Preoperative systemic inflammation and perioperative myocardial injury: prospective observational multicentre cohort study of patients undergoing non-cardiac surgery.

BACKGROUND: Systemic inflammation is pivotal in the pathogenesis of cardiovascular disease. As inflammation can directly cause cardiomyocyte injury, we hypothesised that established systemic inflammation, as reflected by elevated preoperative neutrophil-lymphocyte ratio (NLR) >4, predisposes patients to perioperative myocardial injury. METHODS: We prospectively recruited 1652 patients aged ≥45 yr who underwent non-cardiac surgery in two UK centres. Serum high sensitivity troponin T (hsTnT) concentrations were measured on the first three postoperative days. Clinicians and investigators were blinded to the troponin results. The primary outcome was perioperative myocardial injury, defined as hsTnT≥14 ng L-1 within 3 days after surgery. We assessed whether myocardial injury was associated with preoperative NLR>4, activated reactive oxygen species (ROS) generation in circulating monocytes, or both. Multivariable logistic regression analysis explored associations between age, sex, NLR, Revised Cardiac Risk Index, individual leukocyte subsets, and myocardial injury. Flow cytometric quantification of ROS was done in 21 patients. Data are presented as n (%) or odds ratio (OR) with 95% confidence intervals. RESULTS: Preoperative NLR>4 was present in 239/1652 (14.5%) patients. Myocardial injury occurred in 405/1652 (24.5%) patients and was more common in patients with preoperative NLR>4 [OR: 2.56 (1.92-3.41); P<0.0001]. Myocardial injury was independently associated with lower absolute preoperative lymphocyte count [OR 1.80 (1.50-2.17); P<0.0001] and higher absolute preoperative monocyte count [OR 1.93 (1.12-3.30); P=0.017]. Monocyte ROS generation correlated with NLR (r=0.47; P=0.03). CONCLUSIONS: Preoperative NLR>4 is associated with perioperative myocardial injury, independent of conventional risk factors. Systemic inflammation may contribute to the development of perioperative myocardial injury. CLINICAL TRIAL REGISTRATION: NCT01842568.

Ultrafiltration: contemporary management of fluid overload.

Chronic heart failure is common, with an incidence of 1 in 1000 of the general population, and is rising at 10% per year (Cowie et al, 1999: Owan et al, 2006). In the UK, the prevalence is estimated at 900000 patients, with only 7000 of these under the age of 65 years (Petersen et al, 2002). Approximately 200000 are in New York Heart Association (NYHA) functional class III/IV, meaning they are breathless on mild exertion.

Cardiac magnetic resonance imaging in patients with systemic lupus erythematosus.

OBJECTIVES: To delineate the cardiac magnetic resonance (MR) appearances of cardiovascular disease (CVD) in patients with systemic lupus erythematosus (SLE), in comparison with transthoracic echocardiographs. METHODS: Cardiac MR was performed on 22 patients with SLE-11 with previous CVD and 11 matched controls-using late gadolinium contrast enhancement (LGE) to identify areas of myocardial scarring; Transthoracic echocardiography (TTE) was performed on the same day. RESULTS: Twenty female and two male patients participated. LGE was seen in 5/11 subjects in the CVD group (4/5 with previous myocardial infarction) and 1/11 in the control group. TTE detected myocardial abnormalities in 2/6 patients with LGE. CONCLUSION: The cardiac MR appearance of CVD in these patients with SLE was suggestive of coronary disease, rather than cumulative inflammatory muscle damage. Cardiac MR detected more abnormalities than TTE. Further studies of cardiac MR in patients with SLE are warranted to investigate these preliminary findings.

Lung uptake of thallium-201: a marker of defect reversibility?

High lung uptake of thallium-201 at stress is reported to be associated with a large number of perfusion defects and poor prognosis. This study was performed to assess whether the reversibility of stress perfusion defects was related to lung uptake. Gated planar thallium scans at stress and at redistribution from 102 consecutive patients with essentially normal left ventricular ejection fraction (using 99mTc gated blood pool ventriculography) were graded in terms of defect size. Lung and myocardial uptake of thallium were quantitated by region of interest methods relative to the given activity in a previously validated method. There was no significant correlation (non-parametric) between lung uptake and degree of redistribution (p = ns, rs = 0.140). There was a weak but positive correlation between lung uptake and defect size (p < 0.05, rs = 0.188). Both exercise time and double product showed a negative correlation with lung uptake (e.g. for double product, p < 0.0005, rs = -0.541). In conclusion, contrary to our expectation, lung uptake is not related to the degree of redistribution. High lung uptake seems to reflect poor cardiovascular reserve.

Single crystal biplane equilibrium radionuclide ventriculography: an improved planar imaging technique.

Radionuclide ventriculography in the best septal view is an established method to assess both global and regional ventricular function. Additional projections may be used to delineate the wall motion of inferior myocardial segments. Radionuclide ventriculography was performed in 65 patients using both a single plane (in the best septal view) and a biplane technique. The biplane collimator allowed simultaneous assessment in two planes 40 degrees apart, allowing simultaneous visualization of all four myocardial walls. Seventeen patients with regional wall motion abnormalities were detected with the single plane best septal view and a further 18 patients with impaired wall motion were identified with the biplane collimator (51% of the abnormal ventricles). The additional abnormal segments were seen in only the steep lateral projection. Left ventricular ejection fraction estimation with the biplane technique remains highly reproducible and correlates well with that derived from the best septal view. Biplane radionuclide ventriculography improves the detection of inferior wall motion abnormalities at no expense of time, and offers the possibility of performing two-view stress ventriculography with inotropic agents.

Rest or redistribution thallium myocardial imaging for resting myocardial perfusion: a detailed comparison with regional wall motion.

Redistribution thallium-201 (201T1) imaging is the most common method of assessing resting myocardial perfusion. However, the equivalence of a redistribution image and a separate rest injection is unclear. Although the presence of a defect on rest imaging has normally been equated with the presence of a myocardial infarction, it has recently been shown that a significant proportion of fixed defects on exercise-redistribution 201T1 actually represent areas of viable myocardium. This study was a detailed comparison of rest and redistribution imaging in 30 patients undergoing routine exercise 201T1 scanning for the assessment of coronary artery disease. A small dose (15 MBq) of 201T1 was administered at rest following the imaging in three standard planar views. Similar stress images were acquired using a further 50-55 MBq of 201T1 administered at peak effort. Redistribution images were acquired 3-4 h later and equilibrium blood pool ventriculography performed using in vivo labelling with 600 MBq 99Tcm-pertechnetate. Of 150 abnormal segments on the exercise scans, 74 (49%) were identified as being reversible on the redistribution scans and 58 (39%) on the rest images. Only 39 (53%) of these reversible defects were identified on both the redistribution and rest scans. Only 41% of the fixed defects on the redistribution images (32% of fixed defects on the rest images) had abnormal wall motion. Therefore, rest and redistribution images are not equivalent. Both rest and redistribution images significantly overestimate myocardial infarction. This may have significant effects on patient selection for revascularization procedures and therefore all patients having perfusion scintigraphy should also have additional assessment of regional wall motion to allow accurate classification of the functional status of myocardial segments.

Exercise 201Tl/rest 99Tcm-tetrofosmin myocardial perfusion imaging: a convenient protocol for the assessment of coronary disease.

Standard exercise thallium-201 (201Tl)-redistribution protocols for the detection of coronary artery disease take about 4 h to complete. This is inconvenient for both patients and staff. The higher energy technetium-99m (99Tcm) emissions permit immediate imaging after 201Tl with minimal crosstalk. This study assessed exercise gated planar 201Tl scintigraphy (55 MBq) followed by rest gated planar 99Tcm-tetrofosmin scintigraphy (250 MBq) in 32 patients. The results showed a high sensitivity for the detection of coronary disease (100%) in this highly selective group of patients. In order to diagnose myocardial infarction accurately, it was necessary to view the gated 201Tl images and assess regional wall motion in a defect zone. This gave a specificity of 88% and a sensitivity of 71% for the prediction of myocardial infarction on the angiographic ventriculogram. Stress 201Tl/rest 99Tcm-tetrofosmin is a useful short protocol for patients unable to complete the full 4-h exercise 201Tl-redistribution study.