Comparison of the performance of the AUB-HAS2 Cardiovascular Risk Index in emergency vs elective surgeries.

BACKGROUND: The AUB-HAS2 Cardiovascular Risk Index is a newly derived tool for preoperative cardiovascular evaluation. It is based on six data elements: history of heart disease, symptoms of angina or dyspnea, age ≥ 75 years, hemoglobin < 12 g/dl, vascular surgery, and emergency surgery. This study compares the performance of this new index among emergency and elective surgeries. METHODS AND RESULTS: The study population consisted of 1,167,414 non-cardiac surgeries registered in the American College of Surgeons National Surgical Quality Improvement Program database (153,715 were emergency and 1,013,699 were elective). Each patient was given an AUB-HAS2 score of 0, 1, 2, 3, or >3 depending on the number of data elements s/he has. The outcome measure (death, myocardial infarction, or stroke at 30 days after surgery) was higher in emergency than elective surgeries (7.0 % vs 1.4 %, p < 0.0001). The AUB-HAS2 index was able to stratify risk in both types of surgeries with a gradual increase in risk as the score increased (p < 0.0001). The discriminatory power of the AUB-HAS2 index, measured by the area under the receiver operator characteristic curves, was good and similar in the two types of surgeries (0.804 for emergency vs 0.791 for elective surgeries). CONCLUSION: The AUB-HAS2 index is a versatile tool that can effectively and equally stratify risk in both emergency and elective surgeries with a good discriminatory power.

A novel radical prostatectomy specific index (PSI) for the prediction of major cardiovascular events following surgery.

PURPOSE: Prostate cancer patients tend to be older with multiple comorbidities and are thus at increased risk for postoperative cardiovascular events after radical prostatectomy (RP). Thus, proper patient selection strategies are essential to decide for or against a surgical approach. We aimed to derive a prostatectomy specific index (PSI) for patients undergoing RP and compare its performance to universally used indices. METHODS: The cohort was derived from National Surgical Quality Improvement Program database between 2005 and 2012. The primary outcome was incidence of major adverse cardiovascular events at 30 days post-surgery including: death, myocardial infarction, or stroke. A multivariable logistic regression model was constructed, performance and calibration were evaluated using a ROC analysis and the Hosmer-Lemeshow test, the PSI index was derived and compared to the RCRI and AUB-HAS2 indices. RESULTS: A total of 17,299 patients were included in our cohort, with a mean age of 62 ± 7.4 years. Seventy three patients had a cardiac event post RP. The final PSI index encompassed six variables: history of heart disease, age, anemia, American society of anesthesiology class, surgical approach, and hypertension. The PSI ROC analysis provided C-statistic = 0.72, calibration R2 = 0.99 and proper goodness of fit. In comparison, the C-statistics of RCRI and AUB-HAS2 were found to be 0.57 and 0.65, respectively (p value < 0.001). CONCLUSION: The PSI model is a procedure tailored index for prediction of major cardiovascular events post RP. It was calibrated using a large national database aiming to optimize treatment selection strategies for prostate cancer patients.

Effect of age and gender on pre-operative cardiovascular risk assessment.

BACKGROUND: The AUB-HAS2 Cardiovascular Risk Index is a recently published tool for pre-operative cardiovascular evaluation. It is based on six data elements: history of heart disease, symptoms of angina or dyspnea, age ≥ 75 years, hemoglobin < 12 mg/dl, vascular surgery, and emergency surgery. The objective of this study is to study the effect of age and gender on the performance of the AUB-HAS2 Index in pre-operative cardiovascular risk assessment. METHODS: The study population consisted of 1,167,414 non-cardiac surgeries registered in the ACS NSQIP database. The population was stratified by age (≥ 40 and < 40 years old) and by gender (men and women). Each patient was given an AUB-HAS2 score of 0, 1, 2, 3, or > 3 based on the number of data elements s/he has. The outcome measure was all-cause mortality, myocardial infarction (MI), or stroke at 30 days after surgery. RESULTS: The overall 30-day event rate was higher in patients ≥ 40 years compared to those < 40 years (2.5% vs 0.3%, P < 0.0001) and in men compared to women (2.7% vs 1.8%, P < 0.0001). In both age and gender subgroups, there was a gradual and significant increase in the outcome measure (death, MI, or stroke) as the AUB-HAS2 score increased: from ≤ 0.5% in those with a score of 0 to more than 15% in those with a score > 3 (P < 0.0001). The AUB-HAS2 Index was able to stratify risk in all subgroups into low, intermediate, and high (P < 0.0001). Receiver operating characteristic curves showed the AUB-HAS2 Index has very good discriminatory power in both age (area under the curve (AUC) of 0.81 and 0.78) and gender (AUCs of 0.79 and 0.84) subgroups. CONCLUSION: This study extends the validation of the newly derived AUB-HAS2 Cardiovascular Risk Index to different age and gender subgroups with very good discriminative power.

A 17-year-old boy with chest pain and transient ventricular wall thickening.

We describe the case of a 17-year-old boy who developed acute myopericarditis associated with transient ventricular wall thickening. This is a unique teaching case illustrating that acute myocarditis can be associated with significant oedema, secondary to inflammation, causing marked wall thickening that is apparent on echocardiography. This oedema resolves completely with anti-inflammatory drug treatment.

Major adverse cardiovascular events following partial nephrectomy: a procedure-specific risk index.

Introduction: Partial nephrectomy (PN) is associated with a non-negligible risk of postoperative cardiovascular morbidity and mortality. Identification of high-risk patients may enable optimization of perioperative management and consideration of alternative approaches. The authors aim to develop a procedure-specific cardiovascular risk index for PN patients and compare its performance to the widely used revised cardiac risk index (RCRI) and AUB-HAS2 cardiovascular risk index. Methods: The cohort was derived from the American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) database. The primary outcome was the incidence of major adverse cardiovascular events (MACE), defined as 30-day postoperative incidence of myocardial infarction, stroke, or mortality. A multivariate logistic regression model was constructed; performance and calibration were evaluated using an ROC analysis and the Hosmer-Lemeshow test and compared to the RCRI and the AUB-HAS2 index. Results: In a cohort of 4795 patients, MACE occurred in 52 (1.1%) patients. A univariate analysis yielded 13 eligible variables for entry into the multivariate model. The final PN-A4CH model utilized six variables: Age ⩾75 years, ASA class >2, Anemia, surgical Approach, Creatinine >1.5, and history of Heart disease. Index ROC analysis provided a C-statistic of 0.81, calibration R 2 was 0.99, and sensitivity was 85%. In comparison, the RCRI and AUB-HAS2 C-statistics were 0.59 and 0.68, respectively. Conclusion: This study proposes a novel procedure-specific cardiovascular risk index. The PN-A4CH index demonstrated good predictive ability and excellent calibration using a large national database and may enable further individualization of patient care and optimization of patient selection.

Performance of the AUB-HAS2 Cardiovascular Risk Index in vascular surgery patients.

The American University of Beirut (AUB)-HAS2 risk index is a recently published tool for preoperative cardiovascular evaluation. It is based on six data elements: history of Heart disease, symptoms of Heart disease (angina or dyspnea), Age ⩾ 75 years, Anemia (hemoglobin < 12 mg/dL), emergency Surgery, and vascular Surgery. This study analyzes the performance of a modified AUB-HAS2 index (excluding the vascular surgery element) in a broad spectrum of vascular surgery procedures. The study population consisted of 90,476 vascular surgeries registered in the American College of Surgeons National Surgical Quality Improvement Program database. The performance of the AUB-HAS2 index was studied in seven groups: carotid endarterectomy (CEA), open abdominal aortic aneurysm surgical repair (OAAA), endovascular aortic aneurysm repair, supra-inguinal bypass, infra-inguinal bypass, lower extremity thrombo-endarterectomy, and lower extremity angioplasty. The outcome measure was death, myocardial infarction, or stroke at 30 days after surgery. Each patient was given an AUB-HAS2 score of 0, 1, 2, or > 2 depending on the number of data elements s/he has. The AUB-HAS2 index was able to stratify risk in the majority of patients into low (< 3%, score 0), intermediate (3-10%, score 1-2), and high (> 10%, score > 2) (p < 0.0001). The receiver operating curve had an area of 0.71 in the overall group and it ranged from 0.60 in CEA patients to 0.75 in OAAA patients. In conclusion, the AUB-HAS2 index is a simple tool that can quickly and effectively stratify the risk of patients undergoing a broad spectrum of vascular surgeries into low, intermediate, and high.

AUB-HAS2 Cardiovascular Risk Index: Performance in Surgical Subpopulations and Comparison to the Revised Cardiac Risk Index.

Background The American University of Beirut (AUB)-HAS2 Cardiovascular Risk Index is a newly derived index for preoperative cardiovascular evaluation. It is based on 6 data elements: history of heart disease; symptoms of angina or dyspnea; age ≥75 years; hemoglobin <12 mg/dL; vascular surgery; and emergency surgery. In this study we analyze the performance of this new index and compare it with that of the Revised Cardiac Risk Index in a broad spectrum of surgical subpopulations. Methods and Results The study population consisted of 1 167 278 noncardiac surgeries registered in the American College of Surgeons National Surgical Quality Improvement Program database. Each patient was given an AUB-HAS2 score of 0, 1, 2, 3, or >3, depending on the number of data elements present. The performance of the AUB-HAS2 index was studied in 9 surgical specialty groups and in 8 commonly performed site-specific surgeries. Receiver operating characteristic curves were constructed for the AUB-HAS2 and Revised Cardiac Risk Index measures, and the areas under the curve were compared. The outcome measure was death, myocardial infarction, or stroke at 30 days after surgery. The AUB-HAS2 score was able to stratify risk in all surgical subgroups (P<0.001). In the majority of surgeries, patients with an AUB-HAS2 score of 0 had an event rate of <0.5%. The performance of the AUB-HAS2 index was superior to that of the Revised Cardiac Risk Index in all surgical subgroups (P<0.001). Conclusions This study extends the validation of the AUB-HAS2 index to a broad spectrum of surgical subpopulations and demonstrates its superior discriminatory power compared with the commonly utilized Revised Cardiac Risk Index.

A New Index for Pre-Operative Cardiovascular Evaluation.

BACKGROUND: Currently used indices for pre-operative cardiovascular evaluation are either powerful, but complex, or simple, but with weak discriminatory power. OBJECTIVES: This study sought to prospectively derive and validate a simple powerful index that can stratify the cardiovascular risk of patients undergoing noncardiac surgery. METHODS: The derivation cohort consisted of 3,284 prospectively enrolled adult patients undergoing noncardiac surgery at the American University of Beirut Medical Center. The validation cohort consisted of 1,167,414 patients registered in the American College of Surgeons National Surgical Quality Improvement Program database. The primary outcome measure was death, myocardial infarction, or stroke at 30 days after surgery. RESULTS: The primary outcome occurred in 38 patients (1.2%) in the derivation cohort. Multivariate logistic regression analysis in the derivation cohort identified 6 data elements to be included in the prediction model: age ≥75 years, history of heart disease, symptoms of angina or dyspnea, hemoglobin <12 mg/dl, vascular surgery, and emergency surgery. Each patient was assigned a Cardiovascular Risk Index (CVRI) of 0, 1, 2, 3, and >3 based on the number of data elements present. The incidence of the primary outcome increased steadily across the CVRI groups in both the derivation (0%, 0.5%, 2.0%, 5.6%, and 15.7%, respectively; p < 0.0001) and validation (0.3%, 1.6%, 5.6%, 11.0%, and 17.5%, respectively; p < 0.0001) cohorts. The discriminatory power of the new CVRI was further confirmed by constructing a receiver-operating characteristic curve that had an area under the curve of 0.90 in the derivation cohort and 0.82 in the validation dataset. CONCLUSIONS: This study reports a new index for pre-operative cardiovascular evaluation which has a strong discriminatory power that can effectively stratify patients into low- (CVRI 0 to 1), intermediate- (CVRI 2 to 3), and high-risk (CVRI >3) groups. This has important implications for the efficient triage and management of patients scheduled for noncardiac surgery.

Predictors of In-Hospital Mortality in Patients Admitted with Acute Myocardial Infarction in a Developing Country.

BACKGROUND: Limited data are available on the predictors of mortality in patients hospitalized with acute myocardial infarction (AMI) in developing countries. In this study, we analyze the predictors for in--hospital mortality in patients hospitalized with AMI (ST segment elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI)) in a large tertiary referral university hospital in Lebanon. METHODS: This was a retrospective study of 503 patients admitted to the American University of Beirut Medical Center with AMI (228 with STEMI and 275 with NSTEMI). RESULTS: The in-hospital mortality rate was 7.8%. The multivariate predictors of mortality in the overall population were similar to what has been reported in large registries in the USA and Europe. They included older age (> 65 years) (OR = 2.99, 95% CI = 1.22 - 7.36, P = 0.02), systolic blood pressure < 100 mm Hg (OR = 2.75, 95% CI = 1.12 - 6.76, P = 0.03), history of stroke (OR = 4.28, 95% CI = 1.29 - 14.17, P = 0.02), history of coronary artery bypass graft (CABG) (OR = 2.68, 95% CI = 1.15 - 6.23, P = 0.02), heart failure (OR = 3.92, CI = 1.62 - 9.49, P = 0.002) and ejection fraction (EF) < 35% (OR = 2.32, 95% CI = 1.05 - 5.14, P = 0.04). In a separate analysis of STEMI and NSTEMI patients, age, heart failure and a low EF continued to be multivariate predictors of mortality in both subgroups. In addition, prior stroke was an added predictor in STEMI patients, and prior CABG was an added predictor in NSTEMI. CONCLUSION: Predictors of in-hospital mortality in patients hospitalized with AMI in a tertiary referral university hospital in the Middle East are similar to what has been reported in large registries in the USA and Europe.

The Impact of Formal Training and Certification on the Relationship Between Volume and Outcomes in Percutaneous Coronary Interventions.

BACKGROUND: Little data are available on the impact of formal training and certification on the relationship between volumes and outcome in percutaneous coronary interventions (PCIs).The objective of this report is to study the relationship between PCI volume and outcome for a formally trained interventional cardiologist who is certified by the American Board on Internal Medicine - Interventional Cardiology subspecialty board. METHODS: The operator witnessed 3 different PCI volumes/yr over a 15-year practice period (2000-2014): <50 PCI/yr (years 2000-2006; n = 179), 50-100 PCI/yr (years 2007-2010; n = 256), and >100 PCI/yr (years 2011-2014; n = 427). Angiographic and procedural success rates were compared between the 3 volume groups, as well as in-hospital cardiovascular events (death, recurrent myocardial infarction, repeat PCI, stroke, or coronary artery bypass surgery). RESULTS: The in-hospital mortality rate throughout the study period was 0.8% and was not statistically significant among the 3 volume groups. There was also no significant difference among the 3 groups with respect to recurrent myocardial infarction or repeat PCI. There was a slightly higher rate of same-stay elective coronary artery bypass grafting in the early low-volume period compared with the other 2 groups (2.2% vs. 0.8% vs. 0.2%; P = 0.04). The overall angiographic and procedural success rates were 97.3% and 96.5%, and they were not significantly different among the 3 groups. CONCLUSIONS: Our study shows that the angiographic and procedural success rates of PCI, as well as the in-hospital mortality, do not seem to be dependent on the annual volume for formally trained and certified interventional cardiologists.

Variations in the referral patterns to pharmacologic and exercise myocardial perfusion imaging.

BACKGROUND: Myocardial perfusion imaging (MPI) is commonly utilized for the non-invasive evaluation of patients with suspected coronary artery disease (CAD). It is either performed with exercise or pharmacologic stress. The objective of this study is to compare the referral patterns and diagnostic findings in patients referred for pharmacologic vs exercise MPI. METHODS AND RESULTS: This was a prospective study of 429 consecutive patients who were referred for MPI at the American University of Beirut Medical Center (23% had pharmacologic stress with dipyridamole and 77% had exercise stress testing). Patients referred to pharmacologic stress were older, had a higher percentage of women, and a higher prevalence of diabetes and hypertension. There were more abnormal scans in the pharmacologic stress group (38% vs 20%, P < 0.001), as well as a higher prevalence of ischemia (21% vs 13%, P < 0.001) and impaired left ventricular function with an ejection fraction < 50% (19% vs 7.9%, P < 0.001). The significant predictors for referral to pharmacologic stress by multivariable logistic regression analysis were older age (OR = 2.01 (1.57-2.57), P < 0.001) and diabetes (OR = 2.04 (1.19-3.49), P = 0.009). CONCLUSION: Patients referred for pharmacologic stress MPI are at a higher risk than those referred for exercise stress MPI with more CAD risk factors, older age, and a higher prevalence of abnormal MPI findings.