Perioperative Care – ABC CARDIOL

ABC

Research Letter

Predictive Value of Cardiac Biomarkers on Delayed Graft Function in Renal Transplant Patients

Rodrigo Pinheiro Amantéa et al. Virgílio da Rocha Olsen Laura Caroline Tavares Hastenteufel Flávia K. Borges … Roberto Ceratti Manfro Lívia Adams Goldraich Nadine Clausell

Introduction

Cardiovascular (CV) disease is the leading cause of death among adult kidney transplant recipients, accounting for 25% of deaths in patients with functioning grafts. Cardiac biomarkers, in particular, brain natriuretic peptide (BNP) and cardiac troponin (cTn), are the most studied biomarkers for predicting the risk of major adverse cardiovascular events (MACE) in end-stage kidney disease and kidney transplant.^,

Myocardial injury after non-cardiac surgery (MINS) is a new clinical entity with relevant clinical and prognostic implications. It is defined as ischemic myocardial injury until 30 days after non-cardiac surgery and is independently associated with increased mortality. PJ Devereaux et al. evaluated the cohort of the VISION study, which involved the assessment of perioperative cTn and BNP on more than 20.000 patients, but without a representative number of renal transplant patients.

[…]

Read Full Article

ABC

Editorial

Electrocardiography in the Pre-Operative Assessment of Low-Risk Patients: Current Evidence

Francisco José de Oliveira Filho et al. Leonardo Rufino Garcia Pedro Luciano Mellucci Filho Lenize da Silva Rodrigues Matheus Bertanha

Cardiovascular diseases represent the main cause of mortality in the adult population, both in Brazil and globally. The proportional mortality from these diseases in Brazil is approximately 27%. Cardiovascular alterations become the cause of great concern for patients who will undergo surgical procedures, a time when the body is exposed to a high level of metabolic stress and, therefore, cardiovascular complications can overlap with unfavorable outcomes. Worldwide, it is estimated that annually, approximately 900,000 patients undergoing surgery develop cardiac complications directly related to the surgery. In this context, the perioperative period and, therefore, physiological changes secondary to surgical trauma are a more important risk factor for the manifestation of cardiovascular diseases.

In Brazil, between 2 and 3 million surgeries are performed per year, according to the Department of Informatics of the Unified Health System (DATASUS). The magnitude of the data reiterates the importance of carrying out detailed pre-operative preparation so that the risks related to the surgical procedure are minimized, including cardiological evaluation.

[…]

Read Full Article

IJCS

Original Article

Internal Validation of a Risk Score for Prediction of Postoperative Atrial Fibrillation after Cardiac Surgery

Rafael de March Ronsoni et al. Tiago Luiz Luz Leiria Leonardo Martins Pires Marcelo Lapa Kruse … Edemar Pereira Rogerio Gomes da Silva Gustavo Glotz de Lima

Abstract

Background:

Postoperative atrial fibrillation (POAF) after cardiac surgery has great clinical and economic implications. Many attempts have been made to identify risk factors aiming at a better evaluation of prophylactic treatment strategies.

Objective:

To perform an internal validation of a risk score for POAF.

Methods:

A prospective cohort of 1,054 patients who underwent myocardial revascularization and/or valve surgery was included. The risk score model was developed in 448 patients, and its performance was tested in the remaining 606 patients. Variables with a significance level of 5% in the cohort were included and subjected to a multiple logistic regression model with backward selection. Performance statistics was performed using the c-statistic, the chi-square and the Hosmer-Lemeshow (HL) goodness-of-ﬁt, Pearson’s correlation coefﬁcient.

Results:

Four variables were considered predictors of outcome: age (≥ 70 years), mitral valve disease, the non-use or discontinuation of beta-blockers and a positive water balance (> 1,500 mL). The ROC curve was 0.76 (95% confidence interval [CI]: 0.72-0.79). The risk model showed a good ability according to the performance statistics – HL test x⁽²⁾ = 0.93; p = 0.983 and r = 0.99 (Pearson’s coefficient). There was an increase in the frequency of POAF with the increase of the score: very low risk = 0.0%; low risk = 3.9%; intermediate risk = 10.9%; and high risk = 60.0%; p < 0.0001.

Conclusion:

The predictive variables of POAF allowed us to construct a simplified risk score. This scoring system showed good accuracy and can be used in routine clinical practice.

Read Full Article

ABC

Editorial

From Journals to Bedside: We Must Improve the Compliance with Practice Guidelines

Barbara Kumagai et al. Bruno Caramelli

In this issue of “Arquivos Brasileiros de Cardiologia”, Borges et al. described the rate of non-compliance with practice guidelines in a Hospital-based study regarding the use of antiplatelet agents in the perioperative setting of non-cardiac surgery. The authors found an extremely high non-compliance rate of 80.75%, and depicted a significant negative association among non-compliance, patient education level, and the presence of previous myocardial infarction. The authors concluded that local procedures and protocols must be urgently defined.

Perioperative care underwent profound changes in the past decades. Initially, evaluation was limited to issues related to the anesthetic procedures, or to the cancellation of interventions for patients at high risk of complications. Eventually, population aging, the improvement in surgical techniques, and the development of less invasive procedures brought to operation theaters patients at an increased risk of complications, especially cardiovascular ones. Perioperative care specialists had to develop new and interdisciplinary skills to deal with several aspects of medicine, kindly deserving the nickname Chameleon doctor.^–

[…]

Read Full Article

ABC

Review Article

Acute myocardial infarction after noncardiac surgery

Danielle Menosi Gualandro et al. Daniela Calderaro Pai Ching Yu Bruno Caramelli

Over 230 million surgeries are performed annually worldwide, cardiac complications being the most common causes of postoperative morbidity and mortality. As life expectancy has extended worldwide, a growing number of patients with multiple comorbidities have undergone noncardiac surgeries. Consequently, cardiovascular complications associated with those procedures are expected to increase, and perioperative acute myocardial infarction (AMI) might become a frequent problem. In Brazil, the number of noncardiac surgical procedures has also increased, and approximately three million surgeries are performed annually. Despite advances in surgical and anesthetic techniques, mortality and costs related to those procedures have also increased, thus, requiring the development of strategies to reduce mortality4. The occurrence of perioperative AMI prolongs the need for intensive care and the hospital length of stay, increases the cost of hospitalization, and reduces long-term survival. This literature review approaches the pathophysiology, incidence, diagnosis and treatment of perioperative AMI based on current evidence.

Read Full Article

ABC

Artigo Original

Incidence of pulmonary complications in myocardial revascularization

Leila D. N Ortiz et al. Camila W Schaan Camila P Leguisamo Katiane Tremarin … Waldo L. L. D Mattos Renato A. K Kalil Lucia C Pellanda

BACKGROUND: Despite the increasingly careful attempts to reduce perioperative risks, pulmonary complications following surgery are still very common, leading to longer length of hospital stays or death. OBJECTIVE: To describe the incidence of pulmonary complications and identify their association with duration of extracorporeal circulation (ECC), surgery and ischemia, number of bypass grafts performed, location of drains and length of drainage following myocardial revascularization (MRV). METHODS: This contemporaneous cohort consisted of 202 patients undergoing elective myocardial revascularization (MRV) with saphenous vein graft and internal mammary artery graft and ECC, at a referral university cardiology hospital in Southern Brazil, from April 2006 to November 2007. The following outcomes were analyzed: duration of mechanical ventilation; pneumonia onset; atelectasis; pleural effusion; location of drains and time of removal; and length of hospital stay. RESULTS: Of the 202 patients, 90 developed some sort of pulmonary complication. The incidence of pleural effusion was 84%, whereas atelectasis was 65%. The following variables were associated with pulmonary complications: duration of ECC (p = 0.003), surgery (p = 0.040) and ischemia (p = 0.001); length of drainage (p = 0.050) and location of pleural drains (p = 0.033); age (p = 0.001); ejection fraction (p = 0.010); diagnosis of asthma (p = 0.047) and preoperative abnormal chest X-ray findings (p = 0.029). CONCLUSION: Variables related to the complexity of the surgery and preexisting comorbidities are associated with a high incidence of postoperative pulmonary complications. These data reinforce the importance of having patients undergo perioperative clinical assessment to detect early respiratory complications after MRV.

Read Full Article

ABC

Point of view

Beta-blockers and non-cardiac operations what will change after the POISE study?

Danielle Menosi Gualandro et al. Daniela Calderaro Pai Ching Yu Andre Coelho Marques Bruno Caramelli

POINT OF VIEW

Beta-blockers and non-cardiac operations what will change after the POISE study?

[…]

Read Full Article

ABC

Artigo Original

Peri-operative evaluation by holter in elderly patients submitted to prostatectomy

Thais Orrico de Brito Cançado et al. Fernando Bueno Pereira Leitão Marcelo Luis Abramides Torres Fábio Sândoli de Brito

BACKGROUND: Male patients, aged over 65 years and with no history of heart disease, need the following tests as a preoperative evaluation: blood count, electrocardiogram and X-ray of the chest. OBJECTIVE: To verify the presence of ischemic and heart rate changes and the impact of the anesthetic procedure on these patients. Also to verify, in this population, the value of continuous ambulatory monitoring as a preoperative evaluation, a procedure that is not recommended by current guidelines. METHODS: In this protocol, we used continuous ambulatory monitoring (Holter System), in the perioperative period of 30 patients, aged over 65 years, who underwent transurethral resection of the prostate under spinal anesthesia. RESULTS: In the preoperative and transoperative evaluations, frequent complex ventricular and supraventricular arrhythmias were observed, and also ischemic changes. In the transoperative recording, the patients who had ischemic episodes were the same ones who showed total ischemic burden of more than 60 minutes in the preoperative recording. CONCLUSION: Ambulatory monitoring is not regarded as an appropriate procedure for the screening of myocardial ischemia, due to the characteristics and technical limitations of the method, especially in populations with a low prevalence of coronary disease. In this cross-sectional and observational study, we concluded that the Holter recordings provided additional information which could not be obtained by conventional electrocardiogram.

Read Full Article

ABC

Review Article

Large randomized controlled trials in perioperative cardiovascular medicine: a proposal for the design, conduct and efficient management

Otavio Berwanger et al. Erica Aranha Suzumura PJ Devereaux

The number of patients undergoing noncardiac surgery is growing worldwide. To optimally assist patients during the perioperative period, we must improve our knowledge of how to prevent major perioperative cardiovascular events around the time of noncardiac surgery. To achieve this goal there is a need for large randomized controlled trials that can provide reliable and conclusive results in this field. This narrative review describes a proposal for the design, conduct and management of large controlled trials in perioperative cardiovascular medicine.

Read Full Article

ABC

Artigo Original

Indicators of healthcare quality in isolated coronary artery bypass graft surgery performed at a tertiary cardiology center

Evandro Tinoco Mesquita et al. Ary Ribeiro Mônica Peres de Araújo Luiz Antonio de Almeida Campos … Marco Aurélio Fernandes Alexandre Siciliano Colafranceschi Celso Garcia da Silveira Edson Nunes Antônio Sérgio Cordeiro da Rocha

BACKGROUND: Quality indicators (QI) for cardiac surgery are important instruments for measuring healthcare quality in hospital centers and allow comparison with high-quality healthcare centers. OBJECTIVE: To evaluate QIs in isolated myocardial revascularization procedures (CABG) performed at a tertiary cardiology center. METHODS: One hundred and forty-four consecutive patients who had undergone isolated CABG were evaluated between October 2005 and March 2007. One hundred and eight patients were men (75%), the mean age was 65±11, and the EuroSCORE was 4±3. The following QIs were measured: time elapsed between the surgery date-setting appointment and the actual day of the CABG (TDC); surgery cancellation rate (SCR) due to problems in hospital infrastructure; length of hospital stay (LOS); operative mortality (OM) and rate of readmission (RHR) for infection in the surgical wound. RESULTS: The TDC (n=98) was 4±3 days (median: 4 days) and the SCR was zero. The OM recorded of 4.9% (95% confidence interval [CI] = 2.2 – 9.87%) was lower than the expected OM of 5.1% (95% CI = 1.4% to 14.37%), but with no statistical significance (p=0.65). The area under the ROC curve of the EuroSCORE for the OM was 0.702 (95% CI = 0.485 – 0.919). LOS was 11±9 days. The area under the ROC curve of the EuroSCORE for the LOS was 0.764 (95% CI = 0.675 – 0.852). The RHR recorded was 2.1%. CONCLUSION: The measurement of the QIs showed that, in a medical center with a low annual volume of CABG, the results were compatible with the risk profile of the population involved.

Read Full Article