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REDUCING GLOBAL PERIOPERATIVE RISK


This resource center is jointly hosted by The American Journal of Medicine,
The American Journal of Cardiology, and the Canadian Journal of Cardiology.

Editors’ Welcome Message

Every year, more than 200 million adults across the globe undergo major non-cardiac surgery.  Of these, more than 10 million will experience a major cardiac complication within the first 30 postoperative days. Major perioperative cardiac complications account for at least a third of perioperative deaths, and result in substantial morbidity, prolonged hospitalization, and increased costs. 

PJ Devereaux, MD, PhD, FRCPC

Director, Division of Cardiology McMaster University Senior Scientist and Scientific Leader of the Anesthesiology, Perioperative Medicine, and Surgical Research Group
Population Health Research Institute Hamilton, ON Canada

Michael McGillion, RN, PhD

Associate Professor and Assistant Dean, Research
Scientist, Population Health Research Institute
School of Nursing, Faculty of Health Sciences
McMaster University
Hamilton, ON Canada

 

Featured study

Duceppe E, Parlow J, MacDonald P, et al
Can J Cardiol. 2016 Oct 4. pii: S0828-282X(16)30980-1. doi: 10.1016/j.cjca.2016.09.008

Key Guideline Highlights

The 2016 CCS Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery propose a shift of emphasis from reducing preoperative noninvasive cardiac testing to increased use of biomarkers before and after surgery in patients at risk of perioperative cardiac complications. Also recommended is an increased emphasis on postoperative monitoring and management of cardiac complications. Recommendations are made regarding preoperative cardiac risk assessment, perioperative cardiac risk modification, monitoring and management. 

Key Guideline Recommendations

  • Brain natriuretic peptide (BNP) or N-terminal fragment of proBNP (NT-proBNP) should be measured before surgery in patients who are ≥65 years of age, are 45 to 64 years of age with significant cardiovascular disease, or have a Revised Cardiac Risk Index score ≥1.
  • Physician should avoid performing preoperative resting echocardiography, coronary CT angiography, exercise or cardiopulmonary exercise testing, or pharmacological stress echocardiography or radionuclide imaging.
  • Antiplatelet should be held a minimum of 3 days before surgery, except in patients undergoing carotid surgery and patients with recent coronary stents. In patients with an indication for long-term antiplatelet therapy, these agents should be restarted after surgery when the bleeding risk has subsided (ie, typically postoperative day 8).
  • Beta-blockers should not be initiated before surgery due to their increased risk of mortality and stroke. Due to risk of perioperative hypotension, calcium-channel blockers and alpha-2 agonist should not be initiated within 24 hours before surgery.
  • Patients on chronic beta-blocker and statin therapy should continue their medication when undergoing surgery. Patients on chronic ACEI or ARB should have these agents held at least 24 hours before surgery and restarted after surgery when the risk of hypotension has subsided, usually not until day 2 after surgery.
  • Preoperative interventions for smoking cessation, including short behavioral intervention, have been shown to improve smoking abstinence at the time of surgery and at postoperative follow-up. Considering the long-term cardiovascular benefit of smoking cessation, discussing and facilitating smoking cessation before surgery is recommended.
  • Preoperative coronary revascularization in patients with stable coronary artery disease is not recommended. Preoperative prophylactic coronary revascularization in this population did not clearly demonstrated benefit for the prevention of perioperative cardiac events and can result in increased surgical delays, costs and risk of bleeding with dual antiplatelet therapy.
  • Troponin measurement is recommended daily for 48 to 72 hours after surgery in patients with an elevated NT-proBNP/BNP measurement before surgery or if there is no NT-proBNP/BNP measurement before surgery, in those who have an RCRI score ≥1, age 45 to 64 years with significant cardiovascular disease, or age ≥65 years.
  • In patients who suffer a myocardial injury or myocardial infarction after surgery, initiation of long-term ASA and statin therapy is recommended.

UPCOMING MEETING

November 1-3, 2019

Westin Harbour Castle
Toronto, Ontario, Canada

View Preliminary Program  Register

Additional Readings

Thomsen T, Villebro N, Moller AM. Cochrane Database Syst Rev. 2014;3:CD002294.
McFalls EO, Ward HB, Moritz TE, et al. N Engl J Med. 2004;351:2795-2804.

Featured Review

McGillion MH, Duceppe E, Allan K, et al. Can J Cardiol. 2018;34(7):850-862

KEY HIGHLIGHTS

  • Current systems for postoperative monitoring in surgical populations on hospital wards and at home are inadequate, with infrequent vital signs monitoring contributing to thousands of cases of undetected or delayed detection of hemodynamic compromise.
  • Remote automated monitoring (RAM), a subcomponent of telemedicine, is improving with technological advances that enable data integration and synthesis, as well as directed frontline nurse response, especially in surgical wards and at home.
  • This article reviewed work to date on postoperative RAM on surgical wards and strategies to advance this field.

KEY FINDINGS

  • A challenge to RAM is regional connectivity. Connectivity issues are predominant in remote and densely populated areas where cellular reception is subjected to available infrastructure.
  • Key to the optimal design of future RAM trials is the acquisition of big data through large-scale, prospective, observational studies and adequately powered RCT’s with selective deployment of RAM, incorporation of biomarkers and machine learning.

Featured Study

Key Highlights

  • Trials of beta blockers in patients undergoing non-cardiac surgery have historically reported conflicting results. POISE was a randomized controlled trial, involving 190 hospitals across 23 countries, designed to investigate the effects of perioperative beta blockers.
  • The study randomly assigned 8351 patients with, or at risk of, atherosclerotic disease who were undergoing non-cardiac surgery to receive extended-release metoprolol succinate (n=4174) or placebo (n=4177), by a computerized randomization phone service; participants were  >45 years old, undergoing non-cardiac surgery, and at risk of cardiovascular complication.
  • Study treatment was started 2-4 h before surgery and continued for 30 days.
  • Patients, healthcare providers, data collectors, and outcome adjudicators were masked to treatment allocation. The primary endpoint was a composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal cardiac arrest.

key Findings

  • Metoprolol reduced the risk of myocardial infarction but increased the risk of death and stroke. The negative outcomes appeared to occur through an increase in hypotension on surgical floors.
  • The POISE trial highlighted the risk in assuming a perioperative beta-blocker regimen has benefit without substantial harm, and the importance and need for large randomized trials in the perioperative setting.
  • Patients are unlikely to accept the risks associated with perioperative extended-release metoprolol.

Featured Studies

Devereaux PJ, Sessler DI, Leslie K, et al. N Engl J Med. 2014;370:1504-1513
Devereaux PJ, Mrkobrada M, Sessler DI, et al. N Engl J Med. 2014;370:1494-503

Key Highlights

  • POISE 2 was a blinded factorial randomized controlled trial. A total of 10,010 patients were recruited in 135 centers in 23 countries.
  • Participants were ≥45 years old, having non-cardiac surgery, and at risk of cardiovascular complications.
  • Participants were randomized to ASA versus placebo and clonidine versus placebo.

Key Findings

  • Clonidine had no effect on death or myocardial infarction. Clonidine was associated with an increased risk of non-fatal cardiac arrest and hypotension.
  • ASA had no effect on death or myocardial infarction, but increased the risk of major and life-threatening bleeding.
  • POISE 2 demonstrated that clinicians can improve outcomes by holding ASA during the perioperative period.
  • Perioperative hypotension and major/life threatening bleeding were independent predictors of perioperative myocardial infarction.

Featured Studies

Graham MM, Sessler DI, Parlow JL, et al. Ann Intern Med. 2018 Feb 20;168(4):237-244. doi: 10.7326/M17-2341. Epub 2018 Nov 14
Piccolo R, Windecker S. Ann Intern Med. 2018 Feb 20;168(4):289-290. doi: 10.7326/M17-2954. Epub 2017 Nov 14

KEY HIGHLIGHTS

  • POISE-2 PCI substudy is part of a large international, multicenter, randomized controlled trial with 2x2 factorial design involving 135 centers in 23 countries.
  • POISE-2 PCI included 470 patients who underwent noncardiac surgery with prior PCI.
  • Participants were randomized to aspirin versus placebo.

KEY FINDINGS

  • In the aspirin group, there was a significant reduction in the composite outcome of death and MI (HR 0.50) and MI alone (HR 0.44).
  • There was no significant difference in the incidence of major bleeding between the two groups.
  • This study demonstrated that among patients with prior PCI undergoing noncardiac surgery, perioperative aspirin may be more likely to be beneficial in this subgroup.

Featured Articles

Duceppe E, Mrkobrada M, Thomas S, Devereaux PJ. J Thromb Haemost. 2015;13 Suppl 1:S297-303
Devereaux PJ, Sessler DI. N Engl J Med. 2015;373(23):2258-2269

Key Highlights

  • The authors conducted a systematic review and individual patient meta-analysis to examine the prognostic value of natriuretic peptides (NP) in patients undergoing non-cardiac surgery.
  • The study main objectives were to determine if adding preoperative NP measurement could enhance clinician’s ability to predict a composite of death and non-fatal myocardial infarction at 30 days and ≥180 days after non-cardiac surgery.
  • Individual patient data were obtained from 18 eligible studies for a total of 2179 patients; 10 studies measured NT-proBNP and 8 studies measured BNP. 
  • The authors performed analysis to determine the NP threshold associated with the lowest p value for the composite outcome of death and non-fatal myocardial infarction.
  • A net reclassification approach was used to determine if NP provided additional prognostic information in addition to a clinical model (ie, Revised Cardiac Risk Index) based on risk categories of <5%, 5-10%, >10-15%, and >15%.

Key Findings

  • The overall incidence of the composite of death and non-fatal myocardial infarction at 30 days was 10.8% (235 events).
  • NP threshold values associated with lowest p value for death and myocardial infarction for BNP was 92 ng/L and for NT-proBNP was 300 ng/L.
  • The incidence of death and non-fatal myocardial infarction at 30 days was 21.8% in patients who had a positive preoperative NT-proBNP (≥300 ng/L ) or BNP (≥92 ng/L), compared to 4.9% in patients who had a negative preoperative NT-proBNP (<300 ng/L) or BNP (<92 ng/L).
  • The overall absolute net reclassification showed that in a sample of 1000 patients, a preoperative NP measurement will result in a more appropriate risk estimate in 155 patients compared to a clinical model (ie, Revised Cardiac Risk Index).
  • The 2016 Canadian Cardiology Society Guidelines on perioperative risk prediction and management recommends measuring BNP or NT-proBNP before surgery to enhance perioperative cardiac risk estimation in patients who are ≥65 years of age, are 45 to 64 years of age with significant cardiovascular disease, or have a Revised Cardiac Risk Index (RCRI) score ≥1.

Suggested Readings

Lee TH, Marcantonio ER, Mangione CM, et al. Circulation. 1999;100:1043-1049
Ryding AD, Kumar S, Worthington AM, Burgess D. Anesthesiology. 2009;111:311-319

Featured Study

Sheth T, Chan M, Butler C, et al. BMJ. 2015 Apr 22;350:h1907. doi: 10.1136/bmj.h1907

Key Highlights

  • The objectives were to determine if coronary computed tomographic angiography (CCTA) enhances prediction of perioperative risk in patients before non-cardiac surgery and to assess the preoperative coronary anatomy in patients who experience a myocardial infarction after non-cardiac surgery.
  • CCTA was performed preoperatively.  Results were classified as normal, non-obstructive (<50% stenosis), obstructive (one or two vessels with ≥50% stenosis), or extensive obstructive (≥50% stenosis in two vessels including the proximal left anterior descending artery, three vessels, or left main).
  • This prospective cohort study was conducted in 12 centers in eight countries and enrolled 955 patients with, or at risk of, atherosclerotic disease who underwent non-cardiac surgery.
  • The main outcome was the composite of cardiovascular death and non-fatal myocardial infarction within 30 days after surgery.  The independent variables were scores on the revised cardiac risk index and findings on coronary computed tomographic angiography.

Key Findings

  • Compared with the revised cardiac risk index alone, findings on preoperative CCTA appropriately improved risk estimation among patients who will experience perioperative cardiovascular death or a myocardial infarction (adjusted hazard ratio for extensive obstructive coronary artery disease, 3.76; 95% confidence interval [CI], 1.12 to 12.62).
  • CCTA inappropriately resulted in overestimation of risk among patients who will not experience these outcomes within 30 days of non-cardiac surgery.  With 30-day risk categories of <5%, 5-15%, and >15% for the primary outcome, the net absolute effect in a sample of 1000 patients was that CCTA would result in an inappropriate estimate of risk in 81 patients compared with risk estimation based on the revised cardiac risk index alone.
  • While CCTA can improve risk estimation for patients who incur perioperative cardiovascular death or myocardial infarction, results are more than five times as likely to lead to an inappropriate overestimation of risk among those who will not experience these outcomes.

Featured Articles

Devereaux PJ, Sessler DI. N Engl J Med. 2015;373:2258-2269. doi: 10.1056/NEJMra1502824
Duceppe E, Parlow J, MacDonald P, et al. Can J Cardiol. 2016 Oct 4. pii: S0828-282X(16)30980-1. doi: 10.1016/j.cjca.2016.09.008

Key Highlights

  • The VISION Study (Vascular Events in Noncardiac Surgery Patients Cohort Evaluation) is a prospective multicenter international cohort study.
  • Main study objectives included evaluation of perioperative vascular complications in patients >45 years of age undergoing non-cardiac surgery. The study also assessed the value of routine Troponin (T) measurement for detection of myocardial injury after non-cardiac surgery (MINS) and adverse event prognostication.
  • The study recruited 40,000 patients at 28 sites in 15 countries in North and South America, Europe, Asia, Africa, Australia. Patients were recruited consecutively between August 6, 2007 and January 11, 2011.

Key Findings

  • Among the first 15,000 patients who had fourth-generation Troponin T (TnT) measured, the peak postoperative TnT measurement during the first 3 days after surgery was significantly associated with 30-day mortality.
  • MINS occurred in 8% of the study population, and 85% of MINS would have been missed without perioperative troponin monitoring.
  • Post-op variables predicting death at 30 days after surgery included MINS [(TnT ≥0.03) Adjusted HR (95% CI) 3.87 (2.96-5.08)], Sepsis [Adjusted HR (95% CI) 7.18 (5.17-9.97)], Stroke [Adjusted HR (95% CI) 3.50 (2.05-5.97)], and PE [Adjusted HR (95% CI) 6.11 (3.18-11.74)].

Featured Articles

Kim LJ, Martinez EA, Faraday N, et al. Circulation. 2002;106:2366-2371

Suggested Readings

Featured Study

Vascular Events In Noncardiac Surgery Patients Cohort Evaluation (VISION) Study Investigators, Devereaux PJ, Chan MT, et al. JAMA. 2012;307:2295-2304

Key Highlights

  • The VISION Study (Vascular Events in Noncardiac Surgery Patients Cohort Evaluation) was a prospective multicenter international cohort study. Main study objectives included evaluation of perioperative vascular complications in patients >45 years of age undergoing non-cardiac surgery. The study also assessed the value of routine high-sensitivity Troponin T (hsTnT) measurement for detection of myocardial injury after non-cardiac surgery (MINS) and adverse event prognostication.
  • The study recruited 40,000 patients at 28 sites in 15 countries in North and South America, Europe, Asia, Africa, Australia. Patients were recruited consecutively between August 6, 2007 and January 11, 2011.

Key Findings

  • Among 21,842 patients underwent noncardiac surgery and who had hsTnT measured, peak postoperative hsTnT during the first 3 days after surgery was significantly associated with 30-day mortality. Elevated postoperative hsTnT without an ischemic feature was also associated with 30-day mortality.
  • Multivariable analysis demonstrated that compared with the reference group (peak hsTnT <5 ng/L), peak postoperative hsTnT levels of 20 to <65 ng/L, 65 to <1000 ng/L, and ≥1000 ng/L  had 30-day mortality rates of 3.0%(123/4049; 95%CI, 2.6%-3.6%), 9.1% (102/1118; 95%CI, 7.6%-11.0%), and 29.6%(16/54; 95%CI, 19.1%-42.8%), with corresponding adjusted HRs of 23.63 (95%CI, 10.32-54.09), 70.34 (95% CI, 30.60-161.71), and 227.01 (95%CI, 87.35-589.92), respectively.
  • An absolute hsTnT change of ≥5 ng/L was associated with an increased risk of 30-day mortality (adjusted HR, 4.69; 95%CI, 3.52-6.25). An elevated postoperative hsTnT (ie, 20 to <65 ng/L with an absolute change ≥5 ng/L or hsTnT ≥65 ng/L) without an ischemic feature was associated with 30-day mortality (adjusted HR, 3.20; 95%CI, 2.37-4.32).
  • Among the 3904 patients (17.9%; 95%CI, 17.4%-18.4%) with MINS, 3633 (93.1%; 95%CI, 92.2%-93.8%) did not experience an ischemic symptom.

Featured Articles

Suggested Readings

Giannitsis E, Kurz K, Hallermayer K, et al. Clin Chem. 2010;56:254-261

Key Highlights

  • Examined a cohort of 667 consecutive major vascular surgery patients with an elevated postoperative Troponin I level to determine which patients received medical therapy as per the 2007 American College of Cardiology/American Heart Association recommendations for the medical management of patients with chronic stable angina.
  • The relationship of medical management consistent with guidelines with 12-month survival without a major cardiac event (ie, death, myocardial infarction, coronary revascularization, or pulmonary edema requiring hospitalization) was examined.

Key Findings

  • Therapy was intensified in 43 of 66 patients (65%) who suffered a Troponin I elevation after surgery.
  • Patients with a Troponin I elevation who did not receive intensified cardiovascular treatment had a hazard ratio (HR) of 1.77 (95% confidence interval (CI), 1.13–2.42; P = 0.004) for the primary study outcome as compared with the control group.
  • In contrast, patients with a Troponin I elevation who received intensified cardiovascular treatment had an HR of 0.63 (95% CI, 0.10–1.19; P = 0.45) for the primary outcome as compared with the control group.
  • In patients with elevated Troponin I levels after non-cardiac surgery, long-term adverse cardiac outcomes are likely improved by following evidence-based recommendations for the medical management of acute coronary syndromes, though investigators concluded that this effect needed to be confirmed in a large, randomized, controlled trial.

FEATURED STUDY

Devereaux PJ, Duceppe E, Guyatt G, et al on behalf of the MANAGE Invesitgators. Lancet 2018; 391:2325–2334

KEY HIGHLIGHTS

  • MANAGE trial is an international, multicenter, randomized controlled trial with partial 2x2 factorial design involving 84 centers in 19 countries.
  • Participants aged ≥45 who underwent noncardiac surgery and sustained a myocardial infarction after noncardiac surgery (MINS) were included in the trial.
  • The study randomized 1754 patients to dabigatran or placebo and 556 patients were randomized to omeprazole or placebo.

KEY FINDINGS

  • Compared to placebo, the use of dabigatran reduced major vascular complications (ie, a composite of vascular mortality, nonfatal MI, non-hemorrhagic stroke, peripheral arterial thrombosis, amputation, and symptomatic VTE) by a hazard ratio of 0.72.
  • In terms of primary safety outcome (i.e. a composite of life-threatening, major, and critical organ bleed), there was no significant difference between dabigatran and placebo.
  • MANAGE demonstrated that the use of dabigatran could prevent major vascular complications with no observed increased risk of major bleeding.

 

Featured Articles

Devereaux PJ, Sessler DI. N Engl J Med. 2015;373:2258-2269. doi: 10.1056/NEJMra1502824
Duceppe E, Parlow J, MacDonald P, et al. Can J Cardiol. 2016 Oct 4. pii: S0828-282X(16)30980-1. doi: 10.1016/j.cjca.2016.09.008
Vascular Events In Noncardiac Surgery Patients Cohort Evaluation (VISION) Study Investigators, Devereaux PJ, Chan MT, et al. JAMA. 2012;307:2295-304

Featured Articles

Devereaux PJ, Sessler DI. Leslie K, et al. N Engl J Med. 2014;370:1504-1513

Suggested readings

Grigoryan KV, Javedan H, Rudolph JL. J Orthop Trauma. 2014;28:e49-55

Clinincian Resources

Cardiac Risk Stratification for Noncardiac Surgery: The Cleveland Clinic Center for Continuing Education presents a paper on cardiac risk stratification for patients undergoing noncardiac surgery.

2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: The American Heart Association presents an Executive Summary of the 2014 ACC/AHA Perioperative Guidelines.

For Your Patients

Questions to Ask Before Surgery:  Johns Hopkins provides a list of important questions for patients to review with their healthcare provider before undergoing surgery. 

Getting Ready for Surgery: Hamilton Health Services provides helpful tips for patients undergoing knee replacement surgery.