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.
Risk prevention tab
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.
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
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
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
Suggested Readings
Myles PS, Leslie K, Chan MT, et al. Lancet. 2014;384(9952):1446-1454
Devereaux PJ, Xavier D, Pogue J, Guyatt G, Sigamani A, et al. Ann Intern Med. 2011;145:523-528
Poldermans D, Devereaux PJ. Cleve Clin J Med. 2009;76 Suppl 4:S84-92
