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“La valutazione del rischio cardiologico nel paziente candidato a chirurgia vascolare” D Scrutinio

“La valutazione del rischio cardiologico nel paziente candidato a chirurgia vascolare” D Scrutinio Fondazione S. Maugeri , IRCCS, Cassano M. Incidence of perioperative cardiac events in major noncardiac surgery. J Am Coll Cardiol 2008;51:1913-24.

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“La valutazione del rischio cardiologico nel paziente candidato a chirurgia vascolare” D Scrutinio

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  1. “La valutazione del rischio cardiologico nel paziente candidato a chirurgia vascolare” D Scrutinio Fondazione S. Maugeri, IRCCS, Cassano M

  2. Incidence of perioperative cardiac events in major noncardiacsurgery J Am CollCardiol 2008;51:1913-24

  3. CardiacRisk in VascularNon-CardiacSurgery VASCULAR SURGERY 30-day perioperativecardiaccomplications Cardiactroponinelevation: up to 40% MI/Cardiacdeath: 6.2% J Am CollCardiol 2008;51:1913-24 Anesthesiology 1998;88:561-4 N Engl J Med 1995;333:1750-6

  4. AssociationBetweenPostoperativeTroponinLevels and 30-Day Mortality Among PatientsUndergoingNoncardiacSurgery. The VISION Study.The Vascular Events In NoncardiacSurgeryPatientsCohortEvaluation (VISION) StudyInvestigators 15 133 patients ≥45 yearsofage ; 30-day mortality rate:1.9% peakpostoperative 4th-generation TnT during the first 3 days after surgery decisional cut-off: >0.03 ng/mL (LoD) JAMA. 2012;307(21):2295-2304

  5. Prevalenceofcoronaryarterydisease in electivevascularsurgerypatients Normalcoronaryarteries Mildto moderate CAD Stenosis >70% AAA Lowerextremity ischemia AnnSurg 1984

  6. Step 1. Active cardiac disease The first step in elective vascular surgery should be the identification of active cardiac disease(unstable coronary artery disease, recent myocardial infarction). Referral to cardiologist prior to surgery. Step 2. Surgical risk Vascular surgery patients are at greater cardiac risk than patients undergoing any other type of surgery. However, there is a slight distinction between different procedures: Abdominal aortic aneurysm repair and lower extremity arterial revascularization procedures high risk Endovascular abdominal aortic aneurysm repair, carotid artery endarterectomy and peripheral angioplasty  intermediate-risk

  7. Step 3. Functional capacity Recommendation: assessment of functional capacity in all vascular surgery patients. Patients who have a functional capacity <4 METs (inability to climb two flights of stairs or run a short distance) are at higher risk. In such patients, the identification of cardiac risk factors is the next step. • Step 4. Cardiac risk factors • Risk factors are: • history of myocardial infarction/angina pectoris • diabetes mellitus • renal dysfunction • history of TIA or CVE • congestive heart failure.

  8. From: Systematic Review: Prediction of Perioperative Cardiac Complications and Mortality by the Revised Cardiac Risk Index Ann Intern Med. 2010;152(1):26-35. HSROC curve showing the accuracy of a Revised Cardiac Risk Index score for predicting cardiac complications after vascular noncardiac surgery HSROC: 0.65(95% CI: 0.60 to 0.69)

  9. Definitionofbiomarker(National InstituteofHealth): “a characteristicthatisobjectivelymeasured and evaluated asanindicatorofnormalbiologicalprocesses, pathogenic processes, or pharmacologicalresponsesto a therapeutic intervention” Biomarkers Definitions Working Group. Biomarkers and surrogate endpoints:preferreddefinitions and conceptual framework. ClinPharmacolTher. 2001;69:89 –95.

  10. Clinical applications ofcardiovascularbiomarkers. Circulation. 2007;115:949-952.

  11. Role of hs-CRP and NT-proBNP for risk prediction in vascular surgery. • Prospectivestudy • 411 patientsundergoingelectivevascularsurgery • Primaryoutcome: composite ofdeath, acute coronarysyndromes, acute pulmonary edema, and peri-proceduralmyocardialdamageasassessedbyhs-cTnImeasurement • Time Frame: 30 days post surgery • Blood samples for hs-CRP, NT-proBNP, and hs-cTnIwereobtained on the preoperativeday in allpatients • Bloodsamplesforhs-cTnIwereobtained on the preoperative and post-operative days 1 and 2. Scrutinio D et al., submitted

  12. Role of hs-CRP and NT-proBNP for risk prediction in vascular surgery.

  13. Valore discriminante incrementale della proteina C ad alta sensibilità, dell’NT-proBNP e della loro associazione Rangeofexcellence 0.78 0.75 0.74 0.67 C index Lee index + NT-proBNP Lee index + both Lee index + hs-CRP Lee index

  14. Role of hs-CRP and NT-proBNP for risk prediction in vascular surgery.

  15. Role of hs-CRP and NT-proBNP for risk prediction in vascular surgery. Rangeofexcellence 0.82 0.78 0.75 0.74 0.67 C index Lee index + hs-CRP Lee index + NT-proBNP Lee index + both Multivariable model Lee index

  16. Role of hs-CRP and NT-proBNP for risk prediction in vascular surgery. Observed and predicted rate of the primary outcome within each quartile and as a continuous function of the risk score at 1-point intervals Observed Predicted Score: 0-1 2-4 5-6 ≥7 Score: 0 1 2 3 4 5 6 7 >7

  17. Grazie per l’attenzione

  18. AssociationBetweenPostoperativeTroponinLevels and 30-Day Mortality Among PatientsUndergoingNoncardiacSurgery.The Vascular Events In NoncardiacSurgeryPatientsCohortEvaluation (VISION) StudyInvestigators ≤0.01 ng/mL 0.02 ng/mL 0.03-0.29 ng/mL ≥0.30 ng/mL hs-TnTlevel JAMA. 2012;307(21):2295-2304

  19. Anesthesiology 2011;114:796-806

  20. Cardiac complications after non-cardiac surgery depend on individual patient’s risk , type of surgery, and the circumstances under which it takes place. Surgical factors that influence cardiac risk are related to the urgency, type, and duration of the procedure. Every operation elicits a stress response, mediated by neuroendocrine factors Surgery also causes alterations in the balance between prothrombotic and fibrinolytic factors, resulting in hypercoagulability and possible coronary thrombosis (elevation of fibrinogen and other coagulation factors, increased platelet activation and aggregation, and reduced fibrinolysis).

  21. Role of biomarkers for risk prediction in vascular surgery. Lee Index plus hs-CRP and NT-proBNP 0.774 (p=0.001) 0.749 (p=0.004) Lee Index + hs-CRP Lee Index + NT-proBNP 0.741 (p=0.009) Lee Index 0.670 C-index Scrutinio D et al. J VascSurg, submitted

  22. Role of biomarkers for risk prediction in vascular surgery. (1/4 ofallevents) Riskofclinicalevents and TnI↑: x 22 No biomarker + (36.7%) All 3 biomarkers + (6.3%) Scrutinio D et al. J VascSurg, submitted

  23. Role of biomarkers for risk prediction in vascular surgery. • Clinicalimplications: • Accurate pre-operative evaluation, includingbiomarkermeasurement, and prophylaxis • Carefulperioperativemonitoring and management • (tachycardia, hypertension, hypotension, anemia, hypoxemia, pain, • hemodynamicmonitoring), as appropriate Circulation 2009;119:2936-44

  24. Role of biomarkers for risk prediction in vascular surgery. Lee Index predicted and observed rates of death, ACS; and pulmonary edema 0 (n=149) 1 (n=173) 2 (n=61) ≥3 (n=28) Lee Indexriskmarkers Scrutinio D et al. J VascSurg, submitted

  25. Role of biomarkers for risk prediction in vascular surgery. • NT-proBNPconcentrationsmayreflect: • the presenceof HF or asymptomaticleftventriculardysfunction • the ischemicriskcarriedbyextensive CAD • NT-proBNPconcentrationsincreasewithincreasingextensionof CAD and are independentlyassociatedwithsurvival (N Engl J Med 2005;352:666-75) • Natriureticpeptidespredict CV risk in stablepatientswith CAD . (Circulation 2009;120:2177-87)

  26. Vascular Events In Noncardiac Surgery Patients Cohort Evaluation Study (VISION)This study is currently recruiting participants • The VISION Study is a prospective cohort study of 40,000 patients >45 years of age, undergoing noncardiac surgery and receiving a general or regional anesthetic. • The aims are to determine: • the incidence of major vascular events, the optimal clinical model to predict major perioperative vascular events, and the extent to which troponin measurements post surgery can predict vascular death at 1 year. • the potential association associations between preoperative or postoperative medications and major perioperative vascular events • the value of NT-proBNP (8,000 - 10,000 patients) prior to surgery in predicting major perioperative vascular events. www.clinicaltrials.gov

  27. JAMA 2013

  28. JAMA 2013 30-day mortality

  29. pre-operativehs-TnT pre-operativehs-TnT

  30. 99th percentile: 14 ng/L

  31. Based upon the available evidence, it can be safely concluded that finding elevated cTn in a healthy subject is extremely rare. Therefore, any unexplained elevation of cTn should prompt additional evaluation for cardiovascular disease. The evaluation should include detailed history, physical examination, standard laboratory testing, and an ECG. Given the strong association between cTn elevation and cardiac structural and functional abnormalities, an echocardiogram would also seemprudent. Gupta S. ProgrCardiovascDis 2007;50:151-165

  32. Combinedend-point: • - all-causemortality • - acute myocardialinfarction • cardiacarrest or VF • - acute pulmonary edema • duringhospitalisation

  33. *Combined incidence of cardiac death and nonfatal MI

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