Predictors and outcomes of a perioperative myocardial infarction following elective vascular surgery in patients with documented coronary artery disease: results of the CARP trial
Division of Cardiology (111C), VA Medical Center, 1 Veterans Drive, Minneapolis, MN 55417, USA
Received 18 July 2007; revised 13 November 2007; accepted 13 December 2007.
* Corresponding author. Tel: +1 612 467 3664, Fax: +1 612 727 5668, Email: mcfal00l{at}umn.edu
See page 283 for the editorial comment on this article (doi:10.1093/eurheartj/ehm521)
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionConclusionsFundingAppendixReferences |
|---|
Aims: The predictors and outcomes of patients with a peri-operative elevation in cardiac troponin I above the 99th percentile of normal following an elective vascular operation have not been studied in a homogeneous cohort with documented coronary artery disease.
Methods and results: The Coronary Artery Revascularization Prophylaxis (CARP) trial was a randomized trial that tested the benefit of coronary artery revascularization prior to vascular surgery. Among 377 randomized patients, core lab samples for peak cardiac troponin I concentrations were monitored following the vascular operation and the blinded results were correlated with outcomes. A peri-operative myocardial infarction (MI), defined by an increase in cardiac troponin I greater than the 99th percentile reference (
0.1 µg/L), occurred in 100 patients (26.5%) and the incidence was not dissimilar in patients with and without pre-operative coronary revascularization (24.2 vs. 28.6%; P = 0.32). By logistic regression analysis, predictors of MI (odds risk; 95%CI; P-value) were age >70 (1.84; 1.14–2.98; P = 0.01), abdominal aortic surgery (1.82; 1.09–3.03; P = 0.02), diabetes (1.86; 1.11–3.11; P = 0.02), angina (1.67; 1.03–2.64; P = 0.04), and baseline STT abnormalities (1.62; 1.00–2.6; P = 0.05). At 2.5 years post-surgery, the probability of survival in patients with and without the MI was 0.73 and 0.84, respectively (P = 0.03, log-rank test). Using a Cox proportional hazards regression analysis, a peri-operative MI in diabetic patients was a strong predictor of long-term mortality (hazards ratio: 2.43; 95% CI: 1.31–4.48; P < 0.01).
Conclusion: Among patients with coronary artery disease who undergo vascular surgery, a peri-operative elevation in cardiac troponin levels is common and in combination with diabetes, is a strong predictor of long-term mortality. These data support the utility of cardiac troponins as a means of stratifying high-risk patients following vascular operations.
Key Words: vascular surgery • myocardial infarction • coronary artery revascularization • outcomes • cardiac risks • troponins
Deceased. 
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsFundingAppendixReferences |
|---|
With the aging population, the number of adults undergoing non-cardiac operations and the proportion at risk of peri-operative cardiovascular complications are increasing each year.1,2 Accordingly, there is intense interest in understanding the causative factors and the long-term post-operative outcomes in high-risk subsets. A peri-operative myocardial infarction (MI) following a non-cardiac operation is associated with an increased risk of death.3–5 An elevated cardiac biomarker above the 99th percentile of a normal reference population has become an important threshold for the diagnosis of MI6 and at this lower cut-off value, predicts outcomes following vascular surgery.7,8 The influence of pre-operative coronary artery revascularization on peak troponin I concentrations at a low cutoff value has not been studied in a homogeneous group of patients with coronary artery disease undergoing elective vascular surgery. Bursi et al.8 have shown that applying a standard pre-operative risk assessment protocol in a cohort of patients undergoing elective vascular operations did not reduce the incidence of a peri-operative elevation in cardiac troponins at a low cutoff concentration. These data demonstrate that the pathophysiology of increased cardiac enzymes in the peri-operative period is complex and underscores the potential importance of systemic triggers of myocardial ischaemia, including the stress-induced inflammatory response following non-cardiac operations.9 The Coronary Artery Revascularization Prophylaxis (CARP) trial was a randomized trial that tested the long-term benefit of coronary artery revascularization prior to vascular surgery.10 Using core lab samples that were monitored for peak cardiac troponin I concentrations and blinded to the investigators, the purpose of the present study was to identify the predictors and outcomes of those patients undergoing vascular surgery who had a peak troponin I level above the 99th percentile reference cutoff (
0.1 µg/L).11 |
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsFundingAppendixReferences |
|---|
The Human Rights Committee from the VA Cooperative Studies Program and the Institutional Review Board (IRB) from each VA Medical Center approved the study.
Study protocol
The study design, related to the defined end-points and details of follow-up visits12 as well as the primary study outcome results of the randomized trial10 have been previously published. In brief, patients were considered eligible if they were scheduled for an elective vascular operation for either an expanding abdominal aortic aneurysm or severe symptoms of arterial occlusive disease involving the lower extremities. Coronary angiography was recommended if the patient had no clinical exclusion factors and was considered to be at increased risk of a peri-operative cardiac complication. Based on the coronary angiogram, a patient was eligible for randomization if one or more of the major coronary arteries had a stenosis 70% and was suitable for revascularization. The decision about the type of revascularization procedure, either percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG) was left to the discretion of the local investigators. If PCI was planned, it was advised that the vascular operation be delayed to avoid the increased risk of in-stent thrombus.13
Outcomes
The study cohort comprised 377 patients within the CARP trial who underwent their reference vascular operation and had blood specimens (serum) drawn in the first four post-operative days and stored at –70°C until analysis. The flow chart of patients randomized within the CARP trial and the number of patients undergoing vascular surgery who were included in the present cohort is shown in Figure 1. Post-operative blood samples for the core lab analysis were available in 377 of the 462 patients (82%) undergoing vascular surgery and for logistical reasons, were not available in all patients. No differences in pre-operative clinical variables or post-operative outcomes were noted between patients with and without core lab values and therefore, a selection bias for inclusion into the cohort is unlikely. Cardiac troponin I was measured in the core lab on the Dade Behring Dimension Analyzer along manufacturer guidelines and the results were blinded from the investigators. The lower limit of detection was 0.03 µg/L, and the 20 and 10% total imprecisions were determined at 0.1 and 0.3 µg/L, respectively. The 99th percentile normal reference concentration of the cardiac troponin I assay was predetermined at <0.1 µg/L.14 Baseline troponin I measurements were obtained prior to the vascular operation and were either in the undetectable range or were <0.03 µg/L in all patients. Long-term survival was determined from the time of the vascular operation until the end of the study and was retrieved through the BIRLS system (the DVA's Beneficiary Information and Records Locator Subsystem).
|
Statistics
Univariate analyses included the
2 test for categorical data, the t-test for normally distributed continuous variables and the Wilcoxon two-sample rank-sum test for non-normally distributed continuous variables. Data are expressed as means and standard deviations, or medians with interquartile range for non-normal data. Those univariate predictors of a peri-operative MI with P < 0.20 were entered into a multivariable logistic regression analysis with backward elimination to determine the simultaneous influence of patient risk and processes on the incidence of the MI. A P-value of 0.05 was required to remain in the model. Odds ratios and 95 percent confidence intervals are reported from this analysis. Bootstrapping techniques were used on 1000 samplings (with replacement) of the data to assess the validity of the final multivariable model. Survival curves were generated by the product-limit method and intergroup differences were evaluated by the log-rank tests. Those univariate predictors of survival with P < 0.20 were entered into a Cox proportional hazards regression analysis with backward elimination to determine predictors of long-term mortality. A P-value of 0.05 was required to remain in the model. The final multivariable model was validated using bootstrapping techniques. The models to predict peri-operative MI and long-term survival allowed for the inclusion of all two-factor interaction terms. All tests were two-sided and differences were considered significant at P < 0.05. |
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsFundingAppendixReferences |
|---|
Predictors of a peri-operative myocardial infarction
A peri-operative MI, defined by a peak peri-operative cardiac troponin I concentration greater than the 99th percentile reference cutoff (
0.1 µg/L) occurred in 100 of the 377 patients (26.5%). The baseline characteristics and the peri-operative vascular surgical variables that were included in the univariate model to predict those patients with a peri-operative MI are shown in Table 1. Of the 100 patients with a troponin elevation following vascular surgery, 30 (30.0%) had one-vessel disease, 31 (31.0%) had two-vessel disease, 22 (22.0%) had three-vessel disease, and 17 (17.0%) had multivessel disease with prior CABG as noted by the pre-operative coronary angiogram (P = 0.78). According to the randomization strategy, 178 patients had undergone pre-operative coronary artery revascularization prior to vascular surgery and a peri-operative MI occurred in 43 (24.2%) compared with 57 (28.6%) of 199 patients with no pre-operative revascularization (P = 0.32). Among those patients with a peak peri-operative cardiac troponin I 0.1 µg/L, the median troponin I concentrations (with the interquartile range) among those patients with and without pre-operative coronary artery revascularization were 0.4 (0.2, 2.5) and 0.3 (0.2, 2.1), respectively (P = 0.85). These data show that neither the pre-operative extent of coronary artery disease nor the revascularization status were significant determinants of those patients with a peri-operative elevation in the cardiac biomarker. By logistic regression analysis, predictors of the MI (odds risk; 95%CI; P-value) were age >70 (1.84; 1.14–2.98; P = 0.01), abdominal surgery (1.82; 1.09–3.03; P = 0.02), diabetes (1.86; 1.11–3.11; P = 0.02), angina (1.67; 1.03–2.64; P = 0.04), and STT abnormalities on the baseline electrocardiogram (1.62; 1.00–2.6; P = 0.05) (Figure 2). These five risk factors were the variables most frequently entered in 1000 replications of the modelling using bootstrapping techniques. This result suggests that the probability that any of the factors entered into the final model by chance is minimal. In addition, the parameter estimates from the bootstrapping procedure were within one standard deviation of those from the final model, suggesting that the model estimates are stable.
|
|
Outcome of patients with a peri-operative myocardial infarction
Although the timing of the peak post-operative troponin elevation in the 100 patients with a troponin I
0.1 µg/L was more frequently observed on day 2, the peak value was slightly higher on day 3 following the vascular surgery (Table 2). There were a total of 10 deaths in the first 30-days following surgery and seven had a peri-operative MI with peak troponin I values on day 1 (n = 3), day 2 (n = 2), and day 4 (n = 2) (P = 0.19). Among the 129 patients with no detectable troponin I elevation following vascular surgery, there were no deaths within 30-days following surgery. The mortality at 1 year following vascular surgery was 20.0% in all patients with a peak cardiac troponin I concentration 0.1 µg/L compared with 4.7% in those patients with a peak concentration <0.1'µg/L (P < 0.001).
|
On long-term follow-up at a median (interquartiles) of 2.5 (1.0, 3.8) years following the vascular operation, the probability of survival in patients with a peak cardiac troponin I concentration
0.1 µg/L was 0.73 compared with 0.84 in the remaining patients with a peak concentration <0.1 µg/L (Figure 3; P = 0.03, log-rank test). These data show that a peak peri-operative troponin I level 0.1 predicted both the short-term and long-term risks of death following vascular surgery.
|
To determine whether treatment may have been different in those patients with an elevated peak peri-operative troponin I level of
0.1 µg/L but without the diagnosis of a peri-operative MI, therapy was analysed at 12 months following randomization in all patients with core lab assays. As shown in Table 3, differences in outcome among those patients without the diagnosis of a peri-operative MI could not be attributed to treatment bias based on long-term use of medical therapy or coronary angiography following the event.
|
Predictors of long-term risk of death by multivariable analysis
Following the vascular operation, 92 (24.4%) of the 377 patients died during long-term follow-up. The significant univariate predictors (P
0.20) of long-term risk of death were entered into a Cox proportional hazards regression analysis that included interaction variables. Using this analysis that considers interactions of cardiac risks, the most significant predictor of long-term outcome following vascular surgery (hazard risk; 95%CI; P-value) was peak post-operative cardiac troponin I elevation 0.1 µg/L in those patients with diabetes (2.43; 1.32–4.48; P = 0.005). Risk of death with a peak post-operative cardiac troponin I elevation in non-diabetic patients was not increased (0.83; 0.42–1.65; P = 0.59). Additional identifiers of outcome included pre-operative creatinine 2.0 mg% (2.55; 1.30–5.00; P = 0.007), pre-operative history of congestive heart failure (1.96; 1.09–3.53; P = 0.025), and age >70 (1.62; 1.07–2.46; P = 0.024) (Figure 4). The main effects of age, CHF, and creatine plus the interaction of elevated troponin levels in the presence of diabetes were the four variables most frequently selected from the bootstrapping procedure. The bootstrapping procedure also demonstrated that the model estimates were stable. These data show that among a homogeneous group of patients with documented coronary artery disease who undergo elective vascular surgery, a combination of pre-operative risk variables involving age, renal function, and prior congestive heart failure along with post-operative elevations in cardiac biomarkers in diabetic patients predict long-term outcome.
|
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsFundingAppendixReferences |
|---|
The principal finding of this study is that a peri-operative MI defined by a peak cardiac troponin I concentration above the 99th percentile reference cutoff (
0.1 µg/L) occurred in 27% of patients with coronary artery disease following elective vascular surgery and the incidence was not influenced by the pre-operative revascularization status. Using a Cox proportional hazards regression analysis with interaction variables, the highest risk of long-term mortality following vascular surgery was a peri-operative MI in diabetic patients. After adjusting for the high-risk pre-operative clinical variables associated with age, renal failure, and history of CHF, these data support the utility of peri-operative cardiac troponins as an additional means of stratifying high-risk patients following vascular operations.
Peri-operative myocardial infarction and outcomes
An elevated cardiac biomarker above the 99th percentile of a normal reference population is recognized as an important threshold for the diagnosis of an MI.6 Our findings are consistent with previous studies that have shown that a peak post-operative troponin I or T level above a lower cutoff value, based on the lowest concentration with a coefficient of variation <10%, is predictive of patients with a poor outcome following vascular surgery.7,8 A low cutoff value of peak troponin elevations has also been shown to predict long-term mortality in patients presenting with acute coronary syndromes.15,16 The number of patients who exceeded the lower cutoff of troponin I in our study was nearly two-fold higher than the number of individuals who were diagnosed with a peri-operative MI by the locally collected biomarker. All results of the core lab were blinded to the investigators and it is therefore, unlikely that a treatment bias was created that could have accounted for differences in outcomes. In fact, long-term therapy included antiplatelet agents, beta-blockers, statins, and angiotensin-converting enzyme inhibitors in the vast majority of patients who were followed within the trial.10 The unique aspect of the present study is that outcomes were defined in a homogeneous group of patients with documented coronary artery disease prior to the vascular operation and were based on serial measurements of cardiac biomarkers in all patients with results that were blinded to the investigators.
Peri-operative myocardial infarction and pathophysiology
In the present cohort, the incidence of a peri-operative MI as well as the magnitude of the troponin elevation by the core lab was not related to either the extent of coronary artery disease from the pre-operative coronary angiogram or the revascularization status prior to the vascular operation. This observation underscores the complex pathophysiology of elevated biomarkers associated with vascular operations, including the stress-induced inflammatory response that can be a trigger for myocardial ischaemia.9 The ACC/AHA Task force recommendations on pre-operative risk management prior to non-cardiac surgery have emphasized that use of coronary artery revascularization should not be used as a means of reducing the short-term risks of peri-operative cardiac complications.17 Consistent with these recommendations, is the observation that adherence to a standard pre-operative risk assessment protocol prior to an elective vascular operation may not necessarily reduce the incidence of an elevated cardiac biomarker in those patients who subsequently undergo vascular procedures.8
In the present study, it is not readily apparent why an elevated cardiac biomarker was associated with a worse outcome in diabetic patients compared with non-diabetic patients. Many of the patients in the present cohort had undergone pre-operative coronary artery revascularization with PCIs and it is possible that early rates of restenosis were unmasked by elevated biomarkers at the time of the vascular operation. A retrospective analysis of patients undergoing deployment of non-drug eluting stents has shown that the risk of recurrent need for revascularization from restenosis is high in patients with vascular disease18 and is likely to be even higher in the presence of diabetes. Alternatively, the risk of new plaque rupture in the post-operative period may be higher among diabetic patients independent of prior revascularization therapies. Based on a review of pre-operative coronary angiograms from 21 patients with a post-operative MI, non-obstructive coronary artery disease was present in many patients, raising the suspicion that new vulnerable plaques arise from non-obstructive lesions.19 Perioperative elevations in cardiac biomarkers may also occur in patients with significant collateralized myocardial territories and may be lower in selected patients who have undergone a more complete revascularization procedure with CABG compared with PCI20. The development of a new unstable coronary artery stenosis in the peri-operative period following vascular surgery has certainly been implicated as an important mechanism for the development of an MI, either as a result of the haemodynamic stress of the operation or the release of tissue factors that lead to plaque rupture and thrombus formation.21 In support of this possibility, autopsy studies of patients with a fatal post-operative MI have demonstrated a high prevalence of coronary arteries with plaque rupture and thrombus.22,23 Empirically, stabilization of vulnerable coronary artery plaques with statins may be an important modifiable factor in reducing the risk for development of unstable coronary artery lesions in the peri-operative period.24,25
A major predictor of a peri-operative MI in the present study was an abdominal aortic operation, which supports the results from a large prospectively derived study of patients undergoing non-cardiac surgery.26 The haemodynamic stress associated with abdominal aortic procedures is greater than those involved with infrainguinal vascular operations and may trigger myocardial ischaemia. Previous studies have shown that the severity of the supply–demand mismatch in the peri-operative period, as documented by the duration of ST segment depression during continuous monitoring of the electrocardiogram, correlates well with the magnitude of the troponin elevation following the vascular operation.7 Modification of these haemodynamic variables is an important treatment strategy, particularly with the use of medications that control heart rate and blood pressure in the peri-operative period.27–30 Among high-risk patients undergoing complex vascular operations, titration of incremental doses of beta-blockers to the heart rate response during surgery reduces both the early and late post-surgical cardiac complications.31–33 In the present study, beta-blockers were used within 24 h of the vascular operation in the vast majority of patients and we can not explain why a protective effect was not observed in those individuals compared with the small subset of patients who did not receive those drugs. Because beta-blockers were not randomly assigned, a confounding variable is that treatment with intravenous beta-blockers and nitroglycerine may have been used in those patients who were deemed the highest risk.
|
Conclusions |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsFundingAppendixReferences |
|---|
In summary, in this cohort of the CARP trial, a peri-operative MI defined by a peak troponin I above the 99th percentile reference cutoff (
0.1 µg/L) occurred in 27% of patients undergoing elective vascular operation and the incidence was not influenced by either the extent of coronary artery disease or the pre-operative revascularization status. A peri-operative MI following vascular surgery was a strong predictor of long-term risk of death among patients with diabetes. This increased hazard risk occurred even after adjusting for three other high-risk pre-operative clinical variables associated with age, renal failure, and prior CHF. These long-term outcome data following vascular surgery may be useful for the decision-making process in the pre-operative period, in which consideration of long-term risk of death might alter the decision to proceed with complex vascular interventions. |
Funding |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsFundingAppendixReferences |
|---|
Supported by the Cooperative Studies Program of the Department of Veterans Affairs Office of Research and Development.
|
Appendix |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsFundingAppendixReferences |
|---|
Site Investigators: M. Icenogle, M. Langsfeld, S. Pett, (Albuquerque); K. Mavromatis, A.A. Salam, J.D. Vega, (Atlanta); J. Jean-Claude, G. Pinault, J. Ortiz, (Cleveland); P. Frenkel, M. Jessen, J.G. Modrall, (Dallas); W. Krupski, B. Hattler, (Denver); J. Gray, K. Morris, W. Wolfe, (Durham); R. Kerensky, S. Lind, M. Staples, (Gainesville); A. Greene, S. Lalka, T. Sharp, (Indianapolis); M. Moursi, Y.W. Aude, T. Antakli, (Little Rock); G. Pierpont, S. Santilli, (Minneapolis); M. Amidi, S. Muluk, F. Sonel, M. Zenati, (Pittsburgh); J. Edwards, G. Larsen, P. Ravichandran, (Portland); G. Chilton, E. Sako, M. Sykes, B. Toursarkissian, (San Antonio); J. Rapp, M. Ratcliffe, K. Shunk (San Francisco); T.R. Kohler, K. Lehmann, (Seattle); M. Back, D. Novitzky, M.A. Siddique, (Tampa); S. Goldman, D. Morrison, G. Sethi, A. Westerband, (Tucson); D. Baker, R. Ebrahimi, F. Esmailian, B. Singh, (West Los Angeles); D. DePinto, F. Littooy, H. Loeb, (Hines); T. Gavin, K.B. Ramanathan, D. Weiman, (Memphis); S. Khuri, G. Sharma, (West Roxbury); Endpoint Committee (confirmed endpoints, based on pertinent hospital records): K. Weir, R. Kelly, J. Davenport; Cooperative Studies Program Coordinating Center, Hines, IL: N. Ellis, T. Moritz. W. Henderson, D. Reda, L. Thottapurathu; Clinical Coordinator: C. Jaenicke; Angiography Core Lab (reviewed all angiograms): K. Weir; Specimen Testing Core Laboratory (validated perioperative cardiac enzymes): F. Apple (Hennepin County Medical Center); Good Clinical Practice: C. Haakenson; Study Coordinators: D. Robertson (Albuquerque); D. House, (Atlanta); G. Webbs, (Cleveland); A. Swann, (Dallas); W. Klenke, (Denver); K. Swails, (Durham); J. Brown, (Gainesville); M. Rusomaroff, (Indianapolis); R. Pacheco, (Little Rock); J. Weigenant, (Minneapolis); M. DiTommaso, (Pittsburgh); S. Perez, (San Francisco); A. Sorley, (Seattle); A. Esquivel, (San Antonio); S. Thomas, (Tampa); A. Morgan, K. Zadina, (Tucson); L. Cole, (West Los Angeles); J. Maggio, (Hines); R. Thomas, (Memphis); J. Bannister, (West Roxbury); Executive Committee: E. McFalls (Chairman), H. Ward (Co-Chairman), C. Jaenicke, T. Moritz, S. Goldman, W. Krupski, F. Littooy, D. Reda; Data and Safety Monitoring Board (had nine interim analyses, at 6-month intervals, and made recommendations about the continuation of the trial): N. Hertzer, B.J. Gersh, F. Grover, R. Chappell.
|
Acknowledgments |
|---|
Conflict of interest: none declared.
|
Footnotes |
|---|
Deceased. |
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionConclusionsFundingAppendixReferences |
|---|
- Mangano D. Perioperative cardiac morbidity. Anesthesiology (1990) 72:153–184.[Web of Science][Medline]
- Mangano D, Goldman L. Preoperative assesssment of patients with known or suspected coronary disease. N Engl J Med (1995) 333:1750–1756.
[Free Full Text] - Lopez-Jimenez F, Goldman L, Sacks D, Thomas E, Johnson P, Cook E, Lee T. Prognostic value of cardiac troponin T after noncardiac surgery: 6-month follow-up data. J Am Coll Cardiol (1997) 29:1241–1245.[Abstract]
- McFalls E, Ward H, Santilli S, Scheftel M, Chesler E, Doliszny K. The influence of perioperative myocardial infarction on long-term prognosis following elective vascular surgery. Chest (1998) 113:681–686.[CrossRef][Web of Science][Medline]
- Kim L, Martainez E, Faraday N, Dorman T, Fleisher L, Perler B, Williams G, Chan D, Pronovost P. Cardiac troponin I predicts short-term mortality in vascular surgery patients. Circulation (2002) 106:2366–2371.
[Abstract/Free Full Text] - Alpert J, Thygesen K, Antman E, Bassand J. Myocardial infarction redefined–a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol (2000) 36:959–969.
[Free Full Text] - Landesberg G, Shatz V, Akopnik I, Wof Y, Mayer M, Berlatzky Y, Wieissman C, Mosseri M. Association of cardiac troponin, CK-MB and postoperative myocardial ischemia with long-term survival after major vascular surgery. J Am Coll Cardiol (2003) 42:1547–1554.
[Abstract/Free Full Text] - Bursi F, Babuin L, Barbier A, Politi L, Zennaro M, Grimaldi T, Rumolo A, Gargiulo M, Stella A, Modena M, Jaffe A. Vascular surgery patients: perioperative and long-term risk according to the ACC/AHA guidelines, the additive role of post-operative troponin elevation. Eur Heart J (2005) 26:2448–2456.
[Abstract/Free Full Text] - Devereaux P, Goldman L, Cook D, Gilbert K, Leslie K, Guyatt G. Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. CMAJ (2005) 173:627–634.
[Abstract/Free Full Text] - McFalls E, Ward H, Moritz T, Goldman S, Krupski W, Littooy F, Pierpont G, Santilli S, Rapp J, Hattler B, Shunk K, Jaenicke C, Thottapurathu L, Ellis N, Reda D, Henderson W. Coronary artery revascularization before elective major vascular surgery. N Engl J Med (2004) 351:2795–2804.
[Abstract/Free Full Text] - Apple F, Quist H, Doyle P, Otto A, Murakami M. Plasma 99th percentile reference limits for cardiac troponin and creatine kinase MB mass for use with European Society of Cardiology/American College of Cardiology consensus recommendations. Clin Chem (2003) 49:1331–1336.
[Abstract/Free Full Text] - McFalls E, Ward H, Krupski W, Goldman S, Littooy F, Eagle K, Nyman J, Moritz T, McNabb S, Henderson W. Prophylactic coronary artery revascularization for elective vascular surgery: study design. Control Clin Trials (1999) 20:297–308.[CrossRef][Web of Science][Medline]
- Kaluza G, Joseph J, Lee J, Raizner M, Raizner A. Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol (2000) 35:1288–1294.
[Abstract/Free Full Text] - Apple F, Wu A, Jaffe A. European Society of Cardiology and American College of Cardiology guidelines for redefinition of myocardial infarction: how to use existing assays clinically and for clinical trials. Am Heart J (2002) 144:981–986.[CrossRef][Web of Science][Medline]
- Morrow D, Cannon C, Rifai N, Frey M, Vicari R, Lakkis N, Robertson D, Hille D, DeLucca P, DiBattiste P, Demopoulos L, Weintraub W, Braunwald E. Ability of minor elevations of troponins I and T to predict benefit from an early invasive strategy in patients with unstable angina and non-ST elevation myocardial infarction. JAMA (2001) 286:2405–2412.
[Abstract/Free Full Text] - Thielmann M, Massoudy P, Neuhauser M, Knipp S, Kamler M, Peiotrowski J, Mann K, Jacob H. Prognostic value of peroperative cardiac troponin I in patients with non-ST-segment elevation acute coronary syndromes undergoing coronary artery bypass surgery. Chest (2005) 128:3526–3536.[CrossRef][Web of Science][Medline]
- Eagle K, Berger P, Calkins H, Chaitman B, Ewy G, Fleishmann K, Fleisher L, Froehlich J, Gusberg R, Leppo J, Ryan T, Sclant R, Winters W Jr. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery: executive summary: a report of the American college of Cardiology/American Heart Association task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol (2002) 39:542–553.
[Free Full Text] - Singh M, Lennon R, Darbar D, Gersh B, Holmes D, Rihal C. Effect of peripheral arterial disease in patients undergoing percutaneous coronary intervention with intracoronary stents. Mayo Clin Proc (2004) 79:113–118.
- Ellis S, Hertzer N, Young J, Brener S. Angiographic correlates of cardiac death and myocardial infarction complicating major nonthoracic vascular surgery. Am J Cardiol (1996) 77:1126–1128.[CrossRef][Web of Science][Medline]
- Ward H, Kelly R, Thottapurathu L, Moritz T, Larsen G, Pierpont G, Santilli S, Goldman S, Krupski W, Littooy F, Reda D, McFalls E. Coronary artery bypass grafting is superior to percutaneous coronary intervention in prevention of perioperative myocardial infarctions during subsequent vascular surgery. Ann Thorac Surg (2006) 82:795–801.
[Abstract/Free Full Text] - Fleisher L, Eagle K. Lowering cardiac risk in noncardiac surgery. N Engl J Med (2001) 345:1677–1682.
[Free Full Text] - Dawood M, Gupta D, Southern J, Walia A, Atkinson J, Eagle K. Pathology of fatal perioperative myocardial infarction: implications regarding pathophysiology and prevention. Int J Cardiol (1996) 57:37–44.[CrossRef][Web of Science][Medline]
- Cohen M, Aretz T. Histological analysis of coronary artery lesions in fatal postoperative myocardial infarction. Cardiovasc Pathol (1999) 8:133–139.[CrossRef][Web of Science][Medline]
- Poldermans D, Bax J, Ketai M, Krenning B, Westerhout C, Schinkel A, Thomson I, Lansberg P, Fleisher L, Klein J, van Urk H, Roelandt J, Boersma E. Statins are associated with a reduced incidence of perioperative mortality in patients undergoing major noncardiac vascular surgery. Circulation (2003) 107:1848–1851.
[Abstract/Free Full Text] - O'Neil-Callahan K, Katsimalis G, Tepper M, Ryan J, Mosby C, Ioannidis J, Danias P. Statins decrease perioperative cardiac complications in patients undergoing noncardiac vascular surgery. The Statins for Risk Reduction in Surgery (StaRRS) Study. J Am Coll Cardiol (2005) 45:336–342.
[Abstract/Free Full Text] - Lee T, Marcantonio E, Mangione C, Thomas E, Polanczyk C, Cook E, Sugarbaker D, Donaldson M, Poss R, Ho K, Ludwig L, Pedan A, Goldman L. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation (1999) 100:1043–1049.
[Abstract/Free Full Text] - Auerbach A, Goldman L. Beta-blockers and reduction of cardiac events in noncardiac surgery. Scientific review. JAMA (2002) 287:1435–1444.
[Abstract/Free Full Text] - Boersma E, Poldermans D, Bax J, Steyerberg E, Thomson I, Banga J, van de Ven L, van Urk H, Roelandt J. Predictors of cardiac events after major vascular surgery. Role of clinical characteristics, dobutamine ECHO, and beta-blocker therapy. JAMA (2001) 285:1865–1873.
[Abstract/Free Full Text] - Grayburn P, Hills D. Cardiac events in patients undergoing noncardiac surgery: Shifting the paradigm from noninvasive risk stratification to therapy. Ann Intern Med (2003) 138:506–511.
[Abstract/Free Full Text] - Wijeysundera D, Naik J, Beattie S. Alpha-2 adrenergic agonists to prevent perioperative cardiovascular complications: A meta-analysis. Am J Med (2003) 114:742–752.[CrossRef][Web of Science][Medline]
- Mangano D, Layug E, Wallace A, Tateo I. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. N Engl J Med (1996) 335:1713–1720.
[Abstract/Free Full Text] - Poldermans D, Boersma E, Bax J, Thomson I, van de Ven L, Blankensteijn J, Baars H, Yo T, Trocino G, Vigna C, Roelandt J, van Urk H. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. N Engl J Med (1999) 341:1789–1794.
[Abstract/Free Full Text] - Lindenauer P, Pekow P, Wang K, Mamidi D, Gutierrez B, Benjamin E. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med (2005) 353:349–361.
[Abstract/Free Full Text]
CiteULike 
Connotea 
Del.icio.us What's this?
Related articles in EHJ:
- Preoperative cardiac risk assessment in vascular surgery patients: seeing beyond the perioperative period
- Olaf Schouten, Jeroen J. Bax, and Don Poldermans
EHJ 2008 29: 283-284.[Extract] [Full Text]
This article has been cited by other articles:
|
|
 |
|
  J-H Choi, D K Cho, Y-B Song, J-Y Hahn, S Choi, H-C Gwon, D-K Kim, S H Lee, J K Oh, and E-S Jeon Preoperative NT-proBNP and CRP predict perioperative major cardiovascular events in non-cardiac surgery Heart, January 1, 2010; 96(1): 56 - 62. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. Landesberg, W. S. Beattie, M. Mosseri, A. S. Jaffe, and J. S. Alpert Perioperative Myocardial Infarction Circulation, June 9, 2009; 119(22): 2936 - 2944. [Full Text] [PDF]
|
|
|
|
 |
|
 S. Garcia, T. E. Moritz, S. Goldman, F. Littooy, G. Pierpont, G. C. Larsen, D. J. Reda, H. B. Ward, and E. O. McFalls Perioperative Complications After Vascular Surgery Are Predicted by the Revised Cardiac Risk Index But Are Not Reduced in High-Risk Subsets With Preoperative Revascularization Circ Cardiovasc Qual Outcomes, March 1, 2009; 2(2): 73 - 77. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. L. Pierpont and E. O. McFalls Interpreting troponin elevations: do we need multiple diagnoses? Eur. Heart J., January 2, 2009; 30(2): 135 - 138. [Full Text] [PDF]
|
|
|
|
 |
|
 S. Garcia and E. O. McFalls Preoperative Coronary Revascularization in High-Risk Patients Undergoing Vascular Surgery Anesth. Analg., October 1, 2008; 107(4): 1442 - 1443. [Full Text] [PDF]
|
|
|
|
|
|
O. Schouten, J. J. Bax, and D. Poldermans Preoperative cardiac risk assessment in vascular surgery patients: seeing beyond the perioperative period Eur. Heart J., February 1, 2008; 29(3): 283 - 284. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||