Self-reported Exercise Tolerance and the Risk of Serious Perioperative Complications

Reilly, Dominic F.; McNeely, Marguerite J.; Doerner, Diane; Greenberg, Deborah L.; Staiger, Thomas O.; Geist, Michael J.; Vedovatti, Philip A.; Coffey, John E.; Mora, Marc W.; Johnson, Timothy R.; Guray, Eugenia D.; Norman, Gail A. Van; Fihn, Stephan D.

doi:10.1001/archinte.159.18.2185

Cited by 354 publications

(174 citation statements)

References 32 publications

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“…27) Many trials have sought prognosticating factors in noncardiac surgery. 4,5,6,10,21,22,[27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42] In these studies, poor functional capacity, recent MI and unstable angina, decompensated heart failure, significant arrhythmia, diabetes mellitus, renal insufficiency, cerebrovascular disease, advanced age, tachycardia, anemia, surgical kind, and elevated troponin-I level were determined to be independent prognostic factors after noncardiac surgery, most of which were in agreement with our study. While the results of those studies had been generated after short-term follow-up, the present study extended the follow-up period to 7 years and attempted to provide valuable data regarding longer term mortality.…”

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confidence: 86%

Troponin-I Level After Major Noncardiac Surgery and Its Association With Long-Term Mortality

et al. 2016

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SummaryIndividuals with intermediate to high cardiac risk for major noncardiac surgery suffer from perioperative myocardial ischemic injury. The purpose of this study was to evaluate the long-term impact of postoperative cardiac troponin elevation on clinical outcome after major noncardiac surgery.Patients (n = 750) aged ≥ 50 years who underwent major noncardiac surgery were eligible for the study. Postoperative cardiac troponin-I data were collected retrospectively and consecutively. The primary outcome measure was allcause mortality. The median follow-up period was 1727 days in all patients.Among 750 patients, 92 (12.2%) showed elevated postoperative troponin-I above 0.10 ng/mL. Operative mortality was 4.1% (31 subjects), and patients with troponin-I elevation showed a higher operative mortality rate (RR: 4.23, 95% CI: 2.67-11.31, P < 0.001). In multivariate Cox regression analysis, a troponin-I concentration above 0.10 ng/mL was associated with all-cause mortality (RR: 1.73, 95% CI: 1.27-2.36, P < 0.001). It should be noted that there was a significant difference between patients with elevated and non-elevated troponin-I in the rate of mortality until 6 months. However, these differences disappeared after 6 months. An elevated troponin-I level conferred an increase in mortality during the 7 year follow-up period after major noncardiac surgery. This difference in mortality was mainly derived from the result within the first 6 months. (Int Heart J 2016; 57: 278-284) Key words: Myocardial ischemia, Death, Surgical procedures A ll surgical procedures elicit a stress response, although the extent of the response depends on the extent of the surgery and the use of anesthetics and analgesics that are used to reduce the response. The stress response can lead to increases in heart rate and blood pressure, which can precipitate episodes of myocardial ischemia. 1)Individuals with intermediate to high cardiac risk for noncardiac surgery suffer from perioperative myocardial ischemic injury.2) Cardiac troponins are a useful tool that help clinicians in making the diagnosis of perioperative myocardial infarction.3-5) Many previous studies have investigated the role of cardiac troponins in the diagnosis of perioperative myocardial ischemic events and demonstrated the prognostic value of postoperative cardiac troponin elevation.6-9) A recent metaanalysis of studies in predominantly high-risk surgery patients also showed that cardiac troponin elevation was a strong independent predictor of mortality within the first year after surgery. 10) Editorial p.265The development of perioperative cardiovascular complications not only affects the short-term period prognosis but may also influence the long-term consequences. However, few studies have explored the long-term, defined as beyond the first year after major noncardiac surgery, prognostic value of cardiac troponin elevation in the prediction of postoperative outcome. We undertook this study to evaluate the clinical outcome of cardiac troponin elevation after major noncardiac sur...

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confidence: 86%

Troponin-I Level After Major Noncardiac Surgery and Its Association With Long-Term Mortality

et al. 2016

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“…19 Patients with poor effort tolerance need further cardiac testing as it is a predictor of poor cardiac outcomes after major surgeries. 7 In our study, poor effort tolerance was not associated with increased peri-operative complications.…”

Section: Discussionmentioning

confidence: 99%

A look into Lee's score: peri-operative cardiovascular risk assessment in non-cardiac surgeries—usefulness of revised cardiac risk index

Rao¹,

Yeriswamy

Santhosh

et al. 2012

Indian Heart Journal

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Objective: The revised cardiac risk index (RCRI/Lee's score) was designed for peri-operative risk assessment before elective major non-cardiac surgeries. Through this article, we report the usefulness of RCRI in our daily practice, while evaluating patients undergoing surgeries of varying risk.Methods: Only referred patients, aged ≥ 40 years, were included. Risk stratification was done using RCRI scoring system. Patients were categorised into 4 classes depending on 0, 1, 2, and ≥3 risk predictors (risk predictors were high-risk surgery, history of ischaemic heart disease (IHD), diabetes on insulin, history of stroke (cerebrovascular accident [CVA]), history of congestive heart failure (CHF) and serum creatinine of >2 mg%). Electrocardiograms (ECG) were done in all patients, while troponin I in intermediate and high-risk patients, and in others if symptomatic. Perioperative cardiovascular events were managed appropriately. Results:Of the 920 patients included, only 853 patients were analysed as 67 patients were not operated upon. The mean age was 59 ± 11years and 46% of the patients were women. Two hundred and ninety-two underwent high-risk surgeries, 97 patients had history of IHD, 89 had history of CHF, 36 gave history of CVA, 269 patients were diabetics on insulin and 68 had serum creatinine >2 mg%. Number of patients in Lee's classes I, II, III, and IV were 311, 347, 150, and 52, respectively. 26 out of 853 patients had peri-operative events. Of the six variables in RCRI, only history of IHD was an independent predictor of events. Event rates increased as the RCRI class increased, i.e. 1.7%, 2.0%, 6.7%, and 7.7% for classes I-IV, respectively. Age >70 years, poor general medical condition, emergency surgery and left bundle branch block (LBBB) on ECG, were significantly associated with peri-operative events. Conclusion:The RCRI is a useful tool in pre-operative risk stratification. It should perhaps be further updated to improve its predictive accuracy.

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“…Furthermore, we had no measure of inter-anesthesiologist agreement on ASA-PS score and numerous anesthesiologists, so we could not control for variations at the level of the grader. While the AHA/ACC guidelines were derived for cardiovascular risk, it contains a detailed list of factors plausibly conferring risk for noncardiac complications [23][24][25] . In summary, our analysis indicates good adherence to the desirable practice of performing cholecystectomies within 3 d of presentation to the hospital and raises the question of whether even prompter surgery may reduce the risk of complications.…”

Section: Discussionmentioning

confidence: 99%

Factors associated with time to laparoscopic cholecystectomy for acute cholecystitis

Daniak

Peretz²,

Fine³

et al. 2008

WJG

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AIM:To determine patient and process of care factors associated with performance of timely laparoscopic cholecystectomy for acute cholecystitis. METHODS:A retrospective medical record review of 88 consecutive patients with acute cholecystitis was conducted. Data collected included demographic data, co-morbidities, symptoms and physical findings at presentation, laboratory and radiological investigations, length of stay, complications, and admission service ( m e d i c a l o r s u r g i c a l ) . Pa t i e n t s n o t u n d e r g o i n g cholecystectomy during this hospitalization were excluded from analysis. Hierarchical generalized linear models were constructed to assess the association of pre-operative diagnostic procedures, presenting signs, and admitting service with time to surgery. RESULTS:Seventy cases met inclusion and exclusion criteria, among which 12 were admitted to the medical service and 58 to the surgical service. Mean ± SD time to surgery was 39.3 ± 43 h, with 87% of operations performed within 72 h of hospital arrival. In the adjusted models, longer time to surgery was associated with number of diagnostic studies and endoscopic retrograde cholangio-pancreatography (ERCP, P = 0.01) as well with admission to medical service without adjustment for ERCP (P < 0.05). Patients undergoing both magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT) scans experienced the longest waits for surgery. Patients admitted to the surgical versus medical service underwent surgery earlier (30.4 ± 34.9 vs 82.7 ± 55.1 h, P < 0.01), had less postoperative complications (12% vs 58%, P < 0.01), and shorter length of stay (4.3 ± 3.4 vs 8.1 ± 5.2 d, P < 0.01). CONCLUSION:Admission to the medical service and performance of numerous diagnostic procedures, ERCP, or MRCP combined with CT scan were associated with longer time to surgery. Expeditious performance of ERCP and MRCP and admission of medically stable patients with suspected cholecystitis to the surgical service to speed up time to surgery should be considered.

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Self-reported Exercise Tolerance and the Risk of Serious Perioperative Complications

Abstract: Self-reported exercise tolerance can be used to predict in-hospital perioperative risk, even when using relatively simple and familiar measures.

Cited by 354 publications

References 32 publications

Troponin-I Level After Major Noncardiac Surgery and Its Association With Long-Term Mortality

Troponin-I Level After Major Noncardiac Surgery and Its Association With Long-Term Mortality

A look into Lee's score: peri-operative cardiovascular risk assessment in non-cardiac surgeries—usefulness of revised cardiac risk index

Factors associated with time to laparoscopic cholecystectomy for acute cholecystitis

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