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Simple cardiac blood test before surgery can predict adverse outcomes

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A common cardiac blood test done before surgery can predict who will experience adverse outcomes after most types of surgery, says an international study led by Canadian researchers.

Globally, of the 200m adults who undergo major surgery, 18% will experience serious cardiac and vascular complications including death within 30 days following their intervention, such as hip and knee replacements, bowel resections and abdominal aortic aneurysm repair.

“Any type of surgery has the potential to cause damage to heart tissue, through blood clot formation, long periods of inflammation, or bleeding,” said study lead, Dr PJ Deveraux, professor of medicine, cardiologist at Hamilton Health Sciences (HHS) and scientific lead for peri-operative research at McMaster University and HHS’ Population Health Research Institute (PHRI).

The VISION study looked at whether levels of a cardiac blood test, NT-proBNP, measured before surgery can predict cardiac and vascular complications. Higher levels of NT-proBNP, which can be caused by various anomalies in the cardiac muscle, such as stress, inflammation or overstretch, can help identify which patients are at greatest risk of cardiac complications after surgery.

The study included 10,402 patients aged 45 years or older having non-cardiac surgery with overnight stay from 16 hospitals in nine countries. “As a result of these findings, doctors can predict who is at greater risk of heart attacks and other negative vascular events after surgery,” said Devereaux.

This phase of the VISION study builds upon six years of research studies to understand pre- and post-operative factors that lead to cardiac complications. “This simple blood test can be done quickly and easily as part of patient’s pre-operative evaluation and can help patients better understand their risk of post-operative complications and make informed decisions about their surgery,” said first author of the publication, Dr Emmanuelle Duceppe, internist and researcher at the Centre Hospitalier de l’Universite de Montreal (CHUM), PhD candidate in clinical epidemiology at McMaster University, and associate researcher at PHRI. “This blood test is twenty times cheaper than more time-consuming tests such as cardiac stress tests and diagnostic imaging.”

Results of this simple blood test may inform the type of surgery the patient will undergo, such as laparoscopic or open surgery, the type of anaesthesia used during surgery and who will require more intense monitoring post-operatively.

Blood test results can also reduce the need for pre-surgical medical consultations for patients that show no risk for cardiac complications.

“Heart injury after non-cardiac surgery is emerging as an important health issue requiring attention. Using CIHR funding, the research group led by PHRI and Devereaux, has clarified the association between an elevation of a common biomarker and the risk of per-operative morbidity and mortality,” said Dr Brian H Rowe, scientific director, Institute of Circulatory and Respiratory Health, Canadian Institutes for Health Research.

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.

Authors
Emmanuelle Duceppe; Ameen Patel; Matthew TV Chan; Otavio Berwanger; Gareth Ackland; Peter A Kavsak; Reitze Rodseth; Bruce Biccard; Clara K Chow; Flavia K Borges; Gordon Guyatt; Rupert Pearse; Daniel I Sessler; Diane Heels-Ansdell; Andrea Kurz; Chew Yin Wang; Wojciech Szczeklik; Sadeesh Srinathan; Amit X Garg; Shirley Pettit; Erin N Sloan; James L Januzzi Jr; Matthew McQueen; Giovanna Lurati Buse; Nicholas L Mills; Lin Zhang; Robert Sapsford; Guillaume Paré; Michael Walsh; Richard Whitlock; Andre Lamy; Stephen Hill; Lehana Thabane; Salim Yusuf; PJ Devereaux

McMaster University material

Annals of Internal Medicine abstract

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