[Show abstract][Hide abstract] ABSTRACT: Plasma N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) levels improve preoperative cardiac risk stratification in vascular surgery patients. However, single preoperative measurements of NT-pro-BNP cannot take into account the hemodynamic stress caused by anesthesia and surgery. Therefore, the aim of the present study was to assess the incremental predictive value of changes in NT-pro-BNP during the perioperative period for long-term cardiac mortality. Detailed cardiac histories, rest left ventricular echocardiography, and NT-pro-BNP levels were obtained in 144 patients before vascular surgery and before discharge. The study end point was the occurrence of cardiovascular death during a median follow-up period of 13 months (interquartile range 5 to 20). Preoperatively, the median NT-pro-BNP level in the study population was 314 pg/ml (interquartile range 136 to 1,351), which increased to a median level of 1,505 pg/ml (interquartile range 404 to 6,453) before discharge. During the follow-up period, 29 patients (20%) died, 27 (93%) from cardiovascular causes. The median difference in NT-pro-BNP in the survivors was 665 pg/ml, compared to 5,336 pg/ml in the patients who died (p = 0.01). Multivariate Cox regression analyses, adjusted for cardiac history and cardiovascular risk factors (age, angina pectoris, myocardial infarction, stroke, diabetes mellitus, renal dysfunction, body mass index, type of surgery and the left ventricular ejection fraction), demonstrated that the difference in NT-pro-BNP level between pre- and postoperative measurement was the strongest independent predictor of cardiac outcome (hazard ratio 3.06, 95% confidence interval 1.36 to 6.91). In conclusion, the change in NT-pro-BNP, indicated by repeated measurements before surgery and before discharge is the strongest predictor of cardiac outcomes in patients who undergo vascular surgery.
The American journal of cardiology 02/2011; 107(4):609-14. DOI:10.1016/j.amjcard.2010.10.021 · 3.43 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Both preoperative left ventricular dysfunction (LVD) and acute kidney injury (AKI) in the postoperative period are independently associated with mortality. We evaluated the prevalence and prognostic implications of AKI in a cohort of vascular surgery patients.
Before vascular surgery, 1,158 patients were screened for LVD. Development of AKI, defined by RIFLE classification, was detected by serial serum creatinine measurements at days 1 to 3 after surgery. Primary end point was cardiovascular mortality during a median follow-up of 2.2 years (interquartile range [IQR] 1.0-4.0).
LVD was present in 558 patients (48%), and 120 patients (10%) developed postoperative AKI. Subjects with LVD developed postoperative AKI more often than patients without LVD (8% vs. 13%, p=0.01). Patients were categorized as (i) no LVD, without AKI (n=551, 48%), (ii) LVD without AKI (n=487, 42%), (iii) no LVD, with AKI (n=49, 4%) and (iv) LVD with AKI (n=71/6%). Patients with LVD prior to surgery who developed postoperative AKI had the highest cardiovascular mortality risk (hazard ratio = 4.9; 95% confidence interval, 2.9-8.2).
Patients with preoperatively LVD have an increased risk of developing AKI after vascular surgery. The occurrence of AKI in patients with LVD has an incremental predictive value toward cardiovascular mortality risk during long-term follow-up.
Journal of nephrology 02/2011; 24(6):764-70. DOI:10.5301/JN.2011.6384 · 2.00 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study evaluated timing of β-blocker initiation before surgery and its relationship with: 1) pre-operative heart rate and high-sensitivity C-reactive-protein (hs-CRP) levels; and 2) post-operative outcome.
Perioperative guidelines recommend β-blocker initiation days to weeks before surgery, on the basis of expert opinions.
In 940 vascular surgery patients, pre-operative heart rate and hs-CRP levels were recorded, next to timing of β-blocker initiation before surgery (0 to 1, >1 to 4, >4 weeks). Pre- and post-operative troponin-T measurements and electrocardiograms were performed routinely. End points were 30-day cardiac events (composite of myocardial infarction and cardiac mortality) and long-term mortality. Multivariate regression analyses, adjusted for cardiac risk factors, evaluated the relation between duration of β-blocker treatment and outcome.
The β-blockers were initiated 0 to 1, >1 to 4, and >4 weeks before surgery in 158 (17%), 393 (42%), and 389 (41%) patients, respectively. Median heart rate at baseline was 74 (±17) beats/min, 70 (±16) beats/min, and 66 (±15) beats/min (p < 0.001; comparing treatment initiation >1 with <1 week pre-operatively), and hs-CRP was 4.9 (±7.5) mg/l, 4.1 (±.6.0) mg/l, and 4.5 (±6.3) mg/l (p = 0.782), respectively. Treatment initiated >1 to 4 or >4 weeks before surgery was associated with a lower incidence of 30-day cardiac events (odds ratio: 0.46, 95% confidence interval [CI]: 0.27 to 0.76, odds ratio: 0.48, 95% CI: 0.29 to 0.79) and long-term mortality (hazard ratio: 0.52, 95% CI: 0.21 to 0.67, hazard ratio: 0.50, 95% CI: 0.25 to 0.71) compared with treatment initiated <1 week pre-operatively.
Our results indicate that β-blocker treatment initiated >1 week before surgery is associated with lower pre-operative heart rate and improved outcome, compared with treatment initiated <1 week pre-operatively. No reduction of median hs-CRP levels was observed in patients receiving β-blocker treatment >1 week compared with patients in whom treatment was initiated between 0 and 1 week before surgery.
Journal of the American College of Cardiology 11/2010; 56(23):1922-9. DOI:10.1016/j.jacc.2010.05.056 · 15.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Obesity is a risk factor for atherosclerosis, a polyvascular process associated with reduced survival. In nonvascular surgery populations, a paradox between body mass index (BMI) and survival is described. This paradox includes reduced survival in underweight patients, whereas overweight and obese patients have a survival benefit. No clear explanation for this paradox has been given. Therefore, we evaluated the presence of the obesity paradox in vascular surgery patients and the influence of polyvascular disease on the obesity paradox.
In this retrospective study, 2933 consecutive patients were classified according to their preoperative BMI (kg/m(2)) and screened for polyvascular disease and cardiovascular risk factors before surgery. In addition, medication use at the time of discharge was noted. Outcome was all-cause mortality during a median follow-up of 6.0 years (interquartile range, 2-9 years).
BMI (kg/m(2)) groups included 68 (2.3%) underweight (BMI <18.5), 1379 (47.0%) normal (BMI 18.5-24.9, reference), 1175 (40.0%) overweight (BMI 25-29.9), and 311 (10.7%) obese (BMI ≥ 30) patients. No direct interaction between BMI, polyvascular disease, and long-term outcome was observed. Underweight was an independent predictor of mortality (hazard ratio, 1.65; 95% confidence interval, 1.22-2.22). In contrast, overweight protected for all-cause mortality (hazard ratio, 0.79; 95% confidence interval, 0.700-0.89). Cardioprotective medication usage in underweight patients was the lowest (P < .001), although treatment targets for risk factors were equally achieved within all treated groups.
Overweight patients referred for vascular surgery were characterized by an increased incidence of polyvascular disease and required more extensive medical treatment for cardiovascular risk factors at discharge. Long-term follow-up showed a paradox of reduced mortality in overweight patients.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 10/2010; 53(2):399-406. DOI:10.1016/j.jvs.2010.08.048 · 2.98 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Diabetes mellitus (DM) and left ventricular dysfunction (LVD) are often coexistent and invariably associated with increased mortality. Data on long-term prognosis of "isolated" diastolic LVD in diabetics are lacking; therefore, we evaluated these prognostic implications in patients with peripheral arterial disease (PAD) and DM. Using echocardiography, 1321 patients were screened for diastolic, systolic (ejection fraction <50%) or combined LVD. Diastolic LVD was diagnosed based on the ratio of early rapid filling to late filling due to atrial contraction, pulmonary vein flow, and deceleration time. Patients using glucose-lowering drugs or insulin or with a fasting glucose level >6.1 mmol/L were diagnosed with DM. The primary end point was occurrence of cardiovascular death during a mean follow-up of 2.5 +/- 1.9 years. In the total population, DM was diagnosed in 518 patients (39%), and diastolic, systolic, or combined LVD was present in 356 patients (27%), 102 patients (8%), or 156 patients (12%), respectively. In diabetic patients, diastolic and systolic LVDs were associated with increased cardiovascular mortality (hazard ratio 1.8, 95% confidence interval 1.03 to 3.03; hazard ratio 3.1, 95% confidence interval 1.46 to 6.38). In nondiabetic patients, the same association between diastolic or systolic LVD and outcome was observed (hazard ratio 2.2, 95% confidence interval 1.30 to 3.74; hazard ratio 3.9, 95% confidence interval 2.00 to 7.52). Combined systolic and diastolic LVD had the worst prognosis. In conclusion, diabetic patients with PAD have an increased prevalence of isolated systolic and combined LVD. In patients with PAD the presence of isolated diastolic, systolic, or combined LVD was independently and equally associated with increased cardiovascular mortality, irrespective of the concomitant presence of DM.
The American journal of cardiology 09/2010; 106(6):860-4. DOI:10.1016/j.amjcard.2010.05.010 · 3.43 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Major vascular surgery patients are at high risk for developing asymptomatic perioperative myocardial ischemia reflected by a postoperative troponin release without the presence of chest pain or electrocardiographic abnormalities. Long-term prognosis is severely compromised and characterized by an increased risk of long-term mortality and cardiovascular events. Current guidelines on perioperative care recommend single antiplatelet therapy with aspirin as prophylaxis for cardiovascular events. However, as perioperative surgical stress results in a prolonged hypercoagulable state, the postoperative addition of clopidogrel to aspirin within 7 days after perioperative asymptomatic cardiac ischemia could provide improved effective prevention for cardiovascular events.
DECREASE-VII is a phase III, randomized, double-blind, placebo-controlled, multicenter clinical trial designed to evaluate the efficacy and safety of early postoperative dual antiplatelet therapy (aspirin and clopidogrel) for the prevention of cardiovascular events after major vascular surgery. Eligible patients undergoing a major vascular surgery (abdominal aorta or lower extremity vascular surgery) who developed perioperative asymptomatic troponin release are randomized 1:1 to clopidogrel or placebo (300-mg loading dose, followed by 75 mg daily) in addition to standard medical treatment with aspirin. The primary efficacy end point is the composite of cardiovascular death, stroke, or severe ischemia of the coronary or peripheral arterial circulation leading to an intervention. The evaluation of long-term safety includes bleeding defined by TIMI criteria. Recruitment began early 2010. The trial will continue until 750 patients are included and followed for at least 12 months.
DECREASE-VII is evaluating whether early postoperative dual antiplatelet therapy for patients developing asymptomatic cardiac ischemia after vascular surgery reduces cardiovascular events with a favorable safety profile.
American heart journal 09/2010; 160(3):387-93. DOI:10.1016/j.ahj.2010.06.038 · 4.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Acute kidney injury is an independent predictor of short- and long-term survival; however, data on the relationship between reversible transitory decline of kidney function and chronic kidney disease (CKD) are lacking. We assessed the prognostic value of temporary renal function decline on the development of long-term CKD.
The study included 1308 patients who were undergoing major vascular surgery (aortic aneurysm repair, lower extremity revascularization, or carotid surgery), divided into three groups on the basis of changes in Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) estimated GFR (eGFR) on days 1, 2, and 3 after surgery, compared with baseline: Group 1, improved or unchanged (change in CKD-EPI eGFR+/-10%); group 2, temporary decline (decline>10% at day 1 or 2, followed by complete recovery within 10% to baseline at day 3); and group 3, persistent decline (>10% decrease). Primary end point was the development of incident CKD during a median follow-up of 5 years.
Perioperative renal function was classified as unchanged, temporary decline, and persistent decline in 739 (57%), 294 (22%), and 275 (21%) patients, respectively. During follow-up, 272 (21%) patients developed CKD. In multivariate logistic regression analyses, temporary and persistent declines in renal function both were independent predictors of long-term CKD, compared with unchanged renal function.
Vascular surgery patients have a high incidence of temporary and persistent perioperative renal function declines, both of which were independent predictors for development of long-term incident CKD.
Clinical Journal of the American Society of Nephrology 07/2010; 5(7):1198-204. DOI:10.2215/CJN.00020110 · 5.25 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: During noncardiac surgery, patients may be at risk for developing cardiac events, related to underlying coronary artery disease. Therefore, perioperative cardiac complications remain an area of clinical interest and concern in patients undergoing noncardiac surgery. Over the years, perioperative risk assessment has evolved significantly to detect surgical patients with myocardium at risk due the coronary artery disease. In addition, many efforts have been made to reduce the cardiac risk of patients undergoing noncardiac surgery. The present review article will focus on the definition of high cardiac risk surgery and will discuss patient-related cardiac risk factors. In addition, the preoperative cardiac tests available to detect patients with coronary artery disease and strategies to reduce perioperative cardiac risk, as recommended in most recent perioperative guidelines, will be outlined.
Current Cardiology Reports 07/2010; 12(4):286-94. DOI:10.1007/s11886-010-0116-7
[Show abstract][Hide abstract] ABSTRACT: The prognostic value of heart failure symptoms on postoperative outcome is well acknowledged in perioperative guidelines. The prognostic value of asymptomatic left ventricular (LV) dysfunction remains unknown. This study evaluated the prognostic implications of asymptomatic LV dysfunction in vascular surgery patients assessed with routine echocardiography.
Echocardiography was performed preoperatively in 1,005 consecutive vascular surgery patients. Systolic LV dysfunction was defined as LV ejection fraction less than 50%. Ratio of mitral-peak velocity during early and late filling, pulmonary vein flow, and deceleration time was used to diagnose diastolic LV dysfunction. Troponin-T measurements and electrocardiograms were performed routinely perioperatively. Multivariate regression analyses evaluated the relation between LV function and the study endpoints, 30-day cardiovascular events, and long-term cardiovascular mortality.
Left ventricular dysfunction was diagnosed in 506 (50%) patients of which 80% were asymptomatic. In open vascular surgery (n = 649), both asymptomatic systolic and isolated diastolic LV dysfunctions were associated with 30-day cardiovascular events (odds ratios 2.3, 95% confidence interval [CI] 1.4-3.6 and 1.8, 95% CI 1.1-2.9, respectively) and long-term cardiovascular mortality (hazard ratios 4.6, 95% CI 2.4-8.5 and 3.0, 95% CI 1.5-6.0, respectively). In endovascular surgery (n = 356), only symptomatic heart failure was associated with 30-day cardiovascular events (odds ratio 1.8, 95% CI 1.1-2.9) and long-term cardiovascular mortality (hazard ratio 10.3, 95% CI 5.4-19.3).
This study demonstrated that asymptomatic LV dysfunction is predictive for 30-day and long-term cardiovascular outcome in open vascular surgery patients. These data suggest that preoperative risk stratification should include not only solely heart failure symptoms but also routine preoperative echocardiography to risk stratify open vascular surgery patients.
[Show abstract][Hide abstract] ABSTRACT: Metabolic syndrome (MetSyn) is a well-known risk factor for cardiovascular (CV) disease in the general population; however, the additional predictive value for CV events in high-risk patients with peripheral arterial disease (PAD) is unknown. The aims of the current study were to assess and compare: (1) prevalence of MetSyn, and (2) predictive value of MetSyn for CV events, in patients with either occlusive or aneurysmatic PAD.
We screened 2069 patients scheduled for lower occlusive arterial revascularization (n=1031) or abdominal aortic aneurysm repair (n=1038) for the presence of MetSyn. Adult Treatment Panel III report (ATP III) was used for defining MetSyn. Central obesity was defined as body-mass-index>30 kg/m2. Main outcomes were the occurrence of CV events and CV mortality during a median follow-up of 6 years (IQR 2-9 years).
Metabolic syndrome was diagnosed in 421 (41%) and 432 (42%) patients with occlusive and aneurysmatic PAD, respectively (p=0.72). Patients with occlusive or aneurysmatic PAD and MetSyn had an increased risk for the development of CV events, when compared to patients without MetSyn (27% vs. 18% and 27% vs. 19%, p<0.001, respectively). In occlusive and aneurysmatic PAD, MetSyn was independently associated with an increased risk of CV events (HR=1.6; 95%CI 1.2-2.1 and HR=1.4; 95%CI 1.1-1.8). No significant association between the presence of MetSyn and CV mortality was observed.
Metabolic syndrome is highly prevalent in high-risk PAD patients. In occlusive and aneurysmatic PAD patients, MetSyn is an independent predictor of long-term CV events.
[Show abstract][Hide abstract] ABSTRACT: The pathophysiology of new-onset cardiac arrhythmias is complex and may bring about severe cardiovascular complications. The relevance of perioperative arrhythmias during vascular surgery has not been investigated. The aim of this study was to assess risk factors and prognosis of new-onset arrhythmias during vascular surgery.
A total of 513 vascular surgery patients, without a history of arrhythmias, were included. Cardiac risk factors, inflammatory status, and left ventricular function (LVF; N-terminal pro-B-type natriuretic peptide and echocardiography) were assessed. Continuous electrocardiography (ECG) recordings for 72 hours were used to identify ischemia and new-onset arrhythmias: atrial fibrillation, sustained ventricular tachycardia, supraventricular tachycardia, and ventricular fibrillation. Logistic regression analysis was applied to identify preoperative risk factors for arrhythmias. Cox regression analysis assessed the impact of arrhythmias on cardiovascular event-free survival during 1.7 years.
New-onset arrhythmias occurred in 55 (11%) of 513 patients: atrial fibrillation, ventricular tachycardia, supraventricular tachycardia, and ventricular fibrillation occurred in 4%, 7%, 1%, and 0.2%, respectively. Continuous ECG showed myocardial ischemia and arrhythmias in 17 (3%) of 513 patients. Arrhythmia was preceded by ischemia in 10 of 55 cases. Increased age and reduced LVF were risk factors for the development of arrhythmias. Multivariate analysis showed that perioperative arrhythmias were associated with long-term cardiovascular events, irrespective of the presence of perioperative ischemia (hazard ratio 2.2, 95% CI 1.3-3.8, P = .004).
New-onset perioperative arrhythmias are common after vascular surgery. The elderly and patients with reduced LVF show arrhythmias. Perioperative continuous ECG monitoring helps to identify this high-risk group at increased risk of cardiovascular events and death.
American heart journal 06/2010; 159(6):1108-15. DOI:10.1016/j.ahj.2010.03.035 · 4.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Atherosclerotic disease is often extended to multiple affected vascular beds (AVB). Polyvascular disease (PVD) and chronic kidney disease (CKD) have both separately been associated with an adverse cardiovascular outcome. We assessed the prevalence of PVD in vascular surgery patients with preoperative CKD and studied the influence on long-term cardiovascular survival.
Consecutive patients (2933) were preoperatively screened for PVD, defined as 1-, 2- or 3-AVB. Preoperative glomerular filtration rate (GFR in ml/min/1.73 m(2) body-surface area) was estimated by the Modification of Diet in Renal Disease (MDRD) prediction equation, and patients were categorized according their estimated GFR. Primary end point was (cardiovascular) mortality during a median follow-up of 6.0 years (IQR 2-9).
Preoperative MDRD-GFR was classified as normal kidney function (GFR >or= 90) or mild (GFR 60-89), moderate (GFR 30-59) and severe (GFR < 30) kidney disease in 779 (27%), 1423 (48%), 605 (21%) and 124 (4%) patients, respectively. One-vessel disease was present in 54% of the patients with normal kidney function, while 62% of the patients with CKD (GFR < 60) had PVD. In patients with moderate or severe kidney disease, the presence of PVD was independently associated with even higher cardiovascular mortality rates (2-AVB: HR 1.65 95%CI 1.09-2.48; 3-AVB: 2.07 95%CI 1.08-3.99), compared to 1-AVB.
Patients with CKD had a high prevalence of PVD, which was independently associated with increased all-cause and cardiovascular mortality.
[Show abstract][Hide abstract] ABSTRACT: Patients with peripheral atherosclerotic disease often have multiple affected vascular beds (AVB), however, data on long-term follow-up and medical therapy are scarce. We assessed the prevalence and prognostic implications of polyvascular disease on long-term outcome in symptomatic peripheral arterial disease (PAD) patients.
Two thousand nine hundred and thirty-three consecutive patients were screened prior to surgery for concomitant documented cerebrovascular disease and coronary artery disease. The number of AVB was determined. Cardiovascular medication as recommended by guidelines was noted at discharge. Single, two, and three AVB were detected in 1369 (46%), 1249 (43%), and 315 (11%) patients, respectively. During a median follow-up of 6 years, 1398 (48%) patients died, of which 54% secondary to cardiovascular cause. After adjustment for baseline cardiac risk factors and discharge-medication, the presence of 2-AVB or 3-AVB was associated with all-cause mortality (HR 1.3 95% CI 1.2-1.5; HR 1.8 95% CI 1.5-2.2) and cardiovascular mortality (HR 1.5 95% CI 1.2-1.7; HR 2.0 95% CI 1.6-2.5) during long-term follow-up, respectively. Patients with 2- and 3-AVB received extended medical treatment compared with 1-AVB at the time of discharge.
Polyvascular atherosclerotic disease in PAD patients is independently associated with an increased risk for all-cause and cardiovascular mortality during long-term follow-up.
European Heart Journal 04/2010; 31(8):992-9. DOI:10.1093/eurheartj/ehp553 · 14.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study evaluated the prevalence of left-ventricular (LV) dysfunction in vascular surgery patients and pharmacological treatment, according ESC guidelines.
Echocardiography was performed pre-operatively in 1,005 consecutive patients. Left ventricular ejection fraction (LVEF) <or=50% defined systolic LV dysfunction. Diastolic LV dysfunction was diagnosed based on E/A-ratio, pulmonary vein flow, and deceleration time. Optimal pharmacological treatment to improve LV function was considered as: (i) angiotensin-blocking agent (ACE-I/ARB) in patients with LVEF <or=40%; (ii) ACE-I/ARB and beta-blocker in patients with LVEF <or=40% + heart failure symptoms or previous myocardial infarction; and (iii) a diuretic in patients with symptomatic heart failure, regardless of LVEF. Left-ventricular dysfunction was present in 506 patients (50%), of whom 209 (41%) had asymptomatic diastolic LV dysfunction, 194 (39%) had asymptomatic systolic LV dysfunction, and 103 (20%) had symptomatic heart failure. Treatment with ACE-I/ARB and/or beta-blocker could be initiated/improved in 67 (34%) of the 199 patients with (a)symptomatic LVEF <or=40%. A diuretic could be initiated in 32 patients (31%) with symptomatic heart failure (regardless of LVEF).
This study demonstrates a high prevalence of LV dysfunction in vascular surgery patients and under-utilization of ESC recommended pharmacological treatment. Standard pre-operative evaluation of LV function could be argued based on our results to reduce this observed care gap.
European Journal of Heart Failure 03/2010; 12(3):288-93. DOI:10.1093/eurjhf/hfp201 · 6.58 Impact Factor