S. C. Gibson

Is a pre-operative brain natriuretic peptide or N-terminal pro-B-type natriuretic peptide measurement an independent predictor of adverse cardiovascular outcomes within 30 days of noncardiac surgery? A systematic review and meta-analysis of observational studies.

OBJECTIVES We conducted a systematic review and meta-analysis to determine if pre-operative brain natriuretic peptide (BNP) (i.e., BNP or N-terminal pro-B-type natriuretic peptide [NT-proBNP]) is an independent predictor of 30-day adverse cardiovascular outcomes after noncardiac surgery. BACKGROUND Pre-operative clinical cardiac risk indices have only modest predictive power. BNP predicts adverse cardiovascular outcomes in a variety of nonsurgical settings and may similarly predict these outcomes in the perioperative setting. METHODS We employed 5 search strategies (e.g., searching bibliographic databases), and we included all studies that assessed the independent prognostic value of pre-operative BNP measurement as a predictor of cardiovascular complications after noncardiac surgery. We determined study eligibility and conducted data abstraction independently and in duplicate. We calculated a pooled odds ratio using a random effects model. RESULTS Nine studies met eligibility criteria, and included a total of 3,281 patients, among whom 314 experienced 1 or more perioperative cardiovascular complications. The average proportion of patients with elevated BNP was 24.8% (95% confidence interval [CI]: 20.1 to 30.4%; I(2) = 89%). All studies showed a statistically significant association between an elevated pre-operative BNP level and various cardiovascular outcomes (e.g., a composite of cardiac death and nonfatal myocardial infarction; atrial fibrillation). Data pooled from 7 studies demonstrated an odds ratio (OR) of 19.3 (95% CI: 8.5 to 43.7; I(2) = 58%). The pre-operative BNP measurement was an independent predictor of perioperative cardiovascular events among studies that only considered the outcomes of death, cardiovascular death, or myocardial infarction (OR: 44.2, 95% CI: 7.6 to 257.0, I(2) = 51.6%), and those that included other outcomes (OR: 14.7, 95% CI: 5.7 to 38.2, I(2) = 62.2%); the p value for interaction was 0.28. CONCLUSIONS These results suggest that an elevated pre-operative BNP or NT-proBNP measurement is a powerful, independent predictor of cardiovascular events in the first 30 days after noncardiac surgery.

B‐type natriuretic peptide predicts cardiac morbidity and mortality after major surgery

The objective of this study was to determine whether measurement of B‐type natriuretic peptide (BNP) concentration before operation could be used to predict perioperative cardiac morbidity.

Predictive value of plasma brain natriuretic peptide for cardiac outcome after vascular surgery

Vascular surgery is associated with a substantial risk of cardiovascular events and death.1,2 There is no effective method for determining cardiac risk preoperatively: validated risk prediction instruments are limited by complexity and poor predictive value, and other cardiac investigations such as nuclear stress testing and coronary angiography are limited by time and resources. For these reasons, alternative methods that can predict outcome of at risk patients would be an important advance. Plasma brain natriuretic peptide (BNP) has counter-regulatory vasodilator and natriuretic properties. Plasma BNP concentrations are often increased in cardiac disorders, such as angina and heart failure. The plasma concentrations of BNP are related to prognosis in these conditions.3 Many of these cardiovascular conditions occur in patients with peripheral vascular disease. We investigated the predictive value of preoperative plasma BNP concentration for the occurrence of perioperative fatal or non-fatal myocardial infarction (MI) in high risk vascular surgical patients. We also compared the predictive value of plasma BNP concentration with the Eagle score, a conventional surgical risk assessment instrument.1,2 We screened consecutive patients undergoing major surgery for aortic or peripheral arterial occlusive disease in Gartnavel General Hospital, Glasgow, between April and September 2004. All patients at high risk, defined according to the American Society of Anesthesiology …

Ten-year experience of carbon dioxide laser ablation as treatment for cutaneous recurrence of malignant melanoma.

Cutaneous recurrence of malignant melanoma is distressing for the patient, can be difficult to palliate and is resistant to treatment by conventional methods. Experience with carbon dioxide laser ablation was reviewed to determine the initial efficacy, time to recurrence, number of treatments required and length of palliation achieved.

Measurement of process as quality control in the management of acute surgical emergencies

Quality of care measured by adverse events cannot address errors of process that have no adverse outcomes. The aim of this study was to determine whether process could be used to assess quality of care and whether process analysis could be used to assess interventions designed to improve quality.

B-type natriuretic peptide predicts long-term survival after major non-cardiac surgery

BACKGROUND The prediction of long-term survival after surgery is complex. Natriuretic peptides can predict short-term postoperative cardiac morbidity and mortality. This study aims to determine the long-term prognostic significance of preoperative B-type natriuretic peptide (BNP) concentration after major non-cardiac surgery. METHODS We conducted a prospective single-centre observational cohort study in a West of Scotland teaching hospital. Three hundred and forty-five patients undergoing major non-cardiac surgery were included. The primary endpoint was long-term all-cause mortality. RESULTS Overall survival was 67.8% (234/345), with 27 postoperative deaths (within 42 days) and 84 deaths at subsequent follow-up (median follow-up 953 days). A BNP concentration of >87.5 pg ml(-1) best predicted mortality, and the mean survival of patients with an elevated BNP (>87.5 pg ml(-1)) was 731.9 (95% CI 613.6-850.2) days compared with 1284.6 days [(95% CI 1219.3-1350.0), P<0.001] in patients with a BNP<87.5 pg ml(-1). BNP was an independent predictor of survival. CONCLUSIONS BNP is an independent predictor of long-term survival after major non-cardiac surgery. A simple preoperative blood test can provide predictive information on future risk of death, and potentially has a role in preoperative risk assessment.

Preoperative plasma N‐terminal pro‐brain natriuretic peptide as a marker of cardiac risk in patients undergoing elective non‐cardiac surgery (Br J Surg 2005; 92: 1041‐1045)

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110 THE pre-operative 12 lead ECG; can it predict post-operative cardiac complications?

Introduction The 12 lead electrocardiogram (ECG) is a standard pre-operative investigation for patients undergoing major surgery. A number of recent publications have questioned the predictive value for post-operative cardiac risk. The aim of this study is to investigate the correlation between an abnormal ECG and a post-operative major adverse cardiac event (MACE) and mortality. Methods A prospective single centre observational cohort study of 345 patients undergoing major non-cardiac surgery between January 2004 and August 2006 was performed. Patients underwent standard pre-operative assessment including an ECG. Screening for post-operative events was carried out with serial ECG and troponin measurement. Primary end-points were MACE (cardiac death and non-fatal myocardial infarction) and all-cause mortality. Results Three hundred and forty-five patients were included in the study, performed between January 2004 and August 2006. 276 (80.0%) patients underwent a vascular procedure (aortic surgery 25.8%, lower limb bypass 29.8% and amputation 25.2%) and 69 (20.0%) patients underwent laparotomy. An abnormal ECG (Abstract 110 Table 1) was present in 141 (40.9%) patients. MACE was observed in 46 (13.3) patients, and 27 (7.8%) patients died in the post-operative period. Patients with an abnormal ECG had a higher incidence of MACE (22.0% vs 7.4%, p<0.001), and higher mortality rate (12.1% vs 9.8%, p=0.015). Univariate analysis shows that AF, strain and prolonged QTc interval predict post-operative events. Multivariate analysis of clinical variables and ECG abnormalities showed that strain, prolonged QTc and hypertension independently predicted post-operative MACE. Abstract 110 Table 1 ECG abnormalities recorded Rate and rhythm Abnormal pulse rate Atrial fibrillation Premature ventricular contractions Conducton Cardiac axis deviation Prolonged PR/QRS/QTc intervals Bundle branch block Morphology/pathology Pathological Q waves Left ventricular hypertrophy Cardiac strain/ST segment deviation Conclusion This study shows that ECG abnormalities were more predictive than traditional clinical variables for post-operative MACE, and therefore confirms that an ECG remains a useful adjunct in pre-operative assessment before surgery. An abnormal ECG confers a threefold increase risk of post-operative MACE. This may allow improved pre-operative optimisation and enhanced peri-operative care to reduce the event rates.