Newsletter - September 2018 Must Read Articles

Must-read articles

“Period-dependent Associations between Hypotension during and for Four Days after Noncardiac Surgery and a Composite of Myocardial Infarction and Death: A Substudy of the POISE-2 Trial.”
Reference: Sessler DI et al. Anesthesiology 2018; 128(2): 317-327.
Take home message: This substudy of POISE-2 demonstrated that clinically important hypotension (SBP<90mmHg requiring treatment), during intraoperative or postoperative stages, was significantly associated with composite of 30-day myocardial infarction and death. Odds ratios of outcome for each intraoperative 10min duration in hypotension was 1.08, while for any hypotensive episode in postoperative days one to four was 2.83.

“Dabigatran in patients with myocardial injury after non-cardiac surgery (MANAGE): an international, randomised, placebo-controlled trial.”
Reference: Devereaux PJ et al. The Lancet 2018; 391: 2325–2334.
Take home message: Myocardial injury after non-cardiac surgery (MINS) increases the risk of cardiovascular events and deaths. The results of this trial indicate that addition of dabigatran 110 mg twice daily among patients with MINS had lower major vascular event rates compared with placebo (11 per cent versus 15 per cent, HR 0.72, 95 per cent CI 0.55–0.93; p=0.0115); while bleeding complications were similar (3 per cent [dabigatran] versus 4 per cent [placebo], HR 0.92, 95 per cent CI 0.55–1.53; p=0.76). These results need to be interpreted with the caveat that the trial was terminated early and the primary outcome definition was changed midway through the trial.

“Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study.”
Reference: Wijeysundera DN et al. The Lancet 2018; 391: 2631–2640.
Take home message: Functional capacity is an important component of risk assessment for major surgery. This study compared various modalities of preoperative assessments to predict adverse outcomes after major elective non-cardiac surgery, including clinician’s subjective assessment, the Duke Activity Status Index (DASI) questionnaire, cardiopulmonary exercise testing (CPET), and serum N-terminal pro-B-type natriuretic peptide (NT pro-BNP). Subjective assessment had low sensitivity (19.2 per cent, 95 per cent CI 14.2–25) for identifying the inability to attain four metabolic equivalents during CPET, confirming that clinician’s prediction of low functional capacity has low accuracy.