Assessment and Correction of the Cardiac Complications Risk in Non-cardiac Operations – What's New?

Cardiovascular complications after non-cardiac surgery are the leading cause of 30-day mortality. The need for surgical interventions is approximately 5,000 procedures per 100,000 population, according to experts, the risks of non-cardiac surgical interventions are markedly higher in the elderly. It should be borne in mind that the aging of the population and the increased possibilities of medicine inevitably lead to an increase in surgical interventions in older people. Recent years have been characterized by the appearance of national and international guidelines with various algorithms for assessing and correcting cardiac risk, as well as publications on the validation of these algorithms. The purpose of this review was to provide new information about the assessment and correction of the risk of cardiac complications in non-cardiac operations. Despite the proposed new risk assessment scales, the RCRI scale remains the most commonly used, although for certain categories of patients (with oncopathology, in older age groups) the possibility of using specific questionnaires has been shown. In assessing the functional state, it is proposed to use not only a subjective assessment, but also the DASI questionnaire, 6-minute walking test and cardiopulmonary exercise test). At the next stage, it is proposed to evaluate biomarkers, primarily BNP or NT-proBNP, with a normal level – surgery, with an increased level – either an additional examination by a cardiologist or perioperative troponin screening. Currently, the prevailing opinion is that there is no need to examine patients to detect hidden lesions of the coronary arteries (non-invasive tests, coronary angiography), since this leads to excessive examination of patients, delaying the implementation of non-cardiac surgery. The extent to which this approach has an advantage over the previously used one remains to be studied

Assessment of Pre-test and Clinical Probability in the Diagnosis of Chronic Coronary Syndrome — What's New?

In the 2019 European Society of Cardiology (ESC) guidelines, the diagnostic algorithm for chronic coronary syndrome (CCS) was significantly changed, a significant revision of the pretest probability assessment scale (PTP) was made, an assessment of the clinical probability of obstructive coronary artery disease was proposed, the recommendations on the use of diagnostic tests in various groups of patients were updated. Such a radical change in approaches to the diagnosis of CCS raised many questions that had to be answered by further studies conducted in the past two years. The review provides data on the validation of the new PTP scale and the proposed assessment of the clinical probability of obstructive coronary artery disease, taking into account risk factors and with the additional inclusion of information on the calcium index of coronary arteries. The proposals of experts on new algorithms for the choice of non-invasive / invasive examination of this category of patients were also considered. Overall, the new PTV rating scale (ECS 2019) has been validated and validated in retrospective analyzes of cohort studies. The scale for assessing the clinical likelihood of obstructive coronary artery disease makes it possible to classify 3.8-5 times more patients as a low probability of coronary artery disease compared to the assessment of PTP alone. Assessment of the post-test probability of coronary artery disease does not allow to confirm the presence of obstructive lesion and was not used. The experts proposed new modifications of the diagnostic algorithm (with a detailed assessment of the clinical probability, as well as without taking it into account), which require verification in further studies. Therefore, it is advisable to conduct prospective studies to confirm the possibility of reducing the total number of non-invasive and invasive studies in patients with suspected coronary heart disease, as well as the safety of such a decrease in diagnostic procedures

ОЦЕНКА И СНИЖЕНИЕ РИСКА КАРДИАЛЬНЫХ ОСЛОЖНЕНИЙ ПРИ НЕКАРДИАЛЬНЫХ ОПЕРАЦИЯХ (по материалам Европейского конгресса кардиологов – 2014, Барселона)

This article reviews the new ESC guidelines on cardiovascular risk assessment and therapy for non-cardiac surgery, presented in 2014, discusses the management strategy changes and the questions the new guidelines haven’t answered. The guidelines can be used by a wide range of professionals who practice perioperative risk assessment and management.В данной статье рассматриваются новые рекомендации по оценке и коррекции риска кардиальных осложнений при некардиальных операциях, представленные в 2014 году, обсуждаются изменения в стратегии лечения пациентов и вопросы, на которые рекомендации убедительного ответа не дают. Рекомендации могут быть применены широким кругом специалистов, занимающихся предоперационным обследованием и лечением

Outpatient management of patients with peripheral artery disease by cardiologists or surgeons: influence on the prognosis and prevalence of surgical interventions

Highlights. The study shows for the first time that during the three-year follow-up of patients with diseases of the arteries of the lower extremities in the observation groups of a general surgeon and a cardiologist, adverse events (myocardial infarction, stroke, amputation, disability) and deaths occurred more often in a surgeon than a cardiologist. The study proves the correctness and real benefit of such an approach with the involvement of a cardiologist to the outpatient stage of management of a complex cohort of patients with atherosclerosis of the vessels of the lower extremities.Aim. To study the effect the outpatient observation of patients with peripheral arteries disease (PAD) by cardiologists and surgeons has on timing and prevalence of reconstructive surgery and the prognosis of patients. Methods We analyzed the data on 585 PAD patients who underwent outpatient observation from 2010 to 2017, dividing them into 2 groups. The first group (131 patients) managed by an surgeon; the second (454 patients) managed by a cardiologist. Since the groups were not comparable in terms of the initial parameters, the comparability of patients in the groups (observation by a surgeon or by a cardiologist) was achieved using pseudorandomization. The follow-up period was three years; we assessed the incidence of deaths, adverse events, and the prevalence of reconstructive operations.Results. During a three-year follow-up the 1st group, compared with the 2nd, had more deaths in general (p<0.001), death from cardiac causes (p = 0.045), from stroke (p><0.001), as well as the total number of adverse events (p><0.001) and disability (p = 0.065). Indications for reconstructive surgery on the lower extremities arteries (LEA), and operations frequency were comparatible in groups. Amputation history, taking diuretics, presence of rhythm disturbances, and management by a surgeon increased the risk of adverse outcomes. Management by a cardiologist, reconstructive LEA surgeries, female sex improved the prognosis of patients. Conclusion Observation of PAD patients by a cardiologist contributes to a higher frequency of optimal drug therapy by patients and can reduce the number of adverse events in patients and improve their survival without affecting the timing and frequency of reconstructive LEA surgeries. Keywords Peripheral atherosclerosis • Outpatient follow-up • Optimal drug therapy • Reconstructive surgery>˂ 0.001), death from cardiac causes (p = 0.045), from stroke (p˂ 0.001), as well as the total number of adverse events (p˂ 0.001) and disability (p = 0.065). Indications for reconstructive surgery on the lower extremities arteries (LEA), and operations frequency were comparatible in groups. Amputation history, taking diuretics, presence of rhythm disturbances, and management by a surgeon increased the risk of adverse outcomes. Management by a cardiologist, reconstructive LEA surgeries, female sex improved the prognosis of patients.Conclusion. Observation of PAD patients by a cardiologist contributes to a higher frequency of optimal drug therapy by patients and can reduce the number of adverse events in patients and improve their survival without affecting the timing and frequency of reconstructive LEA surgeries.Highlights. The study shows for the first time that during the three-year follow-up of patients with diseases of the arteries of the lower extremities in the observation groups of a general surgeon and a cardiologist, adverse events (myocardial infarction, stroke, amputation, disability) and deaths occurred more often in a surgeon than a cardiologist. The study proves the correctness and real benefit of such an approach with the involvement of a cardiologist to the outpatient stage of management of a complex cohort of patients with atherosclerosis of the vessels of the lower extremities.Aim. To study the effect the outpatient observation of patients with peripheral arteries disease (PAD) by cardiologists and surgeons has on timing and prevalence of reconstructive surgery and the prognosis of patients. Methods We analyzed the data on 585 PAD patients who underwent outpatient observation from 2010 to 2017, dividing them into 2 groups. The first group (131 patients) managed by an surgeon; the second (454 patients) managed by a cardiologist. Since the groups were not comparable in terms of the initial parameters, the comparability of patients in the groups (observation by a surgeon or by a cardiologist) was achieved using pseudorandomization. The follow-up period was three years; we assessed the incidence of deaths, adverse events, and the prevalence of reconstructive operations.Results. During a three-year follow-up the 1st group, compared with the 2nd, had more deaths in general (p<0.001), death from cardiac causes (p = 0.045), from stroke (p><0.001), as well as the total number of adverse events (p><0.001) and disability (p = 0.065). Indications for reconstructive surgery on the lower extremities arteries (LEA), and operations frequency were comparatible in groups. Amputation history, taking diuretics, presence of rhythm disturbances, and management by a surgeon increased the risk of adverse outcomes. Management by a cardiologist, reconstructive LEA surgeries, female sex improved the prognosis of patients. Conclusion Observation of PAD patients by a cardiologist contributes to a higher frequency of optimal drug therapy by patients and can reduce the number of adverse events in patients and improve their survival without affecting the timing and frequency of reconstructive LEA surgeries. Keywords Peripheral atherosclerosis • Outpatient follow-up • Optimal drug therapy • Reconstructive surgery>˂ 0.001), death from cardiac causes (p = 0.045), from stroke (p˂ 0.001), as well as the total number of adverse events (p˂ 0.001) and disability (p = 0.065). Indications for reconstructive surgery on the lower extremities arteries (LEA), and operations frequency were comparatible in groups. Amputation history, taking diuretics, presence of rhythm disturbances, and management by a surgeon increased the risk of adverse outcomes. Management by a cardiologist, reconstructive LEA surgeries, female sex improved the prognosis of patients.Conclusion. Observation of PAD patients by a cardiologist contributes to a higher frequency of optimal drug therapy by patients and can reduce the number of adverse events in patients and improve their survival without affecting the timing and frequency of reconstructive LEA surgeries

ПОДГОТОВКА ПАЦИЕНТА С СЕРДЕЧНО-СОСУДИСТЫМИ ЗАБОЛЕВАНИЯМИ К ПЛАНОВЫМ ХИРУРГИЧЕСКИМ ВМЕШАТЕЛЬСТВАМ ПРИ ОНКОПАТОЛОГИИ

Significant progress in the diagnosis and treatment of cancer resulted in a marked improvement in the survival of these patients. Declining mortality in acute cardiovascular diseases is accompanied by an increase in the proportion of patients with chronic cardiovascular pathology. Both trends resulted in a growing cohort of patients with concomitant oncology and cardiovascular disease, given rise to cardiooncology, a rapidly growing field. Cardio-oncology incudes a variety of clinical issues, particularly preoperative assessment of patients for cancer surgery. However, this section has been recently neglected in the recent guidelines. This review focuses on the preoperative management of patients with cardiovascular diseases for elective cancer surgeries. It reports the existing algorithm of assessing the risk of cardiac events in non-cardiac surgeries relatively to cancer patients. Current international and national guidelines were published in 2014 and, therefore, do not contain the latest evidences. Thus, this review summarizes all recent data and provides a modified and simplified preoperative management strategy for cancer patients. In particular, surgical risk assessment should be comprehensive, taking into account the complexity of the surgical procedures and the severity of comorbidity. The review discusses specific risk assessment scales proposed for different groups of cancer patients (for example, the ThRCRI scale in surgeries for non-small cell lung cancer). In addition, it contains various options for assessing the functional status of patients (stress tests, including spiroergometry, DASI index, assessment tables). Current recommendations on additional screening and preventive treatment of patients are summarized and addressed to the healthcare specialists and researchers studying perioperative risk assessment in cancer surgery.Существенный прогресс в выявлении и лечении онкопатологии привел к заметному улучшению выживания таких больных. С другой стороны, снижение летальности при острых сердечно-сосудистых заболеваниях сопровождается увеличением пропорции больных с хронической кардиоваскулярной патологией. Неудивительно, что оба этих тренда в результате привели к растущей когорте пациентов с сочетанным наличием онкопатологии и заболеваний сердечно-сосудистой системы, что и послужило основанием для выделения такого направления, как кардиоонкология. Среди направлений в кардиоонкологии выделяют дооперационную оценку больных при онкологических операциях, однако в рекомендациях последнего времени данный раздел обойден вниманием. Настоящий обзор посвящен вопросам подготовки пациента с сердечно-сосудистыми заболеваниями к плановым хирургическим вмешательствам при онкопатологии. В обзоре подробно разбирается существующий пошаговый алгоритм оценки риска кардиальных осложнений при некардиальных операциях применительно к онкологическим больным. Существующие международные и отечественные рекомендации по данному вопросу были выпущены в 2014 г. и на данный момент не учитывают данных ряда недавних исследований. Поэтому в обзоре предложена модифицированная и упрощенная схема предоперационной оценки пациентов с онкопатологией. В частности, риск операции предлагается оценивать комплексно, как с учетом тяжести операции, так и коморбидной патологии пациента. Кроме того, в обзоре рассматриваются специфические шкалы оценки риска, предлагаемые для определенных категорий онкологических пациентов (например, шкала ThRCRI при операциях по поводу немелкоклеточного рака легких). Также в обзоре предложены различные варианты оценки функционального статуса больных (нагрузочные тесты, в том числе спироэргометрия; индекс активности DASI; таблицы оценки). Завершают обзор рекомендации по дополнительному обследованию и превентивному лечению пациентов. Данный обзор будет интересен практическим врачам, работающим с данной категорией больных, а также исследователям, изучающим вопросы оценки периоперационного риска в онкохирургии

ЭХО РОССИЙСКОГО НАЦИОНАЛЬНОГО КОНГРЕССА КАРДИОЛОГОВ (Москва, 22–25 сентября 2015 года): НОВОСТИ ПЕРИОПЕРАЦИОННОЙ МЕДИЦИНЫ

Due to the increasing age of patients in the population people over 45 years old make up about half of the entire cohort of operated patients. Therefore the problem persists of the perioperative cardiac complications development. In 2014, recommendations of the European Society of Cardiology on risk assessment and correction of cardiac complications in extracardiac operations were adopted. However, after they exit this issue remain much debated question. Because every year appear new data on this issue, there is a need for their understanding and discuss the possibility of use in the clinical setting. This review is devoted to some recent publications on the perioperative management of patients, as well as presentations at the Russian National Congress of Cardiology, held in September2015 inMoscow. В связи с повышением возраста пациентов лица старше 45 лет составляют примерно половину из всей когорты оперированных больных, сохраняется проблема развития таких периоперационных осложнений, как инфаркт миокарда и кардиоваскулярная смерть. В 2014 году были приняты рекомендации Европейского общества кардиологов по оценке и коррекции риска кардиальных осложнений при внесердечных операциях, однако и после их выхода остается много дискутабельных вопросов. Поскольку каждый год появляются новые данные по этому вопросу, то возникает необходимость их осмысления и обсуждения возможности применения в клинических условиях. Настоящий обзор посвящен некоторым последним публикациям по вопросам периоперационного ведения пациентов, а также докладам, прозвучавшим на Российском национальном конгрессе кардиологов, состоявшемся в сентябре 2015 года в Москве.

НОВОЕ В ОЦЕНКЕ РИСКА И ЛЕЧЕНИИ КАРДИАЛЬНЫХ ОСЛОЖНЕНИЙ ПРИ НЕКАРДИАЛЬНЫХ ОПЕРАЦИЯХ

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Clinical symptoms and ECG data in women with acute coronary syndrome

Background. There are many differences in chest pain symptoms between men and women in terms of location, nature, and additional symptoms. The issue of describing the differences in chest pain in men and women with acute coronary syndrome (ACS), as well as their correlation with changes in the electrocardiogram (ECG) and coronary angiography (CAG) remains relevant.Methods. The study included 588 patients of the cardiology department of the Novokuznetsk City Clinical Hospital No. 1 from 2013 to 2017 with a diagnosis of ACS. Depending on the gender, the subjects were divided into two groups: Group I – 330 men; Group II – 258 women.Results. ACS with ST elevation was more common in men (45.8 %) than in women (33.3 %; p = 0.002). There were no pathological ECG changes in women in 58.1 % of cases, in men – in 45.5 % (p < 0.001). ECG type Q/ST elevation was detected more often in men (45.8 %) than in women (33.3 %; p = 0.002). The absence of coronary artery lesions was observed in 27.9 % of men and 44.2 % of women (p < 0.001). Hemodynamically significant coronary artery stenosis was more common in men (57.6 %) than in women (38.7 %; p < 0.001). In a typical angina clinic, hemodynamically significant coronary artery disease in patients with Q/without ST elevation ACS was detected in 40.2 % of men and in 58.5 % of women (p = 0.002). In the atypical angina clinic, hemodynamically significant lesions of coronary artery were more common in men (40.6 %) than in women (34.1 %; p = 0.02).Conclusion. In women atypical chest pains and intact coronary arteries were detected more often than in men, and hemodynamically significant coronary artery stenosis were found less often than in men. In men, a more pronounced pathology of the coronary arteries in ACS was revealed, in women – great difficulties in diagnosing ACS