Chronotropic incompetence and myocardial injury after noncardiac surgery: planned secondary analysis of a prospective observational international cohort study

Abstract

Background: Physiological measures of heart failure are common in surgical patients, despite the absence of a diagnosis. Heart rate (HR) increases during exercise are frequently blunted in heart failure (termed chronotropic incompetence), which primarily reflects beta-adrenoreceptor dysfunction. We examined whether chronotropic incompetence was associated with myocardial injury after noncardiac surgery. Methods: This was a predefined analysis of an international cohort study where participants aged !40 yr underwent symptom-limited cardiopulmonary exercise testing before noncardiac surgery. Chronotropic incompetence was defined as the ratio of increase in HR during exercise to age-predicted maximal increase in HR <0.6. The primary outcome was myocardial injury within 3 days after surgery, defined by high-sensitivity troponin assays >99th centile. Explanatory variables were biomarkers for heart failure (ventilatory efficiency slope [minute ventilation/carbon dioxide production] !34; peak oxygen consumption 14 ml kg À1 min À1 ; HR recovery 6 beats min À1 decrease 1 min post-exercise; preoperative N-terminal pro-B-type natriuretic peptide [NT pro-BNP] >300 pg ml À1 ). Myocardial injury was compared in the presence or absence of sympathetic (i.e. chronotropic incompetence) or parasympathetic (i.e. impaired HR recovery after exercise) thresholds indicative of dysfunction. Data are presented as odds ratios (ORs) (95% confidence intervals). Results: Chronotropic incompetence occurred in 396/1325 (29.9%) participants; only 16/1325 (1.2%) had a heart failure diagnosis. Myocardial injury was sustained by 162/1325 (12.2%) patients. Raised preoperative NT pro-BNP was more

Performance of cardiopulmonary exercise testing for the prediction of post-operative complications in non cardiopulmonary surgery: A systematic review

“…We will however highlight key messages from this paper in the context of our other findings. We did include a secondary analysis of this cohort where chronotropic incompetence during CPET was assessed as a predictor of postoperative myocardial injury assessed using rises in serum troponin [41].…”

Can routine perioperative haemodynamic parameters predict postoperative morbidity after major surgery?

“…While this is often attributed to age-related atherosclerosis, its significance in the intraoperative period is unclear, and the mechanism by which wide pulse pressure could cause organ impairment and hence postoperative morbidity is uncertain. Increased PP > 62 mmHg in the preoperative period has been shown to be an independent risk factor for overall postoperative morbidity and myocardial injury during noncardiac surgery in these increased risk patients, while SAP was not (Abbott et al 2017a;Abbott et al 2017b;Abbott et al 2019a;Ackland et al 2018). Elevated PP has been suggested to increase myocardial stress, promote left ventricular hypertrophy, impair coronary perfusion and increase aortic stiffness.…”

“…In addition, dysfunction of the sympathetic nervous system at baseline before surgery has also been associated both with increased postoperative morbidity (Abbott et al 2019a). This is distinct from parasympathetic vagal dysfunction-a secondary analysis of the VISION database has suggested a link between loss of vagal tone preoperatively and MINS (Abbott et al 2019b;May et al 2019).…”

Cardiopulmonary Exercise Testing for Preoperative Evaluation: What Does the Future Hold?

“…Impaired HRR after exercise is common with 40% occurrence being reported in the METS study [65]. Cardiac vagal dysfunction defined as a delayed HRR (where impaired HRR is defined as ≤ 12 beats .…”

“…CI during exercise is a predictor of major adverse cardiovascular events in patients with cardiovascular diseases [71][72][73] but may also be a phenotype that is associated with cardiovascular risk and impaired gas exchange (V O 2 peak) in the general population [74]. Variation in cut-off values and methods used to define CI underpin the disparity in reported prevalence rates, but figures of between 25% and 75% have been reported in HF [75][76][77], patients with known or suspected CAD [78] and prior to high-risk noncardiac surgery [65]. Although related to preoperative biomarker indicators of subclinical HF (N-terminal pro-B-type natriuretic peptide [NT pro-BNP] > 300 pg ml −1 ) and more common in patients with impaired CPET-derived cardiorespiratory fitness ðV O 2 peak ≤ 14 ml .…”