A scoping review of active, participant centred, digital adverse events following immunization (AEFI) surveillance of WHO approved COVID-19 vaccines: A Canadian immunization Research Network study.

This scoping review examines the role of digital solutions in active, participant-centered surveillance of adverse events following initial release of COVID-19 vaccines. The goals of this paper were to examine the existing literature surrounding digital solutions and technology used for active, participant centered, AEFI surveillance of novel COVID-19 vaccines approved by WHO. This paper also aimed to identify gaps in literature surrounding digital, active, participant centered AEFI surveillance systems and to identify and describe the core components of active, participant centered, digital surveillance systems being used for post-market AEFI surveillance of WHO approved COVID-19 vaccines, with a focus on the digital solutions and technology being used, the type of AEFI detected, and the populations under surveillance. The findings highlight the need for customized surveillance systems based on local contexts and the lessons learned to improve future vaccine monitoring and pandemic preparedness.

The barriers, facilitators and association of vaccine certificates on COVID-19 vaccine uptake: a scoping review.

BACKGROUND: Globally, COVID-19 vaccines have proven to be instrumental for promoting population health by reducing illness from SARS-CoV-2. Vaccine certificates emerged as a potentially promising solution for encouraging vaccination and facilitating the safe reopening of society, however, they were controversial due to criticisms of infringing upon individual rights. While there is extensive literature describing the ethical, legal, and public health implications of vaccine certificates, there is currently a gap in knowledge about the association of vaccine certificates on vaccine uptake during the COVID-19 pandemic and barriers and facilitators to their use. OBJECTIVES: The objectives of this scoping review are to (i) describe the existing literature on the association of vaccine certificates on the rates of COVID-19 vaccine uptake across several countries and (ii) describe the intrinsic and extrinsic barriers or facilitators that moderate this relationship. METHODS: We conducted a scoping review based on PRISMA Extension for Scoping Reviews (PRSIMA-ScR) guidelines. We searched three bibliographic databases (APA PsychInfo, Embase Classic + Embase, OVID-Medline) and preprint severs during the first week of July 2023. Three reviewers independently screened the studies based on pre-specified eligibility criteria and performed quality assessments of the primary literature and data extraction. RESULTS: Sixteen studies met the inclusion criteria. 14 or these were surveys and 2 were modelling studies. The majority documented that vaccine certificates were significantly associated with increased rates of COVID-19 vaccine uptake (n = 12), motivated by factors such as travel/employer requirements, influence from the government/peers, and trust in the safety, efficacy, and science behind COVID-19 vaccines. Three studies had non-significant or mixed findings. Only one study found a significant decrease in COVID-19 vaccine uptake, motivated by pervasive distrust in the QR code-based system of digital vaccine certificates in Russia. Quality of survey studies was generally high. CONCLUSION: Our findings provide insights into the existing literature on vaccine certificates association with vaccine uptake in several different jurisdictions and barriers and facilitators to their uptake. This information can be used to guide future examinations of the implementation of vaccine certificates and more effective implementations.

The influence of sociodemographic factors on COVID-19 vaccine certificate acceptance: A cross-sectional study.

Vaccine certificates have been implemented worldwide, aiming to promote vaccination rates and to reduce the spread of COVID-19. However, their use during the COVID-19 pandemic was controversial and has been criticized for infringing upon medical autonomy and individual rights. We administered a national online survey exploring social and demographic factors predicting the degree of public approval of vaccine certificates in Canada. We conducted a multivariate linear regression which revealed which factors were predictive of vaccine certificate acceptance in Canada. Self-reported minority status (p < .001), rurality (p < .001), political ideology (p < .001), age (p < .001), having children under 18 in the household (p < .001), education (p = .014), and income status (p = .034) were significant predictors of attitudes toward COVID-19 vaccine certificates. We observed the lowest vaccine-certificate approval among participants who: self-identify as a visible minority; live in rural areas; are politically conservative; are 18-34 years of age; have children under age 18 living in the household; have completed an apprenticeship or trades education; and those with an annual income between $100,000-$159,999. The present findings are valuable for their ability to inform the implementation of vaccine certificates during future pandemic scenarios which may require targeted communication between public health agencies and under-vaccinated populations.

A scoping review of active, participant-centred, digital adverse events following immunization (AEFI) surveillance: A Canadian immunization research network study.

BACKGROUND: Post-licensure adverse events following immunization (AEFI) surveillance is conducted to monitor vaccine safety, such as identifying batch/brand issues and rare reactions, which consequently improves community confidence. The integration of technology has been proposed to improve AEFI surveillance, however, there is an absence of description regarding which digital solutions are successfully being used and their unique characteristics. OBJECTIVES: The objectives of this scoping review were to 1) map the research landscape on digital systems used for active, participant-centred, AEFI surveillance and 2) describe their core components. METHODS: We conducted a scoping review informed by the PRISMA Extension for Scoping Reviews (PRSIMA-ScR) guideline. OVID-Medline, Embase Classic + Embase, and Medrxiv were searched by a medical librarian from January 1, 2000 to January 28th, 2021. Two independent reviewers determined which studies met inclusion based on pre-specified eligibility criteria. Data extraction was conducted using pre-made tables with specific variables by one investigator and verified by a second. RESULTS: Twenty-seven publications met inclusion, the majority of which came from Australia (n = 15) and Canada (n = 6). The most studied active, participant-centred, digital AEFI surveillance systems were SmartVax (n = 8) (Australia), Vaxtracker (n = 7) (Australia), and Canadian National Vaccine Safety (CANVAS) Network (Canada) (n = 6). The two most common methods of communicating with vaccinees reported were short-message-service (SMS) (n = 15) and e-mail (n = 14), with online questionnaires being the primary method of data collection (n = 20). CONCLUSION: Active, participant-centred, digital AEFI surveillance is an area actively being researched as depicted by the literature landscape mapped by this scoping reviewWe hypothesize that the AEFI surveillance approach herein described could become a primary method of collecting self-reported subjective symptoms and reactogenicity from vaccinees, complementing existing systems. Future evaluation of identified digital solutions is necessary to bring about improvements to current vaccine surveillance systems to meet contemporary and future public health needs.

A scoping review of global vaccine certificate solutions for COVID-19.

Globally, measures, such as lockdown, quarantining, and physical distancing, have been implemented to curb the spread of COVID-19. As the vaccines are now available and reintegration into society is beginning, measures such as vaccine certificates are being implemented around the world. We conducted a scoping review to identify the initial digital solutions for COVID-19 vaccine certificates and evaluate them on the basis of purpose and use case, technological architecture, and ethical and legal implications. Articles identified from a Google search and a search of MEDLINE, Ovid and preprint servers were reviewed in duplicate, and data were extracted using a data extraction form. Data were extracted for date, location, type of article, source, companies identified for creating vaccine certificates, technology used, type of evidence provided (article quoting research study or an expert opinion), digital architecture, security and privacy measures, and use cases. Technology emerged as the most dominant theme followed by ethics, travel, legal concerns, public policy, and scientific concerns. Our review identified eight solutions that are working toward COVID-19 vaccine certificates world-wide, all optimizing blockchain technology. COVID-19 vaccine certificates are being considered in 11 countries and are in place in 5 others. Many issues concerning the themes we identified remain to be addressed to facilitate successful implementation.

Canada's response to international travel during COVID-19 pandemic - a media analysis.

BACKGROUND: The media play a critical role in informing the public about the COVID-19 pandemic. Throughout the pandemic, international travel has been a highly contested subject at both the international and national levels. We examined Canadian media reporting on international travel restrictions during the pandemic, how these restrictions aligned with the International Health Regulations (IHR 2005), and how the narrative around international travel evolved over time. METHODS: We analysed articles from Canada's top three national newspapers by circulation - The Globe and Mail, The National Post and The Toronto Star - published between Jan 1, 2020 - May 31, 2020. Our search yielded a total of 378 articles across the three newspapers. After removing duplicates and screening the remaining articles, we included a total of 62 articles for the analysis. We conducted a qualitative media content analysis by using an inductive coding approach. RESULTS: Three major themes were identified within the articles. These included: 1) The role of scientific and expert evidence in implementing travel restrictions; 2) Federal legislation, regulation and enforcement of international travel measures; and 3) Compliance with World Health Organization (WHO) guidelines in travel restriction policy- and decision-making. The federal government relied primarily on scientific evidence for implementing international travel restrictions and fully exercised its powers under the Quarantine Act to enforce travel regulations and comply with the IHR 2005. The government embraced a rules-based international order by following WHO recommendations on international travel, contributing to a delay in border closure and travel restrictions until mid-March. CONCLUSION: The media focussed significantly on international travel-related issues during the early phase of the pandemic. The dominant media narrative surrounded the need for earlier travel restrictions against international travel.

A survey of International Health Regulations National Focal Points experiences in carrying out their functions.

BACKGROUND: The 2005 International Health Regulations (IHR (2005)) require States Parties to establish National Focal Points (NFPs) responsible for notifying the World Health Organization (WHO) of potential events that might constitute public health emergencies of international concern (PHEICs), such as outbreaks of novel infectious diseases. Given the critical role of NFPs in the global surveillance and response system supported by the IHR, we sought to assess their experiences in carrying out their functions. METHODS: In collaboration with WHO officials, we administered a voluntary online survey to all 196 States Parties to the IHR (2005) in Africa, Asia, Europe, and South and North America, from October to November 2019. The survey was available in six languages via a secure internet-based system. RESULTS: In total, 121 NFP representatives answered the 56-question survey; 105 in full, and an additional 16 in part, resulting in a response rate of 62% (121 responses to 196 invitations to participate). The majority of NFPs knew how to notify the WHO of a potential PHEIC, and believed they have the content expertise to carry out their functions. Respondents found training workshops organized by WHO Regional Offices helpful on how to report PHEICs. NFPs experienced challenges in four critical areas: 1) insufficient intersectoral collaboration within their countries, including limited access to, or a lack of cooperation from, key relevant ministries; 2) inadequate communications, such as deficient information technology systems in place to carry out their functions in a timely fashion; 3) lack of authority to report potential PHEICs; and 4) inadequacies in some resources made available by the WHO, including a key tool - the NFP Guide. Finally, many NFP representatives expressed concern about how WHO uses the information they receive from NFPs. CONCLUSION: Our study, conducted just prior to the COVID-19 pandemic, illustrates key challenges experienced by NFPs that can affect States Parties and WHO performance when outbreaks occur. In order for NFPs to be able to rapidly and successfully communicate potential PHEICs such as COVID-19 in the future, continued measures need to be taken by both WHO and States Parties to ensure NFPs have the necessary authority, capacity, training, and resources to effectively carry out their functions as described in the IHR.

Newcomer knowledge, attitudes, and beliefs about human papillomavirus (HPV) vaccination.

BACKGROUND: Human Papillomavirus (HPV) is the most common sexually transmitted infection in Canada and around the world. Vaccination is an effective prevention strategy, but uptake is low, especially among newcomers to Canada. We sought to understand newcomers' knowledge, attitudes, and beliefs (KAB) on HPV and HPV vaccination and their role in HPV vaccine acceptance. METHODS: Newcomers were defined as individuals born outside Canada, (i.e., individuals born in a different country, the majority of whom are immigrants or refugees, but also includes students and undocumented migrants). Eligible participants were newcomers, aged 16 or older and who could read or write in English, French or Arabic. Surveys were administered in two community health centres in Ottawa, Canada that primarily engage with newcomer populations. Follow-up interviews were conducted either at the community health centre or over the phone, depending on participants' preferences. RESULTS: Fifty participants completed the survey, the majority of whom were women (74%) and spoke Arabic as their first language (54%). Seven participants completed supplemental interviews to complement their survey responses. The majority (70%) of participants had not previously heard of HPV. Less than half (46%) knew that the vaccine is effective in preventing certain types of cancer; nearly 40% incorrectly believed the vaccine could cure HPV. Qualitative interviews supported the survey findings. CONCLUSIONS: Despite a lack of HPV knowledge due to cultural and language barriers, there is still a strong desire among newcomers to receive the vaccine, especially when accompanied by a physician recommendation. Cultural and language-appropriate resources are needed to help newcomers make informed vaccination decisions and promote HPV vaccine uptake.

Reporting on the opioid crisis (2000-2018): role of The Globe and Mail, a Canadian English-language newspaper in influencing public opinion.

BACKGROUND: We aim to describe the general characteristics of how the Canadian newspaper The Globe and Mail reports on opioid-related news, the opioid crisis and its victims, and explore how Canadians' perceptions of the opioid crisis could have developed over time from this reporting. The Globe and Mail has the highest circulation among Canadian newspapers and is Canada's newspaper of record. METHODS: Reviewers performed independent, blinded bibliometric searches of all The Globe and Mail articles archived in the Canadian Periodicals Index Quarterly spanning an 18-year period (1 January 2000-1 June 2018) related to the keywords "opioids" or "drugs and opioids" and "opiates". Independently and in duplicate, reviewers manually extracted qualitative data from articles and identified emergent themes. Articles were screened independently by both reviewers based on the inclusion criteria. Conflicts were resolved by discussion and consensus. Social representation theory was used as a framework for describing how the opioid crisis is portrayed in Canada. RESULTS: Our search yielded 650 relevant opioid articles. The number of articles peaked in 2009, 2012, and in 2016, coinciding with major developments in the epidemic. The language used in this discourse has evolved over the years and has slowly shifted towards less stigmatizing language. Content analysis of the articles revealed common social representations attributing responsibility to pharmaceutical companies, physicians, and foreign countries. CONCLUSIONS: The Globe and Mail's coverage of the opioid crisis is focused on basic social representations and attributed responsibility for the crisis to a few collectives. A shift toward coverage of the root causes of the opioid epidemic could positively influence the general public's perception of the opioid crisis and promote deeper understanding of the issue. Journalists face several obstacles to achieve greater focus and framing of the opioid crisis; a closer working relationship between the media and the research community is needed.

The digital immunization system of the future: imagining a patient-centric, interoperable immunization information system.

To ensure the effectiveness of increasingly complex immunization programs in upper-middle and high-income settings, comprehensive information systems are needed to track immunization uptake at individual and population levels. The maturity of cloud systems and mobile technologies has created new possibilities for immunization information systems. In this paper, we describe a vision for the next generation of digital immunization information systems for upper-middle and high-income settings based on our experience in Canada. These systems center on the premise that the public is engaged and informed about the immunization process beyond their interaction with primary care, and that they will be a contributor and auditor of immunization data. The digital immunization system of the future will facilitate reporting of adverse events following immunization, issue digital immunization receipts, permit identification of areas of need and allow for delivery of interventions targeting these areas. Through features like immunization reminders and targeted immunization promotion campaigns, the system will reduce many of the known barriers that influence immunization rates. In light of the global COVID-19 pandemic, adaptive digital public health information systems will be required to guide the rollout and post-market surveillance of the SARS-CoV-2 vaccine.

Risk of acute kidney injury in patients who undergo coronary angiography and cardiac surgery in close succession.

AIMS: Cardiac surgery and coronary angiography are both associated with risk of acute kidney injury (AKI). We hypothesized that the risk of post-operative AKI increases when coronary angiogram and cardiac surgery are performed in close succession, without sufficient time for recovery from the adverse effects of intravenous contrast. METHODS AND RESULTS: We included 2133 consecutive patients who underwent cardiac surgery at the Minneapolis Veterans Administration Medical Center from 2004 to 2010. Acute kidney injury was defined by the AKI network and the risk, injury, failure, loss, end-stage (RIFLE) criteria. Patients were 66 ± 10 years old. Mean pre-operative creatinine and estimated glomerular filtration rate were 1.1 ± 0.4 mg/dL and 75 ± 22 mL/min/1.73 m(2), respectively. Cardiac surgery was performed 14 days (range 0-235) after coronary angiography. Acute kidney injury occurred in 680 (32%) patients per AKI network, 390 (18%) patients per RIFLE risk, and 111 (5%) patients per RIFLE injury criteria. Age, body mass index, diabetes mellitus, New York Heart Association class III/IV, cardiopulmonary bypass time, and impaired pre-operative renal function were independent predictors of AKI. However, time between coronary angiogram and cardiac surgery was not a predictor (P = 0.41). AKI occurred in 35% of 433 patients operated within 3 days of coronary angiogram vs. 31% of 1700 patients operated after 3 days (P = 0.17). Results were the same in patients with impaired pre-operative renal function and those with contrast-induced nephropathy. CONCLUSION: Risk of AKI after cardiac surgery is not influenced by the time between coronary angiogram and cardiac surgery. These results do not support the notion of delaying cardiac surgery for the sole purpose of renal recovery after coronary angiogram.

Dose-dependent effect of statins on the incidence of acute kidney injury after cardiac surgery.

BACKGROUND: Acute kidney injury (AKI) after cardiac surgery is associated with increased morbidity and mortality. METHODS: We assessed whether statin treatment is associated with a lower incidence of postoperative AKI in 2,104 consecutive patients who underwent coronary artery bypass graft or valve surgery at the Minneapolis Veterans Administration Medical Center. Acute kidney injury was defined as absolute increase greater than 0.3 mg/dL or relative increase greater than 50% in serum creatinine from baseline, within 48 hours after surgery or requiring postoperative hemodialysis per AKI network. Propensity scores were utilized to adjust for the differences between the statin and the no-statin treatment groups. All statins were converted to equivalent-dose simvastatin and divided at the median to construct high-dose (≥40 mg) and low-dose (<40 mg) statin groups. RESULTS: Of the 2,104 patients, 1,435 (68%) were taking statins (638 high-dose) and 495 (24%) developed AKI (25% high-dose vs 40% low-dose vs 35% no-statin; p = 0.014). Estimated preoperative glomerular filtration rate (p = 0.003), diabetes mellitus (p=0.02), valve surgery with or without coronary artery bypass graft (p = 0.024), cardiopulmonary bypass time (p = 0.001), and intraaortic balloon pump (p = 0.055) were independent predictors of AKI. After propensity adjustment statin treatment was not associated with postoperative AKI (odds ratio 0.79; 95% confidence interval 0.59 to 1.06; p = 0.11 for high-dose v. no-statin). After full adjustment for all independent predictors of AKI, the results did not change. Statins also had no effect on the incidence of postoperative hemodialysis (0.8% high-dose vs 1.9% low-dose vs 1% no-statin; p = 0.15). CONCLUSIONS: Statin treatment is not associated with a lower incidence of AKI after cardiac surgery.

Preoperative pulmonary function and mortality after cardiac surgery.

BACKGROUND: The aim of the study was to examine the relationship between preoperative pulmonary function and outcomes after cardiac surgery. METHODS: We performed preoperative pulmonary function tests (PFTs) in 1,169 patients undergoing cardiac surgery at the Minneapolis Veterans Affairs Medical Center. Airway obstruction was defined as forced expiratory volume in 1 minute (FEV(1)) to forced vital capacity ratio <0.7. RESULTS: Of the 1,169 patients, 483 (41%) had a prior history of chronic obstructive pulmonary disease (COPD). However, 178 patients with a history of COPD had no airway obstruction on PFT. Conversely, 186 patients without a COPD history had airway obstruction on PFT. Thus, PFT results helped reclassify the COPD status of 364 patients (31%). Operative mortality was 2% in patients with no or mild airway obstruction versus 6.7% in those with moderate or severe obstruction (ie, FEV(1) to forced vital capacity ratio <0.7 and FEV(1) <80% predicted). Postoperative mortality was higher (odds ratio 3.2, 95% CI 1.6-6.2, P = .001) in patients with moderate or severe airway obstruction and in patients with diffusing capacity of the lung for carbon monoxide <50% of predicted (odds ratio 4.9, 95% CI 2.3-10.8, P = .0001). Notably, mortality risk was 10x higher (95% CI 3.4-27.2, P = .0001) in patients with moderate or severe airway obstruction and diffusing capacity of the lung for carbon monoxide <50% of predicted. CONCLUSIONS: These data show that PFT before cardiac surgery reclassifies the COPD status of a substantial number of patients and provides important prognostic information that the current risk estimate models do not capture.

Dose dependent effect of statins on postoperative atrial fibrillation after cardiac surgery among patients treated with beta blockers.

BACKGROUND: Previous studies on the effects of Statins in preventing atrial fibrillation (AF) after cardiac surgery have shown conflicting results. Whether statins prevent AF in patients treated with postoperative beta blockers and whether the statin-effect is dose related are unknown. METHODS: We retrospectively studied 1936 consecutive patients who underwent coronary artery bypass graft (CABG) (n = 1493) or valve surgery (n = 443) at the Minneapolis Veterans Affairs Medical Center. All patients were in sinus rhythm before the surgery. Postoperative beta blockers were administered routinely (92% within 24 hours postoperatively). RESULTS: Mean age was 66+10 years and 68% of the patients were taking Statins. Postoperative AF occurred in 588 (30%) patients and led to longer length of stay in the intensive care unit versus those without AF (5.1+7.6 days versus 2.5+2.3 days, p < 0.0001). Patients with a past history of AF had a 5 times higher risk of postoperative AF (odds ratio 5.1; 95% confidence interval 3.4 to 7.7; p < 0.0001). AF occurred in 31% of patients taking statins versus 29% of the others (p = 0.49). In multivariable analysis, statins were not associated with AF (odds ratio (OR) 0.93, 95% confidence interval (CI) 0.7 to 1.2; p = 0.59). However, in a subgroup analysis, the patients treated with Simvastatin >20 mg daily had a 36% reduction in the risk of postoperative AF (OR 0.64, 95% CI 0.43 to 0.6; p = 0.03) in comparison to those taking lower dosages. CONCLUSION: Among cardiac surgery patients treated with postoperative beta blockers Statin treatment reduces the incidence of postoperative AF when used at higher dosages.

Efficacy of gemfibrozil in the primary prevention of atrial fibrillation in a large randomized controlled trial.

BACKGROUND: Peroxisome proliferator-activated receptor alpha (PPARalpha) activators reduce inflammation and oxidative stress. Inflammation plays an important role in the initiation and maintenance of atrial fibrillation (AF). It has been suggested that PPARalpha activators may have antiarrhythmic properties, but no clinical data exist. The objective of this study was to investigate whether the PPARalpha activator gemfibrozil prevents or delays the development of AF in patients with coronary heart disease. METHODS: We retrospectively analyzed the electrocardiograms (ECGs) performed in the Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial, a multicenter, randomized, double-blinded, secondary prevention trial of gemfibrozil and matching placebo. The ECGs were performed annually or biannually and when clinically indicated. Participants who were in AF on baseline ECG were excluded from the present analysis. Relative risk for AF was calculated from Cox regression with death as a competing risk factor. RESULTS: A total of 12,605 ECGs from 2,130 participants were interpreted (5.9 +/- 2.1 ECGs per participant, range 2-20). At baseline, the gemfibrozil (n = 1,070) and placebo (n = 1,060) groups were well matched. Mean age was 64.1 +/- 7.1 years. Over 4.4 +/- 1.5 years of follow-up, 123 (5.8%) participants developed new AF. There was no difference in AF incidence between the gemfibrozil and placebo groups (64/1,070 vs 59/1,060, respectively; P = .33). In Cox regression, the risk of AF was similar between the 2 study groups (hazard ratio 1.04, 95% CI 0.73-1.49, P = .82). CONCLUSIONS: In this post hoc analysis of a multicenter, double-blinded, randomized controlled trial, the PPARalpha activator gemfibrozil did not reduce the 4-year incidence of AF among men with coronary heart disease.

Prognostic significance of elevated cardiac troponin I after heart surgery.

BACKGROUND: Cardiac troponin I (cTnI) measured after heart surgery has been associated with operative mortality. We sought to determine whether measuring cTnI after heart surgery provides additional prognostic information beyond that provided by validated preoperative risk scores, the Veterans Affairs (VA) risk score and the European System for Cardiac Operative Risk Evaluation (EuroSCORE). METHODS: We retrospectively collected cTnI levels measured 24 hours after surgery in 1,186 patients who underwent coronary artery bypass graft surgery (n = 696) or valve surgery (n = 490). The outcomes were operative death and perioperative myocardial infarction. The ability of the cTnI and the risk scores to discriminate patients who did or did not have the study outcomes was assessed by the area under the receiver operating curve (c-index). RESULTS: Mean age was 66 +/- 10 years. Median cTnI was 38 ng/mL after valve surgery versus 18 ng/mL after coronary artery bypass graft surgery (p < 0.0001). There were 51 operative deaths (4.3%) and 142 perioperative myocardial infarctions (12%). For every 50 ng/mL increase in cTnI, the odds of operative death increased by 40% (odds ratio, 1.4; 95% confidence interval: 1.2 to 1.6) after coronary artery bypass graft surgery and by 30% (odds ratio, 1.3; 95% confidence interval: 1.1 to 1.5) after valve surgery. Cardiac troponin I was a significant independent correlate of perioperative myocardial infarction and death (p < 0.0001) with a c-index of 0.70 for death. Addition of cTnI improved the c-indexes of the risk scores for predicting death (from 0.75 to 0.79 for the VA risk score; p = 0.1; and from 0.69 to 0.77 for the EuroSCORE; p = 0.005). CONCLUSIONS: Postoperative cTnI measured 24 hours after heart surgery is independently associated with operative death and perioperative myocardial infarction and improves the ability to predict operative mortality in comparison with preoperative risk scores alone.