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“La valutazione del rischio cardiologico nel paziente candidato a chirurgia vascolare” D Scrutinio Fondazione S. Maugeri , IRCCS, Cassano M. Incidence of perioperative cardiac events in major noncardiac surgery. J Am Coll Cardiol 2008;51:1913-24.

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slide1

“La valutazione del rischio cardiologico nel

paziente candidato a chirurgia vascolare”

D Scrutinio

Fondazione S. Maugeri, IRCCS, Cassano M

slide2

Incidence of perioperative cardiac events in major noncardiacsurgery

J Am CollCardiol 2008;51:1913-24

slide3

CardiacRisk in VascularNon-CardiacSurgery

VASCULAR SURGERY

30-day perioperativecardiaccomplications

Cardiactroponinelevation:

up to 40%

MI/Cardiacdeath: 6.2%

J Am CollCardiol 2008;51:1913-24

Anesthesiology 1998;88:561-4

N Engl J Med 1995;333:1750-6

slide4

AssociationBetweenPostoperativeTroponinLevels and 30-Day Mortality Among PatientsUndergoingNoncardiacSurgery. The VISION Study.The Vascular Events In NoncardiacSurgeryPatientsCohortEvaluation (VISION) StudyInvestigators

15 133 patients ≥45 yearsofage ; 30-day mortality rate:1.9%

peakpostoperative 4th-generation TnT

during the first 3 days after surgery

decisional cut-off: >0.03 ng/mL

(LoD)

JAMA. 2012;307(21):2295-2304

slide5

Prevalenceofcoronaryarterydisease

in electivevascularsurgerypatients

Normalcoronaryarteries

Mildto moderate CAD

Stenosis >70%

AAA

Lowerextremity ischemia

AnnSurg 1984

slide6

Step 1. Active cardiac disease

The first step in elective vascular surgery should be the identification of active cardiac disease(unstable coronary artery disease, recent myocardial infarction).

Referral to cardiologist prior to surgery.

Step 2. Surgical risk

Vascular surgery patients are at greater cardiac risk than patients undergoing

any other type of surgery.

However, there is a slight distinction between different procedures:

Abdominal aortic aneurysm repair and lower extremity arterial revascularization

procedures high risk

Endovascular abdominal aortic aneurysm repair, carotid artery endarterectomy

and peripheral angioplasty  intermediate-risk

slide7

Step 3. Functional capacity

Recommendation: assessment of functional capacity in all vascular surgery patients.

Patients who have a functional capacity <4 METs (inability to climb two flights of

stairs or run a short distance) are at higher risk.

In such patients, the identification of cardiac risk factors is the next step.

  • Step 4. Cardiac risk factors
  • Risk factors are:
  • history of myocardial infarction/angina pectoris
  • diabetes mellitus
  • renal dysfunction
  • history of TIA or CVE
  • congestive heart failure.
slide9

From: Systematic Review: Prediction of Perioperative Cardiac Complications and Mortality by the Revised Cardiac Risk Index

Ann Intern Med. 2010;152(1):26-35.

HSROC curve showing the accuracy of a Revised Cardiac Risk Index score for predicting

cardiac complications after vascular noncardiac surgery

HSROC: 0.65(95% CI: 0.60 to 0.69)

slide10

Definitionofbiomarker(National InstituteofHealth):

“a characteristicthatisobjectivelymeasured and evaluated

asanindicatorofnormalbiologicalprocesses, pathogenic

processes, or pharmacologicalresponsesto a therapeutic

intervention”

Biomarkers Definitions Working Group. Biomarkers and surrogate endpoints:preferreddefinitions and conceptual framework.

ClinPharmacolTher. 2001;69:89 –95.

role of hs crp and nt probnp for risk prediction in vascular surgery
Role of hs-CRP and NT-proBNP for risk prediction in vascular surgery.
  • Prospectivestudy
  • 411 patientsundergoingelectivevascularsurgery
  • Primaryoutcome: composite ofdeath, acute coronarysyndromes, acute pulmonary edema, and peri-proceduralmyocardialdamageasassessedbyhs-cTnImeasurement
  • Time Frame: 30 days post surgery
  • Blood samples for hs-CRP, NT-proBNP, and hs-cTnIwereobtained on the preoperativeday in allpatients
  • Bloodsamplesforhs-cTnIwereobtained on the preoperative and post-operative days 1 and 2.

Scrutinio D et al., submitted

slide14

Valore discriminante incrementale

della proteina C ad alta sensibilità, dell’NT-proBNP e

della loro associazione

Rangeofexcellence

0.78

0.75

0.74

0.67

C index

Lee index

+

NT-proBNP

Lee index

+

both

Lee index

+

hs-CRP

Lee index

slide16

Role of hs-CRP and NT-proBNP for risk prediction in vascular surgery.

Rangeofexcellence

0.82

0.78

0.75

0.74

0.67

C index

Lee index

+

hs-CRP

Lee index

+

NT-proBNP

Lee index

+

both

Multivariable

model

Lee index

slide17

Role of hs-CRP and NT-proBNP for risk prediction in vascular surgery.

Observed and predicted rate of the primary outcome within each quartile

and as a continuous function of the risk score at 1-point intervals

Observed

Predicted

Score: 0-1 2-4 5-6 ≥7

Score: 0 1 2 3 4 5 6 7 >7

slide18

Grazie per

l’attenzione

slide20

AssociationBetweenPostoperativeTroponinLevels and 30-Day Mortality Among PatientsUndergoingNoncardiacSurgery.The Vascular Events In NoncardiacSurgeryPatientsCohortEvaluation (VISION) StudyInvestigators

≤0.01 ng/mL 0.02 ng/mL 0.03-0.29 ng/mL ≥0.30 ng/mL

hs-TnTlevel

JAMA. 2012;307(21):2295-2304

slide22

Cardiac complications after non-cardiac surgery depend on individual patient’s risk , type of surgery, and the circumstances under which it takes place.

Surgical factors that influence cardiac risk are related to the urgency, type, and duration of the procedure.

Every operation elicits a stress response, mediated by neuroendocrine factors

Surgery also causes alterations in the balance between prothrombotic and fibrinolytic factors, resulting in hypercoagulability and possible coronary thrombosis (elevation of fibrinogen and other coagulation factors, increased platelet activation and aggregation, and reduced fibrinolysis).

role of biomarkers for risk prediction in vascular surgery
Role of biomarkers for risk prediction in vascular surgery.

Lee Index plus hs-CRP and NT-proBNP

0.774 (p=0.001)

0.749 (p=0.004)

Lee Index + hs-CRP

Lee Index + NT-proBNP

0.741 (p=0.009)

Lee Index

0.670

C-index

Scrutinio D et al. J VascSurg, submitted

slide25

Role of biomarkers for risk prediction in vascular surgery.

(1/4 ofallevents)

Riskofclinicalevents and TnI↑: x 22

No biomarker + (36.7%) All 3 biomarkers + (6.3%)

Scrutinio D et al. J VascSurg, submitted

slide26

Role of biomarkers for risk prediction in vascular surgery.

  • Clinicalimplications:
  • Accurate pre-operative evaluation, includingbiomarkermeasurement, and prophylaxis
  • Carefulperioperativemonitoring and management
  • (tachycardia, hypertension, hypotension, anemia, hypoxemia, pain,
  • hemodynamicmonitoring), as appropriate

Circulation 2009;119:2936-44

slide27

Role of biomarkers for risk prediction in vascular surgery.

Lee Index predicted and observed rates of death, ACS; and pulmonary edema

0 (n=149) 1 (n=173) 2 (n=61) ≥3 (n=28)

Lee Indexriskmarkers

Scrutinio D et al. J VascSurg, submitted

slide28

Role of biomarkers for risk prediction in vascular surgery.

  • NT-proBNPconcentrationsmayreflect:
      • the presenceof HF or asymptomaticleftventriculardysfunction
      • the ischemicriskcarriedbyextensive CAD
        • NT-proBNPconcentrationsincreasewithincreasingextensionof CAD and are independentlyassociatedwithsurvival (N Engl J Med 2005;352:666-75)
        • Natriureticpeptidespredict CV risk in stablepatientswith CAD . (Circulation 2009;120:2177-87)
slide29
Vascular Events In Noncardiac Surgery Patients Cohort Evaluation Study (VISION)This study is currently recruiting participants
  • The VISION Study is a prospective cohort study of 40,000 patients >45 years of age, undergoing noncardiac surgery and receiving a general or regional anesthetic.
  • The aims are to determine:
    • the incidence of major vascular events, the optimal clinical model to predict major perioperative vascular events, and the extent to which troponin measurements post surgery can predict vascular death at 1 year.
    • the potential association associations between preoperative or postoperative medications and major perioperative vascular events
    • the value of NT-proBNP (8,000 - 10,000 patients) prior to surgery in predicting major perioperative vascular events.

www.clinicaltrials.gov

slide32

JAMA 2013

30-day mortality

slide37

pre-operativehs-TnT

pre-operativehs-TnT

slide40

Based upon the available evidence, it can be

safely concluded that finding elevated cTn in a healthy subject is extremely rare.

Therefore, any unexplained elevation of cTn should prompt additional evaluation for cardiovascular disease.

The evaluation should include detailed history, physical examination, standard laboratory testing, and an ECG. Given the strong association between cTn elevation and cardiac structural and functional abnormalities, an echocardiogram would also seemprudent.

Gupta S. ProgrCardiovascDis 2007;50:151-165

slide42

Combinedend-point:

  • - all-causemortality
  • - acute myocardialinfarction
  • cardiacarrest or VF
  • - acute pulmonary edema
  • duringhospitalisation
slide44

*Combined incidence of cardiac

death and nonfatal MI