Nitrates for the prevention of cardiac morbidity and mortality in patients undergoing non-cardiac surgery.
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ABSTRACT:
SUBMITTER: Zhao N
PROVIDER: S-EPMC9278527 | biostudies-literature |
REPOSITORIES: biostudies-literature
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| S-EPMC6761481 | biostudies-literature
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| S-EPMC6755267 | biostudies-literature
Project description:Remote ischaemic preconditioning (RIPC) using transient limb ischaemia failed to improve clinical outcomes following cardiac surgery and the reasons for this remain unclear. In the ERIC-GTN study, we evaluated whether concomitant nitrate therapy abrogated RIPC cardioprotection. We also undertook a post-hoc analysis of the ERICCA study, to investigate a potential negative interaction between RIPC and nitrates on clinical outcomes following cardiac surgery. In ERIC-GTN, 185 patients undergoing cardiac surgery were randomized to: (1) Control (no RIPC or nitrates); (2) RIPC alone; (3); Nitrates alone; and (4) RIPC + Nitrates. An intravenous infusion of nitrates (glyceryl trinitrate 1 mg/mL solution) was commenced on arrival at the operating theatre at a rate of 2-5 mL/h to maintain a mean arterial pressure between 60 and 70 mmHg and was stopped when the patient was taken off cardiopulmonary bypass. The primary endpoint was peri-operative myocardial injury (PMI) quantified by a 48-h area-under-the-curve high-sensitivity Troponin-T (48 h-AUC-hs-cTnT). In ERICCA, we analysed data for 1502 patients undergoing cardiac surgery to investigate for a potential negative interaction between RIPC and nitrates on clinical outcomes at 12-months. In ERIC-GTN, RIPC alone reduced 48 h-AUC-hs-cTnT by 37.1%, when compared to control (ratio of AUC 0.629 [95% CI 0.413-0.957], p = 0.031), and this cardioprotective effect was abrogated in the presence of nitrates. Treatment with nitrates alone did not reduce 48 h-AUC-hs-cTnT, when compared to control. In ERICCA there was a negative interaction between nitrate use and RIPC for all-cause and cardiovascular mortality at 12-months, and for risk of peri-operative myocardial infarction. RIPC alone reduced the risk of peri-operative myocardial infarction, compared to control, but no significant effect of RIPC was demonstrated for the other outcomes. When RIPC and nitrates were used together they had an adverse impact in patients undergoing cardiac surgery with the presence of nitrates abrogating RIPC-induced cardioprotection and increasing the risk of mortality at 12-months post-cardiac surgery in patients receiving RIPC.
| S-EPMC9213287 | biostudies-literature
Project description:Dysnatremia may predispose to falls and fractures, and serum sodium may influence bone health. Little is known of the association of perioperative dysnatremia and clinical outcomes in those undergoing major orthopedic surgery.We examined the association of serum sodium (corrected for glucose) with morbidity and mortality in a sample of hospitalized patients undergoing major orthopedic procedures at 2 large academic medical centers.Retrospective observational study.Adult patients admitted to major academic teaching hospitals for a major orthopedic procedure from January 2006 to January 2011.The association of serum sodium with log-transformed hospital length of stay was assessed by fitting linear regression models. The association with 30-day mortality was assessed by fitting Cox proportional hazards models.There were 16,206 unique admissions, of which 44.8% were male, with a mean age of 62.5 years. Mean corrected serum sodium was 138.5 ± 2.9 mmol/L; 1.2% had moderate/severe hyponatremia, 6.4% had mild hyponatremia, and 2.5% were hypernatremic. In adjusted models, compared with normonatremia, moderate/severe hyponatremia, mild hyponatremia, and hypernatremia were associated with a 1.6-, 1.4-, and 1.4-day-longer hospital stay, respectively, and greater risk of 30-day mortality (hazard ratio [HR]: 2.47, 95% confidence interval [CI]: 1.33-4.59 for moderate/severe hyponatremia; HR: 1.80, 95% CI: 1.21-2.66 for mild hyponatremia; and HR: 2.99, 95% CI: 1.79-4.98 for hypernatremia).Dysnatremia is relatively common in the hospitalized orthopedic population and associated with greater length of stay and 30-day mortality. Future studies should address potential mechanisms underlying these associations and whether correction of perioperative dysnatremia may improve patient outcomes.
| S-EPMC4815900 | biostudies-literature
Project description:Remote ischaemic preconditioning (RIPC) has been shown to have a protective role on vital organs exposed to reperfusion injury. The aim of this systematic review was to evaluate the effects of non-invasive RIPC on clinical and biochemical outcomes in patients undergoing non-cardiac surgery. A systematic literature search of PubMed, EMBASE, Scopus, and Cochrane databases was carried out in February 2020. RCTs investigating the effect of non-invasive RIPC in adults undergoing non-cardiac surgery were included. Meta-analyses and trial sequential analyses (TSAs) were performed on cardiovascular events, acute kidney injury, and short- and long-term mortality. Some 43 RCTs including 3660 patients were included. The surgical areas comprised orthopaedic, vascular, abdominal, pulmonary, neurological, and urological surgery. Meta-analysis showed RIPC to be associated with fewer cardiovascular events in non-cardiac surgery (13 trials, 1968 patients, 421 events; odds ratio (OR) 0.68, 95 per cent c.i. 0.47 to 0.96; P = 0.03). Meta-analyses of the effect of RIPC on acute kidney injury (12 trials, 1208 patients, 211 events; OR 1.14, 0.78 to 1.69; P = 0.50; I2 = 9 per cent), short-term mortality (7 trials, 1239 patients, 65 events; OR 0.65, 0.37 to 1.12; P = 0.12; I2 = 0 per cent), and long-term mortality (4 trials, 1167 patients, 9 events; OR 0.67, 0.18 to 2.55; P = 0.56; I2 = 0 per cent) showed no significant differences for RIPC compared with standard perioperative care in non-cardiac surgery. However, TSAs showed that the required information sizes have not yet been reached. Application of RIPC to non-cardiac surgery might reduce cardiovascular events, but not acute kidney injury or all-cause mortality, but currently available data are inadequate to confirm or reject an assumed intervention effect.
| S-EPMC7970092 | biostudies-literature
Project description:BackgroundThere is limited evidence to clarify the specific relationship between preoperative estimated glomerular filtration rate (preop-eGFR) and postoperative 30-day mortality in Asian patients undergoing non-cardiac and non-neuron surgery. We aimed to investigate details of this relationship.MethodsWe reanalyzed a retrospective analysis of the clinical records of 90,785 surgical patients at the Singapore General Hospital from January 1, 2012 to October 31, 2016. The main outcome was postoperative 30-day mortality.ResultsThe average age of these recruited patients was 53.96?±?16.88 years, of which approximately 51.64% were female. The mean of preop-eGFR distribution was 84.45?±?38.56 mL/min/1.73 m2. Multivariate logistic regression analysis indicated that preop-eGFR was independently associated with 30-day mortality (adjusted odds ratio: 0.992; 95% confidence interval [CI] 0.990-0.995; P?<?0.001). A U-shaped relationship was detected between preop-eGFR and 30-day mortality with an inflection point of 98.688 (P for log likelihood ratio test?<?0.001). The effect sizes and confidence intervals on the right and left sides of the inflection point were 1.013 (1.007 to 1.019) [P?<?0.0001] and 0.984 (0.981 to 0.987) [P?<?0.0001], respectively. Preoperative comorbidities such as congestive heart failure (CHF), type 1 diabetes, ischemic heart disease (IHD), and anemia were associated with the odds ratio of preop-eGFR to 30-day mortality (interaction P?<?0.05).DiscussionThe relationship between preop-eGFR and 30-day mortality is U-shaped. The recommended preop-eGFR at which the rate of the 30-day mortality was lowest was 98.688 mL/min/1.73 m2.
| S-EPMC7936476 | biostudies-literature
Project description:Despite the epidemic rise in obesity, few studies have evaluated the effect of obesity on cost following cardiac surgery. We hypothesized that increasing body mass index (BMI) is associated with worse risk-adjusted outcomes and higher cost.Medical records for 13 637 consecutive patients who underwent coronary artery bypass grafting (9702), aortic (1535) or mitral (837) valve surgery, and combined valve-coronary artery bypass grafting (1663) procedures were extracted from a regional Society of Thoracic Surgeons certified database. Patients were stratified by BMI: normal to overweight (BMI 18.5-30), obese (BMI 30-40), and morbidly obese (BMI >40). Differences in outcomes and cost were compared between BMI strata and also modeled as a continuous function of BMI with adjustment for preoperative risk using Society of Thoracic Surgeons predictive risk indices. Morbidly obese patients incurred nearly 60% greater observed mortality than normal weight patients. Moreover, morbidly obese patients had greater than 2-fold increase in renal failure and 6.5-fold increase in deep sternal wound infection. After risk adjustment, a significant association was found between BMI and mortality (P<0.001) and major morbidity (P<0.001). The risk-adjusted odds ratio for mortality for morbidly obese patients was 1.57 (P=0.02) compared to normal patients. Importantly, risk-adjusted total hospital cost increased with BMI, with 17.2% higher costs in morbidly obese patients.Higher BMI is associated with increased mortality, major morbidity, and cost for hospital care. As such, BMI should be more strongly considered in risk assessment and resource allocation.
| S-EPMC5523989 | biostudies-other
Project description:ObjectiveTo determine the effectiveness of the revised Risk Analysis Index (RAI-rev), administrative Risk Analysis Index (RAI-A), cancer-corrected Risk Analysis Index [RAI-rev (cancer-corrected)], and 5-variable modified Frailty Index for predicting 30-day morbidity and mortality in patients undergoing high-risk surgery.BackgroundThere are several frailty composite measures, but none have been evaluated for predicting morbidity and mortality in patients undergoing high-risk surgery.MethodsUsing the National Surgical Quality Improvement Program database, we performed a retrospective study of patients who underwentcolectomy/proctectomy, coronary artery bypass graft (CABG), pancreaticoduodenectomy, lung resection, or esophagectomy from 2006 to 2017. RAI-rev, RAI-A, RAI-rev (cancer corrected), and 5-variable modified Frailty Index scores were calculated. Pearson's chi-square tests and C-statistics were used to assess the predictive accuracy of each score's logistic regression model.ResultsIn the cohort of 283,545 patients, there were 178,311 (63%) colectomy/proctectomy, 38,167 (14%) pancreaticoduodenectomy, 40,328 (14%) lung resection, 16,127 (6%) CABG, and 10,602 (3%) esophagectomy cases. The RAI-rev was a fair predictor of mortality in the total cohort (C-statistic, 0.71, 95% CI 0.70-0.71, P < 0.001) and for patients who underwent colectomy/proctectomy (C-statistic 0.73, 95% CI 0.72-0.74, P < 0.001) and CABG (C-statistic 0.70, 95% CI 0.68-0.73, P < 0.001), but a poor predictor of mortality in all other operation cohorts. The RAI-A was a fair predictor of mortality for colectomy/proctectomy patients (C-statistic 0.74, 95% CI 0.73- 0.74, P < 0.001). All indices were poor predictors of morbidity. The RAI-rev (cancer corrected) did not improve the accuracy of morbidity and mortality prediction.ConclusionThe presently studied frailty indices are ineffective predictors of 30-day morbidity and mortality for patients undergoing high-risk operations.
| S-EPMC11292114 | biostudies-literature
Project description:PurposeThe Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM) and its Portsmouth modification (P-POSSUM) are comprehensive assessment methods for evaluating patient and surgical factors widely used to predict 30-day mortality rates. In this retrospective study, we evaluated the usefulness of POSSUM and P-POSSUM in predicting 30-day mortality after intraoperative cardiac arrests in adult patients undergoing non-cardiac surgery.Materials and methodsAmong 190486 patients who underwent anesthesia, 51 experienced intraoperative cardiac arrest as defined in our study protocol. Predicted mortality rates were calculated using POSSUM and P-POSSUM equations and were compared with actual outcomes using exponential and linear analyses. In addition, a receiver operating characteristic curve analysis was undertaken, and area-under-the-curve (AUC) values with confidence intervals (CIs) were calculated for POSSUM and P-POSSUM.ResultsAmong the 51 patients with intraoperative cardiac arrest, 32 (62.7%) died within 30 days postoperatively. The overall predicted 30-day mortality rates using POSSUM and P-POSSUM were 65.5% and 57.5%, respectively. The observed-to-predicted (O:E) ratio for the POSSUM 30-day mortality was 1.07, with no significant difference between the observed and predicted values (χ²=4.794; p=0.779). P-POSSUM predicted mortality equally well, with an O:E ratio of 1.10 (χ²=8.905; p=0.350). AUC values (95% CI) were 0.771 (0.634-0.908) and 0.785 (0.651-0.918) for POSSUM and P-POSSUM, respectively.ConclusionBoth POSSUM and P-POSSUM performed well to predict overall 30-day mortality following intraoperative cardiac arrest in adults undergoing non-cardiac surgery at a university teaching hospital in Korea.
| S-EPMC4541674 | biostudies-literature
Project description:AimsHeart failure (HF) affects ∼5.7 million US adults and many of these patients develop non-cardiac disease that requires surgery. The aim of this study was to determine perioperative outcomes associated with HF in a large cohort of patients undergoing in-hospital non-cardiac surgery.Methods and resultsAdults ≥18 years old undergoing non-cardiac surgery between 2012 and 2014 were identified using the Healthcare Cost and Utilization Project National Inpatient Sample. Patients with HF were identified by ICD-9 diagnosis codes. The primary outcome was all-cause in-hospital mortality. Multivariable logistic regression models were used to estimate associations between HF and outcomes. A total of 21 560 996 surgical hospitalizations were identified, of which 1 063 405 (4.9%) had a diagnosis of HF. Among hospitalizations with HF, 4.7% had acute HF, 11.3% had acute on chronic HF, 27.8% had chronic HF, and 56.2% had an indeterminate diagnosis code that did not specify temporality. In-hospital perioperative mortality was more common among patients with any diagnosis of HF compared to those without HF [4.8% vs. 0.78%, P < 0.001; adjusted odds ratio (aOR) 2.15, 95% confidence interval (CI) 2.09-2.22], and the association between HF and mortality was greatest at small and non-teaching hospitals. Acute HF without chronic HF was associated with 8.0% mortality. Among patients with a chronic HF diagnosis, perioperative mortality was greater in those with acute on chronic HF compared to chronic HF alone (7.8% vs. 3.9%, P < 0.001; aOR 1.78, 95% CI 1.67-1.90).ConclusionIn patients hospitalized for non-cardiac surgery, HF was common and was associated with increased risk of perioperative mortality. The greatest risks were in patients with acute HF.
| S-EPMC7834859 | biostudies-literature