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

Although brain natriuretic peptide has been shown to be superior to the revised cardiac risk index for risk stratification of vascular surgical patients, it remains unknown whether it is superior to alternative dynamic risk predictors, such as other pre-operative biomarkers (C-reactive protein and troponins) or myocardial ischaemia monitoring. The aim of this prospective observational study was to determine the relative clinical utility of these risk predictors for the prediction of postoperative cardiac events in elective vascular surgical patients. Only pre-operative troponin elevation (OR 56.8, 95% CI 6.5-496.0, p < 0.001) and brain natriuretic peptide above the optimal discriminatory point (OR 6.0, 95% CI 2.7-12.9, p < 0.001) were independently associated with cardiac events. Both brain natriuretic peptide and troponin risk stratification significantly improved overall net reclassification (74.6% (95% CI 51.6%-97.5%) and 38.5% (95% CI 22.4-54.6%, respectively)); however, troponin stratification decreased the correct classification of patients with cardiac complications (-59%, p < 0.001). Pre-operative brain natriuretic peptide evaluation was the only clinically useful predictor of postoperative cardiac complications.     

A meta-analysis of the utility of pre-operative brain natriuretic peptide in predicting early and intermediate-term mortality and major adverse cardiac events in vascular surgical patients

We conducted a meta-analysis of the utility of pre-operative B-type natriuretic peptide (BNP) and N-terminal-pro B-type natriuretic peptide in predicting early (< 30 days) and intermediate (< 180 days) term mortality and major adverse cardiac events (cardiac death and nonfatal myocardial infarction) in patients following vascular surgery. A Pubmed Central and EMBASE search was conducted up to January 2008. Of 81 studies identified, seven prospective observational studies were included in the meta-analysis representing five patient cohorts: early outcomes (504 patients) and intermediate-term outcomes (623 patients). A B-type natriuretic peptide or N-terminal-pro B-type natriuretic peptide above the optimal discriminatory threshold determined by receiver operating characteristic curve analysis was associated with 30-day cardiac death (OR 7.6, 95% CI 1.33-43.4, p = 0.02), nonfatal myocardial infarction (OR 6.24, 95% CI 1.82-21.4, p = 0.004) and major adverse cardiac events (OR 17.37, 95% CI 3.31-91.15, p = 0.0007), and intermediate-term, all-cause mortality (OR 3.1, 95% CI 1.85-5.2, p < 0.0001), nonfatal myocardial infarction (OR 2.95, 95% CI 1.17-7.46, p = 0.02) and major adverse cardiac events (OR 3.31, 95% CI 2.1-5.24, p < 0.00001). B-type natriuretic peptide and N-terminal-pro B-type natriuretic peptide are potentially useful pre-operative prognostic tests in vascular surgical patients.     

The influence of clinical risk factors on pre-operative B-type natriuretic peptide risk stratification of vascular surgical patients

The role of the revised cardiac risk index in risk stratification has recently been challenged by studies reporting on the superior predictive ability of pre‐operative B‐type natriuretic peptides. We found that in 850 vascular surgical patients initially risk stratified using B‐type natriuretic peptides, reclassification with the number of revised cardiac risk index risk factors worsened risk stratification (p < 0.05 for > 0, > 2, > 3 and > 4 risk factors, and p = 0.23 for > 1 risk factor). When evaluated with pre‐operative B‐type natriuretic peptides, none of the revised cardiac risk index risk factors were independent predictors of major adverse cardiac events in vascular patients. The only independent predictor was B‐type natriuretic peptide stratification (OR 5.1, 95% CI 1.8–15 for the intermediate class, and OR 25, 95% CI 8.7–70 for the high‐risk class). The clinical risk factors in the revised cardiac risk index cannot improve a risk stratification model based on B‐type natriuretic peptides.     

Utility of B-type natriuretic peptide in predicting perioperative cardiac events in patients undergoing major non-cardiac surgery

Background: B-type natriuretic peptide (BNP) levels predict cardiovascularrisk in several settings. We hypothesized that they would identifyindividuals at increased risk of early cardiac complicationsafter major non-cardiac surgery. The current study tests thishypothesis. Methods: Two hundred and four patients undergoing major non-cardiac surgerywere studied. The primary end-point was the development of acutemyocardial injury [defined as cardiac troponin I (cTnI) level> 0.32 ng ml^–1] or death in the 3 days after surgery. Results: Preoperative BNP levels were raised in patients who died orsuffered perioperative myocardial injury (median 52.2 vs 22.2pg ml^–1, P = 0.01) and BNP predicted this outcome withan area under the receiver operating characteristic curve of0.72 [95% confidence interval (CI) 0.59–0.86, P = 0.01].A preoperative BNP value > 40 pg ml^–1 was associatedwith an increased risk of death or perioperative myocardialinjury [odds ratio (OR) 6.8, 95% CI 1.8–25.9, P = 0.003],and remained independently predictive after correction for theRevised Cardiac Risk Index. Preoperative BNP levels were higherin patients who exhibited new onset atrial fibrillation or ST/T-wavechanges on their postoperative ECG (median 50.5 vs 22.5 pg litre^–1,P = 0.01). They were also higher in patients who had eitherelevation of cTnI > 0.32 ng ml^–1 or postoperative ECGabnormalities (median 50.4 vs 21.5 pg ml^–1, P < 0.001). Conclusions: In the setting of major non-cardiac surgery, preoperative BNPlevels are higher in patients who experience perioperative deathand myocardial injury. Larger studies are required to confirmthese data and to clarify what BNP levels may add to existingmethods of risk stratification.     

Cardiac natriuretic peptides are related to left ventricular mass and function and predict mortality in dialysis patients.

This study was designed to investigate the relationship among brain natriuretic peptide (BNP) and atrial natriuretic peptide (ANP) and left ventricular mass (LVM), ejection fraction, and LV geometry in a large cohort of dialysis patients without heart failure (n = 246) and to test the prediction power of these peptides for total and cardiovascular mortality. In separate multivariate models of LVM, BNP and ANP were the strongest independent correlates of the LVM index. In these models, the predictive power of BNP was slightly stronger than that of ANP. Both natriuretic peptides also were the strongest independent predictors of ejection fraction, and again BNP was a slightly better predictor of ejection fraction than ANP. In separate multivariate Cox models, the relative risk of death was significantly higher in patients of the third tertile of the distribution of BNP and ANP than in those of the first tertile (BNP, 7.14 [95% confidence interval (CI), 2.83 to 18.01, P = 0.00001]; ANP, 4.22 [95% CI, 1.79 to 9.92, P = 0.001]), and a similar difference was found for cardiovascular death (BNP, 6.72 [95% CI, 2.44 to 18.54, P = 0.0002]; ANP, 3.80 [95% CI, 1.44 to 10.03, P = 0.007]). BNP but not ANP remained as an independent predictor of death in a Cox's model including LVM and ejection fraction. Cardiac natriuretic peptides are linked independently to LVM and function in dialysis patients and predict overall and cardiovascular mortality. The measurement of the plasma concentration of BNP and ANP may be useful for risk stratification in these patients.     

Cardiac biomarkers in the prediction of risk in the non‐cardiac surgery setting

B‐Type natriuretic peptides and troponin measurements have potential in predicting risk in patients undergoing non‐cardiac surgery. Using the American Heart Association framework for the evaluation of novel biomarkers, we review the current evidence supporting the peri‐operative use of these two biomarkers. In patients having major non‐cardiac surgery who are risk stratified using clinical risk scores, the measurement of natriuretic peptides and troponin, both before and after surgery, significantly improves risk stratification. However, only pre‐ and postoperative natriuretic peptide measurement and postoperative troponin measurement have shown clinical utility. It is now important for trials to be conducted to determine whether integrating pre‐ and postoperative natriuretic peptide and postoperative troponin measurement into clinical practice is able to improve clinical outcomes in patients undergoing non‐cardiac surgery.     

Early mortality in coronary bypass surgery: the EuroSCORE versus The Society of Thoracic Surgeons risk algorithm

BACKGROUND: We compare two widely used risk algorithms for coronary bypass surgery: The European System for Cardiac Operative Risk Evaluation (EuroSCORE) and The Society of Thoracic Surgeons (STS) risk stratification algorithm. METHODS: Risk factors for all adult patients undergoing heart surgery at the University Hospital of Lund between 1996 and 2001 were collected prospectively at preoperative admission. Predictive accuracy for 30-day mortality was assessed by comparing the observed and the expected mortality for equal-sized quintiles of risk by using the Hosmer-Lemeshow goodness-of-fit test. The discriminatory power was evaluated by calculating the areas under receiver operating characteristics (ROC) curves. RESULTS: The study included 4497 coronary artery bypass-only operations. The average age was 66.4 +/- 9.3 years (range 31 to 90 years). Most patients were men (77.0% versus 23.0%). The actual 30-day mortality was 1.89%. The Hosmer-Lemeshow goodness-of-fit test gave a p value of 0.81 (EuroSCORE) and 0.83 (STS), which indicates a good accuracy of both models. The area under the ROC curve was 0.84 (95% confidence interval [CI] 0.80 to 0.88) for EuroSCORE and 0.71 (95% CI 0.66 to 0.77) for STS. The discriminatory power (area under the ROC curve) was significantly larger for EuroSCORE compared with STS (p < 0.00005). CONCLUSIONS: In this large, single institution study the additive EuroSCORE algorithm had a significantly better discriminatory power to predict 30-day mortality than the STS risk algorithm for patients undergoing coronary artery bypass.     

HIV,vascular surgery and cardiovascular outcomes: a South African cohort study

Risk factors for peri‐operative cardiac morbidity are poorly described in HIV‐positive patients. This prospective observational study describes cardiovascular risk factors in a cohort of vascular surgical patients of known HIV status. We recruited 225 patients with 73 (32%) being HIV‐positive. When compared with HIV‐negative patients, the HIV‐positive patients were younger (mean (SD) 56.4 (13.3) vs 40.5 (10.4) years, respectively, p < 0.01). They had fewer Revised Cardiac Risk Index cardiovascular risk factors (median (range [IQR]) 1 (0–5 [0–2]) vs 0 (0–2 [0–0]), respectively, p < 0.001), with the exception of congestive cardiac failure (p = 0.23) and renal dysfunction (p = 0.32), and so were of a significantly lower Revised Cardiac Risk Index risk category (p < 0.01). HIV‐positive and ‐negative patients had similar outcomes in: 30‐day mortality (p = 0.78); three‐day postoperative troponin leak (p = 0.66); and a composite outcome of mortality and troponin release (p = 0.69). We conclude that although HIV‐positive patients have fewer cardiovascular risk factors, they have similar peri‐operative major adverse cardiac events to HIV‐negative patients. Research should focus on why this is the case, and if alternative clinical risk predictors can be developed for HIV patients.     

The utility of B-type natriuretic peptide in predicting postoperative cardiac events and mortality in patients undergoing major emergency non-cardiac surgery

B-type natriuretic peptide (BNP) levels predict cardiovascular risk in several settings. We hypothesised that they would identify individuals at increased risk of complications and mortality following major emergency non-cardiac surgery. Forty patients were studied with a primary end-point of a new postoperative cardiac event, and/or development of significant ECG changes, and/or cardiac death. The main secondary outcome was all-cause mortality at 6 months. Pre-operative BNP levels were higher in 11 patients who suffered a new postoperative cardiac event (p = 0.001) and predicted this outcome with an area under the receiver operating characteristic curve of 0.85 (CI = 0.72-0.98, p = 0.001). A pre-operative BNP value > 170 pg x ml(-1) has a sensitivity of 82% and a specificity of 79% for the primary end-point. In this small study, pre-operative BNP levels identify patients undergoing major emergency non-cardiac surgery who are at increased risk of early postoperative cardiac events. Larger studies are required to confirm these data.     

Pre-operative high sensitivity C-reactive protein and postoperative outcome in patients undergoing elective orthopaedic surgery

High-sensitivity C-reactive protein (hsCRP) adds important prognostic information, not reflected by traditional risk factors, to the prediction of both the development and outcome of cardiovascular pathology. HsCRP levels also correlate inversely with cardiorespiratory fitness, an important determinant of peri-operative outcome. We hypothesised that pre-operative hsCRP should be associated with excess peri-operative morbidity and longer length of stay. Pre-operative hsCRP was measured blinded to standardised postoperative outcomes in 129 elective orthopaedic patients. HsCRP levels were divided into high (> 3 mg x l(-1)) or low (< 3 mg x l(-1)) groups (Center for Disease Control stratification). High-CRP patients had significant cardiovascular history, received cardiac medication or steroid therapy (p < 0.05). Higher pre-operative hsCRP was associated with longer length of stay: mean 7.5 days (95% CI: 6.2-8.8) vs 6.0 days (95% CI: 5.5-6.5; p = 0.03; log rank test). In 21 patients with > 8 days length of stay, high pre-operative hsCRP patients were over-represented (p = 0.04). Pre-operative hsCRP is related to length of stay and delayed postoperative complications.     

B-type natriuretic peptide and the prediction of outcome in patients admitted to intensive care

B-type natriuretic peptide is known to predict outcome in congestive cardiac failure and myocardial infarction. We aimed to determine whether measurement of B-type natriuretic peptide would predict hospital mortality in patients admitted to an intensive care unit. We conducted a prospective observational cohort study in 78 consecutive patients. Demographics, clinical details and clinical outcomes were recorded. Admission and 24 h B-type natriuretic peptide and cardiac troponin I levels were measured. B-type natriuretic peptide and cardiac troponin I levels taken on intensive care admission and 24 h after admission did not accurately predict hospital mortality for all patients, including patients with severe sepsis or septic shock (all p > 0.05). B-type natriuretic peptide levels were higher in patients with severe sepsis and septic shock (p = 0.02), in patients > or = 65 years (p = 0.04) and in patients with raised creatinine > or = 110 micromol.l(-1) (p = 0.02). We concluded that B-type natriuretic peptide, measured soon after admission to intensive care, does not usefully predict outcome after intensive care.     

The use of pre-operative brain natriuretic peptides as a predictor of adverse outcomes after cardiac surgery: a systematic review and meta-analysis

The objective of this systematic review was to assess whether pre-operative brain natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT pro-BNP) are independent predictors of adverse outcomes after cardiac surgery. MEDLINE, Embase and the Cochrane Controlled Trials Register databases were searched. Eligible studies included observational or randomized control trials measuring natriuretic peptide concentrations before induction of anaesthesia for cardiac surgery. Two investigators independently extracted the data and assessed the validity of the included studies. The predictive ability of pre-operative BNP or NT pro-BNP on mortality, post-operative atrial fibrillation (AF) and intra-aortic balloon pump (IABP) requirement was meta-analysed. The association between BNP or NT pro-BNP and other outcomes was systematically summarized. A total of 4933 patients from 22 studies were considered in the systematic review. Ten studies with one or more outcomes of interest were included in the meta-analyses. The strength of association between pre-operative natriuretic peptide levels and adverse outcomes after surgery was variable, as was the size and quality of the included studies. The summary areas under the receiver operating characteristic curve for mortality, post-operative AF and post-operative IABP requirement were 0.61 (95% confidence interval [CI] 0.51-0.70), 0.61 (95% CI 0.58-0.64) and 0.81 (95% CI 0.73-0.89), respectively. With the limited data available, the associations between pre-operative natriuretic peptide levels and adverse outcomes after cardiac surgery were moderate. Future studies should assess whether pre-operative natriuretic peptides can provide additional independent predictive information to well-validated prognostic scores of cardiac surgery.     

Value of Plasma Brain Natriuretic Peptide Levels for Predicting Postoperative Atrial Fibrillation: A Systemic Review and Meta-analysis

Background

Blood natriuretic peptide (NP) levels have been reported to be useful for predicting postoperative atrial fibrillation (AF). We aimed to quantitatively synthesize the current evidence of the accuracy of using NP levels in predicting postoperative AF.

Methods and Results

Medline, Embase, and reference lists were searched. Studies were included if either brain natriuretic peptide (BNP) or N-terminal pro-b type natriuretic peptide (NT-proBNP) had been evaluated perioperatively to predict postoperative AF. Data were analyzed to obtain summary accuracy estimates. Data from 1,844 patients in 10 studies were analyzed. Summary estimates for the sensitivity and specificity of using NP levels for predicting postoperative AF were 75 % [95 % confidence interval (CI) 67–79 %] and 80 % (95 % CI 62–91 %), respectively. The overall diagnostic odds ratio was 3.28 (95 % CI 2.23–4.84). Subgroup analysis showed that elevated NP levels in the perioperative period were a strong independent predictor of postoperative AF. NT-proBNP appeared to have better predictive value than BNP, as did postoperative assessment over preoperative assessment. BNP had a better correlation with postoperative AF in patients undergoing thoracic surgery than in patients undergoing cardiac surgery.

Conclusions

Perioperative assessment of the natriuretic peptide level in patients undergoing major cardiothoracic surgery could be a valuable diagnostic aid for identifying patients at high risk of developing postoperative AF, and for providing critical clinical information to guide prophylactic antiarrhythmic therapy in the perioperative period.     

The revised cardiac risk index is associated with morbidity and mortality independent of injury severity in elderly patients with rib fractures

BackgroundRisk factors for mortality and in-hospital morbidity among geriatric patients with traumatic rib fractures remain unclear. Such patients are often frail and demonstrate a high comorbidity burden. Moreover, outcomes anticipated by current rubrics may reflect the influence of multisystem injury or surgery, and thus not apply to isolated injuries in geriatric patients. We hypothesized that the Revised Cardiac Risk Index (RCRI) may assist in risk-stratifying geriatric patients following rib fracture.MethodsAll geriatric patients (age ≥65 years) with a conservatively managed rib fracture owing to an isolated thoracic injury (thorax AIS ≥1), in the 2013-2019 TQIP database were assessed including demographics and outcomes. The association between the RCRI and in-hospital morbidity as well as mortality was analyzed using Poisson regression models while adjusting for potential confounders.Results96,750 geriatric patients sustained rib fractures. Compared to those with RCRI 0, patients with an RCRI score of 1 had a 16% increased risk of in-hospital mortality [adjusted incidence rate ratio (adj-IRR), 95% confidence interval (CI): 1.16 (1.02-1.32), p=0.020]. An RCRI score of 2 [adj-IRR (95% CI): 1.72 (1.44-2.06), p<0.001] or ≥3 [adj-IRR (95% CI): 3.07 (2.31-4.09), p<0.001] was associated with an even greater mortality risk. Those with an increased RCRI also exhibited a higher incidence of myocardial infarction, cardiac arrest, stroke, and acute respiratory distress syndrome.ConclusionsGeriatric patients with rib fractures and an RCRI ≥1 represent a vulnerable and high-risk group. This index may inform the decision to admit for inpatient care and can also guide patient and family counseling as well as computer-based decision-support.     

The influence of aneurysm size on perioperative cardiac outcome in elective open infrarenal aortic aneurysm repair

BACKGROUND: Abdominal aortic aneurysm (AAA) size and growth has been found to be associated with local generation of inflammation markers such as interleukin-6. Inflammation also seems to be important in perioperative adverse cardiac events. We hypothesized that patients with a large AAA are at increased risk for cardiac events. METHODS: Consecutive patients who underwent a computed tomography angiography scan before open elective infrarenal AAA repair between March 2000 and December 2005 at three hospitals were analyzed. All patients were screened for the clinical risk factors of age, gender, angina pectoris, myocardial infarction, heart failure, diabetes, stroke, renal failure, and chronic obstructive pulmonary disease, as well as for cardioprotective medication. Postoperative data on troponin release, creatine kinase/creatine kinase isoenzyme MB, and electrocardiogram were routinely collected on days 1, 3, 7, and 30. The main outcome measure was the combined end point of 30-day cardiovascular death and nonfatal myocardial infarction. Multivariate Cox regression analysis was used to evaluate the influence of AAA size on postoperative cardiac outcome. RESULTS: The study included 500 patients. Their mean age was 69.8 +/- 9.5 years, and 431 (86%) were men. Thirty-one patients (6.2%) had perioperative cardiovascular complications, consisting of 15 (3.0%) cardiovascular deaths and 16 (3.2%) nonfatal myocardial infarctions. After correction for other risk factors, including age, Revised Cardiac Risk Index, medication use, duration of surgery, and intraoperative blood loss, AAA size was independently associated with perioperative nonfatal myocardial infarction and cardiovascular death (3.2% increase in risk for each millimeter added, 95% confidence interval 1.1% to 6.2%, P = .007). CONCLUSION: A larger AAA size is independently associated with an increased incidence of perioperative cardiovascular complications after elective infrarenal AAA repair.     

Changes in calcitonin gene-related peptide,atrial natriuretic peptide and brain natriuretic peptide in patients undergoing coronary artery bypass grafting

The initiation of cardiopulmonary bypass creates significant derangements in cardiovascular volume status and both endocrine and autonomic nervous system function. To examine whether such derangements might differ in patients with different pre-operative physical status scores, we measured the plasma concentrations of calcitonin gene-related peptide, atrial natriuretic peptide and brain natriuretic peptide, catecholamines and antidiuretic hormone, as well as haemodynamic variables, during and after cardiopulmonary bypass in 27 consecutive patients undergoing coronary artery bypass grafting. The pre-operative levels of atrial natriuretic peptide and brain natriuretic peptide differed significantly between ASA II patients and III and IV patients [mean (SD) brain natriuretic peptide levels = 14 (8.2) vs. 129 (51) pg.ml-1]. Plasma calcitonin gene-related peptide increased significantly in both groups after the initiation of cardiopulmonary bypass, and remained increased throughout cardiopulmonary bypass. The changes in plasma epinephrine, norepinephrine and antidiuretic hormone were similar to those reported previously. The changes in plasma calcitonin gene-related peptide, atrial natriuretic peptide and brain natriuretic peptide did not correlate with any changes in haemodynamic variables before or after cardiopulmonary bypass. Measurement of plasma brain natriuretic peptide might usefully be included in the pre-operative evaluation of patients with cardiac disease.     

Atrial fibrillation and plasma troponin I elevation after cardiac surgery: relation to inflammation-associated parameters

BACKGROUND: Recent studies have demonstrated correlation between inflammation to plasma troponin (cTnI) levels elevation and atrial fibrillation (AF) in noncardiac surgery settings. The goal of this prospective study was to examine the relation between inflammation associated parameters (IAPs) to post cardiac surgery cTnI elevation and AF. METHODS: A single post CABG cTnI measurement was assessed in 156 consecutive patients. Clinical, operative and postoperative data, IAPs (hypophosphatemia, preoperative statin treatment, immediate postoperative fever, and prolonged mechanical ventilation) and in-hospital AF episodes were prospectively recorded. RESULTS: Mean cTnI level was 14.4 +/- 12.4 ng/mL. In the two in-hospital deaths (1.2%) cTnI concentration was less than 12 ng/mL. Cardiac troponin-I levels were significantly higher in patients not preoperatively treated with statins (21.6 +/- 4.1 vs. 13.3 +/- 0.9, p = 0.05), in patients who needed intraoperative cardioversion (16.7 +/- 2.2 vs. 12.2 +/- 0.9, p = 0.07), in patients with postoperative hypophosphatemia (16.9 +/- 10.0 vs. 11.1 +/- 13.7, p = 0.04), postoperative fever (18.6 +/- 3.0 vs. 13.7 +/- 1.0, p = 0.07) and postoperative respiratory complications (23.9 +/- 4.3 vs. 13.5 +/- 1.0, p = 0.04). Step-wise logistic regression analysis revealed the following parameters as independently associated with elevated cTnI levels: preoperative statin treatment (CI 95%-15.9; -1.7, p = 0.02), intraoperative ventricular arrhythmia (CI 95%-0.7; 13.8, p = 0.08), hypophosphatemia (CI 95% 0.9; 8.6, p = 0.02), postoperative fever (CI 95% 0.9; 11.0, p = 0.02), and postoperative respiratory complications (CI 95% 0.1; 0.5, p = 0.01). Of the 156 patients, 50 (32.1%) had postoperative AF. The first episode of AF occurred between postoperative day 1 and 6 (mean-day 2). Mean duration of AF was 21.8 +/- 8.1 hours. Postoperative AF was significantly associated with age above 75 (50% vs. 29.4%, p = 0.01), hypertension (37% vs. 18%, p = 0.02), preoperative calcium channel blockers treatment (44% vs. 26%, p = 0.02), furosemide treatment (58% vs. 30%, p = 0.05), and preoperative left atrial diameter above 40 mm (56% vs. 29%, p = 0.01). Postoperatively, AF was significantly associated with postoperative renal failure (70% vs. 29%, p = 0.01), respiratory complications (61% vs. 29%, p = 0.02), and prolonged hospital stay (OR 1.1; CI 1.0-1.3; p < 0.05). No association was found between troponin levels and postoperative AF. Multivariable analysis found only left atrial enlargement and prolonged hospital stay independently associated with AF. CONCLUSIONS: A significant correlation between clinical IAPs and cTnI plasma level elevation was found after cardiac surgery. There was no correlation between these parameters and postoperative AF, and there was no correlation between postoperative plasma cTnI levels and the occurrence of AF. Preoperative treatment with statins may be beneficial in reducing postoperative inflammatory response but further study has to be carried out.     

Nutritional status affects the rate of pancreatic fistula after distal pancreatectomy: a multivariate analysis of 132 patients

BACKGROUND: Although malnutrition was found to increase the risk of intraabdominal and systemic complications in surgical patients, data for distal pancreatic resections are scarce. STUDY DESIGN: Data on 132 consecutive patients undergoing distal pancreatectomy as the primary procedure for pancreatic pathology, between 1996 and 2005, were reviewed to identify risk factors for postoperative complications and determine the impact of nutritional status. Nutritional assessment was performed with clinical and laboratory variables, including unintentional weight loss, body mass index, blood albumin level, lymphocyte count, and Nutritional Risk Index (NRI) and Instant Nutritional Assessment (INA) scores. RESULTS: Seventy-five (56.8%) patients developed 1 or more complications, including 18 (13.6%) cases of pancreatic fistula. The median values of NRI were significantly lower in patients with pancreatic fistula (96.9; 95% CI, 89.8 to 101.0) compared with those in the remaining subjects (102.5; 95% CI, 101.5 to 105.5; p=0.014). In the univariate analysis, the incidence of malnutrition defined by NRI (61% versus 30%, p=0.019) and the Instant Nutritional Assessment (67% versus 34%, p=0.017) was significantly higher in patients who developed pancreatic fistula. In the multivariate analysis, malnutrition characterized as NRI of 100 or less was the only factor that significantly increased the risk of pancreatic fistula, with an odds ratio of 8.12 (95% CI, 1.06 to 22.30). CONCLUSIONS: Malnutrition, as defined by composite nutritional assessment scales consisting of clinical and laboratory parameters, is a major risk factor for pancreatic fistula after distal pancreatectomy.     

Risk of surgery in geriatric age: prospective evaluation of risk factors

The use of Risk Index in surgery is aimed to plan surgical strategy in order to achieve a better post-operative prognosis. This is especially true in geriatric surgery where ASA Index and, more recently, Reiss Index are widely employed. Since the mentionated Risk Indices are calculated on the basis of different factors, in this prospective study we compared the two Risk Indices with the aim of verify which index offers better prognostic indications. 125 consecutive patients, aged older 70 years, undergoing surgical treatment, were investigated. The patients were grouped according to ASA Index and Reiss Index and postoperative morbidity and mortality rate was calculated. Both Indices resulted good predictive for the postoperative prognosis (ASA: G Statistic = 31.531, p < 0.001; Reiss: G Statistic = 18.416, p < 0.001), but ASA Index sensitivity was better (Specificity = 100%, sensitivity = 28%, false negative rate = 72%) than Reiss Index (Specificity = 100%, sensitivity = 0, false negative rate = 100%). Therefore ASA Index has clinical valid role in valuing surgical risk in elderly.     

Right ventricular dysfunction in patients with COVID-19 pneumonitis whose lungs are mechanically ventilated: a multicentre prospective cohort study

Cardiovascular complications due to COVID-19, such as right ventricular dysfunction, are common. The combination of acute respiratory distress syndrome, invasive mechanical ventilation, thromboembolic disease and direct myocardial injury creates conditions where right ventricular dysfunction is likely to occur. We undertook a prospective, multicentre cohort study in 10 Scottish intensive care units of patients with COVID-19 pneumonitis whose lungs were mechanically ventilated. Right ventricular dysfunction was defined as the presence of severe right ventricular dilation and interventricular septal flattening. To explore the role of myocardial injury, high-sensitivity troponin and N-terminal pro B-type natriuretic peptide plasma levels were measured in all patients. We recruited 121 patients and 118 (98%) underwent imaging. It was possible to determine the primary outcome in 112 (91%). Severe right ventricular dilation was present in 31 (28%), with interventricular septal flattening present in nine (8%). Right ventricular dysfunction (the combination of these two parameters) was present in seven (6%, 95%CI 3–13%). Thirty-day mortality was 86% in those with right ventricular dysfunction as compared with 45% in those without (p = 0.051). Patients with right ventricular dysfunction were more likely to have: pulmonary thromboembolism (p < 0.001); higher plateau airway pressure (p = 0.048); lower dynamic compliance (p = 0.031); higher plasma N-terminal pro B-type natriuretic peptide levels (p = 0.006); and raised plasma troponin levels (p = 0.048). Our results demonstrate a prevalence of right ventricular dysfunction of 6%, which was associated with increased mortality (86%). Associations were also observed between right ventricular dysfunction and aetiological domains of: acute respiratory distress syndrome; ventilation; thromboembolic disease; and direct myocardial injury, implying a complex multifactorial pathophysiology.