Development of clinical risk-prediction models for uterine atony following vaginal and cesarean delivery.

BACKGROUND: Uterine atony is the most common cause of postpartum hemorrhage and is associated with substantial morbidity. Prospectively identifying women at increased risk of atony may reduce the incidence of subsequent adverse events. We sought to develop and evaluate clinical risk-prediction models for uterine atony following vaginal and cesarean delivery, using prespecified risk factors identified from systematic review. METHODS: Using retrospective data from vaginal and cesarean deliveries occurring at a single institution between 2010 and 2019, antepartum and intrapartum risk-prediction models for uterine atony, defined by supplementary uterotonic administration in addition to prophylactic oxytocin infusion, were developed using logistic regression. The C-statistic quantified the ability of the model to discriminate between cases and controls. RESULTS: Data were available for 4773 atony cases and 23 933 controls. The antepartum model included 20 risk factors and exhibited moderate discriminatory ability (C-statistic 0.61, 95% confidence interval 0.60 to 0.62). The intrapartum model included 27 risk factors and showed improved discriminatory ability (C-statistic 0.68, 95% confidence interval 0.67 to 0.69). CONCLUSIONS: We identified antepartum and intrapartum risk-prediction models to quantify patients' risk of uterine atony. Models performed similarly for all delivery modes, races, and ethnic groups. Future work should further improve these models through inclusion of more comprehensive prediction data.

Reprinted article "A combination of statins and beta-blockers is independently associated with a reduction in the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery".

OBJECTIVE: To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA). BACKGROUND: Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers. METHODS: We studied 570 patients (mean age 69 ±9 years, 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC. Patients were evaluated for clinical risk factors (age>70 years, histories of MI, angina, diabetes mellitus, stroke, renal failure, heart failure and pulmonary disease), DSE, statin and beta-blocker use. The main outcome was a composite of perioperative mortality and MI within 30 days of surgery. RESULTS: Perioperative mortality or MI occurred in 51 (8.9%) patients. The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (3.7% vs. 11.0%; crude odds ratio (OR): 0.31, 95% confidence interval (CI): 0.13-0.74; p = 0.01). After correcting for other covariates, the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR: 0.24,95% CI: 0.10-0.70; p = 0.01). Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR: 0.24, 95% CI: 0.11-0.54). Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata; particularly patients with 3 or more risk factors experienced significantly lower perioperative events. CONCLUSIONS: A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk.

Intraoperative use of packed red blood cell transfusion and mortality in patients undergoing abdominal or thoracoabdominal aortic aneurysm surgery.

AIM: A direct association between intraoperative use of red blood cell (RBC) transfusion and perioperative mortality in patients undergoing aortic aneurysm surgery has not been studied before. METHODS: One thousand patients (mean age, 69.0 +/- 10.0 years; males 810) who underwent acute or elective abdominal or thoracoabdominal aortic aneurysm surgery between January 1999 and April 2007 at Semmelweis Medical University (Budapest, Hungary), were studied. Patients were evaluated for clinical risk factors, chronic medication use and surgical characteristics. Propensity score analysis was used to adjust for the potential bias in the intraoperative use of RBC transfusion. Multivariable logistic regression analyses were applied to study the association between the likelihood of intraoperative use of RBC transfusion and mortality occurring within 30 days of surgery. RESULTS: Perioperative mortality occurred in 85 (8.5%) patients. Thirty-day mortality was significantly higher in patients who received intraoperative RBC transfusion compared to patients who did not receive it (1 or 2 units of RBCs, crude odds ratio [OR]: 6.2, 95% confidence interval [CI]: 1.8-21.0; P = 0.003; 3 or more units, OR: 35.7, 95% CI: 11.1-115.4; P < 0.0001). Even after correction for other baseline covariates and propensity for RBC transfusion intraoperative use of RBC transfusion was associated with increased 30-day mortality (1 or 2 units of RBCs, OR: 4.6, 95% CI: 1.1-18.5; P = 0.03; 3 or more units, OR: 4.0, 95% CI: 1.0-16.0; P = 0.05). CONCLUSIONS: Intraoperative use of RBC transfusion in patients with acute or elective aortic aneurysm surgery is independently associated with an increased incidence of perioperative mortality.

Dihydropiridine calcium-channel blockers and perioperative mortality in aortic aneurysm surgery.

BACKGROUND: Dihydropiridine calcium-channel blockers are often used as an alternative to beta-blockers for the treatment of hypertension in patients undergoing aortic aneurysm surgery. We studied the relation between dihydropiridine calcium-channel blocker use and perioperative mortality in patients undergoing aortic aneurysm surgery. METHODS: We studied 1000 patients [mean (range) age, 69 (22-95) yr; males 810] who underwent acute or elective abdominal or thoracoabdominal aortic aneurysm surgery between January 1999 and April 2007, at Semmelweis Medical University (Budapest, Hungary). Patients were evaluated for clinical risk factors, chronic medication use, and surgical characteristics. Propensity score analysis was used to adjust for the potential bias in dihydropiridine calcium-channel blocker use. Multivariable logistic regression analyses were applied to study the association between the likelihood of dihydropiridine calcium-channel blocker use and mortality occurring within 30 days of surgery. RESULTS: Perioperative mortality occurred in 85 (8.5%) patients. Thirty-day mortality was significantly higher in dihydropiridine calcium-channel blocker users compared with non-users, 14.0% vs 6.0%; crude odds ratio (OR) 2.6, 95% confidence interval (CI): 1.6-4.0, P<0.0001. Even after correcting for other baseline covariates and propensity for these agents dihydropiridine calcium-channel blocker use was associated with increased 30-day mortality, OR (95% CI) 2.5(1.3-4.6), P=0.003. CONCLUSIONS: Dihydropiridine calcium-channel blocker use in patients with acute or elective aortic aneurysm surgery is independently associated with an increased incidence of perioperative mortality.

Effects of fructose-1,6-diphosphate on endo- and myocardial purine metabolism during coronary artery bypass grafting surgery.

AIM: During ischemia, the glycolytic pathway is up-regulated to anaerobically produce adenosine triphosphate (ATP). However, this is short-lived, due to negative feedback on phosphofructokinase from accumulating lactate. Since fructose-1,6-diphosphate (FDP) enters glycolysis distal to this inhibitory site, exogenously administered FDP may yield ATP-independent lactate accumulation and thus ameliorate ischemic injury. The aim of this prospective randomized study was to investigate whether the improved myocardial preservation by FDP could be attributed to improved intermediary metabolism in patients who underwent coronary artery bypass grafting surgery (CABG). METHODS: Thirty-eight patients scheduled for elective CABG were studied. During operation, aortic and coronary sinus blood were collected at different timepoints and analysed by chromatography. Ten patients received 250 mg/kg FDP and 10 received 5% dextrose (control) as intravenous pretreatment prior to cardiopulmonary bypass. In the second stage, 9 patients received 2.5 mM (1.4 g/L) FDP and 9 patients 5% dextrose with the cardioplegic solution. Myocardial metabolism was quantified by measuring nucleotide catabolites including inosine and hypoxanthine. RESULTS: The release of inosine-hypoxantine was increased in both the FDP and the control groups; however, compared to baseline, inosine-hypoxantine levels were significantly elevated at 0, 1, 5 and 10 minutes following reperfusion in the control group. This was in contrast to the earlier recovery to baseline levels (after 5 minutes following reperfusion) in the FDP group. CONCLUSION: These data suggest that FDP may contribute to myocardial cytoprotection during cardiopulmonary bypass. Moreover, myocardial nucleotide metabolite levels showed no evidence for a protective effect of FDP on nucleotide degradation between the treated and the control groups.

Aprotinin and perioperative complications in cardiac surgery.

AIM: Recently, the clinical significance of aprotinin-induced renal dysfunction and other end-organ complications in patients undergoing cardiac surgery has engendered substantial controversy. Therefore, we assessed the effect of aprotinin on end-organ complications in patients undergoing cardiac surgery. METHODS: Data of 674 patients (mean age 65.4 +/- 11.0 years, 457 males) undergoing cardiac surgery between January 1 and December 31, 2005 at Semmelweis University were used for the analyses. Preoperative, intraoperative and postoperative clinical and surgical variables were recorded. Patients administered aprotinin received the drug either as a low-dose regimen, a loading dose of 1 million kallikrein-inhibitor units (KIU), 1 million KIU in pump, and 1 million KIU post pump (or continuous infusion of 0.25 million KIU per hour); or a high-dose regimen, a loading dose of 2 million KIU, 2 million KIU in pump, and 2 million KIU post pump (or continuous infusion of 0.5 million KIU per hour). The outcomes were renal complications defined as a 25% reduction in postoperative calculated creatinine clearance compared to the preoperative baseline or renal failure requiring dialysis; and the composite of renal, cardiovascular and cerebrovascular complications and all-cause mortality. RESULTS: Patients underwent coronary artery bypass surgery (63%), valvular (27%) or a combination (5%) and surgery on the ascending aorta (5%). There were 550 patients (81.6%) who received aprotinin treatment. In multivariate regression analyses when the relation between high or low dose aprotinin compared to no aprotinin was evaluated, the likelihood of renal complications [high dose: odds ratio (OR)=1.4, 95% confidence interval (CI), 0.6-3.0, P=0.4; low dose: OR=1.2, 95%CI, 0.7-2.3, p=0.5], and the composite outcome variable (high dose: OR=1.6, 95%CI, 0.8-3.4, P=0.2; low dose: OR=1.3, 95%CI, 0.7-2.3, P=0.4) were not significantly increased. CONCLUSION: Our analysis suggests that aprotinin use in either a high or low dose regimen was not associated with an increase in adverse end-organ complications.

Coronary revascularization in transition from on-pump to off-pump: the effect of the off-pump coronary artery bypass on medium-term outcome.

AIM: We previously reported that early patient outcome, chiefly ischaemic injury, was reduced in patients allocated to off pump coronary artery bypass (OPCAB) surgery. This report concerns the medium-term outcome for this cohort of patients. METHODS: A prospective observational study was carried out in a single cardiothoracic specialty hospital. Forty-four patients scheduled for elective multivessel coronary artery bypass grafting (CABG) surgery using either off pump (OPCAB) (n=21) or on pump (cardiopulmonary bypass, CPB) (n=23) were included in the study. Data on the symptoms, quality of life, need for cardiovascular therapy, and occurrence of cardiovascular events or death among patients at 6- and 12-months after surgery were collected by a patient questionnaire and reviewing the medical charts. RESULTS: Compared with patients who underwent CPB surgery, OPCAB patients required a smaller increase in cardiovascular medication (5.6% versus 47.1%; P=0.007) at the 6-month follow-up and demonstrated a trend toward improved symptoms (dyspnea at 6 months, 0, range 0-4 versus 1, range 0-4; P=0.03) and quality of life (Duke Activity Status Index at 6 months, 20.8+5.6 versus 19+6.8; P=0.13). No differences in the incidence of cardiologic intervention or mortality were observed between groups. CONCLUSIONS: The trend toward improved medium-term outcome variables among patients treated with OPCAB may have owed to the reduced cardiac ischemic injury associated with OPCAB compared with CPB.

Pre-operative coronary revascularization: an optimal therapy for high-risk vascular surgery patients?

Cardiac complications are the leading cause of peri-operative morbidity and mortality of patients undergoing vascular surgery. This high incidence of cardiac complications is related to the presence of underlying coronary artery disease. The optimal treatment strategy for these high-risk patients, including the use of pre-operative coronary revascularization for the purpose of improving peri-operative and long-term cardiac outcomes, has been controversial for several decades. Recently, the results of the Coronary Artery Revascularization Prophylaxis (CARP) trial showed that in the short term there is no reduction in the number of post-operative myocardial infarctions, deaths or length of stay in the hospital, or in long-term outcomes in patients who underwent pre-operative coronary revascularization compared with patients who received optimized medical therapy. In this review, we summarize the role of pre-operative revascularization before elective vascular surgery using current evidence from the CARP trial and of those from published studies.

Cardiac risk reduction in non-cardiac surgery: the role of anaesthesia and monitoring techniques.

Cardiac complications are the major cause of perioperative morbidity and mortality of patients undergoing non-cardiac surgery. This is related to the frequent presence of underlying coronary artery disease. In the last few decades, attention has focused on preoperative cardiac risk assessment that may help to identify patients at increased cardiac risk for whom cardioprotective medication and, when indicated, coronary revascularization may improve perioperative outcome. On the other hand, less attention was given to the role of anaesthesia and monitoring techniques in the cardiac risk management of high-risk patients undergoing non-cardiac surgery. The aim of this review was to summarize the current evidence from published studies on the effect of the type of anaesthesia and monitoring techniques on perioperative cardiac outcome in non-cardiac surgery.

Beta-blockers improve in-hospital and long-term survival in patients with severe left ventricular dysfunction undergoing major vascular surgery.

OBJECTIVES: To study whether beta-blockers reduce in-hospital and long-term mortality in patients with severe left ventricular dysfunction (LVD) undergoing major vascular surgery. DESIGN: Observational cohort study. MATERIALS: Five hundred and eleven patients with severe LVD (ejection fraction<30%) undergoing major non-cardiac vascular surgery. METHODS: In all patients, cardiac risk factors, medication (including beta-blockers), and dobutamine stress echocardiography (DSE) results were noted prior to surgery. DSE was evaluated for rest and stress-induced new wall motion abnormalities. Endpoint was in-hospital and long-term mortality. Propensity scores for beta-blockers were calculated and regression models were used to analyse the relation between beta-blockers and mortality. RESULTS: Mean age was 64+/-11 years and 383 patients (75%) were male. 139 patients (27%) used beta-blockers. Stress-induced ischemia occurred in 82 patients (16%). Median follow-up was 7 years (interquartile range: 3-10). In-hospital and long-term mortality was observed in 64 (13%) and 171 (33%) patients, respectively. After adjusting for clinical variables, DSE results and propensity scores, beta-blockers were significantly associated with reduced in-hospital and long-term mortality (OR: 0.18, 95% CI: 0.04-0.74 and HR: 0.38, 95% CI: 0.22-0.65, respectively). CONCLUSION: In patients with severe LVD undergoing major vascular surgery, the use of beta-blockers is associated with a reduced incidence of in-hospital and long-term postoperative mortality.

A combination of statins and beta-blockers is independently associated with a reduction in the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery.

OBJECTIVE: To investigate the combined beneficial effect of statin and beta-blocker use on perioperative mortality and myocardial infarction (MI) in patients undergoing abdominal aortic aneurysm surgery (AAA). BACKGROUND: Patients undergoing elective AAA-surgery identified by clinical risk factors and dobutamine stress echocardiography (DSE) as being at high-risk often have considerable cardiac complication rate despite the use of beta-blockers. METHODS: We studied 570 patients (mean age 69+/-9 years, 486 males) who underwent AAA-surgery between 1991 and 2001 at the Erasmus MC. Patients were evaluated for clinical risk factors (age>70 years, histories of MI, angina, diabetes mellitus, stroke, renal failure, heart failure and pulmonary disease), DSE, statin and beta-blocker use. The main outcome was a composite of perioperative mortality and MI within 30 days of surgery. RESULTS: Perioperative mortality or MI occurred in 51 (8.9%) patients. The incidence of the composite endpoint was significantly lower in statin users compared to nonusers (3.7% vs. 11.0%; crude odds ratio (OR): 0.31, 95% confidence interval (CI): 0.13-0.74; p=0.01). After correcting for other covariates, the association between statin use and reduced incidence of the composite endpoint remained unchanged (OR: 0.24, 95% CI: 0.10-0.70; p=0.01). Beta-blocker use was also associated with a significant reduction in the composite endpoint (OR: 0.24, 95% CI: 0.11-0.54). Patients using a combination of statins and beta-blockers appeared to be at lower risk for the composite endpoint across multiple cardiac risk strata; particularly patients with 3 or more risk factors experienced significantly lower perioperative events. CONCLUSIONS: A combination of statin and beta-blocker use in patients with AAA-surgery is associated with a reduced incidence of perioperative mortality and nonfatal MI particularly in patients at the highest risk.

Long-term prognostic value of asymptomatic cardiac troponin T elevations in patients after major vascular surgery.

BACKGROUND: Cardiac troponin T (cTnT) is a sensitive and specific marker for myocardial injury, but elevations of cTnT without clinical evidence of ischemia and persistent or new electrocardiographic (ECG) abnormalities are common in patients undergoing major vascular surgery. We explored the long-term prognostic value of cTnT levels in these patients. METHODS: A follow-up study was conducted between 1996-2000 in 393 patients who underwent successful aortic or infrainguinal vascular surgery and routine sampling of cTnT. Patients were followed until May 2003 (median of 4 years [25th-75th percentile, 2.8-5.3 years]). Total creatine kinase (CK), CK-MB, and cTnT were routinely screened in all patients, and included sampling after surgery and the mornings of postoperative days 2, 3 and 7. Electrocardiograms were also routinely evaluated for sign of ischemia. An elevated cTnT was defined as serum concentrations >/=0.1 ng/ml in any of these samples. All-cause mortality was evaluated during long-term follow-up. RESULTS: Eighty patients (20%) had late death. The incidence of all-cause mortality (41% vs. 17%; p<0.001) was significantly higher in patients with an elevated cTnT level compared to patients with normal cTnT. After adjustment for baseline clinical characteristics, the association between an elevated cTnT level and increased incidence of all-cause mortality (adjusted hazard ratio, 1.9; 95% CI, 1.1-3.1) persisted. Elevated cTnT had significant prognostic value in patients with and without renal dysfunction, abnormal levels of CK-MB, and in patients with transient ECG abnormalities. CONCLUSIONS: Elevated cTnT levels are associated with an increased incidence of all-cause mortality in patients undergoing major vascular surgery.

Repetitive dobutamine stress echocardiography for the prediction of anthracycline cardiotoxicity.

AIMS: To evaluate whether repetitive assessment of systolic and diastolic cardiac function by dobutamine stress echocardiography (DSE) can predict anthracycline cardiotoxicity. METHODS AND RESULTS: Thirty-one patients (age, 57+/-13 years, 22 male) were studied before chemotherapy, with follow-ups during, at the end, and 6 months after chemotherapy. Left ventricular (LV) function was assessed by two-dimensional (2D) echocardiographic wall motion score index (WMSI) and by Doppler echocardiography of mitral valve inflow at rest and during DSE. Radionuclide ventriculography was used as an independent reference for ejection fraction (EF). A reduction of EF >/=5% occurred in 17 patients (group A) at the last follow-up. Patients without decreased EF comprised group B. Early/late diastolic velocity of mitral inflow (E/A ratio) at rest was lower in group A (0.91+/-0.2 vs 1.28+/-0.3, P<0.001), and it was an independent predictor of cardiotoxicity (adjusted for baseline patient characteristics and parameters of systolic and diastolic function). At follow-up, WMSI at rest paralleled radionuclide EF. Contractile reserve at low-dose DSE was preserved in group A. CONCLUSIONS: WMSI measured by 2D echocardiography parallels radionuclide EF at follow-up. Assessment of contractile reserve has no incremental value for the early detection of cardiotoxicity. A baseline abnormal E/A ratio is an independent predictor of anthracycline cardiotoxicity.

A meta-analysis comparing the prognostic accuracy of six diagnostic tests for predicting perioperative cardiac risk in patients undergoing major vascular surgery.

OBJECTIVE: To evaluate the discriminatory value and compare the predictive performance of six non-invasive tests used for perioperative cardiac risk stratification in patients undergoing major vascular surgery. DESIGN: Meta-analysis of published reports. METHODS: Eight studies on ambulatory electrocardiography, seven on exercise electrocardiography, eight on radionuclide ventriculography, 23 on myocardial perfusion scintigraphy, eight on dobutamine stress echocardiography, and four on dipyridamole stress echocardiography were selected, using a systematic review of published reports on preoperative non-invasive tests from the Medline database (January 1975 and April 2001). Random effects models were used to calculate weighted sensitivity and specificity from the published results. Summary receiver operating characteristic (SROC) curve analysis was used to evaluate and compare the prognostic accuracy of each test. The relative diagnostic odds ratio was used to study the differences in diagnostic performance of the tests. RESULTS: In all, 8119 patients participated in the studies selected. Dobutamine stress echocardiography had the highest weighted sensitivity of 85% (95% confidence interval (CI) 74% to 97%) and a reasonable specificity of 70% (95% CI 62% to 79%) for predicting perioperative cardiac death and non-fatal myocardial infarction. On SROC analysis, there was a trend for dobutamine stress echocardiography to perform better than the other tests, but this only reached significance against myocardial perfusion scintigraphy (relative diagnostic odds ratio 5.5, 95% CI 2.0 to 14.9). CONCLUSIONS: On meta-analysis of six non-invasive tests, dobutamine stress echocardiography showed a positive trend towards better diagnostic performance than the other tests, but this was only significant in the comparison with myocardial perfusion scintigraphy. However, dobutamine stress echocardiography may be the favoured test in situations where there is valvar or left ventricular dysfunction.

The prognostic value of dobutamine stress echocardiography in patients with abdominal aortic aneurysm and concomitant coronary artery disease.

Patients undergoing abdominal aortic aneurysm (AAA) are at increased risk for cardiovascular complications such as cardiac death and nonfatal myocardial infarction. Dobutamine stress echocardiography is an established, cost-effective technique for the detection of coronary artery disease (CAD). This review will focus on the additional prognostic value of dobutamine stress echocardiography for perioperative and late prognosis in patients with AAA and CAD.

Cardiac risk and perioperative management.

Cardiovascular complications are the major cause of perioperative and late morbidity and mortality in patients undergoing major vascular surgery. This is related to the frequent presence of underlying coronary artery disease (CAD). CAD may be asymptomatic because of reduced exercise capacity due to pre-existing non-cardiac conditions like stroke or claudication. Careful preoperative evaluation of CAD and perioperative management with beta-blockers and statins may offer the physician a unique opportunity to improve patients' perioperative and long-term outcome.

Cardiac complications after elective major vascular surgery.

Cardiac complications are the major cause of perioperative and late mortality and morbidity in patients undergoing elective major vascular surgery. This review focuses on the pathophysiology of perioperative complications, risk assessment and risk reduction strategies, all related to cardiovascular disease. Patients without cardiac risk factors are considered to be at low risk and no additional evaluation for coronary artery disease is recommended; beta-adrenergic blockers may reduce perioperative cardiac events; patients with one or more risk factors represent an intermediate to high-risk population. beta-Adrenergic blockers should be prescribed to all patients and coronary revascularization should be reserved for patients who have a clearly defined need for revascularization independent of the need for vascular surgery.

Comparison between serum creatinine and creatinine clearance for the prediction of postoperative mortality in patients undergoing major vascular surgery.

BACKGROUND: Poor renal function prior to surgery is associated with increased risk for mortality in patients undergoing major vascular surgery. Traditionally, this function is assessed by serum creatinine concentration (SeCreat). However, SeCreat is also influenced by age, gender and body weight. Hence, creatinine clearance (C(Cr)) is considered to be a better reflection of renal function. This study was undertaken to explore the prognostic value of preoperative calculated Cc, compared to SeCreat for the prediction of postoperative mortality. PATIENTS AND METHODS: The study group comprised 852 consecutive patients who underwent elective major vascular surgery at the Erasmus Medical Center, Rotterdam. Preoperative C(Cr) was calculated based on the Cockroft-Gault equation using preoperative SeCreat, age, body weight and gender. Univariable logistic regression analyses were used to study the relation between preoperative SeCreat, C(Cr) and postoperative mortality. Furthermore, multivariable logistic regression analysis was applied to evaluate the additional predictive value of age, body weight and gender additional to SeCreat. The receiver operating characteristic (ROC) curve was determined to evaluate the predictive power of several regression models for perioperative mortality. RESULTS: Postoperative mortality was 5.9% (50/852) within 30 days of surgery. In a univariable analysis, 10 micromol/l increment of SeCreat were associated with a 20% increased risk of postoperative mortality (OR = 1.2, 95% CI, 1.1-1.3) with an area under the ROC curve of 0.64 (95% CI, 0.56-0.71). If age, gender and body weight were added, the area under the ROC curve increased to 0.70 (95% CI, 0.63-0.77; p < 0.001), indicating that these risk factors had additional prognostic value. Indeed, in a separate regression analysis 10 ml/min decrease in C(Cr) was associated with a 40% increased risk of postoperative mortality (OR = 1.4,95% CI, 1.2-1.5; ROC area: 0.70, 95% CI, 0.63-0.76). ROC curve analysis showed that the cut-off value of 64 ml/min for C(Cr) yielded the highest sensitivity/specificity to predict postoperative mortality. CONCLUSION: Preoperative SeCreat was strongly associated with postoperative mortality, and adding age, gender, and body weight to the model showed improved predictive power indicating that preoperative C(Cr) calculated with these data has additional prognostic value.

Which stress test is superior for perioperative cardiac risk stratification in patients undergoing major vascular surgery?

OBJECTIVE: to compare the additional prognostic value of Dobutamine Stress Echocardiography (DSE), Dipyridamole Stress Echocardiography (DiSE) and Perfusion Scintigraphy (DTS) on clinical risk factors in patients undergoing major vascular surgery. DESIGN: retrospective analysis. MATERIALS: 2204 consecutive patients who underwent DSE (n=1093), DiSE (n=394), or DTS (n=717) testing before major vascular surgery were studied. METHODS: primary endpoint was a composite of cardiac death and non-fatal myocardial infarction (MI). Logistic regression analysis was performed to evaluate the relation between cardiac risk factors, stress test results and the incidence of the composite endpoint. RESULTS: there were 138 patients (6.3%) with cardiac death or MI. Patients with 0, 1-2, and 3 or more risk factors experienced respectively 3.0, 5.7 and 17.4% cardiac events. We found no statistically significant difference in the predictive value of a positive test result for DiSE and DSE (Odds ratio (OR) of 37.1 [95% CI, 8.1-170.1] vs 9.6 [95% CI, 4.9-18.4]; p=0.12), whereas a positive test result for DTS had significantly lower prognostic value (OR=1.95 [95% CI, 1.2-3.2]). CONCLUSION: a result of stress echocardiography effectively stratified patients into low- and high-risk groups for cardiac complications, irrespective of clinical risk profile. In contrast, the prognostic value of DTS results was more likely to be dependent on patients' clinical risk profile.