 mg of acetylsalicylic acid or placebo 7 days prior to surgery until the third postoperative day. This study showed that treatment with acetylsalicylic acid resulted in an 8% (95% CI 1-15%) absolute risk reduction of having a postoperative major adverse cardiac event. No statistically significant differences of bleeding complications were seen between the groups.

In conclusion, this thesis contributes to the understanding of the clinical relevance of elevated cardiac markers (with or without clinical or ECG signs of myocardial damage) in patients undergoing elective or emergency surgery. Moreover, we have identified predictors of poor outcome in the perioperative period that could be used as tools for identifying patients at risk. Finally, we have shown that continuing acetylsalicylic acid in the perioperative period reduced the risk of major adverse cardiac events within 30 days of surgery.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2009. , 89 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1141
Keyword [en]
Myocardial damage, cardiac complication, outcome, aspirin, acetylsalicylic acid
National Category
Anesthesiology and Intensive Care
Identifiers
URN: urn:nbn:se:liu:diva-20240ISBN: 978-91-7393-572-2 (print)OAI: oai:DiVA.org:liu-20240DiVA: diva2:233376
Public defence
2009-10-02, Victoriasalen, Hälsouniversitetet, Campus US, Linköpings Universitet, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2009-09-18 Created: 2009-08-31 Last updated: 2012-05-09Bibliographically approved
List of papers
1. Troponin T-values provide long-term prognosis in elderly patients undergoing non-cardiac surgery.
Open this publication in new window or tab >>Troponin T-values provide long-term prognosis in elderly patients undergoing non-cardiac surgery.
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2004 (English)In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 48, no 9, 1071-9 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The aim of this study was to evaluate the significance of elevated postoperative Troponin T (TnT) levels in an elderly population undergoing non-cardiac surgery. METHODS: Five hundred and forty-six consecutive patients aged 70 years or older undergoing non-cardiac surgery of >30-min duration were enrolled in this prospective, observational study. A postoperative TnT measurement was obtained on the 5th to 7th postoperative day. Troponin T values greater than 0.02 ng ml(-1) were considered positive. Patients were followed over a 1-year period, and mortality and non-fatal cardiac events (acute myocardial infarction and coronary interventions) were recorded. RESULTS: Troponin T concentrations greater than 0.02 ng ml(-1) were detected in 53 of the study subjects (9.7%). Eleven per cent of the patients with elevated TnT had electrocardiographic or clinical signs of myocardial ischemia. One year after surgery, 17 (32%) of the patients with abnormal TnT concentrations had died. In a multivariate Cox regression analysis adjusting for baseline and perioperative data, a TnT value >0.02 ng ml(-1) was an independent correlate of the mortality adjusted hazard ratio (HR): 14.9 (95% CI 3.7-60.3). Other independent predictors of death were tachycardia (HR, 14.9 95% CI 3.45-64.8), ASA 4 (HR, 8.1 95% CI 1.3-50.0), reoperation (HR, 6.4 95% CI 1.1-36.9), and use of diuretics (HR, 4.2 95% CI 1.3-13.8). CONCLUSION: We conclude that elevated TnT levels in the postoperative period confer a 15-fold increase in mortality during the first year after surgery. Our findings also provide evidence that silent myocardial ischemia is common in an elderly population. Routine perioperative surveillance for TnT might therefore be of use in detecting patients at an increased risk of mortality during the first postoperative year.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-20245 (URN)10.1111/j.1399-6576.2004.00463.x (DOI)15352951 (PubMedID)
Available from: 2009-08-31 Created: 2009-08-31 Last updated: 2017-12-13Bibliographically approved
2. Predictors of cardiac events in high-risk patients undergoing emergency surgery
Open this publication in new window or tab >>Predictors of cardiac events in high-risk patients undergoing emergency surgery
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2009 (English)In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 53, no 8, 986-994 p.Article in journal (Refereed) Published
Abstract [en]

Background: The aim of this study was to determine the incidence of myocardial damage and left ventricular myocardial dysfunction and their influence on outcome in high-risk patients undergoing non-elective surgery.

Methods: In this prospective observational study, 211 patients with American Society of Anesthesiologists classification III or IV undergoing emergent or urgent surgery were included. Troponin I (TnI) was measured pre-operatively, 12 and 48 h post-operatively. Pre-operative N-terminal fragment of B-type natriuretic peptide (NT-proBNP), as a marker for left ventricular systolic dysfunction, was analyzed. The diagnostic thresholds were set to TnI andgt; 0.06 mu g/l and NT-proBNP andgt; 1800 pg/ml, respectively. Post-operative major adverse cardiac events (MACE), 30-day and 3-months mortality were recorded.

Results: Elevated TnI levels were detected in 33% of the patients post-operatively. A TnI elevation increased the risk of MACE (35% vs. 3% in patients with normal TnI levels, P andlt; 0.001) and 30-day mortality (23% vs. 7%, P=0.003). Increased concentrations of NT-proBNP were seen in 59% of the patients. Elevated NT-proBNP was an independent predictor of myocardial damage post-operatively, odds ratio, 6.2 [95% confidence interval (CI) 2.1-18.0] and resulted in an increased risk of MACE (21% vs. 2.5% in patients with NT-proBNP andlt; 1800 pg/ml, P andlt; 0.001).

Conclusion: Myocardial damage is common in a high-risk population undergoing unscheduled surgery. These results suggest a close correlation between myocardial damage in the post-operative period and increased concentration of NT-proBNP before surgery. The combinations of TnI and NT-proBNP are reliable markers for monitoring patients at risk in the peri-operative period as well as useful tools in our risk assessment pre-operatively in emergency surgery.

Place, publisher, year, edition, pages
Wiley-Blackwell, 2009
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:liu:diva-20010 (URN)10.1111/j.1399-6576.2009.01971.x (DOI)000268789300002 ()19388892 (PubMedID)
Available from: 2009-08-24 Created: 2009-08-24 Last updated: 2017-12-13Bibliographically approved
3. N-terminal fragment of pro-B-type natriuretic peptide is a predictor of cardiac events in high-risk patients undergoing acute hip fracture surgery
Open this publication in new window or tab >>N-terminal fragment of pro-B-type natriuretic peptide is a predictor of cardiac events in high-risk patients undergoing acute hip fracture surgery
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2009 (English)In: British Journal of Anaesthesia, ISSN 0007-0912, E-ISSN 1471-6771, ISSN 0007-0912, Vol. 103, no 2, 206-212 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this investigation was to assess the incidence of elevated N-terminal fragment of pro-B-type natriuretic peptide (NT-proBNP) and its relation to outcome defined as perioperative adverse cardiac events and all-cause mortality in high-risk patients undergoing non-elective surgery for hip fracture. A cohort of patients with hip fractures were extracted from a prospective observational study of high-risk patients (ASA class III or IV) undergoing emergency surgery. NT-proBNP and troponin I were measured before operation. An NT-proBNP greater than= 3984 ng litre(-1) was set as the cut-off level for significance. Perioperative adverse cardiac events and 30 day and 3 month mortality were recorded. Sixty-nine subjects were included. Thirty-four subjects (49%) had an NT-proBNP greater than= 3984 ng litre(-1) before surgery. Thirty-four subjects (49%) had a perioperative adverse cardiac event. Of these, 22 subjects (65%) had NT-proBNP above the diagnostic threshold compared with 12 subjects (34%) who had an NT-proBNP below the diagnostic threshold (P=0.01). Preoperative NT-proBNP greater than= 3984 ng litre(-1) [odds ratio (OR) 3.0; 95% confidence interval (CI) 1.0-8.9] and congestive heart failure (OR 3.0; 95% CI 1.0-9.0) were independent predictors of perioperative adverse cardiac events. A total of eight subjects (12%) died within 30 days after operation. There is a high incidence of elevated NT-proBNP in subjects undergoing non-elective hip fracture surgery. Preoperative NT-proBNP is a valuable predictor of cardiac complications in the perioperative period.

Place, publisher, year, edition, pages
Oxford University Press, 2009
Keyword
complications; morbidity; heart; myocardial function; surgery; non-cardiac; surgery; orthopaedic
National Category
Surgery
Identifiers
urn:nbn:se:liu:diva-20147 (URN)10.1093/bja/aep139 (DOI)000268107800009 ()19525507 (PubMedID)
Available from: 2009-09-01 Created: 2009-08-31 Last updated: 2017-12-13Bibliographically approved
4. To continue or discontinue aspirin in the perioperative period: a randomized, controlled clinical trial
Open this publication in new window or tab >>To continue or discontinue aspirin in the perioperative period: a randomized, controlled clinical trial
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2010 (English)In: British Journal of Anaesthesia, ISSN 0007-0912, E-ISSN 1471-6771, Vol. 104, no 3, 305-312 p.Article in journal (Refereed) Published
Abstract [en]

Background: Major adverse cardiac events (MACEs) are a common cause of deathafter non-cardiac surgery. Despite evidence for the benefitof aspirin for secondary prevention, it is often discontinuedin the perioperative period due to the risk of bleeding.

Methods: We conducted a randomized, double-blind, placebo-controlledtrial in order to compare the effect of low-dose aspirin withthat of placebo on myocardial damage, cardiovascular, and bleedingcomplications in high-risk patients undergoing non-cardiac surgery.Aspirin (75 mg) or placebo was given 7 days before surgery andcontinued until the third postoperative day. Patients were followedup for 30 days after surgery.

Results: A total of 220 patients were enrolled, 109 patients receivedaspirin and 111 received placebo. Four patients (3.7%) in theaspirin group and 10 patients (9.0%) in the placebo group hadelevated troponin T levels in the postoperative period (P=0.10).Twelve patients (5.4%) had an MACE during the first 30 postoperativedays. Two of these patients (1.8%) were in the aspirin groupand 10 patients (9.0%) were in the placebo group (P=0.02). Treatmentwith aspirin resulted in a 7.2% absolute risk reduction [95%confidence interval (CI), 1.3–13%] for postoperative MACE.The relative risk reduction was 80% (95% CI, 9.2–95%).Numbers needed to treat were 14 (95% CI, 7.6–78). No significantdifferences in bleeding complications were seen between thetwo groups.

Conclusions: In high-risk patients undergoing non-cardiac surgery, perioperativeaspirin reduced the risk of MACE without increasing bleedingcomplications. However, the study was not powered to evaluatebleeding complications.

 

Keyword
analgesics non-opioid, aspirin; complications, haemorrhage; heart, ischaemia; surgery, non-cardiac
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-20759 (URN)10.1093/bja/aeq003 (DOI)000274485900006 ()
Note
This is a pre-copy-editing, author-produced PDF of an article accepted for publication in British Journal of Anaesthesia following peer review. The definitive publisher-authenticated version: Anna Oscarsson Tibblin, Anil Gupta, Mats Fredrikson, Johannes Järhult, Matti Nyström, Eva Pettersson, Bijan Darvish, Helena Krook, Eva Swahn and Christina Eintrei, To continue or discontinue aspirin in the perioperative period: a randomized, controlled clinical trial, 2010, British Journal of Anaesthesia, (104), 3, 305-312. is available online at: http://dx.doi.org/doi:10.1093/bja/aeq003 Copyright: Oxford University Press http://www.oxfordjournals.org/ Available from: 2009-09-18 Created: 2009-09-18 Last updated: 2017-12-13Bibliographically approved

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