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Background: Consensus recommendations regarding the threshold levels of cardiac troponin elevations for the definition of perioperative myocardial infarction and clinically important periprocedural myocardial injury in patients undergoing cardiac surgery range widely (from >10 times to ≥70 times the upper reference limit for the assay). Limited evidence is available to support these recommendations., Methods: We undertook an international prospective cohort study involving patients 18 years of age or older who underwent cardiac surgery. High-sensitivity cardiac troponin I measurements (upper reference limit, 26 ng per liter) were obtained 3 to 12 hours after surgery and on days 1, 2, and 3 after surgery. We performed Cox analyses using a regression spline that explored the relationship between peak troponin measurements and 30-day mortality, adjusting for scores on the European System for Cardiac Operative Risk Evaluation II (which estimates the risk of death after cardiac surgery on the basis of 18 variables, including age and sex)., Results: Of 13,862 patients included in the study, 296 (2.1%) died within 30 days after surgery. Among patients who underwent isolated coronary-artery bypass grafting or aortic-valve replacement or repair, the threshold troponin level, measured within 1 day after surgery, that was associated with an adjusted hazard ratio of more than 1.00 for death within 30 days was 5670 ng per liter (95% confidence interval [CI], 1045 to 8260), a level 218 times the upper reference limit. Among patients who underwent other cardiac surgery, the corresponding threshold troponin level was 12,981 ng per liter (95% CI, 2673 to 16,591), a level 499 times the upper reference limit., Conclusions: The levels of high-sensitivity troponin I after cardiac surgery that were associated with an increased risk of death within 30 days were substantially higher than levels currently recommended to define clinically important periprocedural myocardial injury. (Funded by the Canadian Institutes of Health Research and others; VISION Cardiac Surgery ClinicalTrials.gov number, NCT01842568.)., (Copyright © 2022 Massachusetts Medical Society.)

Background: The National Surgical Quality Improvement Program Myocardial Infarction & Cardiac Arrest (NSQIP MICA) calculator and the Revised Cardiac Risk Index (RCRI) were derived using currently outdated methods of diagnosing perioperative myocardial infarctions. We tested the external validity of these tools in a setting of a systematic perioperative cardiac biomarker measurement., Methods: Analysis of routinely collected data nested in the Vascular Events In Noncardiac Surgery Patients Cohort Evaluation Study. A consecutive sample of patients ≥45 yr old undergoing in-hospital noncardiac surgery in a single tertiary care centre was enrolled. The predictive performance of the models was tested in terms of the occurrence of major cardiac complications defined as a composite of a nonfatal myocardial infarction, a nonfatal cardiac arrest, or a cardiac death within 30 days after surgery. The plasma concentration of high-sensitivity troponin T was measured before surgery, 6-12 h after operation, and on the first, second, and third days after surgery. Myocardial infarction was diagnosed according to the Third Universal Definition., Results: The median age was 65 (59-72) yr, and 704/870 (80.9%) subjects were male. The primary outcome occurred in 76/870 (8.7%; 95% confidence interval [CI], 6.9-10.8%) patients. The c-statistic was 0.64 (95% CI, 0.57-0.70) for the NSQIP MICA and 0.60 (95% CI, 0.54-0.65) for the RCRI. Predicted risks were systematically underestimated in calibration belts (P<0.001). The RCRI and the NSQIP MICA showed no clinical utility before recalibration., Conclusions: The NSQIP and RCRI models had limited predictive performance in this at-risk population. The recently updated version of the RCRI was more reliable than the original index., (Copyright © 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Background: Inappropriate staff behaviour during surgical procedures may disrupt the surgical performance and compromise patient safety. We developed an innovative monitoring and feedback system combined with an adaptive approach to optimise staff behaviour intraoperatively and prevent post-operative complications (POC) in orthopaedic surgery., Methods/design: This protocol describes a parallel-group, cluster randomised, controlled trial with orthopaedic centre as the unit of randomisation. The intervention period will last 6 months and will be based on the monitoring of two surrogates of staff behaviour: the frequency of doors opening and the level of noise. Both will be collected from incision to wound closure, using wireless sensors and sonometers, and recorded and analysed on a dedicated platform (Livepulse®). Staff from centres randomised to the intervention arm will be informed in real time on their own data through an interactive dashboard available in each operating room (OR), and a posteriori for hip and knee replacement POC. Aggregated data from all centres will also be displayed for benchmarking. A lean method will be applied in each centre by a local multidisciplinary team to analyse baseline situations, determine the target condition, analyse the root cause(s), and take countermeasures. The education and awareness of participants on the impact of their behaviour on patient safety will assist the quality improvement process. The control centres will be blinded to monitoring data and quality improvement approaches. The primary outcome will be any POC occurring during the 30 days post operation. We will evaluate this outcome using local and national routinely collected data from hospital discharge and disease databases. Thirty orthopaedic centres will be randomised for a total of 9945 hip and knee replacement surgical procedures., Discussion: The field of human factors and behaviour in the OR seems to offer potential room for improvement. An intervention providing goal-setting, monitoring, feedback and action planning may reduce the traffic flow and interruptions/distractions of the surgical team during procedures, preventing subsequent POCs. The results of this trial will provide important data on the impact of OR staff behaviour on patient safety, and promote best practice during surgical procedures., Trial Registration: ClinicalTrials.gov, NCT03158181 .

Introduction: In elderly patients, goal-directed haemodynamic therapy (GDHT), depth of anaesthesia monitoring and lung-protective ventilation have been shown to improve postoperative outcomes. The aim of this study was to evaluate current practices concerning strategies of anaesthesia optimisation in patients aged≥75 years., Patients and Methods: A multicentre observational study was performed from February to May 2015 in 23 French academic centres. On 30 consecutive days in each centre, patients≥75 years with at least one major comorbidity undergoing elective or emergency procedures (femoral-neck fractures surgery, intraperitoneal abdominal surgery or vascular surgery) were included. Patient characteristics and data related to GHDT, management of hypotension, monitoring of temperature and depth of anaesthesia, lung ventilation, point of care haemoglobin testing were collected., Results: In total, 807 patients were included. Only 2% of patients [95% CI: 1-3] received GHDT in full accordance with guidelines. Depth of anaesthesia monitoring was largely performed (53% [95% CI: 50-56]). The multifaceted strategy of lung-protective ventilation combining low tidal volumes (6-8mL/kg), PEEP of 5-8cm cmH 2 O, and repeated recruitment manoeuvres, was performed in only 4% [95% CI: 3-5] of patients. A centre effect was a major determinant of variation concerning implementation of these strategies., Discussion: In patients'≥75 years, strategies of anaesthesia optimisation are not in accordance with eligible guidelines. Implementation of these techniques varies independently of factors related to the patient or the type of surgery and may be dependent on the generated constraints., (Copyright © 2018 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Background: The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications., Methods: ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery., Results: The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784., Conclusions: This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance., Clinical Trial Registration: NCT03044899., (Copyright © 2018 British Journal of Anaesthesia. All rights reserved.)

Objectives: To compare the association between a restrictive transfusion strategy and cardiovascular complications during hospitalization for hip fracture with the association between a liberal transfusion strategy and cardiovascular complications, accounting for all transfusions from the emergency department to postacute rehabilitation settings., Design: Retrospective study., Setting: Perioperative geriatric care unit., Participants: All individuals aged 70 and older admitted to the emergency department for hip fracture and hospitalized in our perioperative geriatric care unit (N=667; n=193 in the liberal transfusion group, n=474 in the restrictive transfusion group) from July 2009 to April 2016., Intervention: A restrictive transfusion strategy (hemoglobin level threshold ≥8 g/dL or symptoms) used from January 2012 to April 2016 was compared with the liberal transfusion strategy (hemoglobin level threshold ≥10 g/dL) used from July 2009 to December 2011., Measurements: Primary endpoint was in-hospital acute cardiovascular complications (heart failure, myocardial infarction, atrial fibrillation or stroke)., Results: The change to a restrictive transfusion strategy was associated with fewer acute cardiovascular complications (odds ratio=0.45, 95% confidence interval (CI)=0.31-0.67, p<.001), without any noticeable difference in in-hospital or 6-month mortality. The change also led to a reduction in packed red blood cell units used per participant (median 1, interquartile range (IQR) 0-2 in restrictive vs median 2, IQR 0-3 in liberal transfusion strategy, P<.001). In rehabilitation settings, the frequency of transfusion was greater with the restrictive transfusion strategy than the liberal transfusion strategy (18% vs 9%, P<.001)., Conclusion: A restrictive transfusion strategy in older adults with hip fracture was found to be safe and was associated with fewer cardiovascular complications but more transfusions in rehabilitation settings. Prospective studies are needed to confirm these findings., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Background: Myocardial injury after noncardiac surgery (MINS) is a mostly asymptomatic condition that is strongly associated with 30-day mortality; however, it remains mostly undetected without systematic troponin T monitoring. We evaluated the cost and consequences of postoperative troponin T monitoring to detect MINS., Methods: We conducted a model-based cost-consequence analysis to compare the impact of routine troponin T monitoring versus standard care (troponin T measurement triggered by ischemic symptoms) on the incidence of MINS detection. Model inputs were based on Canadian patients enrolled in the Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) study, which enrolled patients aged 45 years or older undergoing inpatient noncardiac surgery. We conducted probability analyses with 10 000 iterations and extensive sensitivity analyses., Results: The data were based on 6021 patients (48% men, mean age 65 [standard deviation 12] yr). The 30-day mortality rate for MINS was 9.6%. We determined the incremental cost to avoid missing a MINS event as $1632 (2015 Canadian dollars). The cost-effectiveness of troponin monitoring was higher in patient subgroups at higher risk for MINS, e.g., those aged 65 years or more, or with a history of atherosclerosis or diabetes ($1309)., Conclusion: The costs associated with a troponin T monitoring program to detect MINS were moderate. Based on the estimated incremental cost per health gain, implementation of postoperative troponin T monitoring seems appealing, particularly in patients at high risk for MINS.

Background: The effect on cardiovascular outcomes of withholding angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers in chronic users before noncardiac surgery is unknown., Methods: In this international prospective cohort study, the authors analyzed data from 14,687 patients (including 4,802 angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users) at least 45 yr old who had in-patient noncardiac surgery from 2007 to 2011. Using multivariable regression models, the authors studied the relationship between withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers and a primary composite outcome of all-cause death, stroke, or myocardial injury after noncardiac surgery at 30 days, with intraoperative and postoperative clinically important hypotension as secondary outcomes., Results: Compared to patients who continued their angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, the 1,245 (26%) angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users who withheld their angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers in the 24 h before surgery were less likely to suffer the primary composite outcome of all-cause death, stroke, or myocardial injury (150/1,245 [12.0%] vs. 459/3,557 [12.9%]; adjusted relative risk, 0.82; 95% CI, 0.70 to 0.96; P = 0.01) and intraoperative hypotension (adjusted relative risk, 0.80; 95% CI, 0.72 to 0.93; P < 0.001). The risk of postoperative hypotension was similar between the two groups (adjusted relative risk, 0.92; 95% CI, 0.77 to 1.10; P = 0.36). Results were consistent across the range of preoperative blood pressures. The practice of withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers was only modestly correlated with patient characteristics and the type and timing of surgery., Conclusions: Withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers before major noncardiac surgery was associated with a lower risk of death and postoperative vascular events. A large randomized trial is needed to confirm this finding. In the interim, clinicians should consider recommending that patients withhold angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers 24 h before surgery.

Background: An accurate risk score able to predict in-hospital mortality in patients undergoing surgery may improve both risk communication and clinical decision making. The aim of the study was to develop and validate a surgical risk score based solely on preoperative information, for predicting in-hospital mortality., Methods: From January 1, 2010, to December 31, 2010, data related to all surgeries requiring anesthesia were collected from all centers (single hospital or hospitals group) in France performing more than 500 operations in the year on patients aged 18 yr or older (n = 5,507,834). International Statistical Classification of Diseases, 10th revision codes were used to summarize the medical history of patients. From these data, the authors developed a risk score by examining 29 preoperative factors (age, comorbidities, and surgery type) in 2,717,902 patients, and then validated the risk score in a separate cohort of 2,789,932 patients., Results: In the derivation cohort, there were 12,786 in-hospital deaths (0.47%; 95% CI, 0.46 to 0.48%), whereas in the validation cohort there were 14,933 in-hospital deaths (0.54%; 95% CI, 0.53 to 0.55%). Seventeen predictors were identified and included in the PreOperative Score to predict PostOperative Mortality (POSPOM). POSPOM showed good calibration and excellent discrimination for in-hospital mortality, with a c-statistic of 0.944 (95% CI, 0.943 to 0.945) in the development cohort and 0.929 (95% CI, 0.928 to 0.931) in the validation cohort., Conclusion: The authors have developed and validated POSPOM, a simple risk score for the prediction of in-hospital mortality in surgical patients.

Aims: The aim of this study was to assess the effects of pre-operative statin therapy on cardiovascular events in the first 30-days after non-cardiac surgery., Methods and Results: We conducted an international, prospective, cohort study of patients who were ≥45 years having in-patient non-cardiac surgery. We estimated the probability of receiving statins pre-operatively using a multivariable logistic model and conducted a propensity score analysis to correct for confounding. A total of 15 478 patients were recruited at 12 centres in eight countries from August 2007 to January 2011. The matched population consisted of 2845 patients (18.4%) treated with a statin and 4492 (29.0%) controls. The pre-operative use of statins was associated with lower risk of the primary outcome, a composite of all-cause mortality, myocardial injury after non-cardiac surgery (MINS), or stroke at 30 days [relative risk (RR), 0.83; 95% confidence interval (CI), 0.73-0.95; P = 0.007]. Statins were also associated with a significant lower risk of all-cause mortality (RR, 0.58; 95% CI, 0.40-0.83; P = 0.003), cardiovascular mortality (RR, 0.42; 95% CI, 0.23-0.76; P = 0.004), and MINS (RR, 0.86; 95% CI, 0.73-0.98; P = 0.02). There were no statistically significant differences in the risk of myocardial infarction or stroke., Conclusion: Among patients undergoing non-cardiac surgery, pre-operative statin therapy was independently associated with a lower risk of cardiovascular outcomes at 30 days. These results require confirmation in a large randomized trial., Clinical Trial Registration: Clinical Trials.gov NCT00512109., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: Journals.permissions@oup.com.)

Background: Acute cardiac events are a frequent cause of morbidity after vascular surgery. The impact of early evidence-based treatment for patients with an acute cardiac event after vascular surgery on long-term postoperative outcomes has not been extensively studied. We hypothesized that providing appropriate evidence-based treatment to patients with elevated postoperative cardiac troponin levels may limit long-term mortality., Methods: We conducted a study of 667 consecutive major vascular surgery patients with an elevated postoperative troponin I level. We then determined which of these patients received medical therapy as per the 2007 American College of Cardiology/American Heart Association recommendations for the medical management of patients with chronic stable angina. All patients with troponin elevation were then matched with 2 control patients without postoperative troponin elevation. Matching was done using logistic regression and nearest-neighbor matching methods. The primary study end point was 12 months survival without a major cardiac event (i.e., death, myocardial infarction, coronary revascularization, or pulmonary edema requiring hospitalization)., Results: Therapy was intensified in 43 of 66 patients (65%) who suffered a troponin I elevation after surgery. Patients with a troponin I elevation not receiving intensified cardiovascular treatment had a hazard ratio (HR) of 1.77 (95% confidence interval (CI), 1.13-2.42; P = 0.004) for the primary study outcome as compared with the control group. In contrast, patients with a troponin I elevation who received intensified cardiovascular treatment had an HR of 0.63 (95% CI, 0.10-1.19; P = 0.45) for the primary outcome as compared with the control group. Patients with a troponin I elevation not receiving treatment intensification likely were at higher risk for a major cardiac event (HR, 2.80; 95% CI, 1.05-24.2; P = 0.04) compared with patients who did receive treatment intensification., Conclusions: The main finding of this study was that in patients with elevated troponin I levels after noncardiac surgery, long-term adverse cardiac outcomes may likely be improved by following evidence-based recommendations for the medical management of acute coronary syndromes.

Background: There is substantial variability in the perioperative administration of aspirin in patients undergoing noncardiac surgery, both among patients who are already on an aspirin regimen and among those who are not., Methods: Using a 2-by-2 factorial trial design, we randomly assigned 10,010 patients who were preparing to undergo noncardiac surgery and were at risk for vascular complications to receive aspirin or placebo and clonidine or placebo. The results of the aspirin trial are reported here. The patients were stratified according to whether they had not been taking aspirin before the study (initiation stratum, with 5628 patients) or they were already on an aspirin regimen (continuation stratum, with 4382 patients). Patients started taking aspirin (at a dose of 200 mg) or placebo just before surgery and continued it daily (at a dose of 100 mg) for 30 days in the initiation stratum and for 7 days in the continuation stratum, after which patients resumed their regular aspirin regimen. The primary outcome was a composite of death or nonfatal myocardial infarction at 30 days., Results: The primary outcome occurred in 351 of 4998 patients (7.0%) in the aspirin group and in 355 of 5012 patients (7.1%) in the placebo group (hazard ratio in the aspirin group, 0.99; 95% confidence interval [CI], 0.86 to 1.15; P=0.92). Major bleeding was more common in the aspirin group than in the placebo group (230 patients [4.6%] vs. 188 patients [3.8%]; hazard ratio, 1.23; 95% CI, 1.01, to 1.49; P=0.04). The primary and secondary outcome results were similar in the two aspirin strata., Conclusions: Administration of aspirin before surgery and throughout the early postsurgical period had no significant effect on the rate of a composite of death or nonfatal myocardial infarction but increased the risk of major bleeding. (Funded by the Canadian Institutes of Health Research and others; POISE-2 ClinicalTrials.gov number, NCT01082874.).

Background: Marked activation of the sympathetic nervous system occurs during and after noncardiac surgery. Low-dose clonidine, which blunts central sympathetic outflow, may prevent perioperative myocardial infarction and death without inducing hemodynamic instability., Methods: We performed a blinded, randomized trial with a 2-by-2 factorial design to allow separate evaluation of low-dose clonidine versus placebo and low-dose aspirin versus placebo in patients with, or at risk for, atherosclerotic disease who were undergoing noncardiac surgery. A total of 10,010 patients at 135 centers in 23 countries were enrolled. For the comparison of clonidine with placebo, patients were randomly assigned to receive clonidine (0.2 mg per day) or placebo just before surgery, with the study drug continued until 72 hours after surgery. The primary outcome was a composite of death or nonfatal myocardial infarction at 30 days., Results: Clonidine, as compared with placebo, did not reduce the number of primary-outcome events (367 and 339, respectively; hazard ratio with clonidine, 1.08; 95% confidence interval [CI], 0.93 to 1.26; P=0.29). Myocardial infarction occurred in 329 patients (6.6%) assigned to clonidine and in 295 patients (5.9%) assigned to placebo (hazard ratio, 1.11; 95% CI, 0.95 to 1.30; P=0.18). Significantly more patients in the clonidine group than in the placebo group had clinically important hypotension (2385 patients [47.6%] vs. 1854 patients [37.1%]; hazard ratio 1.32; 95% CI, 1.24 to 1.40; P<0.001). Clonidine, as compared with placebo, was associated with an increased rate of nonfatal cardiac arrest (0.3% [16 patients] vs. 0.1% [5 patients]; hazard ratio, 3.20; 95% CI, 1.17 to 8.73; P=0.02)., Conclusions: Administration of low-dose clonidine in patients undergoing noncardiac surgery did not reduce the rate of the composite outcome of death or nonfatal myocardial infarction; it did, however, increase the risk of clinically important hypotension and nonfatal cardiac arrest. (Funded by the Canadian Institutes of Health Research and others; POISE-2 ClinicalTrials.gov number, NCT01082874.).

Objectives: The objective of this study was to determine whether measuring post-operative B-type natriuretic peptides (NPs) (i.e., B-type natriuretic peptide [BNP] and N-terminal fragment of proBNP [NT-proBNP]) enhances risk stratification in adult patients undergoing noncardiac surgery, in whom a pre-operative NP has been measured., Background: Pre-operative NP concentrations are powerful independent predictors of perioperative cardiovascular complications, but recent studies have reported that elevated post-operative NP concentrations are independently associated with these complications. It is not clear whether there is value in measuring post-operative NP when a pre-operative measurement has been done., Methods: We conducted a systematic review and individual patient data meta-analysis to determine whether the addition of post-operative NP levels enhanced the prediction of the composite of death and nonfatal myocardial infarction at 30 and ≥180 days after surgery., Results: Eighteen eligible studies provided individual patient data (n = 2,179). Adding post-operative NP to a risk prediction model containing pre-operative NP improved model fit and risk classification at both 30 days (corrected quasi-likelihood under the independence model criterion: 1,280 to 1,204; net reclassification index: 20%; p < 0.001) and ≥180 days (corrected quasi-likelihood under the independence model criterion: 1,320 to 1,300; net reclassification index: 11%; p = 0.003). Elevated post-operative NP was the strongest independent predictor of the primary outcome at 30 days (odds ratio: 3.7; 95% confidence interval: 2.2 to 6.2; p < 0.001) and ≥180 days (odds ratio: 2.2; 95% confidence interval: 1.9 to 2.7; p < 0.001) after surgery., Conclusions: Additional post-operative NP measurement enhanced risk stratification for the composite outcomes of death or nonfatal myocardial infarction at 30 days and ≥180 days after noncardiac surgery compared with a pre-operative NP measurement alone., (Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: It is unclear whether postoperative B-type natriuretic peptides (i.e., BNP and N-terminal proBNP) can predict cardiovascular complications in noncardiac surgery., Methods: The authors undertook a systematic review and individual patient data meta-analysis to determine whether postoperative BNPs predict postoperative cardiovascular complications at 30 and 180 days or more., Results: The authors identified 18 eligible studies (n = 2,051). For the primary outcome of 30-day mortality or nonfatal myocardial infarction, BNP of 245 pg/ml had an area under the curve of 0.71 (95% CI, 0.64-0.78), and N-terminal proBNP of 718 pg/ml had an area under the curve of 0.80 (95% CI, 0.77-0.84). These thresholds independently predicted 30-day mortality or nonfatal myocardial infarction (adjusted odds ratio [AOR] 4.5; 95% CI, 2.74-7.4; P < 0.001), mortality (AOR, 4.2; 95% CI, 2.29-7.69; P < 0.001), cardiac mortality (AOR, 9.4; 95% CI, 0.32-254.34; P < 0.001), and cardiac failure (AOR, 18.5; 95% CI, 4.55-75.29; P < 0.001). For greater than or equal to 180-day outcomes, natriuretic peptides independently predicted mortality or nonfatal myocardial infarction (AOR, 3.3; 95% CI, 2.58-4.3; P < 0.001), mortality (AOR, 2.2; 95% CI, 1.67-86; P < 0.001), cardiac mortality (AOR, 2.1; 95% CI, 0.05-1,385.17; P < 0.001), and cardiac failure (AOR, 3.5; 95% CI, 1.0-9.34; P = 0.022). Patients with BNP values of 0-250, greater than 250-400, and greater than 400 pg/ml suffered the primary outcome at a rate of 6.6, 15.7, and 29.5%, respectively. Patients with N-terminal proBNP values of 0-300, greater than 300-900, and greater than 900 pg/ml suffered the primary outcome at a rate of 1.8, 8.7, and 27%, respectively., Conclusions: Increased postoperative BNPs are independently associated with adverse cardiac events after noncardiac surgery.

Background: Chronic statin therapy is associated with reduced postoperative mortality. Renal and cardiovascular benefits have been described, but the effect of chronic statin therapy on postoperative adverse events has not yet been explored., Methods: In this observational study involving 1,674 patients undergoing aortic reconstruction, we prospectively assessed chronic statin therapy compared with no statin therapy, with regard to serious outcomes, by propensity score and multivariable methods., Results: In propensity-adjusted multivariable logistic regression (c-index: 0.83), statins were associated with an almost threefold reduction in the risk of death in patients undergoing major vascular surgery (odds ratio: 0.40; 95% CI: 0.28-0.59) and an almost twofold reduction in the risk of postoperative myocardial infarction (odds ratio: 0.52; 95% CI: 0.38-0.71). Likewise, the use of chronic statin therapy was associated with a reduced risk of postoperative stroke and renal failure. Statins did not significantly reduce the risk of pneumonia, multiple organ dysfunction syndrome, and surgical complications; however, in the case of postoperative multiple organ dysfunction syndrome (odds ratio: 0.34; 95% CI: 0.12-0.94) and surgical complications (odds ratio: 0.39; 95% CI: 0.17-0.86), reduced mortality was observed., Conclusions: Chronic statin therapy was associated with a reduction in all cardiac and vascular outcomes after major vascular surgery. Furthermore, in major adverse events, such as multiple organ dysfunction syndrome and surgical complications, statins were also associated with decreased mortality.

Objective: The aim of this study was to determine whether perioperative statin therapy was associated with a dose-dependent decrease in adverse cardiovascular events after coronary artery bypass graft (CABG) surgery., Design: A prospective observational study., Setting: A cardiovascular anesthesia unit in a university hospital., Participants: Four hundred eighteen consecutive patients undergoing CABG surgery between October 2004 and October 2005., Interventions: Patients were divided in 2 groups depending on whether their preoperative treatment included statins or not. In patients receiving statins, high- and low-dose regimens were respectively defined as a regimen recognized to induce a theoretic reduction of low-density lipoprotein cholesterol level equal to 45% (n = 87) or <45% (n = 258). In treated patients, statin therapy was maintained until the day of surgery and was restarted soon thereafter., Measurements and Main Results: The measured endpoint was adverse in-hospital cardiovascular outcomes including heart failure and/or malignant arrhythmia and/or cardiac death. Stepwise logistic regression and a multivariate analysis of propensity-matched cohort were used for analysis of the findings. After adjustment for propensity score, statin therapy was found to produce a significant reduction in cardiovascular outcomes (odds ratio = 0.56; 95% confidence interval [CI], 0.32-0.96, p < 0.05). By using multivariate analysis, the odds ratio for cardiovascular outcomes in patients receiving high-dose statins compared with those treated by low-dose statins was 0.62 (95% CI, 0.41-0.93; p < 0.05)., Conclusion: Statin therapy is associated with a significant and dose-dependent reduction in adverse cardiovascular events after CABG surgery. However, further randomized trials still require confirming a causal association between statins and better postoperative outcomes and evaluating the tolerance of such perioperative therapy.

Background: Simultaneous assessment of cardiac troponin I, B-type natriuretic peptide, and C-reactive protein has been found to provide unique prognostic information in acute coronary syndromes. The current study addressed the prognostic implication of a multiple-marker approach in cardiac surgery., Methods: Two hundred twenty-four patients undergoing cardiac surgery were included and followed up within 12 months after surgery. Serial blood samples were drawn in all patients the day before surgery, at the end of surgery, and 6, 24, and 120 h after surgery. Major adverse cardiac events within 12 months after surgery were chosen as study endpoints and were defined as malignant ventricular arrhythmia, myocardial infarction, congestive heart failure, the need for myocardial revascularization, and/or death from cardiac cause. Predictive ability of each cardiac biomarker was assessed using logistic regression., Results: Accuracies of C-reactive protein, cardiac troponin I, and B-type natriuretic peptide, considered as continuous variables, to predict the occurrence of major adverse cardiac events were limited (area under receiver operating characteristic curve: 0.54 [0.47-0.60], P = 0.42; 0.62 [0.55-0.68], P = 0.01; and 0.68 [0.61-0.74], P < 0.001, respectively). When biomarkers were considered as 75% specificity dichotomized variables, elevated C-reactive protein (> 180 mg/l), cardiac troponin I (> 3.5 ng/ml), and B-type natriuretic peptide (> 880 pg/ml) were independent predictors of major adverse cardiac events (odds ratio: 2.14 [1.03-4.49], P = 0.043; 2.37 [1.25-5.64], P = 0.011; and 2.65 [1.16-4.85], P = 0.018, respectively) in a multivariate model including the European System for Cardiac Operative Risk Evaluation score., Conclusions: Simultaneous measurement of cardiac troponin I, B-type natriuretic peptide, and C-reactive protein improves the risk assessment of long-term adverse cardiac outcome after cardiac surgery.

Objective: Procalcitonin has been advocated as a specific biomarker for bacterial infection. We performed this study to determine whether accuracy of procalcitonin for diagnosis of postoperative bacterial infection is affected by renal function after aortic surgery., Design: Single-center prospective study., Setting: University hospital., Patients: Two hundred seventy-six patients scheduled for elective major aortic surgery., Interventions: Blood samples were taken before surgery and each day over the 5-day postoperative period, and measurement of serum procalcitonin was performed. Diagnosis of infection was performed by a blinded expert panel. Renal function was assessed using an estimate of creatinine clearance with the Cockcroft formulas. Renal dysfunction was defined as a creatinine clearance <50 mL x min(-1)., Measurements and Main Results: Infection was diagnosed in 67 patients. Seventy five patients (27%) had postoperative renal dysfunction. Procalcitonin was significantly higher in infected patients, with a peak reached at the fourth postoperative day, but it was significantly higher in patients with impaired renal function in both control and infected patients. The optimal threshold of procalcitonin markedly differed in patients with renal dysfunction compared with patients without renal dysfunction (2.57 vs. 0.80 ng x mL(-1), p < .05). The diagnostic accuracy of procalcitonin significantly increased (0.74 vs. 0.70, p < .05) when the threshold of procalcitonin was adapted to the renal function. The elevation of procalcitonin occurred 2 days before the medical team was able to diagnose infection., Conclusions: Procalcitonin is a valuable marker of bacterial infections after major aortic surgery, but renal function is a major determinant of procalcitonin levels and thus different thresholds should be applied according to renal function impairment.

Background: Recent publications have reported high incidence of perioperative complications in patients with drug-eluting stent (DES). The recommendations for bare-metal stents (BMS) are not applicable to DES. In fact, large evidence-based studies are lacking on which to base a consensus for the perioperative management of patients with DES. The aim of the present study is to evaluate the postoperative cardiac risk associated with DES., Methods: Prospectively collected data were examined for the rate of postoperative cardiac complications in 96 consecutive patients with DES who underwent digestive, urologic, orthopaedic, or vascular surgery. The average delay between revascularization and non-cardiac surgery was 14 (11) months (extremes 1 week and 36 months). The occurrence of postoperative troponin release (troponin I > or =0.15 ng ml(-1)) and the rate of in-stent thrombosis were analysed., Results: Twelve patients (12%) presented a postoperative troponin release, without EKG abnormalities in 10 cases (83%). Two patients (2%) developed an in-stent thrombosis. None of the patients had excessive postoperative blood loss., Conclusions: Patients with DES are at higher risk of postoperative cardiac complications. Nevertheless, the specific thrombotic complications of the DES were uncommon in this series and this is in contrast to previous alarming reports. A balanced perioperative management of anti-platelet agents, considering both risk for bleeding and risk of thrombotic complications, in patients with DES, is associated with a low risk of thrombosis in the postoperative period. The rate of cardiac complications remains high in these patients due to co-morbidities.

Introduction: The objective of the present study was to compare postoperative cardiac troponin I (cTnI) release and the thresholds of cTnI that predict adverse outcome after elective coronary artery bypass graft (CABG), after valve surgery, and after combined cardiac surgery., Methods: Six hundred and seventy-five adult patients undergoing conventional cardiac surgery with cardiopulmonary bypass were retrospectively analyzed. Patients in the CABG (n = 225) and valve surgery groups (n = 225) were selected after matching (age, sex) with those in the combined surgery group (n = 225). cTnI was measured preoperatively and 24 hours after the end of surgery. The main endpoint was a severe postoperative cardiac event (sustained ventricular arrhythmias requiring treatment, need for inotropic support or intraaortic balloon pump for at least 24 hours, postoperative myocardial infarction) and/or death. Data are presented as the median and the odds ratio (95% confidence interval)., Results: Postoperative cTnI levels were significantly different among the three groups (combined surgery, 11.0 (9.5-13.1) ng/ml versus CABG, 5.2 (4.7-5.7) ng/ml and valve surgery, 7.8 (7.6-8.0) ng/ml; P < 0.05). The thresholds of cTnI predicting severe cardiac event and/or death were also significantly different among the three groups (combined surgery, 11.8 (11.5-14.8) ng/ml versus CABG, 7.8 (6.7-8.8) ng/ml and valve surgery, 9.3 (8.0-14.0) ng/ml; P < 0.05). An elevated cTnI above the threshold in each group was significantly associated with a severe cardiac event and/or death (odds ratio, 4.33 (2.82-6.64))., Conclusion: The magnitude of postoperative cTnI release is related to the type of cardiac surgical procedure. Different thresholds of cTnI must be considered according to the procedure type to predict early an adverse postoperative outcome.

Background: Although postoperative myocardial infarction (PMI) after vascular surgery has been described to be associated with prolonged ischemia, its exact pathophysiology remains unclear., Methods: The authors used intense cardiac troponin I (cTnI) surveillance after abdominal aortic surgery in 1,136 consecutive patients to better evaluate the incidence and timing of PMI (cTnI > or = 1.5 ng/ml) or myocardial damage (abnormal cTnI < 1.5 ng/ml)., Results: Abnormal cTnI concentrations was noted in 163 patients (14%), of which 106 (9%) had myocardial damage and 57 (5%) had PMI. In 34 patients (3%), PMI was preceded by a prolonged (> 24 h) period of increased cTnI (delayed PMI), and in 21 patients (2%), the increase in cTnI lasted less than 24 h (early PMI). The mean times from end of surgery to PMI were 37 +/- 22 and 74 +/- 39 h in the early PMI and delayed PMI groups, respectively (P < 0.001). The mean time between the first abnormal cTnI and PMI in the delayed PMI group was 54 +/- 35 h, during which the cTnI profiles of the myocardial damage and delayed PMI groups were identical. In-hospital mortality rates were 24, 21, 7, and 3% for the early PMI, delayed PMI, myocardial damage, and normal groups, respectively., Conclusions: Intense postoperative cTnI surveillance revealed two types of PMI according to time of appearance and rate of increase in cTnI. The identification of early and delayed PMI may be suggestive of different pathophysiologic mechanisms. Abnormal but low postoperative cTnI is associated with increased mortality and may lead to delayed PMI.