C-Reactive protein predicts acute myocardial infarction during high-risk noncardiac and vascular surgery

BACKGROUND: High-sensitivity C-reactive protein predicts cardiovascular events in a wide range of clinical contexts. However, the role of high-sensitivity C-reactive protein as a predictive marker for perioperative acute myocardial infarction during noncardiac surgery is not yet clear. The present study investigated high-sensitivity C-reactive protein levels as predictors of acute myocardial infarction risk in patients undergoing high-risk noncardiac surgery. METHODS: This concurrent cohort study included patients aged >50 years referred for high-risk noncardiac surgery according to American Heart Association/ACC 2002 criteria. Patients with infections were excluded. Electrocardiograms were performed, and biomarkers (Troponin I or T) and/or total creatine phosphokinase and the MB fraction (CPK-T/MB) were evaluated on the first and fourth days after surgery. Patients were followed until discharge. Baseline high-sensitivity C-reactive protein levels were compared between patients with and without acute myocardial infarction. RESULTS: A total of 101 patients undergoing noncardiac surgery, including 33 vascular procedures (17 aortic and 16 peripheral artery revascularizations), were studied. Sixty of the patients were men, and their mean age was 66 years. Baseline levels of high-sensitivity C-reactive protein were higher in the group with perioperative acute myocardial infarction than in the group with non-acute myocardial infarction patients (mean 48.02 vs. 4.50, p = 0.005). All five acute myocardial infarction cases occurred in vascular surgery patients with high CRP levels. CONCLUSIONS: Patients undergoing high-risk noncardiac surgery, especially vascular surgery, and presenting elevated baseline high-sensitivity C-reactive protein levels are at increased risk for perioperative acute myocardial infarction.

Acquired bleeding disorders: bleeding in obstetrics and surgery.

Hemorrhage continues to be the leading cause of maternal mortality and morbidity throughout the world. In England and Wales from 1970-87 hemorrhage, including ectopic pregnancy, was a major factor in over 40 maternal deaths. In the majority of deaths the care was substandard. In 70% of obstetric deaths from hemorrhage defective hemostasis contributes to the bleeding. Inappropriate correction of hypovolemia, failure to recognise and treat coagulation failure, and failure to control traumatic bleeding are the main causes of preventable death. In developing countries, cross matched blood and blood products may not be readily available. Surgical intervention should be preceded or accompanied by correction of the hemostatic defect with fresh frozen plasma and if necessary platelet concentrates. Teamwork with experienced staff is the essence of successful management of severe hemorrhage in obstetrics and surgery. A protocol should be agreed between medical nursing and laboratory staff for dealing with massive blood loss.