In patients 45 years or older hospitalized for at least one night after elective non-cardiac surgery, the overall 30-day mortality rate in a large multinational study involving more than 40,000 patients was 1.8%, with variations in rate depending on region of the world. For the 22,447 patients within the study from North America, Europe and Australia, overall 30-day mortality was 1.1% .The 30-day mortality risk for non-elective urgent/emergent surgery is at least double the risk of elective surgery. (1)
Many of these deaths are linked to cardiac complications. (1) Myocardial Injury after Noncardiac Surgery (MINS) occurs in 12%-24% of these mortality cases, as indicated by troponin levels exceeding the 99th percentile within 3 days of surgery and presumed to be due to myocardial ischemia,. (2) MINS is associated with a postoperative 30-day mortality rate of 9.8%, compared to 1% for those without it, and increases the risk of major vascular complications, such as myocardial infarction and stroke (3,4,5). Most patients suffering MINS postoperatively are asymptomatic for ischemic features or symptoms. Without postoperative troponin testing, 90% of patients experiencing MINS would remain undetected. (3, 6, 7).
Screening Tools
The Revised Cardiac Risk Index (RCRI) is a six-question tool used to estimate a patient’s risk of major perioperative cardiac complications after non-cardiac surgery. (8, 9) For patients aged ≥ 65, or for patients aged 45-64 with either significant cardiovascular disease, or an RCRI score ≥ 1, measuring NT-proBNP or BNP before non-cardiac surgery can improve risk assessment (10). When the postoperative risk of MINS is deemed to be greater than a 5% risk based on NTproBNP or BNP levels, then postoperative MINS Surveillance by way of Troponin testing is indicated (10).
Revised Cardiac Risk Index (RCRI)
Prehabilitation and Optimization Algorithm
Prehabilitation and Optimization Recommendations
| Order NT-proBNP/BNP |
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| Referral for Anesthesia Consult |
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| Postoperative Monitoring |
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| Communicate with Primary Care Provider for Outpatient Follow-up |
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References
1. Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) Study Investigators, Spence, J., LeManach, Y., Chan, M. T. V., Wang, C. Y., Sigamani, A., Xavier, D., Pearse, R., Alonso-Coello, P., Garutti, I., Srinathan, S. K., Duceppe, E., Walsh, M., Borges, F. K., Malaga, G., Abraham, V., Faruqui, A., Berwanger, O., Biccard, B. M., Villar, J. C., … Devereaux, P. J. (2019). Association between complications and death within 30 days after noncardiac surgery. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, 191(30), E830–E837. https://doi.org/10.1503/cmaj.190221
2. Smilowitz, N. R., Redel-Traub, G., Hausvater, A., Armanious, A., Nicholson, J., Puelacher, C., & Berger, J. S. (2019). Myocardial Injury After Noncardiac Surgery: A Systematic Review and Meta-Analysis. Cardiology in review, 27(6), 267–273. https://doi.org/10.1097/CRD.0000000000000254
3. Writing Committee for the VISION Study Investigators, Devereaux, P. J., Biccard, B. M., Sigamani, A., Xavier, D., Chan, M. T. V., Srinathan, S. K., Walsh, M., Abraham, V., Pearse, R., Wang, C. Y., Sessler, D. I., Kurz, A., Szczeklik, W., Berwanger, O., Villar, J. C., Malaga, G., Garg, A. X., Chow, C. K., Ackland, G., … Guyatt, G. H. (2017). Association of Postoperative High-Sensitivity Troponin Levels With Myocardial Injury and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery. JAMA, 317(16), 1642–1651. https://doi.org/10.1001/jama.2017.4360
4. Devereaux, P. J., Duceppe, E., Guyatt, G., Tandon, V., Rodseth, R., Biccard, B. M., Xavier, D., Szczeklik, W., Meyhoff, C. S., Vincent, J., Franzosi, M. G., Srinathan, S. K., Erb, J., Magloire, P., Neary, J., Rao, M., Rahate, P. V., Chaudhry, N. K., Mayosi, B., de Nadal, M., … MANAGE Investigators (2018). Dabigatran in patients with myocardial injury after non-cardiac surgery (MANAGE): an international, randomised, placebo-controlled trial. Lancet (London, England), 391(10137), 2325–2334. https://doi.org/10.1016/S0140-6736(18)30832-8
5. Botto, F., Alonso-Coello, P., Chan, M. T., Villar, J. C., Xavier, D., Srinathan, S., Guyatt, G., Cruz, P., Graham, M., Wang, C. Y., Berwanger, O., Pearse, R. M., Biccard, B. M., Abraham, V., Malaga, G., Hillis, G. S., Rodseth, R. N., Cook, D., Polanczyk, C. A., Szczeklik, W., … Vascular events In noncardiac Surgery patIents cOhort evaluatioN VISION Study Investigators (2014). Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology, 120(3), 564–578.https://doi.org/10.1097/ALN.0000000000000113
6. Devereaux PJ, Xavier D, Pogue J, Guyatt G, Sigamani A, Garutti I, Leslie K, Rao-Melacini P, Chrolavicius S, Yang H, Macdonald C, Avezum A, Lanthier L, Hu W, Yusuf S; POISE (PeriOperative ISchemic Evaluation) Investigators. Characteristics and short-term prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery: a cohort study. Ann Intern Med. 2011 Apr 19;154(8):523-8. doi: 10.7326/0003-4819-154-8-201104190-00003. PMID: 21502650.
7. Botto F, Alonso-Coello P, Chan MT, Villar JC, Xavier D, Srinathan S, et al.; Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Writing Group, on behalf of The Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Investigators; Appendix 1. The Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Study Investigators Writing Group; Appendix 2. The Vascular events In noncardiac Surgery patIents cOhort evaluatioN Operations Committee; Vascular events In noncardiac Surgery patIents cOhort evaluatioN VISION Study Investigators. Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology. 2014 Mar;120(3):564-78. doi: 10.1097/ALN.0000000000000113. PMID: 24534856.
8. Lee, T. H., Marcantonio, E. R., Mangione, C. M., Thomas, E. J., Polanczyk, C. A., Cook, E. F., Sugarbaker, D. J., Donaldson, M. C., Poss, R., Ho, K. K., Ludwig, L. E., Pedan, A., & Goldman, L. (1999). Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation, 100(10), 1043–1049. https://doi.org/10.1161/01.cir.100.10.1043
9. Ford, M. K., Beattie, W. S., & Wijeysundera, D. N. (2010). Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index. Annals of internal medicine, 152(1), 26–35. https://doi.org/10.7326/0003-4819-152-1-201001050-00007
10. Duceppe, E., Parlow, J., MacDonald, P., Lyons, K., McMullen, M., Srinathan, S., Graham, M., Tandon, V., Styles, K., Bessissow, A., Sessler, D. I., Bryson, G., & Devereaux, P. J. (2017). Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery. The Canadian journal of cardiology, 33(1), 17–32. https://doi.org/10.1016/j.cjca.2016.09.008
