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P J Devereaux - One of the best experts on this subject based on the ideXlab platform.

  • suboptimal outcome of myocardial infarction after Noncardiac Surgery physicians can and should do more
    Circulation, 2018
    Co-Authors: P J Devereaux
    Abstract:

    Article, see p 2332 Among the 100 million adults worldwide ≥45 years of age who undergo major Noncardiac Surgery annually, it is estimated that 3 million will suffer a perioperative myocardial infarction (MI).1 Of these patients who will have an MI after Noncardiac Surgery, one third will experience an ischemic symptom, but two thirds will not experience an ischemic symptom.2 A proposed explanation for these asymptomatic events is that >70% of perioperative MIs occur within the first 48 hours after Noncardiac Surgery, a period when most patients receive analgesic medications that can mask ischemic symptoms.2 Based on a recent study by Smilowitz and colleagues3 that used administrative data from a 20% stratified sample of all US hospitals, in 2013, ≈40 000 Americans were diagnosed with an MI while in the hospital after Noncardiac Surgery. This figure is an underestimation of the true incidence because it is uncommon that surgeons routinely obtain perioperative troponin measurements in at-risk patients undergoing Noncardiac Surgery. Consequently, 65% of the perioperative MIs were likely missed because these patients would not have experienced an ischemic symptom that would have prompted surgeons to order troponin measurements. Therefore, in the United States, it is likely that 120 000 adults have an MI after Noncardiac Surgery every year. Myocardial injury after Noncardiac Surgery (MINS) is more inclusive of individuals at risk who may benefit from additional surveillance and includes (1) MI based on the universal definition of MI (ie, an elevated troponin measurement with ≥1 ischemic features, such as an ischemic ECG finding),4 and (2) isolated ischemic troponin elevation (ie, a troponin elevation after Surgery with no alternative nonischemic explanation [eg, sepsis, rapid atrial fibrillation, pulmonary embolism, chronic troponin elevation] for myocardial injury), occurring in ≤30 days after Surgery.5 MI accounts for 22% to 29% of …

  • association of postoperative high sensitivity troponin levels with myocardial injury and 30 day mortality among patients undergoing Noncardiac Surgery
    JAMA, 2017
    Co-Authors: P J Devereaux, Alben Sigamani, Bruce M Biccard, Matthew T V Chan, Sadeesh Srinathan, Denis Xavier, Michael Walsh, Valsa Abraham, Rupert M Pearse, C Y Wang
    Abstract:

    Importance Little is known about the relationship between perioperative high-sensitivity troponin T (hsTnT) measurements and 30-day mortality and myocardial injury after Noncardiac Surgery (MINS). Objective To determine the association between perioperative hsTnT measurements and 30-day mortality and potential diagnostic criteria for MINS (ie, myocardial injury due to ischemia associated with 30-day mortality). Design, Setting, and Participants Prospective cohort study of patients aged 45 years or older who underwent inpatient Noncardiac Surgery and had a postoperative hsTnT measurement. Starting in October 2008, participants were recruited at 23 centers in 13 countries; follow-up finished in December 2013. Exposures Patients had hsTnT measurements 6 to 12 hours after Surgery and daily for 3 days; 40.4% had a preoperative hsTnT measurement. Main Outcomes and Measures A modified Mazumdar approach (an iterative process) was used to determine if there were hsTnT thresholds associated with risk of death and had an adjusted hazard ratio (HR) of 3.0 or higher and a risk of 30-day mortality of 3% or higher. To determine potential diagnostic criteria for MINS, regression analyses ascertained if postoperative hsTnT elevations required an ischemic feature (eg, ischemic symptom or electrocardiography finding) to be associated with 30-day mortality. Results Among 21 842 participants, the mean age was 63.1 (SD, 10.7) years and 49.1% were female. Death within 30 days after Surgery occurred in 266 patients (1.2%; 95% CI, 1.1%-1.4%). Multivariable analysis demonstrated that compared with the reference group (peak hsTnT Conclusions and Relevance Among patients undergoing Noncardiac Surgery, 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.

  • cardiac complications in patients undergoing major Noncardiac Surgery
    The New England Journal of Medicine, 2015
    Co-Authors: P J Devereaux, Daniel I Sessler
    Abstract:

    Each year, cardiac complications occur within 30 days after major Noncardiac Surgery in more than 10 million people worldwide; postoperative mortality is 1.5%. Enhanced patient monitoring and measurement of natriuretic hormone and troponin levels may improve outcomes.

  • clonidine in patients undergoing Noncardiac Surgery
    The New England Journal of Medicine, 2014
    Co-Authors: P J Devereaux, Kate Leslie, Andrea Kurz, Marko Mrkobrada, Pablo Alonsocoello, Alben Sigamani, G H Guyatt, A Robinson, F Botto
    Abstract:

    Background Marked activation of the sympathetic nervous system occurs during and after Noncardiac Surgery. Low-dose clonidine, which blunts central sympathetic outflow, may prevent perioperative myocardial infarction and death without inducing hemodynamic instability. Methods We performed a blinded, randomized trial with a 2-by-2 factorial design to allow separate evaluation of low-dose clonidine versus placebo and low-dose aspirin versus placebo in patients with, or at risk for, atherosclerotic disease who were undergoing Noncardiac Surgery. A total of 10,010 patients at 135 centers in 23 countries were enrolled. For the comparison of clonidine with placebo, patients were randomly assigned to receive clonidine (0.2 mg per day) or placebo just before Surgery, with the study drug continued until 72 hours after Surgery. The primary outcome was a composite of death or nonfatal myocardial infarction at 30 days. Results Clonidine, as compared with placebo, did not reduce the number of primary-outcome events (367 and 339, respectively; hazard ratio with clonidine, 1.08; 95% confidence interval [CI], 0.93 to 1.26; P = 0.29). Myocardial infarction occurred in 329 patients (6.6%) assigned to clonidine and in 295 patients (5.9%) assigned to placebo (hazard ratio, 1.11; 95% CI, 0.95 to 1.30; P = 0.18). Significantly more patients in the clonidine group than in the placebo group had clinically important hypotension (2385 patients [47.6%] vs. 1854 patients [37.1%]; hazard ratio 1.32; 95% CI, 1.24 to 1.40; P<0.001). Clonidine, as compared with placebo, was associated with an increased rate of nonfatal cardiac arrest (0.3% [16 patients] vs. 0.1% [5 patients]; hazard ratio, 3.20; 95% CI, 1.17 to 8.73; P = 0.02). Conclusions Administration of low-dose clonidine in patients undergoing Noncardiac Surgery did not reduce the rate of the composite outcome of death or nonfatal myocardial infarction; it did, however, increase the risk of clinically important hypotension and nonfatal cardiac arrest. (Funded by the Canadian Institutes of Health Research and others; POISE-2 ClinicalTrials.gov number, NCT01082874.)

  • the association between perioperative hemoglobin and acute kidney injury in patients having Noncardiac Surgery
    Anesthesia & Analgesia, 2013
    Co-Authors: Michael Walsh, P J Devereaux, Amit X Garg, Maged Argalious, Hooman Honar, Daniel I Sessler
    Abstract:

    BACKGROUND:Acute kidney injury (AKI) is a common complication of Noncardiac Surgery and is associated with excess morbidity and mortality. Perioperative hemoglobin concentrations are strongly associated with surgical mortality, but little is known about their relationship with AKI. We studied hemogl

Daniel I Sessler - One of the best experts on this subject based on the ideXlab platform.

Gordon H Guyatt - One of the best experts on this subject based on the ideXlab platform.

  • withholding versus continuing angiotensin converting enzyme inhibitors or angiotensin ii receptor blockers before Noncardiac Surgery an analysis of the vascular events in Noncardiac Surgery patients cohort evaluation prospective cohort
    Anesthesiology, 2017
    Co-Authors: Pavel S Roshanov, Bram Rochwerg, Ameen Patel, Omid Salehian, Emmanuelle Duceppe, Emilie P Belleycote, Gordon H Guyatt, Daniel I Sessler, Yannick Le Manach, Flavia Kessler Borges
    Abstract:

    Background:The effect on cardiovascular outcomes of withholding angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers in chronic users before Noncardiac Surgery is unknown.Methods:In this international prospective cohort study, the authors analyzed data from 14,687 patients (i

  • myocardial injury after Noncardiac Surgery a large international prospective cohort study establishing diagnostic criteria characteristics predictors and 30 day outcomes
    Anesthesiology, 2014
    Co-Authors: Fernando Botto, Gordon H Guyatt, Pablo Alonsocoello, Matthew T V Chan, Patricia Cruz, Sadeesh Srinathan, Denis Xavier, Juan Carlos Villar
    Abstract:

    Background Myocardial injury after Noncardiac Surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after Noncardiac Surgery. The study's four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS. Methods In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient Noncardiac Surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated "abnormal" laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria. Results An elevated troponin after Noncardiac Surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors' diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96-5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6-41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom. Conclusion Among adults undergoing Noncardiac Surgery, MINS is common and associated with substantial mortality.

  • characteristics and short term prognosis of perioperative myocardial infarction in patients undergoing Noncardiac Surgery
    Annals of Internal Medicine, 2011
    Co-Authors: P J Devereaux, Gordon H Guyatt, Kate Leslie, Alben Sigamani, Denis Xavier, Janice Pogue, Ignacio Garutti, Purnima Raomelacini, Sue Chrolavicius, Homer Yang
    Abstract:

    Little is known about the characteristics and short-term prognosis of perioperative myocardial infarction (MI) in the setting of Noncardiac Surgery. In this multinational study of 8351 patients und...

  • prognostic value of troponin and creatine kinase muscle and brain isoenzyme measurement after Noncardiac Surgery a systematic review and meta analysis
    Anesthesiology, 2011
    Co-Authors: Michael Levy, Gordon H Guyatt, Salim Yusuf, Juan Carlos Villar, Diane Heelsansdell, Rajesh Hiralal, Mohit Bhandari, Deborah J Cook, Matthew J Mcqueen, Edward O Mcfalls
    Abstract:

    There is uncertainty regarding the prognostic value of troponin and creatine kinase muscle and brain isoenzyme measurements after Noncardiac Surgery.

  • rationale design and organization of the perioperative ischemic evaluation poise trial a randomized controlled trial of metoprolol versus placebo in patients undergoing Noncardiac Surgery
    American Heart Journal, 2006
    Co-Authors: Poise Trial Investigators, Gordon H Guyatt, P J Devereaux, Kate Leslie, Homer Yang, Juan Carlos Villar, Victor M Monteri, Peter T Choi, Julian W Giles, Salim Yusuf
    Abstract:

    BACKGROUND: Noncardiac Surgery is associated with significant cardiovascular mortality, morbidity, and cost. Small trials of beta-blockers suggest that they may prevent cardiovascular events in patients undergoing Noncardiac Surgery, but trial results are inconclusive. We have initiated the POISE trial to definitively establish the effects of beta-blocker therapy in patients undergoing Noncardiac Surgery. METHODS: The POISE trial is a blinded, randomized, and controlled trial of controlled-release metoprolol versus placebo in 10000 patients at risk for a perioperative cardiovascular event who are undergoing Noncardiac Surgery. Patients will receive the study drug 2 to 4 hours before Surgery and subsequently for 30 days. The primary outcome is a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal cardiac arrest at 30 days. Patients will also be followed for events at 1 year. RESULTS: To date, the POISE trial has recruited >6300 patients in 182 centers in 21 countries. Currently, the patients' mean age is 69 years; 63% are males, 43% have a history of coronary artery disease, 43% have a history of peripheral arterial disease, and 30% have diabetes. Most participants have undergone vascular (42%), intraabdominal (23%), or orthopedic (19%) Surgery. CONCLUSIONS: The POISE trial is a large international trial that will provide a reliable assessment of the effects of beta-blocker therapy in patients undergoing Noncardiac Surgery.

Jeffrey S Berger - One of the best experts on this subject based on the ideXlab platform.

  • cardiovascular risk factors and perioperative myocardial infarction after Noncardiac Surgery
    Canadian Journal of Cardiology, 2021
    Co-Authors: Tanya Wilcox, Nathaniel R Smilowitz, Joshua A Beckman, Yuhe Xia, Jeffrey S Berger
    Abstract:

    Abstract Background Perioperative cardiovascular events are a leading cause of morbidity and mortality after Noncardiac Surgery. We propose a simplified method for perioperative risk stratification. Methods In a retrospective cohort study we identified patients who underwent Noncardiac Surgery between 2009 and 2015 in the US National Surgical Quality Improvement Program. Multivariable logistic regression models adjusted for age, sex, race, and Surgery type were generated to estimate the effect of traditional cardiovascular risk factors (hypertension, diabetes mellitus, current smoking) on odds of perioperative myocardial infarction (MI). Time to event analysis was conducted using competing risk analysis, with MI as the outcome event and death as the competing risk. Results A total of 3,848,501 Noncardiac surgeries were identified. Postoperative MI occurred in 0.37% of patients and 1.04% of patients died. The 30-day event rate of perioperative MI increased in a stepwise fashion with additional risk factors (0.42% for 1, 0.82% for 2, and 1.08% for 3; P for trend Conclusions Patients with cardiovascular risk factors are at increased risk of perioperative MI, those without risk factors are at low risk. Further evaluation is needed to determine the effect of a simplified risk score in the perioperative setting.

  • atrial septal defect and the risk of ischemic stroke in the perioperative period of Noncardiac Surgery
    American Journal of Cardiology, 2019
    Co-Authors: Nathaniel R Smilowitz, Varun Subashchandran, Jeffrey S Berger
    Abstract:

    Stroke is a serious complication of Noncardiac Surgery. Congenital defects of the interatrial septum may be a potent risk factor for perioperative stroke. The aim of the present study was to determine the association between atrial septal defect (ASD) or patent foramen ovale (PFO) and in-hospital perioperative ischemic stroke after non-cardiac Surgery in a large nationwide cohort of patients hospitalized in the United States. Patients undergoing Noncardiac Surgery between 2004 and 2014 were identified using the Healthcare Cost and Utilization Project's National Inpatient Sample. Patients without an in-hospital echocardiogram were excluded. The presence of an ostium secundum-type ASD or PFO was identified by ICD-9 diagnosis code 745.5. The primary study outcome was perioperative acute ischemic stroke. Between 2004 and 2014, there were 639,985 admissions for Noncardiac Surgery with an in-hospital echocardiogram. An ASD or PFO was documented in 9,041 (1.4%) hospitalizations. Perioperative ischemic stroke occurred more frequently in patients with an ASD or PFO compared with those without an ASD or PFO (35.1% vs 6.0%, p

  • hospital readmission after perioperative acute myocardial infarction associated with Noncardiac Surgery
    Circulation, 2018
    Co-Authors: Nathaniel R Smilowitz, Joshua A Beckman, Scott E Sherman, Jeffrey S Berger
    Abstract:

    Background: Acute myocardial infarction (AMI) is a major cardiovascular complication of Noncardiac Surgery. We aimed to evaluate the frequency, causes, and outcomes of 30-day hospital readmission after perioperative AMI. Methods: Patients who were diagnosed with AMI during hospitalization for major Noncardiac Surgery were identified using the 2014 US Nationwide Readmission Database. Rates, causes, and costs of 30-day readmissions after Noncardiac Surgery with and without perioperative AMI were identified. Results: Among 3 807 357 hospitalizations for major Noncardiac Surgery, 8085 patients with perioperative AMI were identified. A total of 1135 patients (14.0%) with perioperative AMI died in-hospital during the index admission. Survivors of perioperative AMI were more likely to be readmitted within 30 days than surgical patients without perioperative AMI (19.1% versus 6.5%, P Conclusions: Among patients undergoing Noncardiac Surgery who develop a perioperative MI, ≈1 in 3 suffer from in-hospital death or hospital readmission in the first 30 days after discharge. Strategies to improve outcomes of surgical patients early after perioperative AMI are warranted.

  • perioperative major adverse cardiovascular and cerebrovascular events associated with Noncardiac Surgery
    JAMA Cardiology, 2017
    Co-Authors: Nathaniel R Smilowitz, Jeffrey S Berger, Navdeep Gupta, Harish Ramakrishna, Yu Guo, Sripal Bangalore
    Abstract:

    Importance Major adverse cardiovascular and cerebrovascular events (MACCE) are a significant source of perioperative morbidity and mortality following Noncardiac Surgery. Objective To evaluate national trends in perioperative cardiovascular outcomes and mortality after major Noncardiac Surgery and to identify surgical subtypes associated with cardiovascular events using a large administrative database of United States hospital admissions. Design, Setting, Participants Patients who underwent major Noncardiac Surgery from January 2004 to December 2013 were identified using the National Inpatient Sample. Main Outcomes and Measures Perioperative MACCE (primary outcome), defined as in-hospital, all-cause death, acute myocardial infarction (AMI), or acute ischemic stroke, were evaluated over time. Results Among 10 581 621 hospitalizations (mean [SD] patient age, 65.74 [12.32] years; 5 975 798 female patients 56.60%]) for major Noncardiac Surgery, perioperative MACCE occurred in 317 479 hospitalizations (3.0%), corresponding to an annual incidence of approximately 150 000 events after applying sample weights. Major adverse cardiovascular and cerebrovascular events occurred most frequently in patients undergoing vascular (7.7%), thoracic (6.5%), and transplant Surgery (6.3%). Between 2004 and 2013, the frequency of MACCE declined from 3.1% to 2.6% ( P for trend P for trend Conclusions and Relevance Perioperative MACCE occurs in 1 of every 33 hospitalizations for Noncardiac Surgery. Despite reductions in the rate of death and AMI among patients undergoing major Noncardiac Surgery in the United States, perioperative ischemic stroke increased over time. Additional efforts are necessary to improve cardiovascular care in the perioperative period of patients undergoing Noncardiac Surgery.

Flavia Kessler Borges - One of the best experts on this subject based on the ideXlab platform.

  • preoperative n terminal pro b type natriuretic peptide and cardiovascular events after Noncardiac Surgery a cohort study
    Annals of Internal Medicine, 2020
    Co-Authors: Emmanuelle Duceppe, Ameen Patel, Bruce M Biccard, Matthew T V Chan, Pa Kavsak, Otavio Berwanger, Gareth L Ackland, Reitze N Rodseth, Clara K Chow, Flavia Kessler Borges
    Abstract:

    Background Preliminary data suggest that preoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP) may improve risk prediction in patients undergoing Noncardiac Surgery. Objective To determine whether preoperative NT-proBNP has additional predictive value beyond a clinical risk score for the composite of vascular death and myocardial injury after Noncardiac Surgery (MINS) within 30 days after Surgery. Design Prospective cohort study. Setting 16 hospitals in 9 countries. Patients 10 402 patients aged 45 years or older having inpatient Noncardiac Surgery. Measurements All patients had NT-proBNP levels measured before Surgery and troponin T levels measured daily for up to 3 days after Surgery. Results In multivariable analyses, compared with preoperative NT-proBNP values less than 100 pg/mL (the reference group), those of 100 to less than 200 pg/mL, 200 to less than 1500 pg/mL, and 1500 pg/mL or greater were associated with adjusted hazard ratios of 2.27 (95% CI, 1.90 to 2.70), 3.63 (CI, 3.13 to 4.21), and 5.82 (CI, 4.81 to 7.05) and corresponding incidences of the primary outcome of 12.3% (226 of 1843), 20.8% (542 of 2608), and 37.5% (223 of 595), respectively. Adding NT-proBNP thresholds to clinical stratification (that is, the Revised Cardiac Risk Index [RCRI]) resulted in a net absolute reclassification improvement of 258 per 1000 patients. Preoperative NT-proBNP values were also statistically significantly associated with 30-day all-cause mortality (less than 100 pg/mL [incidence, 0.3%], 100 to less than 200 pg/mL [incidence, 0.7%], 200 to less than 1500 pg/mL [incidence, 1.4%], and 1500 pg/mL or greater [incidence, 4.0%]). Limitation External validation of the identified NT-proBNP thresholds in other cohorts would reinforce our findings. Conclusion Preoperative NT-proBNP is strongly associated with vascular death and MINS within 30 days after Noncardiac Surgery and improves cardiac risk prediction in addition to the RCRI. Primary funding source Canadian Institutes of Health Research.

  • withholding versus continuing angiotensin converting enzyme inhibitors or angiotensin ii receptor blockers before Noncardiac Surgery an analysis of the vascular events in Noncardiac Surgery patients cohort evaluation prospective cohort
    Anesthesiology, 2017
    Co-Authors: Pavel S Roshanov, Bram Rochwerg, Ameen Patel, Omid Salehian, Emmanuelle Duceppe, Emilie P Belleycote, Gordon H Guyatt, Daniel I Sessler, Yannick Le Manach, Flavia Kessler Borges
    Abstract:

    Background:The effect on cardiovascular outcomes of withholding angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers in chronic users before Noncardiac Surgery is unknown.Methods:In this international prospective cohort study, the authors analyzed data from 14,687 patients (i