The comparative and added prognostic value of biomarkers to the Revised Cardiac Risk Index for preoperative prediction of major adverse cardiac events and all-cause mortality in patients who undergo noncardiac surgery.
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ABSTRACT:
SUBMITTER: Vernooij LM
PROVIDER: S-EPMC8689147 | biostudies-literature | 2021 Dec
REPOSITORIES: biostudies-literature
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The comparative and added prognostic value of biomarkers to the Revised Cardiac Risk Index for preoperative prediction of major adverse cardiac events and all-cause mortality in patients who undergo noncardiac surgery.
Vernooij Lisette M LM van Klei Wilton A WA Moons Karel Gm KG Takada Toshihiko T van Waes Judith J Damen Johanna Aag JA
The Cochrane database of systematic reviews 20211221
<h4>Background</h4>The Revised Cardiac Risk Index (RCRI) is a widely acknowledged prognostic model to estimate preoperatively the probability of developing in-hospital major adverse cardiac events (MACE) in patients undergoing noncardiac surgery. However, the RCRI does not always make accurate predictions, so various studies have investigated whether biomarkers added to or compared with the RCRI could improve this.<h4>Objectives</h4>Primary: To investigate the added predictive value of biomarker ...[more]
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Project description:BackgroundIncreased postoperative cardiac troponin (cTn) independently predicts short-term mortality. Previous studies suggest that preoperative cTn also predicts major adverse cardiovascular events (MACE) and mortality after noncardiac surgery. The value of preoperative and perioperative changes in cTn as a prognostic tool for adverse outcomes has been sparsely investigated.Methods and findingsA systematic review and meta-analysis of the prognostic value of cTns for adverse outcome was conducted. Adverse outcome was defined as short-term (in-hospital or <30 days) and long-term (>30 days) MACE and/or all-cause mortality, in adult patients undergoing noncardiac surgery. The study protocol (CRD42018094773) was registered with an international prospective register of systematic reviews (PROSPERO). Preoperative cTn was a predictor of short- (OR 4.3, 95% CI 2.9-6.5, p<0.001, adjusted OR 5.87, 95% CI 3.24-10.65, p<0.001) and long-term adverse outcome (OR 4.2, 95% CI 1.0-17.3, p = 0.05, adjusted HR 2.0, 95% CI 1.4-3.0, p<0.001). Perioperative change in cTn was a predictor of short-term adverse outcome (OR 10.1, 95% CI 3.2-32.3, p<0.001). It was not possible to conduct pooled analyses for adjusted estimates of perioperative change in cTn as predictor of short- (a single study identified) and long-term (no studies identified) adverse outcome. Further, it was not possible to conduct pooled analyses for unadjusted estimates of perioperative change in cTn as predictor of long-term adverse outcome, since only one study was identified. Bivariate analysis of sensitivities and specificities were performed, and overall prognostic performance was summarized using summary receiver operating characteristic (SROC) curves. The pooled sensitivity and specificity for preoperative cTn and short-term adverse outcome was 0.43 and 0.86 respectively (area under the SROC curve of 0.68). There were insufficient studies to construct SROCs for perioperative changes in cTn and for long-term adverse outcome.ConclusionOur study indicates that although preoperative cTn and perioperative change in cTn might be valuable predictors of MACE and/or all-cause mortality in adult noncardiac surgical patients, its overall prognostic performance remains uncertain. Future large, representative, high-quality studies are needed to establish the potential role of cTns in perioperative cardiac risk stratification.
| S-EPMC6476502 | biostudies-literature
Project description:Background Cardiac complications are associated with perioperative mortality, but perioperative adverse cardiac events (PACEs) that are associated with long-term mortality have not been clearly defined. We identified PACE as a composite of myocardial infarction, coronary revascularization, congestive heart failure, arrhythmic attack, acute pulmonary embolism, cardiac arrest, or stroke during the 30-day postoperative period and we compared mortality according to PACE occurrence. Methods and Results From January 2011 to June 2019, a total of 203 787 consecutive adult patients underwent noncardiac surgery at our institution. After excluding those with 30-day mortality, mortality during a 1-year follow-up was compared. Machine learning with the extreme gradient boosting algorithm was also used to evaluate whether PACE was associated with 1-year mortality. After excluding 1203 patients with 30-day mortality, 202 584 patients were divided into 7994 (3.9%) patients with PACE and 194 590 (96.1%) without PACE. After an adjustment, the mortality was higher in the PACE group (2.1% versus 7.7%; hazard ratio [HR], 1.90; 95% CI, 1.74-2.09; P<0.001). Results were similar for 7839 pairs of propensity-score-matched patients (4.9% versus 7.9%; HR, 1.64; 95% CI, 1.44-1.87; P<0.001). PACE was significantly associated with mortality in the extreme gradient boostingmodel. Conclusions PACE as a composite outcome was associated with 1-year mortality. Further studies are needed for PACE to be accepted as an end point in clinical studies of noncardiac surgery.
| S-EPMC9238468 | biostudies-literature
Project description:ImportanceMajor adverse cardiovascular and cerebrovascular events (MACCE) are a significant source of perioperative morbidity and mortality following noncardiac surgery.ObjectiveTo evaluate national trends in perioperative cardiovascular outcomes and mortality after major noncardiac surgery and to identify surgical subtypes associated with cardiovascular events using a large administrative database of United States hospital admissions.Design, setting, participantsPatients who underwent major noncardiac surgery from January 2004 to December 2013 were identified using the National Inpatient Sample.Main outcomes and measuresPerioperative MACCE (primary outcome), defined as in-hospital, all-cause death, acute myocardial infarction (AMI), or acute ischemic stroke, were evaluated over time.ResultsAmong 10 581 621 hospitalizations (mean [SD] patient age, 65.74 [12.32] years; 5 975 798 female patients 56.60%]) for major noncardiac surgery, perioperative MACCE occurred in 317 479 hospitalizations (3.0%), corresponding to an annual incidence of approximately 150 000 events after applying sample weights. Major adverse cardiovascular and cerebrovascular events occurred most frequently in patients undergoing vascular (7.7%), thoracic (6.5%), and transplant surgery (6.3%). Between 2004 and 2013, the frequency of MACCE declined from 3.1% to 2.6% (P for trend <.001; adjusted odds ratio [aOR], 0.95; 95% CI, 0.94-0.97) driven by a decline in frequency of perioperative death (aOR, 0.79; 95% CI, 0.77-0.81) and AMI (aOR, 0.87; 95% CI, 0.84-0.89) but an increase in perioperative ischemic stroke from 0.52% in 2004 to 0.77% in 2013 (P for trend <.001; aOR 1.79; CI 1.73-1.86).Conclusions and relevancePerioperative MACCE occurs in 1 of every 33 hospitalizations for noncardiac surgery. Despite reductions in the rate of death and AMI among patients undergoing major noncardiac surgery in the United States, perioperative ischemic stroke increased over time. Additional efforts are necessary to improve cardiovascular care in the perioperative period of patients undergoing noncardiac surgery.
| S-EPMC5563847 | biostudies-literature
Project description:ObjectiveFrailty is an emerging risk factor for adverse outcomes. However, perioperative frailty assessments derived from electronic health records have not been studied on a large scale. We aim to estimate the prevalence of frailty and the associated incidence of major adverse cardiovascular events (MACE) among adults hospitalized for noncardiac surgery.MethodsAdults aged ≥45 years hospitalized for noncardiac surgery from 2004-2014 were identified from the National Inpatient Sample. The validated Hospital Frailty Risk Score (HFRS) derived from International Classification of Diseases codes was used to classify patients as low (HFRS <5), medium (5-10), or high (>10) frailty risk. The primary outcome was MACE, defined as myocardial infarction, cardiac arrest, and in-hospital mortality. Multivariable logistic regression was used to estimate the adjusted odds of MACE stratified by age and HFRS.ResultsA total of 55,349,978 hospitalizations were identified, of which 81.0%, 14.4%, and 4.6% had low, medium, and high HFRS, respectively. Patients with higher HFRS had more cardiovascular risk factors and comorbidities. MACE occurred during 2.5% of surgical hospitalizations and was common among patients with high frailty scores (high HFRS: 9.1%, medium: 6.9%, low: 1.3%, P < .001). Medium (adjusted odds ratio [aOR] 2.05; 95% confidence interval [CI], 2.02-2.08) and high (aOR 2.75; 95% CI, 2.70-2.79) HFRS were associated with greater odds of MACE vs low HFRS, with the greatest odds of MACE observed in younger individuals 45-64 years (interaction P value < .001).ConclusionsThe HFRS may identify frail surgical inpatients at risk for adverse perioperative cardiovascular outcomes.
| S-EPMC10038881 | biostudies-literature
Project description:BackgroundOptimised use of kidney function information might improve cardiac risk prediction in noncardiac surgery.MethodsIn 35,815 patients from the VISION cohort study and 9219 patients from the POISE-2 trial who were ≥45 yr old and underwent nonurgent inpatient noncardiac surgery, we examined (by age and sex) the association between continuous nonlinear preoperative estimated glomerular filtration rate (eGFR) and the composite of myocardial injury after noncardiac surgery, nonfatal cardiac arrest, or death owing to a cardiac cause within 30 days after surgery. We estimated contributions of predictive information, C-statistic, and net benefit from eGFR and other common patient and surgical characteristics to large multivariable models.ResultsThe primary composite occurred in 4725 (13.2%) patients in VISION and 1903 (20.6%) in POISE-2; in both studies cardiac events had a strong, graded association with lower preoperative eGFR that was attenuated by older age (Pinteraction<0.001 for VISION; Pinteraction=0.008 for POISE-2). For eGFR of 30 compared with 90 ml min-1 1.73 m-2, relative risk was 1.49 (95% confidence interval 1.26-1.78) at age 80 yr but 4.50 (2.84-7.13) at age 50 yr in female patients in VISION. This differed modestly (but not meaningfully) in men in VISION (Pinteraction=0.02) but not in POISE-2 (Pinteraction=0.79). eGFR contributed the most predictive information and mean net benefit of all predictors in both studies, most C-statistic in VISION, and third most C-statistic in POISE-2.ConclusionsContinuous preoperative eGFR is among the best cardiac risk predictors in noncardiac surgery of the large set examined. Along with its interaction with age, preoperative eGFR would improve risk calculators.Clinical trial registrationClinicalTrials.gov NCT00512109 (VISION) and NCT01082874 (POISE-2).
| S-EPMC11775841 | biostudies-literature
Project description:Background The Healthy Aging Index (HAI) has been regarded as useful in capturing the health status of multiple organ systems. However, to what extent the HAI is associated with major cardiovascular events remains largely unknown. The authors constructed a modified HAI (mHAI) to quantify the association of physiological aging with major vascular events and explored how the effects of a healthy lifestyle can modify this association. Methods and Results The participants with either missing values of any individual mHAI component or major illnesses such as heart attack, angina and stroke, and self-reported cancer at baseline were excluded. The mHAI components include systolic blood pressure, reaction time, forced vital capacity, serum cystatin c, and serum glucose. The authors used Cox proportional hazard models to quantify the association of mHAI with major adverse cardiac events, major coronary events, and ischemic heart disease. Cumulative incidence at 5 and 10 years was estimated, and joint analyses were stratified by age group and 4 mHAI categories. The mHAI was significantly correlated with major cardiovascular events, which is a better reflection of the aging level of the body than chronological age. An mHAI was calculated in 338 044 participants aged 38 to 73 years in the UK Biobank. Each point increase in the mHAI was associated with a 44% higher risk of major adverse cardiac events (adjusted hazard ratio [aHR], 1.44 [95% CI, 1.40-1.49]), 44% higher risk of major coronary events (aHR, 1.44 [95% CI, 1.40-1.48]), and 36% higher risk of ischemic heart disease (aHR, 1.36 [95% CI, 1.33-1.39]). The percentage of population-attribution risk was 51% (95% CI, 47-55) for major adverse cardiac events, 49% (95% CI, 45-53) for major coronary events, and 47% (95% CI, 44-50) for ischemic heart disease, which means that a substantial portion of these events could be prevented. Systolic blood pressure was the factor most significantly associated with major adverse cardiac events (aHR, 1.94 [95% CI, 1.82-2.08]; percentage of population-attribution risk, 36%), major coronary events (aHR, 2.01 [95% CI, 1.85-2.17]; percentage of population-attribution risk, 38%), and ischemic heart disease (aHR, 1.80 [95% CI, 1.71-1.89]; percentage of population-attribution risk, 32%). A healthy lifestyle significantly attenuated mHAI associations with incidence of vascular events. Conclusions Our findings indicate that higher mHAI is associated with increased major vascular events. A healthy lifestyle may attenuate these associations.
| S-EPMC10111455 | biostudies-literature
Project description:BackgroundPeople with kidney failure have high risk of postoperative morbidity and mortality. Although the revised cardiac risk index (RCRI) is used to estimate the risk of major postoperative events, it has not been validated in this population. We aimed to externally validate the RCRI and determine whether updating the model improved predictions for people with kidney failure.MethodsWe derived a retrospective, population-based cohort of adults with kidney failure (maintenance dialysis or sustained estimated glomerular filtration rate < 15 mL/min per 1.73 m2) who had surgery in Alberta, Canada between 2005 and 2019. We categorized participants based on RCRI variables and assigned risk estimates of death or major cardiac events, and then estimated predictive performance. We re-estimated the coefficients for each RCRI variable and internally validated the updated model. Net benefit was estimated with decision curve analysis.ResultsAfter 38,541 surgeries, 1204 events (3.1%) occurred. The estimated C-statistic for the original RCRI was 0.64 (95% confidence interval: 0.62, 0.65). Examination of calibration revealed significant risk overestimation. In the re-estimated RCRI model, discrimination was marginally different (C-statistic 0.67 [95% confidence interval: 0.66, 0.69]), though calibration was improved. No net benefit was observed when the data were examined with decision curve analysis, whereas the original RCRI was associated with harm.ConclusionsThe RCRI performed poorly in a Canadian kidney failure cohort and significantly overestimated risk, suggesting that RCRI use in similar kidney failure populations should be limited. A re-estimated kidney failure-specific RCRI may be promising but needs external validation. Novel perioperative models for this population are urgently needed.
| S-EPMC9568714 | biostudies-literature
Project description:BackgroundPerioperative 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.MethodsData 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.ResultsThere 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]).ConclusionsAmong 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
| S-EPMC9771981 | biostudies-literature
Project description:Neurological pupil index (NPi) calculated by automated pupillometry predicts clinical outcomes in critically ill patients. However, there are few data on intraoperative NPi and postoperative outcome after cardiac surgery. We evaluated the relationships between intraoperative NPi and clinical outcomes, such as delirium, in cardiac surgery patients. NPi was measured at baseline, after anesthesia induction, at 30 min intervals after initiation of cardiopulmonary bypass or anastomosis of coronary artery bypass graft, and at skin closure. Abnormal NPi was defined as one or more measurements of NPi < 3.0 during surgery. The worst intraoperative NPi was recorded, then multivariate logistic regression analysis was performed to evaluate the relationship between abnormal NPi and postoperative delirium following cardiac surgery. Among 123 included patients, postoperative delirium developed in 19.5% (24/123) of patients. Intraoperative abnormal NPi was significantly associated with postoperative delirium (odds ratio 6.078; 95% confidence interval 1.845-20.025; P = 0.003) after adjustment for Society of Thoracic Surgeons Predicted Risk of Mortality score, coronary artery disease, and use of calcium channel blockers. In conclusion, abnormal intraoperative NPi independently predicted postoperative delirium following cardiac surgery. Intraoperative application of pupillometry may have prognostic value for development of postoperative delirium, thereby enabling close surveillance and early intervention in high-risk patients.Registry number: ClinicalTrials.gov (NCT04136210).
| S-EPMC10449781 | biostudies-literature
Project description:Major adverse cardiac events (MACE) triggered by non-cardiac surgery are prognostically important perioperative complications. However, due to often asymptomatic presentation, the incidence and timing of postoperative MACE are incompletely understood. We conducted a prospective observational study implementing a perioperative screening for postoperative MACE [cardiovascular death (CVD), acute heart failure (AHF), haemodynamically relevant arrhythmias, spontaneous myocardial infarction (MI), and perioperative myocardial infarction/injury (PMI)] in patients at increased cardiovascular risk (≥65 years OR ≥45 years with history of cardiovascular disease) undergoing non-cardiac surgery at a tertiary hospital. All patients received serial measurements of cardiac troponin to detect asymptomatic MACE. Among 2265 patients (mean age 73 years, 43.4% women), the incidence of MACE was 15.2% within 30 days, and 20.6% within 365 days. CVD occurred in 1.2% [95% confidence interval (CI) 0.9-1.8] and in 3.7% (95% CI 3.0-4.5), haemodynamically relevant arrhythmias in 1.2% (95% CI 0.9-1.8) and in 2.1% (95% CI 1.6-2.8), AHF in 1.6% (95% CI 1.2-2.2) and in 4.2% (95% CI 3.4-5.1), spontaneous MI in 0.5% (95% CI 0.3-0.9) and in 1.6% (95% CI 1.2-2.2), and PMI in 13.2% (95% CI 11.9-14.7) and in 14.8% (95% CI 13.4-16.4) within 30 days and within 365 days, respectively. The MACE-incidence was increased above presumed baseline rate until Day 135 (95% CI 104-163), indicating a vulnerable period of 3-5 months. One out of five high-risk patients undergoing non-cardiac surgery will develop one or more MACE within 365 days. The risk for MACE remains increased for about 5 months after non-cardiac surgery. https://www.clinicaltrials.gov. Unique identifier: NCT02573532.
| S-EPMC8245139 | biostudies-literature