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1.
Eur Heart J ; 41(5): 645-651, 2020 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-31237939

RESUMO

AIMS: To determine the 1-year risk of stroke and other adverse outcomes in patients with a new diagnosis of perioperative atrial fibrillation (POAF) after non-cardiac surgery. METHODS AND RESULTS: The PeriOperative ISchemic Evaluation (POISE)-1 trial evaluated the effects of metoprolol vs. placebo in 8351 patients, and POISE-2 compared the effect of aspirin vs. placebo, and clonidine vs. placebo in 10 010 patients. These trials included patients with, or at risk of, cardiovascular disease who were undergoing non-cardiac surgery. For the purpose of this study, we combined the POISE datasets, excluding 244 patients who were in atrial fibrillation (AF) at the time of randomization. Perioperative atrial fibrillation was defined as new AF that occurred within 30 days after surgery. Our primary outcome was the incidence of stroke at 1 year of follow-up; secondary outcomes were mortality and myocardial infarction (MI). We compared outcomes among patients with and without POAF using multivariable adjusted Cox proportional hazards models. Among 18 117 patients (mean age 69 years, 57.4% male), 404 had POAF (2.2%). The stroke incidence 1 year after surgery was 5.58 vs. 1.54 per 100 patient-years in patients with and without POAF, adjusted hazard ratio (aHR) 3.43, 95% confidence interval (CI) 2.00-5.90; P < 0.001. Patients with POAF also had an increased risk of death (incidence 31.37 vs. 9.34; aHR 2.51, 95% CI 2.01-3.14; P < 0.001) and MI (incidence 26.20 vs. 8.23; aHR 5.10, 95% CI 3.91-6.64; P < 0.001). CONCLUSION: Patients with POAF have a significantly increased risk of stroke, MI, and death at 1 year. Intervention studies are needed to evaluate risk reduction strategies in this high-risk population.

2.
Ann Surg ; 271(2): 283-289, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30048320

RESUMO

OBJECTIVE: To compare the accuracy of the modified Fried Index (mFI) and the Clinical Frailty Scale (CFS) to predict death or patient-reported new disability 90 days after major elective surgery. BACKGROUND: The association of frailty with patient-reported outcomes, and comparisons between preoperative frailty instruments are poorly described. METHODS: This was a prospective multicenter cohort study. We determined frailty status in individuals ≥65 years having elective noncardiac surgery using the mFI and CFS. Outcomes included death or patient-reported new disability (primary); safety incidents, length of stay (LOS), and institutional discharge (secondary); ease of use, usefulness, benefit, clinical importance, and feasibility (tertiary). We measured the adjusted association of frailty with outcomes using regression analysis and compared true positive and false positive rates (TPR/FPR). RESULTS: Of 702 participants, 645 had complete follow up. The CFS identified 297 (42.3%) with frailty, the mFI 257 (36.6%); 72 (11.1%) died or experienced a new disability. Frailty was significantly associated with the primary outcome (CFS adjusted odds ratio, OR, 2.51, 95% confidence interval, CI, 1.50-4.21; mFI adjusted-OR 2.60, 95% CI 1.57-4.31). TPR and FPR were not significantly different between instruments. Frailty was the only significant predictor of death or new disability in a multivariable analysis. Need for institutional discharge, costs and LOS were significantly increased in individuals with frailty. The CFS was easier to use, required less time and had less missing data. CONCLUSIONS: Older people with frailty are significantly more likely to die or experience a new patient-reported disability after surgery. Clinicians performing frailty assessments before surgery should consider the CFS over the mFI as accuracy was similar, but ease of use and feasibility were higher.

4.
Anesth Analg ; 128(3): 533-542, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30676348

RESUMO

Perioperative intermediate care units (termed surgical special care units) have been widely implemented across health systems because they are believed to improve surveillance and management of high-risk surgical patients. Our objective was to conduct a systematic review to investigate the effects of a 3-level model of perioperative care delivery (ie, ward, surgical special care unit, or intensive care unit) compared to a 2-level model of care (ie, ward, intensive care unit) on postoperative outcomes. Our protocol was registered with PROSPERO, the international prospective register of systematic reviews (CRD42015025155). Randomized controlled studies and nonrandomized comparator studies were included. We performed a systematic search of Medline, Cumulative Index to Nursing and Allied Health Literature, Embase, and the Cochrane library (inception - 11/2017). The primary outcome was mortality; secondary outcomes included length of stay and hospital costs. We identified 1995 citations with our search, and 21 studies met eligibility criteria (2 randomized controlled studies and 19 nonrandomized comparator studies; 44,134 patients in total). Surgical special care units were characterized by continuous monitoring (12 studies), the absence of mechanical ventilation (8 studies), nurse-to-patient ratios (range, 1:2-1:4), and number of beds (median: 5; range: 3-33). Thirteen studies reported on mortality. Notable findings included no observed difference in overall in-hospital mortality, but an apparent increase in intensive care unit mortality in a 3-level model of care. This may reflect a decanting of lower acuity patients from the intensive care unit to the surgical special care unit. No significant difference was found in hospital length of stay; however, 2 studies demonstrated reductions in hospital costs with the implementation of a surgical special care unit. Significant clinical and methodological heterogeneity precluded pooled analysis. Given the prevalence of surgical special care units, the results of our review suggest that additional methodologically rigorous investigations are needed to understand the effect of these units on the surgical population.


Assuntos
Unidades de Terapia Intensiva/tendências , Aceitação pelo Paciente de Cuidados de Saúde , Assistência Perioperatória/mortalidade , Assistência Perioperatória/tendências , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Assistência Perioperatória/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Resultado do Tratamento
5.
Syst Rev ; 6(1): 226, 2017 11 07.
Artigo em Inglês | MEDLINE | ID: mdl-29116020

RESUMO

BACKGROUND: Despite advances in treatment, acute myocardial infarction (MI) is still associated with significant morbidity and mortality, especially in patients with extensive damage and scar formation. Based on some promising preclinical studies, there is interest in the use of mesenchymal stromal cells (MSCs) to promote cardiac repair after acute MI. However, there is a need for a systematic review of this evidence to summarize the efficacy and safety of MSCs in preclinical models of MI. This will better inform the translation of MSC therapy for acute MI and guide the design of a future clinical trial. METHODS/DESIGN: A systematic literature search of MEDLINE, Embase, and BIOSIS Previews will be conducted. We will identify comparative preclinical studies (randomized and non-randomized) of myocardial infarction that include animals given MSC therapy versus a vehicle/placebo. The primary outcome will be left ventricular ejection fraction. Secondary and tertiary outcomes will include death, infarct size, measures of cardiac function, biochemical outcomes, and MSC retention and differentiation. Risk of bias will be assessed using the Cochrane Risk of Bias Tool. Subgroup analyses will be performed to measure how various sources of preclinical study heterogeneity affect the direction and magnitude of the primary outcome. We will meta-analyze data using inverse variance random effects modeling. DISCUSSION: This systematic review of preclinical evidence will provide a summary of the efficacy and safety of MSCs in animal models of MI. The results will help determine whether sufficient evidence exists to conduct a clinical trial in humans and inform its design.


Assuntos
Transplante de Células-Tronco Mesenquimais , Células-Tronco Mesenquimais , Infarto do Miocárdio/cirurgia , Animais , Humanos , Infarto do Miocárdio/fisiopatologia , Projetos de Pesquisa , Revisões Sistemáticas como Assunto , Função Ventricular Esquerda
6.
CMAJ ; 189(27): E905-E912, 2017 Jul 10.
Artigo em Inglês | MEDLINE | ID: mdl-28694308

RESUMO

BACKGROUND: Delay of surgery for hip fracture is associated with increased risk of morbidity and mortality, but the effects of surgical delays on mortality and resource use in the context of other emergency surgeries is poorly described. Our objective was to measure the independent association between delay of emergency surgery and in-hospital mortality, length of stay and costs. METHODS: We identified all adult patients who underwent emergency noncardiac surgery between January 2012 and October 2014 at a single tertiary care centre. Delay of surgery was defined as the time from surgical booking to operating room entry exceeding institutionally defined acceptable wait times, based on a standardized 5-level priority system that accounted for surgery type and indication. Patients with delayed surgery were matched to those without delay using propensity scores derived from variables that accounted for details of admission and the hospital stay, patient characteristics, physiologic instability, and surgical urgency and risk. RESULTS: Of 15 160 patients, 2820 (18.6%) experienced a delay. The mortality rates were 4.9% (138/2820) for those with delay and 3.2% (391/12 340) for those without delay (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.30-1.93). Within the propensity-matched cohort, delay was significantly associated with mortality (OR 1.56, 95% CI 1.18-2.06), increased length of stay (incident rate ratio 1.07, 95% CI 1.01-1.11) and higher total costs (incident rate ratio 1.06, 95% CI 1.01-1.11). INTERPRETATION: Delayed operating room access for emergency surgery was associated with increased risk of inhospital mortality, longer length of stay and higher costs. System issues appeared to underlie most delays and must be addressed to improve the outcomes of emergency surgery.


Assuntos
Tratamento de Emergência , Mortalidade Hospitalar , Tempo de Internação , Procedimentos Cirúrgicos Operatórios/mortalidade , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Tempo para o Tratamento , Adulto , Idoso , Idoso de 80 Anos ou mais , Canadá , Bases de Dados Factuais , Feminino , Custos Hospitalares , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Pontuação de Propensão , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios/classificação , Centros de Atenção Terciária
7.
Anesth Analg ; 125(1): 162-169, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28622175

RESUMO

BACKGROUND: Despite the frequency of new clinically important atrial fibrillation (AF) after noncardiac surgery and its increased association with the risk of stroke at 30 days, there are limited data informing their prediction, association with outcomes, and management. METHODS: We used the data from the PeriOperative ISchemic Evaluation trial to determine, in patients undergoing noncardiac surgery, the association of new clinically important AF with 30-day outcomes, and to assess management of these patients. We also aimed to derive a clinical prediction rule for new clinically important AF in this population. We defined new clinically important AF as new AF that resulted in symptoms or required treatment. We recorded an electrocardiogram 6 to 12 hours postoperatively and on the 1st, 2nd, and 30th days after surgery. RESULTS: A total of 211 (2.5% [8351 patients]; 95% confidence interval, 2.2%-2.9%) patients developed new clinically important AF within 30 days of randomization (8140 did not develop new AF). AF was independently associated with an increased length of hospital stay by 6.0 days (95% confidence interval, 3.5-8.5 days) and vascular complications (eg, stroke or congestive heart failure). The usage of an oral anticoagulant at the time of hospital discharge among patients with new AF and a CHADS2 score of 0, 1, 2, 3, and ≥4 was 6.9%, 10.2%, 23.0%, 9.4%, and 33.3%, respectively. Two independent predictors of patients developing new clinically important AF were identified (ie, age and surgery). The prediction rule included the following factors and assigned weights: age ≥85 years (4 points), age 75 to 84 years (3 points), age 65 to 74 years (2 points), intrathoracic surgery (3 points), major vascular surgery (2 points), and intra-abdominal surgery (1 point). The incidence of new AF based on scores of 0 to 1, 2, 3 to 4, and 5 to 6 was 0.5%, 1.0%, 3.1%, and 5.3%, respectively. CONCLUSIONS: Age and surgery are independent predictors of new clinically important AF in the perioperative setting. A minority of patients developing new clinically important AF with high CHADS2 scores are discharged on an oral anticoagulant. There is a need to develop effective and safe interventions to prevent this outcome and to optimize the management of this event when it occurs.


Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Abdome/cirurgia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Eletrocardiografia , Feminino , Humanos , Incidência , Laparotomia/efeitos adversos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Procedimentos Cirúrgicos Torácicos/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos
8.
Can J Anaesth ; 64(4): 411-415, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-28078546

RESUMO

PURPOSE: This case report outlines the utility and challenges of remote continuous postoperative electrocardiography ECG) monitoring, which is routed through a secure smartphone to provide real-time detection and management of myocardial ischemia. CLINICAL FEATURES: A 42-yr-old male with previous myocardial infarction and angioplasty underwent a radical prostatectomy. At three hours and 45 min postoperatively, remote real-time ECG monitoring was initiated upon the patient's arrival on a regular surgical ward. Monitor alerts were routed to a study clinician's smartphone. About six hours postoperatively, alarms were received and horizontal ST segment depressions were observed. A 12-lead ECG validated the ST segment changes, prompting initiation of a metoprolol iv and a red blood cell transfusion. Approximately seven hours and 30 min postoperatively, the ST segments normalized. The patient was discharged on postoperative day 3 and followed for four years without any sequelae. CONCLUSION: This case report illustrates the use of remote ECG monitoring and clinician response in real time with the use of a smartphone. With each alert, a small ECG strip is transmitted to the smartphone for viewing. In our view, this technology and management system provides a possible means to interrupt myocardial ischemic cascades in real time and prevent postoperative myocardial infarction.


Assuntos
Eletrocardiografia/métodos , Monitorização Fisiológica/métodos , Isquemia Miocárdica/diagnóstico , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/diagnóstico , Adulto , Sistemas Computacionais , Humanos , Masculino , Monitorização Fisiológica/instrumentação , Smartphone
9.
IEEE Trans Biomed Eng ; 64(6): 1318-1325, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-27576238

RESUMO

OBJECTIVE: The objective of this study is to propose and validate an alarm gating system for a myocardial ischemia monitoring system that uses ambulatory electrocardiogram. The PeriOperative ISchemic Evaluation study recommended the selective administration of ß blockers to patients at risk of cardiac events following noncardiac surgery. Patients at risk are identified by monitoring ST segment deviations in the electrocardiogram (ECG); however, patients are encouraged to ambulate to improve recovery, which deteriorates the signal quality of the ECG leading to false alarms. METHODS: The proposed alarm gating system computes a signal quality index (SQI) to quantify the ECG signal quality and rejects alarms with a low SQI. The system was validated by artificially contaminating ECG records with motion artifact records obtained from the long-term ST database and MIT-BIH noise stress test database, respectively. RESULTS: Without alarm gating, the myocardial ischemia monitoring system attained a Precision of 0.31 and a Recall of 0.78. The alarm gating improved the Precision to 0.58 with a reduction of Recall to 0.77. CONCLUSION: The proposed system successfully gated false alarms with future work exploring the misidentification of fiducial points by myocardial ischemia monitoring systems. SIGNIFICANCE: The reduction of false alarms due to the proposed system will decrease the incidence of the alarm fatigue condition typically found in clinicians. Alarm fatigue condition was rated as the top patient safety hazard from 2012 to 2015 by the Emergency Care Research Institute.


Assuntos
Alarmes Clínicos , Diagnóstico por Computador/métodos , Eletrocardiografia Ambulatorial/métodos , Isquemia Miocárdica/diagnóstico , Reconhecimento Automatizado de Padrão/métodos , Processamento de Sinais Assistido por Computador , Diagnóstico por Computador/instrumentação , Eletrocardiografia Ambulatorial/instrumentação , Reações Falso-Positivas , Humanos , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Razão Sinal-Ruído
10.
Can J Anaesth ; 64(2): 149-157, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27650648

RESUMO

PURPOSE: Is professionalism in medicine just another bureaucratic imposition on our practice or a fundamental concept for physicians at all stages in their career? In this review, the historical perspectives of professionalism are explored as well as the what, why, and how questions concerning this topic. SOURCE: The key words "professionalism" and "anesthesia" were used to conduct a search of the PubMed database, the policies and publications of relevant Canadian and international physician regulatory bodies and organizations, historical documents, and other internet publications. PRINCIPAL FINDINGS: Professionalism in anesthesia has a long history. While there are many definitions for professionalism, some very dated, all are based on virtues, behaviour, or professional identity. Professionalism plays a central role in the balance between physician autonomy and social contract, and it has a significant impact on patient safety and medicolegal litigation. CONCLUSION: Considerable evidence exists to suggest that professionalism must be treated seriously, particularly in these times of social accountability and budgetary pressures.


Assuntos
Anestesiologia , Profissionalismo , Humanos , Colaboração Intersetorial , Segurança do Paciente , Médicos , Autonomia Profissional , Responsabilidade Social , Virtudes
12.
BMC Anesthesiol ; 16(1): 111, 2016 11 14.
Artigo em Inglês | MEDLINE | ID: mdl-27842511

RESUMO

BACKGROUND: Frailty is an aggregate expression of susceptibility to poor outcomes, owing to age-, and disease-related deficits that accumulate within multiple domains. Older patients who are frail before surgery are at an increased risk of morbidity and mortality, and use a disproportionately high amount of healthcare resources. While frailty is now a well-established risk factor for adverse postoperative outcomes, the perioperative literature lacks studies that: 1) compare the predictive accuracy of different frailty instruments; 2) consider the impact of frailty on patient-reported outcome measures; and 3) consider the acceptability and feasibility of using frailty instruments in clinical practice. METHODS: We will conduct a multicenter prospective cohort study comparing the predictive accuracy of the modified Fried Index (mFI) with the Clinical Frailty Scale (CFS) among consenting patients aged 65 years and older having elective major non-cardiac surgery. The primary outcome will be disability free survival at 90 days after surgery, a patient-reported outcome measure. Secondary outcomes will include complications, length of stay, discharge disposition, readmission and total health system costs. We will compare the accuracy of frailty instruments using the relative true positive rate and relative false positive rate. These measures can be interpreted as the relative difference in the probability of one instrument identifying a true case of death or new disability compared to another instrument, or the relative difference in the probability of one instrument identifying a false case of death or new disability, respectively. We will also assess the acceptability and feasibility of each instrument. DISCUSSION: Frailty is an important prognostic factor in the growing population of older patients having surgery. This study will provide novel findings regarding the choice of an accurate, clinically useable frailty instrument in predicting patient reported outcomes, as well as morbidity, mortality and resource use. These findings will inform current practice and future research.


Assuntos
Idoso Fragilizado , Avaliação Geriátrica/métodos , Complicações Pós-Operatórias/epidemiologia , Idoso , Estudos de Coortes , Avaliação da Deficiência , Reações Falso-Positivas , Humanos , Medidas de Resultados Relatados pelo Paciente , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Medição de Risco/métodos , Fatores de Risco , Análise de Sobrevida
14.
Anesthesiology ; 125(1): 72-91, 2016 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-27077638

RESUMO

BACKGROUND: The prognostic value of perioperative diastolic dysfunction (PDD) in patients undergoing noncardiac surgery remains uncertain, and the current guidelines do not recognize PDD as a perioperative risk factor. This systematic review aimed to investigate whether existing evidence supports PDD as an independent predictor of adverse events after noncardiac surgery. METHODS: Ovid MEDLINE, PubMed, EMBASE, the Cochrane Library, and Google search engine were searched for English-language citations in April 2015 investigating PDD as a risk factor for perioperative adverse events in adult patients undergoing noncardiac surgery. Two reviewers independently assessed the study risk of bias. Extracted data were verified. Random-effects model was used for meta-analysis, and reviewers' certainty was graded. RESULTS: Seventeen studies met eligibility criteria; however, 13 contributed to evidence synthesis. The entire body of evidence addressing the research question was based on a total of 3,876 patients. PDD was significantly associated with pulmonary edema/congestive heart failure (odds ratio [OR], 3.90; 95% CI, 2.23 to 6.83; 3 studies; 996 patients), myocardial infarction (OR, 1.74; 95% CI, 1.14 to 2.67; 3 studies; 717 patients), and the composite outcome of major adverse cardiovascular events (OR, 2.03; 95% CI, 1.24 to 3.32; 4 studies; 1,814 patients). Evidence addressing other outcomes had low statistical power, but higher long-term cardiovascular mortality was observed in patients undergoing open vascular repair (OR, 3.00; 95% CI, 1.50 to 6.00). Reviewers' overall certainty of the evidence was moderate. CONCLUSION: Evidence of moderate certainty indicates that PDD is an independent risk factor for adverse cardiovascular outcomes after noncardiac surgery.


Assuntos
Doenças Cardiovasculares/epidemiologia , Insuficiência Cardíaca Diastólica/epidemiologia , Período Perioperatório , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Humanos , Assistência Perioperatória , Complicações Pós-Operatórias/epidemiologia , Fatores de Risco
16.
Anesth Analg ; 116(5): 1034-40, 2013 May.
Artigo em Inglês | MEDLINE | ID: mdl-23337413

RESUMO

BACKGROUND: In this post hoc subanalysis of the Perioperative Ischemic Evaluation (POISE) trial, we sought to determine whether nitrous oxide was associated with the primary composite outcome of cardiovascular death, nonfatal myocardial infarction (MI), and nonfatal cardiac arrest within 30 days of randomization. METHODS: The POISE trial of perioperative ß-blockade was undertaken in 8351 patients. Nitrous oxide anesthesia was defined as the coadministration of nitrous oxide in patients receiving general anesthesia, with or without additional neuraxial blockade or peripheral nerve blockade. Logistic regression, with inverse probability weighting using estimated propensity scores, was used to determine the association of nitrous oxide with the primary outcome, MI, stroke, death, and clinically significant hypotension. RESULTS: Nitrous oxide was administered to 1489 (29%) of the 5133 patients included in this analysis. Nitrous oxide had no significant effect on the risk of the primary outcome (112 [7.5%] vs 248 [6.9%]; odds ratio [OR], 1.08; 95% confidence interval [CI], 0.82-1.44; 99% CI, 0.75-1.57; P = 0.58), MI (89 [6.0] vs 204 [5.6]; OR, 0.99; 95% CI, 0.75-1.31; 99% CI, 0.69-1.42; P = 0.94), stroke (6 [0.4%] vs 28 [0.8%]; OR, 0.85; 95% CI, 0.26-2.82; 99% CI, 0.17-4.11; P = 0.79), death (40 [2.7%] vs 100 [2.8%]; OR, 1.04; 95% CI, 0.6-1.81; 99% CI, 0.51-2.15; P = 0.88) or clinically significant hypotension (219 [14.7%] vs 544 [15.0%]; OR, 0.92; 95% CI, 0.74-1.15; 99% CI, 0.70-1.23; P = 0.48). CONCLUSIONS: In this post hoc subanalysis, nitrous oxide was not associated with an increased risk of adverse outcomes in the POISE trial patients. This analysis was limited by the observational nature of the data and the lack of information on the concentration and duration of nitrous oxide administration. Further randomized controlled trial evidence is required.


Assuntos
Anestésicos Inalatórios/efeitos adversos , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/mortalidade , Óxido Nitroso/efeitos adversos , Período Perioperatório/mortalidade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/mortalidade , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Anestesia por Inalação/efeitos adversos , Intervalos de Confiança , Interpretação Estatística de Dados , Método Duplo-Cego , Uso de Medicamentos , Feminino , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Razão de Chances , Medicação Pré-Anestésica , Pontuação de Propensão , Fatores Sexuais , Resultado do Tratamento
17.
Ann Intern Med ; 154(8): 523-8, 2011 Apr 19.
Artigo em Inglês | MEDLINE | ID: mdl-21502650

RESUMO

BACKGROUND: Each year, millions of patients worldwide have a perioperative myocardial infarction (MI) after noncardiac surgery. OBJECTIVE: To examine the characteristics and short-term outcome of perioperative MI. DESIGN: Cohort study. (ClinicalTrials.gov registration number: NCT00182039) SETTING: 190 centers in 23 countries. PATIENTS: 8351 patients included in the POISE (PeriOperative ISchemic Evaluation) trial. MEASUREMENTS: Four cardiac biomarker or enzyme assays were measured within 3 days of surgery. The definition of perioperative MI included either autopsy findings of acute MI or an elevated level of a cardiac biomarker or enzyme and at least 1 of the following defining features: ischemic symptoms, development of pathologic Q waves, ischemic changes on electrocardiography, coronary artery intervention, or cardiac imaging evidence of MI. RESULTS: Within 30 days of random assignment, 415 patients (5.0%) had a perioperative MI. Most MIs (74.1%) occurred within 48 hours of surgery; 65.3% of patients did not experience ischemic symptoms. The 30-day mortality rate was 11.6% (48 of 415 patients) among patients who had a perioperative MI and 2.2% (178 of 7936 patients) among those who did not (P < 0.001). Among patients with a perioperative MI, mortality rates were elevated and similar between those with (9.7%; adjusted odds ratio, 4.76 [95% CI, 2.68 to 8.43]) and without (12.5%; adjusted odds ratio, 4.00 [CI, 2.65 to 6.06]) ischemic symptoms. LIMITATION: Cardiac markers were measured only until day 3 after surgery, and additional asymptomatic MIs may have been missed. CONCLUSION: Most patients with a perioperative MI will not experience ischemic symptoms. Data suggest that routine monitoring of troponin levels in at-risk patients is needed after surgery to detect most MIs, which have an equally poor prognosis regardless of whether they are symptomatic or asymptomatic.


Assuntos
Infarto do Miocárdio/diagnóstico , Período Perioperatório , Biomarcadores/sangue , Estudos de Coortes , Creatina Quinase Forma MB/sangue , Eletrocardiografia , Humanos , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Prognóstico , Troponina/sangue
19.
Can J Anaesth ; 58(5): 428-35, 2011 May.
Artigo em Inglês | MEDLINE | ID: mdl-21347737

RESUMO

PURPOSE: To determine whether patients with isolated systolic hypertension (ISH) undergoing non-cardiac surgery have a higher incidence of perioperative myocardial ischemia than normotensive patients and hence a greater risk for perioperative adverse events. METHODS: After obtaining Research Ethics Board approval, patients were recruited to either an ISH group (systolic blood pressure [SBP] > 140 mmHg with diastolic blood pressure [DBP] < 90 mmHg) or a normotensive group (SBP < 140 mmHg and DBP < 90 mmHg), according to their resting preoperative blood pressure. The primary outcome was the overall incidence of perioperative myocardial ischemia (PMI) as determined by 48-hr ambulatory Holter monitoring. P values ≤ 0.05 were considered to be statistically significant. RESULTS: A total of 312 (150 ISH and 162 normotensive) patients completed the study. Orthopedic surgery was the most frequent surgical procedure in both groups. The overall incidence of PMI was 19.7% in the ISH group compared with 18.8% in the normotensive group (difference 0.9%; 95% confidence interval [CI], -7.9% to 9.8%). The overall incidence of adverse events was 4.0% in the ISH group compared with 1.9% in the normotensive group (difference 2.2%; 95% CI, -1.6% to 5.9%). CONCLUSION: In this study, we chose to examine ISH as potential cardiac risk factor for patients undergoing non-cardiac surgery. The incidence of myocardial ischemia, a surrogate outcome, was similar in the two groups. The relatively high incidence of myocardial ischemia (19.2%) was of particular interest in this relatively low cardiac risk surgical population. (ClinicalTrials.gov number, NCT01237652).


Assuntos
Hipertensão/complicações , Complicações Intraoperatórias/epidemiologia , Isquemia Miocárdica/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Idoso , Pressão Sanguínea , Estudos de Casos e Controles , Eletrocardiografia Ambulatorial , Feminino , Humanos , Incidência , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/etiologia , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Fatores de Risco , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/métodos
20.
Ann Intern Med ; 154(8): 523-528, 2011. ilus, tab
Artigo em Inglês | Sec. Est. Saúde SP, SESSP-IDPCPROD, Sec. Est. Saúde SP | ID: ses-29247

RESUMO

BACKGROUND: Each year, millions of patients worldwide have a perioperative myocardial infarction (MI) after noncardiac surgery.OBJECTIVE: To examine the characteristics and short-term outcome of perioperative MI.DESIGN: Cohort study. (ClinicalTrials.gov registration number: NCT00182039)SETTING: 190 centers in 23 countries.PATIENTS: 8351 patients included in the POISE (PeriOperative ISchemic Evaluation) trial.MEASUREMENTS: Four cardiac biomarker or enzyme assays were measured within 3 days of surgery. The definition of perioperative MI included either autopsy findings of acute MI or an elevated level of a cardiac biomarker or enzyme and at least 1 of the following defining features: ischemic symptoms, development of pathologic Q waves, ischemic changes on electrocardiography, coronary artery intervention, or cardiac imaging evidence of MI.RESULTS: Within 30 days of random assignment, 415 patients (5.0%) had a perioperative MI. Most MIs (74.1%) occurred within 48 hours of surgery; 65.3% of patients did not experience ischemic symptoms. The 30-day mortality rate was 11.6% (48 of 415 patients) among patients who had a perioperative MI and 2.2% (178 of 7936 patients) among those who did not (P < 0.001). Among patients with a perioperative MI, mortality rates were elevated and similar between those with (9.7%; adjusted odds ratio, 4.76 [95% CI, 2.68 to 8.43]) and without (12.5%; adjusted odds ratio, 4.00 [CI, 2.65 to 6.06]) ischemic symptoms.LIMITATION: Cardiac markers were measured only until day 3 after surgery, and additional asymptomatic MIs may have been missed.CONCLUSION: Most patients with a perioperative MI will not experience ischemic symptoms. Data suggest that routine monitoring of troponin levels in at-risk patients is needed after surgery to detect most MIs, which have an equally poor prognosis regardless of whether they are symptomatic or asymptomatic. (AU)


Assuntos
Infarto do Miocárdio , Prognóstico , Cuidados Pré-Operatórios
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