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Canadian Journal of Cardiology

Underutilization of Perioperative Screening for Cardiovascular Events After Noncardiac Surgery in Alberta

Published:December 09, 2020DOI:https://doi.org/10.1016/j.cjca.2020.06.003

      Abstract

      Background

      Perioperative myocardial injury after noncardiac surgery affects more than 10% of individuals, with increased morbidity and mortality. Perioperative cardiac risk assessment targets the identification of this high-risk population using preoperative natriuretic peptides and postoperative troponin measurements. Our objective was to assess the use of these biomarkers in the province of Alberta.

      Methods

      A retrospective cohort of all patients who underwent noncardiac surgery in Alberta from January 2013 to December 2017 was created using linked provincial administrative databases. Inclusion criteria were modified from recommendations for perioperative cardiac screening including: patients with a Revised Cardiac Risk Index score ≥ 1 and age 65 years or older, or 45 years of age or older with history of cardiovascular disease, with planned overnight hospital stay.

      Results

      In our cohort of 59,506 patients, only 6.8% underwent preoperative natriuretic peptide screening. Rates of appropriate preoperative natriuretic peptide testing increased marginally from 5.7% to 8.8% over the study period. Postoperative troponin was measured at least once in 19.5% of patients. Patients with elevated perioperative screening biomarkers showed increased 6-month mortality, and increased hospitalizations for heart failure and acute coronary syndromes.

      Conclusions

      The use of biomarkers to assist in cardiac risk stratification and postoperative monitoring remains low. Addressing access to these tests and improving physician education regarding the asymptomatic nature of postoperative cardiac events might improve compliance with national guidelines.

      Résumé

      Contexte

      Après une intervention chirurgicale non cardiaque, on observe des lésions myocardiques périopératoires chez plus de 10 % des patients, ce qui accroît la morbidité et la mortalité. L’objectif de l’évaluation du risque cardiaque périopératoire est de cerner cette population présentant un risque élevé par le dosage préopératoire des peptides natriurétiques et le dosage postopératoire de la troponine. Notre objectif était d’évaluer l’utilisation de ces biomarqueurs en Alberta.

      Méthodologie

      À partir de bases de données administratives provinciales liées, nous avons créé une étude rétrospective auprès d’une cohorte composée de tous les patients ayant subi une intervention chirurgicale non cardiaque en Alberta entre janvier 2013 et décembre 2017. Les critères d’inclusion ont été modifiés à partir des recommandations en matière de dépistage cardiaque périopératoire, comme suit : patients chez qui le score à l’indice de risque cardiaque révisé (RCRI; Revised Cardiac Risk Index) était d’au moins 1 et qui avaient 65 ans ou plus, ou patients de 45 ans ou plus ayant des antécédents de maladie cardiovasculaire et chez qui un séjour d’une nuit à l’hôpital était prévu.

      Résultats

      Seulement 6,8 % des patients de notre cohorte de 59 506 patients avaient été soumis à un dosage préopératoire des peptides natriurétiques à des fins de dépistage. Les taux de dosage préopératoire approprié des peptides natriurétiques ont légèrement augmenté pendant la période d’étude, passant de 5,7 % à 8,8 %. Le dosage postopératoire de la troponine avait été effectué au moins une fois chez 19,5 % des patients. Chez les patients dont le taux des biomarqueurs était élevé selon les dosages périopératoires, la mortalité à 6 mois ainsi que les taux d’hospitalisations pour insuffisance cardiaque et de syndromes coronariens aigus étaient plus élevés que chez les autres patients.

      Conclusions

      Le dosage des biomarqueurs demeure peu utilisé pour la stratification du risque cardiaque et la surveillance postopératoire. L’amélioration de l’accès à ces tests et l’approfondissement des connaissances des médecins sur la nature asymptomatique des manifestations cardiaques postopératoires pourrait accroître l’observance des lignes directrices nationales.
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