What is the best pre‐operative risk stratification tool for major adverse cardiac events following elective vascular surgery? A prospective observational cohort study evaluating pre‐operative myocardial ischaemia monitoring and biomarker analysis

Biccard, Bruce; Naidoo, Prebashini; Vasconcellos, Kim de

doi:10.1111/j.1365-2044.2011.07020.x

Cited by 45 publications

(38 citation statements)

References 23 publications

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“…[6] With regard to MINS, only a single vascular surgical cohort has been studied in South Africa (SA). [7][8][9] Because of differing patient characteristics and risk profiles, extrapolation of the incidence of MINS from international data to SA surgical patients may be inappropriate.…”

Section: Researchmentioning

confidence: 99%

Incidence of myocardial injury after non-cardiac surgery: Experience at Groote Schuur Hospital, Cape Town, South Africa

et al. 2018

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Background. Myocardial injury after non-cardiac surgery (MINS) is a newly recognised entity identified as an independent risk factor associated with increased 30-day all-cause mortality. MINS increases the risk of death in the perioperative period by ~10-fold. More than 80% of patients with MINS are asymptomatic, so the majority of diagnoses are missed. Awareness of MINS is therefore important for perioperative physicians. Objectives. To investigate the incidence of MINS after elective elevated-risk non-cardiac surgery at Groote Schuur Hospital, Cape Town, South Africa (SA). Methods. Patients aged ≥45 years undergoing elective elevated-risk non-cardiac surgery were enrolled via convenience sampling. The new fifth-generation high-sensitivity cardiac troponin T blood test was used postoperatively to identify MINS. Preoperative troponin levels were not measured. Results. Among 244 patients included in the study, the incidence of MINS was 4.9% (95% confidence interval (CI) 2.8 -8.5), which was not significantly different from that in a major international prospective observational study (VISION) (8.0% (95% CI 7.5 -8.4)); p=0.080. Conclusions. Our SA cohort had a lower cardiovascular risk profile but a similar incidence of MINS to that described in international literature. The impact of MINS on morbidity and mortality is therefore likely to be proportionally higher in SA than in published international studies. The limited sample size and lower event rate weaken our conclusions. Larger studies are required to establish patient and surgical risk factors for MINS, allowing for revision of cardiovascular risk prediction models in SA.

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Section: Researchmentioning

confidence: 99%

Incidence of myocardial injury after non-cardiac surgery: Experience at Groote Schuur Hospital, Cape Town, South Africa

et al. 2018

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“…In total, 24 of the 28 studies 29,[34][35][36][37][38][40][41][42][43][46][47][48][49][50][51][52][53][55][56][57][58][59][60] were prospective observational cohort studies. Of the remaining four studies: …”

Section: Methodsmentioning

confidence: 99%

“…Of the remaining studies, three reported exclusively on patients undergoing emergency surgery, 38,45,48 and one documented both elective and emergency surgeries that were classified as being high risk. 46 Certain studies investigated outcomes in a specific surgical discipline, including thoracic surgery (4), 36,50,51,54 vascular (7), 29,40,42,44,55,57,59 orthopaedic (5), 45,[47][48][49]60 major abdominal (1), 56 oesophagectomy (1), 41 while the rest documented outcomes following a variety of surgeries performed (10), 34,35,[37][38][39]43,46,52,53,58 including a mix of general, head and neck, gynaecological, orthopaedic, vascular, urological, neurosurgery and thoracic surgery.…”

Section: Included Studiesmentioning

confidence: 99%

Preoperative B-type natriuretic peptides in patients undergoing noncardiac surgery: a cumulative meta-analysis

Ryan

Rajah

Simmers

et al. 2015

Southern African Journal of Anaesthesia and Analgesia

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Background: A plethora of studies have shown elevated preoperative natriuretic peptide measurements to predict postoperative mortality and adverse cardiac events. Objectives: The current study aimed to demonstrate this overwhelming association and to show that further studies of this nature are unwarranted. Methods: A cumulative meta-analysis of 28 studies was conducted where the primary outcomes of mortality and adverse cardiac events were associated with elevated preoperative natriuretic peptides. Results:Cumulative meta-analysis demonstrated an odds ratio trending to a constant of 5.66, with a marked narrowing in the 95% confidence interval. Conclusions:Further studies aiming only to demonstrate an association between a preoperative natriuretic peptide threshold and the risk of postoperative adverse cardiac events are not justified. Future investigation should focus on the clinical implications of these data and the application of these findings with regard to further investigation, optimisation and appropriate adaptation of perioperative management.

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“…[3] Definitions of established cardiac risk factors for perioperative MACEs were adopted from the study of Lee et al [4] Patients' troponin-I levels were measured on the first 3 postoperative days, with a level of ≥0.1 ng/ml considered a positive result. [10] The primary outcome was a MACE, defined as a composite of death within 30 days of surgery or peri-operative troponin-I leak. We have used this definition of MACE in a previous publication that used this dataset.…”

Section: Objectivesmentioning

confidence: 99%

“…We have used this definition of MACE in a previous publication that used this dataset. [10] Statistical analysis Independent Student's t-tests and analysis of variance (ANOVA) were used to analyse continuous data, expressed as means (± stand ard deviation (SD)) or medians (inter quartile range (IQR)). Categorical data were analysed using descriptive statistics and χ 2 or Fisher's exact tests, where appropriate.…”

Section: Objectivesmentioning

confidence: 99%

The South African Vascular Surgical Cardiac Risk Index (SAVS-CRI): A prospective observational study

2013

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It is estimated that 234 million major non-cardiac surgical procedures are undertaken worldwide each year, [1] with rates of cardiac morbidity or mortality following these procedures ranging between 0.5% and 30%.[2] Pre-operative cardiac evaluation and prognostication using clinical risk scores may allow physicians to reduce cardiac risk following non-cardiac surgery. Risk stratification allows physicians to identify patients at risk for cardiac complications, optimise treatment of co-morbid conditions before surgery, or offer high-risk patients the option of conservative management rather than surgery. [3] Lee's Revised Cardiac Risk Index (RCRI) has superseded several early risk stratification models. [4][5][6] The RCRI consists of six independent predictors of major adverse cardiac events (MACEs) following non-cardiac surgery: ischaemic heart disease, cerebrovascular accident, congestive heart failure, renal impairment, major surgery and diabetes. The peri-operative risk of MACEs depends on the number of risk factors present, ranging between approximately 0.5% (no risk factors present) and 11% (three or more risk factors present). Although it is widely utilised and has been validated in several surgical populations, the appropriateness of the RCRI for risk stratification in some populations remains debatable. A recent meta-analysis by Ford et al. [7] found that although the RCRI was able to discriminate well between low-and high-risk patients who underwent mixed non-cardiac surgery, it performed poorly in patients who underwent vascular surgery. The Vascular Study Group of New England (VSG) developed a risk scoring model, the VSG cardiac risk index (VSG-CRI), for vascular surgical patients from a retrospective cohort which appears to perform better than the RCRI at predicting peri-operative MACEs in vascular surgery patients. [8] This clinical scoring system identified nine clinical variables, namely age, smoking, prior surgical intervention for coronary artery disease, diabetes, ischaemic heart disease, heart failure, chronic β-blockade, chronic obstructive airway disease and renal impairment, to stratify vascular surgery patients into increasing levels of cardiac risk. However, the VSG-CRI requires prospective validation prior to its use in clinical practice.While the RCRI has been validated in European and American surgical populations, data from developing countries remain scant. In addition, shifts in disease patterns are becoming more common in developing countries. This epidemiological transition may impact on the importance and weighting of several risk factors associated with MACEs following non-cardiac surgery between developing and developed countries.[9] A retrospective study by Biccard and Bandu [9] found that of all the RCRI risk factors, only elevated serum creatinine was a predictor of cardiac mortality in South African (SA) vascular surgery patients. A history of smoking, which is not an RCRI risk factor, was also found to be a predictor of cardiac mortality in the same study. These conflictin...

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What is the best pre‐operative risk stratification tool for major adverse cardiac events following elective vascular surgery? A prospective observational cohort study evaluating pre‐operative myocardial ischaemia monitoring and biomarker analysis

Cited by 45 publications

References 23 publications

Incidence of myocardial injury after non-cardiac surgery: Experience at Groote Schuur Hospital, Cape Town, South Africa

Incidence of myocardial injury after non-cardiac surgery: Experience at Groote Schuur Hospital, Cape Town, South Africa

Preoperative B-type natriuretic peptides in patients undergoing noncardiac surgery: a cumulative meta-analysis

The South African Vascular Surgical Cardiac Risk Index (SAVS-CRI): A prospective observational study

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