Table of Contents  
REVIEW ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 4  |  Page : 144-151

Perioperative vascular events and myocardial injury after noncardiac surgery in vascular surgery: An overview of the current emerging evidence and guidelines


Department of Clinical Research, Narayana Hrudayalaya Limited, Bengaluru, Karnataka, India

Date of Web Publication31-Oct-2017

Correspondence Address:
Alben Sigamani
Department of Clinical Research, Narayana Hrudayalaya Limited, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_61_17

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  Abstract 


Vascular surgery is considered a high-risk noncardiac surgery. It is associated with an increased risk of cardiovascular events in the perioperative period. Preoperative assessment of risk using validated scales such as Revised Cardiac Risk Index, helps informing patients, surgeons, and anesthetists on the potential risk of cardiovascular events. Cardiac biomarkers, such as NT pro-brain natriuretic peptide (pro-BNP)/BNP, improve the sensitivity of these scales, in predicting potential serious perioperative cardiovascular outcomes. It is cost effective and quicker than other invasive or noninvasive procedures, usually done before any vascular surgery. Several interventions have been tested in trials for potentially preventing an event, but none have given good quality evidence for benefit, except the use of statins. Postoperatively, use of drugs to prevent a cardiovascular event has not been as effective as in the nonsurgical setting (aspirin, β-blockers, α2agonists, and angiotensin-converting-enzyme inhibitors/angiotensin receptor blockers). Monitoring of highly sensitive troponins better predicts 30-day mortality in patients undergoing any noncardiac surgery. This event is called myocardial injury after noncardiac surgery (MINS) or in short MINS. Currently, MINS is not detected in over 75% of vascular surgery patients as it is not routinely performed. As per the evidence reviewed in this article and as recommended by the Canadian Cardiovascular Society Guidelines, it is imperative we monitor all patients aged above 45 years undergoing vascular surgery. Even though there is no evidence for an effective intervention of MINS, detections help in better monitoring of the patient and initiating effective secondary prevention treatment, as indicated.

Keywords: Guidelines, myocardial injury after noncardiac surgery, noncardiac surgery, vascular surgery


How to cite this article:
Sigamani A. Perioperative vascular events and myocardial injury after noncardiac surgery in vascular surgery: An overview of the current emerging evidence and guidelines. Indian J Vasc Endovasc Surg 2017;4:144-51

How to cite this URL:
Sigamani A. Perioperative vascular events and myocardial injury after noncardiac surgery in vascular surgery: An overview of the current emerging evidence and guidelines. Indian J Vasc Endovasc Surg [serial online] 2017 [cited 2017 Dec 14];4:144-51. Available from: http://www.indjvascsurg.org/text.asp?2017/4/4/144/217461




  Introduction Top


Vascular surgery is considered high-risk surgery.[1] The estimated incidence of cardiovascular events within 30 days following surgery is the highest among all noncardiac surgeries. Over 200 million people across the world suffer from peripheral vascular disease, and most of them require surgery for correction of the disease.[2],[3]

Various societies across the world have written specific guidelines for the cardiovascular event management among noncardiac surgery patients.[4],[5],[6] Some of them have also been written with a special focus on vascular surgery patients.[7]

Recently, the Canadian Cardiovascular Society (CCS) released its guidelines on cardiac risk assessment in the perioperative period.[8] The differentiating factor of this updated set of guidelines is that the task force adopted Grading of Recommendations Assessment, Development and Evaluation system. This system considers not only the quality of the studies done to generate evidence but also the strength of the evidence.[9]

This paper summarizes the society's recommendations with a special mention for vascular surgery. Henceforth, in this article, the authors of the guideline will be referred to as “CCS.” The recommendations apply to all noncardiac surgeries that require at least an overnight stay in the hospital after surgery, because of the availability of evidence, and these surgeries are most likely to produce sufficient cardiac stressors to put these patients at risk of a cardiac complication.


  Preoperative Cardiac Risk Assessment Top


CCS recommends[8] that all patients aged above 45 years and those 18–44 years with known significant cardiovascular disease (i.e., coronary artery disease, cerebral vascular disease, peripheral arterial disease, congestive heart failure, severe pulmonary hypertension, or a severe obstructive intracardiac abnormality, such as aortic stenosis, mitral stenosis, and hypertrophic obstructive cardiomyopathy) must undergo a preoperative cardiac risk assessment.

CCS recommends that it is Good Clinical Practice to have physicians perform a preoperative cardiac risk assessment. The appropriateness of surgery and management decisions can be benefitted by accurate preoperative cardiac risk assessment. Management decisions such as using endovascular versus open surgical approach or performing cardiac biomarkers monitoring can be better justified.

Engaging the patients in a shared decision, regarding the risk of surgery, weighed against its potential benefits, has ethical value in itself.[10] Providing an accurate risk assessment is a prerequisite for shared decision-making in the perioperative setting.[11]

Patients undergoing vascular surgery have the most gain from preoperative cardiac risk evaluation.[12] If the surgery is urgent/emergent acute limb ischemia, then precious time should not be wasted in performing this assessment but rather taken into surgery immediately. Unless there is, unstable cardiovascular condition (unstable angina, acute stroke), severe obstructive intracardiac abnormality, or severe pulmonary hypertension, which can influence the decision around delaying, canceling, or proceeding with surgery, and the choice of the surgical and anesthetic techniques.[8]


  How to Perform Preoperative Risk Assessment Top


CCS reviewed Revised Cardiac Risk Index (RCRI) along with 2 risk indices that were recently developed using data from the National Surgical Quality Improvement Program (NSQIP).

RCRI is the most validated tool used for the assessment of risk before surgery.[13] It includes six factors, each worth 1 point (i.e., history of ischemic heart disease, cerebrovascular disease, congestive heart failure, preoperative insulin use, preoperative creatinine >177 mmol/L (2 mg/dL), and high-risk surgery).

Although some risk factors (e.g., severe aortic stenosis) have important perioperative prognostic implications, a risk factor might not show up in a risk index because few or no patients in the original study had the relevant risk factor or it was not assessed.

CCS recommends[8] the use of RCRI based on the evidence from the pooled risk estimates of external validation studies. The pooled risk estimates of external validation studies of the RCRI that were published in the past 15 years were reviewed. It systematically monitored perioperative troponin measurements and reported event rates for the various RCRI scores. The results showed risk estimates for myocardial infarction, cardiac arrest, or death of 3.9% (95% confidence interval [CI], 2.8%–5.4%) for an RCRI score of 0, 6.0% (95% CI, 4.9%–7.4%) for an RCRI score of 1, 10.1% (95% CI, 8.1%–12.6%) for an RCRI score of 2, and 15.0% (95% CI, 11.1%–20.0%) for an RCRI score of 3. These values are higher than the risk estimates on the basis of the original data that were used to derive the RCRI. The likely explanation for these differences is that the original RCRI did use creatinine kinase muscle and brain isoenzyme and did not include emergent surgeries.

The NSQIP Myocardial Infarction and Cardiac Arrest (MICA) risk index and the American College of Surgeons (ACS) NSQIP risk index have both been developed using large datasets.[8] In these studies, these risk indices showed superior discrimination compared with the RCRI; however, it is highly probable that the NSQIP MICA and the ACS NSQIP risk indices underestimated cardiac risk because patients did not undergo systematic measurements of perioperative troponin levels in these studies.

Without cardiac biomarker screening, more than half of all perioperative myocardial infarctions go undetected. This likely explains the low number of perioperative myocardial infarctions in these studies that developed the NSQIP MICA and the ACS NSQIP risk indices. Moreover, the NSQIP MICA and the ACS NSQIP risk indices have not undergone external validation in a study that has systematically monitored troponin measurements after noncardiac surgery. For these reasons, the CCS favored the RCRI for cardiac risk prediction.

The vascular study group of New England Cardiac Risk Index (VSG–CRI) published in 2010[14] does claim that their risk index (compared to RCRI), more accurately predicts in-hospital cardiac events after vascular surgery. However, they did not measure cardiac biomarkers, as done in external validation studies of RCRI. This could have grossly underestimated the real event rate[12] following vascular surgery and is a limitation to accepting it as a recommendation.


  Cardiac Biomarkers Top


Brain natriuretic peptides (BNP) and N-terminal fragment of pro-BNP (NT-proBNP) are released from myocardium following a stressful stimulus such as stretch or infarction.[15] CCS strongly recommends measuring NT-proBNP or BNP before noncardiac surgery to enhance perioperative cardiac risk estimation in patients who are 65 years of age or older, are 45–64 years of age with significant cardiovascular disease, or have a RCRI score 1.

An individual patient data meta-analysis included 2179[15] patients from 18 studies and showed that a preoperative NT-proBNP/BNP measurement was independently associated with the primary outcome (i.e., death or nonfatal myocardial infarction) at 30 days after noncardiac surgery (average odds ratio [aOR], 3.40; 95% CI, 2.57–4.47; P < 0.001). The authors received data on 2477 patients from 18 studies. They excluded 298 patients, across all studies, who did not have both a pre- and post-operative BNP measurement. A total of 2,179 patients were included; 8 studies evaluated BNP (n = 619), and ten studies evaluated NT-proBNP (n = 1560). A postoperative sample was drawn within the 1st day after surgery from 88% of these patients (1921 of 2179) and within the first 3 days after surgery in 98% of patients (2139 of 2179). The mean (standard deviation) age was 68 (12) years. Sixty-five percent of patients were male, 31% of patients had a history of coronary artery disease, and the most commonly performed surgery was vascular (40% of the sample).

A preoperative NT-proBNP/BNP measurement before noncardiac surgery improved risk prediction among patients who did and did not suffer the primary outcome.[16] Values >300 ng/L for NT-proBNP and >92 mg/L for BNP were identified as significant thresholds associated with an increased risk of the primary outcome. According to these thresholds, 7.6% of patients had an elevated NT-proBNP/BNP measurement before noncardiac surgery. Death or nonfatal myocardial infarction within 30 days after surgery occurred in 4.9% of patients with preoperative NT-proBNP/BNP values below these thresholds compared with 21.8% of patients with NT-proBNP/BNP values at or above these thresholds.

Cost and accessibility are considered important determinants of biomarker selection. The Data from Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) study, showed that patients 65years of age or older or 45–64 years of age with known cardiovascular disease have a baseline risk >5% for cardiovascular death or nonfatal myocardial infarction at 30 days after surgery. This also includes all patients undergoing a major vascular surgery.

Considering cost, NT-proBNP/BNP biomarkers testing restricted to patient groups that have a baseline clinical risk estimate >5% compared with cardiac imaging and noninvasive cardiac stress testing, are inexpensive and avoid the need for return visits. Hospitals that do not analyze NT-proBNP/BNP in their core laboratory can obtain an instrument to allow clinicians to obtain NT-proBNP as a point of care test in the preoperative setting, offering biomarker information within minutes.[8]


  Other Routinely Performed Tests Top


[Table 1] summarizes[8] the other routinely performed tests. Resting echocardiography, computed coronary tomography angiogram, pharmacological stress echo, and radionuclide imaging do not add much incremental value. For these reasons, CCS strongly recommends against the performance of these as routine tests for the preoperative cardiac risk assessment.
Table 1: Preoperative tests performed for assessment of cardiovascular risk assessment

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  Perioperative Cardiac Risk Modification Top


[Table 2] summarizes commonly used agents for risk modification and the available evidence from clinical trials.
Table 2: Management of interventions targeting the prevention of perioperative cardiac events

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In summary, the use of acetylsalicylic acid (ASA) during the perioperative period[17] does not offer benefit in preventing cardiovascular events. Among chronic users, discontinuing ASA for 72 h before surgery did not increase the incidence of thrombotic events. The risk of bleeding was higher in patients who continued ASA during perioperative period; however, the risk disappears after 7–8 days from the date of surgery. The use of β-blockers[18] and α2 agonists[19] does not offer any additional benefits in the perioperative period and is safer to be discontinued on the day of surgery and immediately after. However, the use of statins does offer the benefit of being an effective medical therapy, especially among patients with cardiac risk.[20] To prevent hemodynamic fluctuations,[21] the use of angiotensin-converting enzyme inhibitors and angiotensin 2 receptor blockers must be discontinued on day of surgery.[8]

Even though the evidence for interventions aimed at smoking cessation are weak,[22] CCS makes a strong recommendation of making all effort to achieve smoking cessation before surgery and forever after.


  Coronary Artery Angiogram and Revascularization Procedures Top


CCS reviewed evidence pertaining to the practice of performing a coronary artery angiogram (CAG) in patients before noncardiac surgery. One trial randomized 426 patients posted for carotid endarterectomy (CEA); 216 to CAG and 210 no CAG. The short-term and long-term results were published,[23],[24] and showed significant benefits of performing CAG, followed by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) – as indicated – before CEA. The external validity of these results is weak to extend to all vascular surgeries.

The coronary artery revascularization prophylaxis (CARP) trial[25] randomized 510 patients with known significant coronary artery disease to preoperative coronary revascularization versus no coronary revascularization before vascular surgery. The indications for a vascular surgery were an expanding abdominal aortic aneurysm (33%) or arterial occlusive disease of the legs (67%).

At a median of 2.7 years after randomization, mortality was 22% in the coronary revascularization group and 23% in the no-revascularization group (relative risk, 0.98; 95% CI, 0.70–1.37; P = 0.92). Vascular surgery was undertaken a median of 48 days after CABG surgery and 41 days after PCI. As given in [Table 2], CCS recommends against performing CAG followed by any revascularization, before any noncardiac surgery (including vascular surgery) in patients with stable coronary artery disease.


  Perioperative Monitoring for Cardiovascular Events and Myocardial Injury After Noncardiac Surgery – a Case for Cardiac Troponin Monitoring Top


The largest, prospective, international cohort study (VISION; n = 15,133)[12] showed that the detection of an elevated troponinTlevel in the postoperative period was the strongest predictor of 30-day mortality. Recently, the group published data from high sensitivity troponinTdone in 21,842 patients.[26] This paper is only summarizing data from the first publication as it was included in the CCS guidelines.

Myocardial injury after noncardiac surgery (MINS) was defined as a peak fourth-generation troponinT≥0.03 ng/mL believed to be due to myocardial ischemia. The prognostic importance of an elevated troponin measurement after surgery was supported by a previous meta-analysis of 14 studies that enrolled 3318 patients.[27] The meta-analysis showed that an elevated troponin level was an independent predictor of all-cause mortality (OR, 6.7; 95% CI, 4.1–10.9) at 1 year after surgery.

MINS was observed in 8% of patients in the VISION study and was associated with a marked increase in 30-day mortality (9.8% vs. 1.1%), and had the largest population attributable risk of all the complications after surgery.[12] Most of these MINS patients (84%) remained asymptomatic and were only detected through the routine surveillance of postoperative troponin levels. More than 90% of the cohort had more than 1 troponin measurement postoperatively, with only 1431 of 15,102 (9.5%) of the entire patient cohort and 42 of 502 (8.4%) of the vascular surgery patients having had a single postoperative troponin measurement. Of these patients, 96 (19.1%; 95% CI 15.7%–22.6%) patients developed MINS at a median of 1 day (range 0–16 days, interquartile range (IQR) 0–2 days) after surgery.

Of the 15,102 patients, mortality data were missing in 18 of the patients (2 from the vascular cohort, and 16 from the nonvascular cohort). Of the remaining 15,084 patients, 18 (3.6%; 95% CI, 2.3–5.6) of 500 vascular patients died within 30 days after surgery compared with 250 (1.7%; 95% CI, 1.5–1.9) of 14,584 nonvascular patients in the VISION cohort (P < 0.005).

Mortality was significantly higher (12.5% vs. 1.5%; P < 0.001) in patients who developed MINS compared with those who did not develop MINS (OR 9.48; 95% CI, 3.46–25.96). Multivariable regression analysis suggested that the impact of MINS on 30-day mortality was similar after vascular and nonvascular surgery (P > 0.573 for test of interaction).

Patients with MINS also had higher 30-day rates of nonfatal cardiac arrest, congestive heart failure, stroke, and coronary revascularization than patients without MINS. Vascular surgical patients who suffered MINS[28] had a significantly increased length of stay (17 days; IQR 5–31 days) compared to vascular surgical patients who did not suffer MINS (length of stay 6 days; IQR 3–10 days), P < 0.001.

Among the vascular surgery patients who suffered MINS,[28] 81 of 96 (84.4%) had a plasma TnT concentration 0.04 ng/mL or higher. Of these patients, 41 (49.4%) had 1 or more ischemic features (i.e., they fulfilled the universal definition of MI) and 40 (50.6%) did not. Twenty-one (25.9%) of the MINS patients had clinical ischemic symptoms. The most common ischemic ECG findings wereT-wave inversion (30.9%) and ST depression (19.8%). Timing of diagnosis of asymptomatic and symptomatic MINS was similar (median 1 day after surgery [IQR 0–1 days] and 1 day after surgery [IQR, 0–2], respectively).

One hundred and forty-five of 15,102 (1.0%) of patients had troponin measurements after the third postoperative day for clinical symptoms, of which 45 were diagnosed with MINS. Of the vascular surgery patients, 13 of 502 (2.6%) had troponin measurements after the third postoperative day for the clinical symptoms, of which 5 were diagnosed with MINS.[28] Therefore, 361 of 406 (89.1%) of all patients and 91 of 96 (94.8%) of vascular patients were diagnosed with MINS within the first 3 postoperative days.

The 30-day mortality was not significantly different (P > 0.76) between MINS patients with (15.0%; 95% CI, 7.1–29.1; OR, 11.71; 95% CI, 3.58–38.27) and without an ischemic feature (12.2%; 95% CI, 5.3–25.5; OR, 9.21; 95% CI, 2.68–31.67).[28]

The strong association between an elevated troponin level detected during routine postoperative surveillance and 30-day mortality was confirmed in 2 large cohort studies.[29],[30] Moreover, a recent analysis suggests that perioperative troponin surveillance is cost-effective.[31] Because most patients who suffer a postoperative myocardial infarction or MINS are asymptomatic, routine troponin monitoring can detect patients who are at markedly increased risk of death within 30 days of surgery.

Although the optimal management of patients with MINS remains an area of ongoing investigation,[32] we believe that these individuals can benefit from intensification of medical management and close monitoring during their postoperative recovery.

The proportion of MINS in vascular surgery patients[28] that would have gone undetected without troponin monitoring (i. e., asymptomatic MINS) was 60 of 81 (74.1%; 95% CI, 63.6–82.4).

Other monitoring methods and their available evidence are summarized in [Table 3].
Table 3: Monitoring for perioperative cardiac events

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  Medical Management of Postoperative Events Top


Initiation of ASA (72 h after surgery)[18],[28] and statins[29],[33] is strongly recommended. Currently, there is an ongoing clinical trial evaluating safety and efficacy of dabigatran, a factor Xa oral antithrombotic, in patients who suffered a MINS event.[32] Simply starting ASA and statins at discharge showed evidence of benefit.[34] A prospective cohort study of 415 patients who suffered a myocardial infarction following noncardiac surgery had a significant reduction in 30-day mortality (aOR, 0.54; 95% CI, 0.29–0.99, and aOR, 0.26; 95% CI, 0.13–0.54, respectively).


  Conclusion Top


Vascular surgery is a stand-alone risk factor for cardiovascular events in the postoperative period after noncardiac surgery. Using simple risk estimation scales such as RCRI and cost-effective cardiac biomarker screening (NT proBNP/BNP), it is possible to identify patients who are at high risk for cardiovascular events in the postoperative period. Management of the risk, presently, does not have effective interventions. There is a need for prospective studies and randomized controlled trials to identify new interventions or gathering evidence on existing interventions. Monitoring troponins for 24–48 h following surgery helps in identifying patients who suffer a MINS event. At present, there is no effective therapy for mitigating the increased risk of cardiac events following MINS, but patients can certainly benefit from enhanced comprehensive medical management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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