Combining CHA2DS2-VASc score into RCRI for prediction perioperative cardiovascular outcomes in patients undergoing non-cardiac surgery: a retrospective pilot study.

BACKGROUND: Treatment decisions in patients undergoing non-cardiac surgery are based on clinical assessment. The Revised Cardiac Risk Index (RCRI) is pragmatic and widely used but has only moderate discrimination. We aimed to test the efficacy of the CHA2DS2-VASc score and the combination of CHA2DS2-VASc and RCRI to predict perioperative risks for non-cardiac surgery. METHODS: This pre-specified analysis was performed in a retrospective cohort undergoing intra-abdominal surgery in our center from July 1st, 2007 to June 30th, 2008. The possible association between the baseline characteristics (as defined by CHA2DS2-VASc and RCRI) and the primary outcome of composite perioperative cardiac complications (myocardial infarction, cardiac ischemia, heart failure, arrhythmia, stroke, and/or death) and secondary outcomes of individual endpoints were explored using multivariate Logistic regression. The area under the receiver operating characteristic curve (C-statistic) was used for RCRI, CHA2DS2-VASc, and the combined models, and the net reclassification improvement (NRI) was calculated to assess the additional discriminative ability. RESULTS: Of the 1079 patients (age 57.5 ± 17.0 years), 460 (42.6%) were women. A total of 83 patients (7.7%) reached the primary endpoint. Secondary outcomes included 52 cardiac ischemic events, 40 myocardial infarction, 20 atrial fibrillation, 18 heart failure, four strokes, and 30 deaths. The endpoint events increased with the RCRI and CHA2DS2-VASc grade elevated (P < 0.05 for trend). The RCRI showed a moderate predictive ability with a C-statistics of 0.668 (95%CI 0.610-0.725) for the composite cardiac outcome. The C-statistics for the CHA2DS2-VASc was 0.765 (95% CI 0.709-0.820), indicating better performance than the RCRI (p = 0.011). Adding the CHA2DS2-VASc to the RCRI further increased the C-statistic to 0.774(95%CI 0.719-0.829), improved sensitivity, negative predictive value, and enhanced reclassification in reference to RCRI. Similar performance of the combined scores was demonstrated in the analysis of individual secondary endpoints. The best cut-off of a total of 4 scores was suggested for the combined CHA2DS2-VASc and RCRI in the prediction of the perioperative cardiac outcomes. CONCLUSIONS: The CHA2DS2-VASc score significantly enhanced risk assessment for the composite perioperative cardiovascular outcome in comparison to traditional RCRI risk stratification. Incorporation of CHA2DS2-VASc scores into clinical-decision making to improve perioperative management in patients undergoing non-cardiac surgery warrants consideration.

Differences in perioperative cardiovascular outcomes in elderly male and female patients undergoing intra-abdominal surgery: a retrospective cohort study.

OBJECTIVE: Perioperative cardiovascular events constitute the majority of complications in noncardiac surgery. Older and female patients have been less investigated. We aimed to evaluate differences in perioperative cardiovascular outcomes by age and sex. METHODS: We enrolled 1079 patients (57.5 ± 17.0 years, 42.6% women) undergoing intra-abdominal surgery from July 2007 to June 2008 and compared occurrence of perioperative cardiac events by age (≥65 vs. <65 years) and sex. Multivariable logistic regression was used to investigate associations between age, sex, and outcomes. RESULTS: Age ≥65 years was associated with perioperative myocardial infarction (MI) (odds ratio [OR] 2.9, 95% confidence interval [CI]: 1.3-6.6) and total cardiovascular events (OR 2.4, 95% CI: 1.3-4.2). Age ≥65 years was associated with higher perioperative MI risks in men (OR 4.7, 95% CI: 1.3-17.6) than in women (OR 3.1, 95% CI: 1.2-8.3). Advanced age was associated with heart failure in women (OR 13.9, 95% CI: 1.7-110.5). Female sex was a risk factor for heart failure in elderly patients (OR 4.2, 95% CI: 1.1-15.7). CONCLUSIONS: Advanced age appeared to be associated with increased perioperative cardiac risk but differed by sex. Tailored strategies should be considered with respect to the patient's sex.

Plasma catecholamine release-inhibitory peptide catestatin in patients with essential hypertension.

BACKGROUND: Catestatin plays an important role in the adjustment of blood pressure and cardiac function. We investigated levels of plasma catestatin in essential hypertension and the relationship between catestatin and left ventricular hypertrophy. METHODS: Plasma was collected from 136 patients with essential hypertension and 61 healthy controls. Plasma catestatin was measured by enzyme-linked immunosorbent assay (ELISA). Plasma norepinephrine was measured by high-performance liquid chromatography. All patients underwent echocardiography, measurement of fasting blood glucose, body mass index (BMI) and lipid levels. RESULTS: Plasma levels of catestatin and norepinephrine were significantly higher in patients with essential hypertension than in normal controls (both P<0.01). The ratio of catestatin to norepinephrine was significantly lower in patients with essential hypertension than in normal controls (P<0.01). In patients with essential hypertension, plasma norepinephrine level was significantly higher in patients with than without left ventricular hypertrophy (P<0.01). Plasma catestatin level was lower, but not significantly, in patients with than without left ventricular hypertrophy. The ratio of catestatin to norepinephrine was significantly lower in patients with than without left ventricular hypertrophy (P<0.01). CONCLUSION: Plasma catestatin is elevated in patients with essential hypertension. The ratio of catestatin to norepinephrine was lower in patients with left ventricular hypertrophy. Catestatin might participate in the development of hypertension and left ventricular hypertrophy.