title: Vascular surgery patients: perioperative and long-term risk according to the ACC/AHA guidelines, the additive role of post-operative troponin elevation.
abstract: OBJECTIVE
  The objectives of this study are to evaluate the prognostic role of pre-operative stratification in patients undergoing elective major vascular surgery, the timing of adverse outcomes, and the predictive role of troponin (cTn).
  
  
  RESULTS
  Consecutive vascular surgery candidates (n=391) were prospectively stratified and treated according to the ACC/AHA guidelines. The patients were categorized into three groups: (1) with coronary revascularization in the past 5 years, (2) with intermediate clinical risk predictors, and (3) with minor or no clinical risk predictors. cTnI was measured post-operatively. By 18 months, 18.7% of subjects had experienced death or acute myocardial infarction (MI) (by the ACC/ESC criteria). The hazard ratio (HR) was 5.21 (95% CI=2.60-10.43; P<0.0001) in group 1 and 2.58 (95% CI=1.27-4.38; P=0.004) in group 2 when compared with group 3. Most events occurred within 30 days. Elevations of cTnI were associated with adverse outcomes even after multivariable adjustment at long-term (adjusted overall HR=4.73, 95% CI=2.92-7.65; P<0.0001) and at 30 days (adjusted HR=5.52, 95% CI=3.23-9.42; P<0.0001).
  
  
  CONCLUSIONS
  After pre-operative stratification, patients undergoing elective major vascular surgery remain at high risk of MI and death. Events occur mainly early after surgery. cTnI elevations are frequent and independently associated with increased risk. These findings suggest the need for a major re-evaluation of our approach to these patients.
authors.affiliation: Institute of Cardiology, Policlinico Hospital, Modena and Reggio Emilia University School of Medicine, Italy.
authors.forename: Francesca
authors.initials: F
authors.lastname: Bursi
authors.forename: Luciano
authors.initials: L
authors.lastname: Babuin
authors.forename: Andrea
authors.initials: A
authors.lastname: Barbieri
authors.forename: Luigi
authors.initials: L
authors.lastname: Politi
authors.forename: Mauro
authors.initials: M
authors.lastname: Zennaro
authors.forename: Teresa
authors.initials: T
authors.lastname: Grimaldi
authors.forename: Antonio
authors.initials: A
authors.lastname: Rumolo
authors.forename: Mauro
authors.initials: M
authors.lastname: Gargiulo
authors.forename: Andrea
authors.initials: A
authors.lastname: Stella
authors.forename: Maria Grazia
authors.initials: MG
authors.lastname: Modena
authors.forename: Allan S
authors.initials: AS
authors.lastname: Jaffe
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000328:Adult; D002309:Cardiology; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000097:blood / Q000209:etiology; D011182:Postoperative Care / Q000379:methods; D011183:Postoperative Complications / Q000097:blood / Q000209:etiology*; D017410:Practice Guidelines as Topic; D011379:Prognosis; D011446:Prospective Studies; D012307:Risk Factors; D012955:Societies, Medical; D019210:Troponin I / Q000378:metabolism*; D014656:Vascular Surgical Procedures / Q000009:adverse effects*
chemical_list: D000319:Adrenergic beta-Antagonists; D019210:Troponin I