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Incidence and Outcome of Perioperative Myocardial Injury After Non-cardiac Surgery (BASEL-PMI)

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ClinicalTrials.gov Identifier: NCT02573532
Recruitment Status : Recruiting
First Posted : October 9, 2015
Last Update Posted : September 16, 2020
Sponsor:
Collaborator:
Cantonal Hospital of Aarau, Switzerland
Information provided by (Responsible Party):
University Hospital, Basel, Switzerland

Brief Summary:
This observational study includes patients undergoing major non-cardiac surgery, and screens them for the occurrence of perioperative myocardial injuries (PMI). Incidence, patient characteristics, pathophysiology, potential prevention and therapy strategies and 1-year outcomes of PMI will be described.

Condition or disease
Perioperative Myocardial Injury

Detailed Description:

Background: Worldwide more than 230 million surgical operations are performed each year. Despite advances in all fields of medicine, there is still a significant risk of death related to major non-cardiac surgical procedures. The observed 30-day mortality depends on patient- as well as procedural factors and ranges between 1% and 10%. Cardiovascular complications, particularly perioperative myocardial injury/infarction (PMI) seem to be major contributors to about a third of all deaths. PMI may differ from spontaneous acute myocardial infarction (AMI). The vast majority of patients experiencing PMI do NOT have acute chest pain or other symptoms typical for AMI likely because they are narcotized or sedated and random ECGs are often not informative. Accordingly, most patients with PMI are currently not detected in routine clinical practice. Missed diagnosis is invariably associated with missed opportunity for the initiation of treatment. As most patients with PMI are missed in routine clinical care, the true incidence of and outcome after PMI are largely unknown. Prior studies have often not obtained a baseline sample and thus have suggested that all cTn elevations are likely due to AMI which may exaggerate the numbers. In addition, usually conventional less sensitive assays have been used. Further, the predominant pathophysiology of PMI is currently unknown. It has been suggested that type II MI characterized by coronary perfusion pressure mismatch and not type I MI characterized by acute thrombotic coronary occlusion is the predominate mechanism. However, autopsy data suggest that plaque rupture is more common. Thus, it may be that type 2 AMI is more common but that the modest incidence of type 1 AMI is not dangerous prognostically.

Aim: To explore the incidence, patient characteristics, pathophysiology, potential prevention and therapy strategies and long-term outcome of PMI after major non-cardiac surgery

Methodology: Consecutive high-risk patients undergoing major non-cardiac surgery will be included and followed for one year for the occurrence of all-cause death and other major adverse cardiac events. Patients receive a standardized assessment of cardiovascular status and systematic perioperative screening for PMI using high sensitivity cardiac troponin T (hs-cTnT) at baseline prior to surgery, as well as on day 1 and day 2 after surgery. Acute cardiac injury will be defined as an absolute increase in h/s-cTn of the 99th percentile of healthy individuals for the respective assay above baseline cTn-value or between two postoperative values if the preoperative value is missing. A search for possible alternative causes for hs-cTnT elevations will be aggressively sought if a rising pattern of values is detected. Two independent experts will adjudicate the most likely cause of PMI using all clinical information pertaining to the individual patient including the 12-lead ECG, peak hs-cTnT blood concentrations, coronary angiography and myocardial perfusion scanning. Influence of PMI on occurrence of all-cause death will be assessed using multivariate Cox-proportional hazards analysis. Further, pre-operative and post-operative prediction models for death, major adverse cardiac events, and PMI shall be derived using a derivation-validation design.

Potential Significance: This study will generate scientific data that have major scientific implications by contributing to closing current knowledge gaps concerning the influence of PMI on long-term mortality as well as the incidence, patient characteristics, and pathophysiology of PMI after non-cardiac surgery. This knowledge will have immediate clinical implications as it could e.g. lead to major changes in perioperative management with reconsiderations of the necessary target blood pressure to avoid coronary perfusion mismatch and consecutive cardiac injury.

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Study Type : Observational
Estimated Enrollment : 20000 participants
Observational Model: Cohort
Time Perspective: Prospective
Official Title: Basel Incidence, Patient Characteristics, Outcome and Possible Strategies to Improve Outcome of Perioperative Myocardial Injury After Non-cardiac Surgery: 1-Year Follow-up
Study Start Date : October 2015
Estimated Primary Completion Date : February 2022
Estimated Study Completion Date : May 2023



Primary Outcome Measures :
  1. Deaths in one year after non-cardiac surgery in patients with and without PMI [ Time Frame: 1 year ]

Secondary Outcome Measures :
  1. MACE in one year after non-cardiac surgery in patients with and without PMI [ Time Frame: 1 year ]
    MACE is defined as a composite of death, acute myocardial infarction, life-threatening arrhythmia (cardiac arrest, sustained ventricular tachycardia, atrioventricular (AV) -block III), or acute heart failure (requiring admission to a hospital or intra-hospital transfer to the intensive care unit) within one year. Two independent cardiologists or anaesthesiologists will adjudicate all MACE.

  2. Incidence of PMI within a screening program in high-risk patients undergoing major non-cardiac surgery [ Time Frame: 3 days after surgery ]
    PMI is defined as an absolute increase in h/s-cTn of the 99th percentile of healthy individuals for the respective assay above baseline cTn-value or between two postoperative values if the preoperative value was missing. PMI will be further classified as type I myocardial infarction, type II myocardial infarction, or myocardial injury due to non-cardiac causes.

  3. Number of patients with PMI with ischemic symptoms and signs detected in a screening program in high-risk patients undergoing major non-cardiac surgery [ Time Frame: 3 days after surgery ]
    Patients with PMI are evaluated for: presence of chest pain, atypical symptoms, palpitations, dyspnea, edema, or nausea; ST-changes, Q-waves, T-wave abnormalities, new bundle branch block

  4. Number of patients with PMI with management changes after screening-induced consultation [ Time Frame: 3 days after surgery, followed for 1 year ]
    Changes in management can be: changes in medication, intensification of surveillance, call for use of coronary angiography, myocardial stress testing, other, or none

  5. Generate a pre- and an immediate postoperative prediction score for occurrence of major adverse cardiac events including PMI [ Time Frame: 1 year ]
  6. Costs related to the introduction of perioperative hs-cTnT screening. [ Time Frame: 1 year ]
    Health system costs of implementation of screening is calculated as number of interventions initiated additionally to routine care after screening

  7. Derive and validate a risk score in patients with different subtypes of PMI for the occurrence of major cardiac adverse events to inform treatment decisions. [ Time Frame: 1 year ]
    Endpoint: percentage of correctly classified patients in validation cohort.

  8. Derive and validate an improved diagnostic screening approach for detection of PMI. [ Time Frame: 3 days after surgery ]
    Endpoint: sensitivity and specificity for PMI.

  9. Evaluate the effect of pre-operative medication use. [ Time Frame: 3 days after surgery ]
    Endpoint: number of patients undergoing elective non-cardiac surgery suffering PMI (cardiac origin) after non-cardiac surgery with vs without pre-operative statin/RAAS blocker/β-blocker therapy.

  10. Evaluate the effect of post-PMI medication on outcome of PMI. [ Time Frame: 1 year ]
    Endpoint: death and MACE in patients suffering PMI (cardiac origin) with vs without statin/RAAS blocker/β-blocker therapy.

  11. Description of PMI subtypes and potential diagnostic criteria available at time of PMI detection. [ Time Frame: 3 days after surgery ]
  12. Validate the diagnosis of PMI within a screening program in high-risk patients undergoing major non-cardiac sur-gery with other troponin assays. [ Time Frame: 3 days after surgery ]
    PMI is defined as an absolute increase in h/s-cTn of the 99th percentile of healthy individuals for the respective assay above baseline cTn-value or between two postoperative values if the preoperative value was missing.


Other Outcome Measures:
  1. Estimate potential effect of detection and management of PMI on major adverse cardiac events by a screening program implemented within clinical routine [ Time Frame: 1 year ]
  2. Compare cardiac troponin T and I in the detection of PMI [ Time Frame: 3 days after surgery ]


Information from the National Library of Medicine

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Ages Eligible for Study:   45 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Sampling Method:   Probability Sample
Study Population

Consecutive patients that underwent a systematic approach to PMI detection at the participating hospitals as clinical routine will be included.

The screening consists of a pre-operative "baseline" measurement of hs-cTnT within 30 days prior to surgery, and two post-operative measurements taken on the first and second day after surgery. Screening is done in patients requiring hospitalization >24 hours after surgery AND (aged ≥ 65 years OR history of coronary artery disease OR peripheral artery occlusive disease OR cerebrovascular disease). Patients are seen by a cardiologist in case of detection of a PMI.

Criteria

Inclusion criteria

  • Patients received a perioperative hs-cTnT screening for PMI
  • Patient consent available Exclusion criteria
  • Patient's refusal

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT02573532


Contacts
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Contact: Christian Müller, MD, Prof +41 61 328 6549 christian.mueller@usb.ch
Contact: Christian Puelacher, MD-PhD +41 61 556 5830 christian.puelacher@usb.ch

Locations
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Switzerland
University Hospital Basel Recruiting
Basel, BS, Switzerland, 4031
Contact: Christian Müller, MD, Prof    +41 61 328 6549    christian.mueller@usb.ch   
Sub-Investigator: Christian Puelacher, MD-PhD         
Sub-Investigator: Danielle M. Gualandro, MD-PhD         
Sub-Investigator: Daniel Bolliger, MD, Prof         
Sub-Investigator: Christoph Kindler, MD, Prof         
Sponsors and Collaborators
University Hospital, Basel, Switzerland
Cantonal Hospital of Aarau, Switzerland
Investigators
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Principal Investigator: Christian Müller, MD, Prof University Hospital, Basel, Switzerland
Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):

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Responsible Party: University Hospital, Basel, Switzerland
ClinicalTrials.gov Identifier: NCT02573532    
Other Study ID Numbers: BASEL-PMI
First Posted: October 9, 2015    Key Record Dates
Last Update Posted: September 16, 2020
Last Verified: September 2020

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Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No
Keywords provided by University Hospital, Basel, Switzerland:
myocardial ischemia/diagnosis
myocardial ischemia/epidemiology
perioperative
perioperative complications/diagnosis
prognosis
Additional relevant MeSH terms:
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Wounds and Injuries