Each risk factor has points, and based on their accumulated points, patients fall into categories of low-, moderate-, to high- risk groups for CHD. The risk score was developed based on risk factors such as total cholesterol, high-density lipoprotein cholesterol (HDL-C), blood pressure, age, smoking, and gender. Based on these risk factor scores, the risk for CHD can be classified from low- to high-risk, and one can estimate the 10-year likelihood of developing a major cardiac event, as shown in Table 3. Low-risk CHD correlates with 10% mortality at 10 years, moderate-risk with 10%–20%, and high-risk with greater than 20% risk of mortality. This can readily be calculated by using an online Framingham risk calculator at http://hp2010.nhlbihin.net/ATPiii/calculator. asp?usertype = prof; http://www.framinghamheartstudy.org/ risk/hrdcoronary.html.
Twenty-nine consecutive ESRD patients on dialysis referred for RT evaluation at Henry Ford Hospital were prospectively studied. All patients signed a written informed consent and the study was approved by the institutional review board at Henry Ford Hospital. One patient could not com- plete the CCTA due to IV infiltration and therefore was excluded from analysis, resulting in a final sam- ple size of 28 patients. All were required to under- go a standard CCTA examination, as per the study protocol. Cardiac CTA findings were blinded to the referring physician as well as to the patient. Any significant non-cardiac findings noted were commu- nicated to the patient’s primary physician. Patients underwent routine clinical risk assessment as per our institution’s RT work-up protocol and 23 pa- tients also underwent a DSE (n = 20) or single- -photon emission computed tomography (SPECT) (n = 3) examination as part of their risk stratifica- tion. The clinical assessment and stress test results were the only information used to make decisions for RT candidacy.
Introduction: Cardiovascular complications arising from noncardiac surgery contribute substantially to perioperative morbidity and mortality. Methods: Review of relevant literature; clinical experience. Results: The basic tools for preoperative risk assessment are the evaluation of specific risk factors, of the patient’s functional capacity, and of procedure specific risks. Additional non-invasive tests have low predictive value for riskstratification. Preoperative coronary revascularization is seldom beneficial. Patients at low or intermediate perioperative risk should therefore not undergo complex examinations or interventions, which entail unnecessary delay and increased costs. Patients at high risk should be evaluated by stress testing or dobutamine stress echocardiography and possibly by invasive strategies, as individually indicated. The indication for revascularization relates to pre- existing symptoms and disease, and must be assessed independently of surgery. Beta-blockers and statins have recently been shown to decrease perioperative ischemia and should be administered where there is significant cardiovascular risk. Discussion: This review presents an algorithm for the management of patients undergoing noncardiac surgery. Continuing to improve perioperative strategies remains a pivotal interdisciplinary task and should be undertaken with respect to existing evidence and clinical guidelines. Dtsch Arztebl 2007; 104(22): A 1581–7.
stress-related enzyme, myeloperoxidase (MPO), a heme peroxidase, participates in LDL oxidation mediated by radical 1e-oxidation and non-radical 2e-oxidation . Detection, quantification and imaging of MPO mass and activity are useful in cardiacriskstratification . Mean- while, urokinase-type plasminogen activator receptor (uPAR) is a GPI-anchored membrane protein that, during inflammation, becomes shedded from cell membrane and forms soluble uPAR (suPAR) . The levels of plasma suPAR were shown to correlate with pro-inflammatory markers and even outperform CRP at prognosticating CVD [68, 69]. Another protein, pentraxin-3 (PTX3) is re- leased upon primary inflammatory signals  and has been implicated as an inflammatory biomarker for CAD . In two independent clinical trials (CORONA and GISSI-HF) enrolling patients with chronic HF, PTX3 was consistently associated with adverse outcomes . Fi- nally, matrix metalloproteinases (MMP) are implicated in plaque formation and rupture, leading to coronary occlu- sion . Individuals with acute coronary syndrome and CAD were shown to possess elevated levels of MMP-1, − 2, − 8 and − 9 in their plasma [74, 75].
70–98) and a specificity of 60% (95% CI 55–64), and the SFSR 81% (95% CI 61–93) and 63% (95% CI 58–67), in predicting an adverse outcome within 10 days. The clinical judgment (ie, the doctor’s decision to admit or discharge patients from ED independently of any strict adherence to predefined protocol or risk scores) had a sensitiv- ity of 77% (95% CI 56–91) and a specificity of 69% (95% CI 64–73). The sensitivities of the 3 decision-making approaches were not significantly different, but the SFSR and OESIL would have recognized all 5 patients who died within 10 days from syncope, whereas the clinical judg- ment missed 2 deaths. However, the numbers of patients and events were inadequate to draw defin- itive conclusions. Although derived on events at 1 year, the OESIL risk score proved to be useful even in the short-term riskstratification of patients with syncope. Major limitations of OESIL result from the small number of its independent valida- tions, whereas its main strength is its simplicity, which enables its use even by nurses triaging patients with syncope.
was derived from data in the TIMI 11B trial 5 and has been validated in retrospective analyses of five additional large registries and trials: ESSENCE, 6,7 TACTICS-TIMI 18, 8 PRISM-PLUS, 9,10 TIMI-III, 11,12 and CURE. 13,14 The TIMI risk score is of potential interest even beyond simple prognostication of outcomes because it also appears to be predictive of increasing benefit from specific therapies as risk increases. 4,8,10 It was developed from the retrospec- tive analysis of a relatively high-risk NSTE ACS random- ized clinical trial and therefore may not be appropriate for use in screening an unselected ED chest pain population, in which the aggregate cardiacrisk would be expected to be significantly lower. Despite this concern, the score has been recommended as a potential screening tool in just such a population. 2,15 We therefore sought to determine the applicability of this instrument to an unselected ED chest pain population, in terms not only of predicting ad- verse events over the ensuing 30 days but also of predict- ing the benefit of specific management strategies. If it could accurately risk-stratify patients at the time of initial ED evaluation, it potentially could be used as a tool to assist triage or disposition decisions.
visit, and with complete data on risk equation covariates for Framingham Risk Score. Consistent with previous studies, patients were classified into 3 age groups (30–44, 45–59, and 60–74 years) [3, 15]. Clinically relevant demographic, historical, and lifestyle parameters were collected via a stan- dardized questionnaire provided to all patients and reviewed by a trained healthcare provider. In addition to collecting physiometric data at the time of visit, HbA1c was collected as part of the standard serum testing panel from all patients at each visit. Each respective model was gener- ated based on one of two riskstratification methods: (I) BMI classification (underweight, BMI <18.5; normal weight, BMI 18.6–24.9; overweight, BMI 25–29.9; and obese, BMI ≥ 30 [20, 21]); or (II) Framingham Risk Score for 10-year cardiovascular risk (low risk, <10%; moderate risk, 10% ≤ score < 20%; and high risk, ≥20%) [22, 23]. BMI and Framingham Risk Score parameters were collected during the routine health check up at the same time and in the same facility in which HbA1c was measured; the Framingham Risk Score has been previously validated in the Japanese population .
Results: Copeptin levels were elevated in non-survivors (n = 29) compared to survivors at 30 days (108 pmol/l, interquartile range (IQR) 37 to 197 pmol/l) vs. 18 pmol/l, IQR 7 to 43 pmol/l; P < 0.0001). The areas under the receiver operating characteristic curve (AUC) to predict 30-day mortality were 0.83 (95% confidence interval (CI) 0.76 to 0.90), 0.76 (95% CI 0.67 to 0.84) and 0.63 (95% CI 0.53 to 0.74) for Copeptin, NT-proBNP and BNP, respectively (Copeptin vs. NTproBNP P = 0.21; Copeptin vs. BNP P = 0.002). When adjusted for common cardiovascular risk factors and NT-proBNP, Copeptin was the strongest independent predictor for short-term mortality in all patients (HR 3.88 (1.94 to 7.77); P < 0.001) and especially in patients with acute decompensated heart failure (ADHF) (HR 5.99 (2.55 to 14.07); P < 0.0001). With the inclusion of Copeptin to the adjusted model including NTproBNP, the net reclassification improvement (NRI) was 0.37 (P < 0.001). An additional 30% of those who experienced events were reclassified as high risk, and an additional 26% without events were reclassified as low risk.
The next step on the pyramid has been classed as procurement officer outsourcing which is focused on saving money using performance over the previous 12 to 18 months as a benchmark from which to make logistics procurement decisions. This commoditisation of logistics procurement does not rely on a high degree of ongoing control from the customer supply chain team, if indeed there is one in situ. There is a high risk that this commodity based purchase will move to another provider at contract term and this is not a basis for the long term success of such an agreement.
Numerous physiologic, psychologic, and metabolic health/fitness benefits result from participation in regular physical activity. As illustrated in Chapter 1, how- ever, there are documented risks associated with physical activity. Although there is risk of acute musculoskeletal injury during exercise, the major concern is the increased risk of sudden cardiac death and myocardial infarction that is sometimes associated with vigorous physical exertion. A major public health goal is to increase individual participation in regular, moderate-to-vigorous physical activity. Pursuit of this goal must include a process for identifying indi- viduals at increased risk for adverse exercise-related events. At the same time, the riskstratification process should not present a significant barrier to partici- pation. This chapter presents guidelines for (a) evaluating an individual’s risk for adverse exercise-related events and (b) making appropriate recommenda- tions regarding the initiation, continuation, or progression of an individual’s physical activity program to reduce the potential occurrence of these types of catastrophic events.
To the best of our knowledge, this study is the first to de- termine the prognostic value of copeptin measurement in unselected patients ≥40- years old admitted to both med- ical and surgical departments. Copeptin measurement had a strong and independent prognostic importance for all patients and seems not to be related to any specific diag- nosis. Patients with low copeptin concentrations had an excellent short-term prognosis with no fatal outcomes within the first week and only very few deaths within three months. On the other hand, high copeptin concentrations identified a subgroup of patients with a very high risk of short-term mortality.
Unfortunately, there is no convincing evidence that this is the case. There are three potential circumstances under which RISKSTRATIFICATION makes sense: (1) If the results would alter the surgical plan, leading either to cancellation of surgery or to an alternative procedure, such as amputation instead of peripheral arterial bypass. (2) If the results indicate a need for coronary revascularization before non cardiac surgery, either by coronary artery bypass grafting or percutaneous transluminal angioplasty; and (3) If the results would alter perioperative management. Each of these potential applications warrants careful scrutiny because even if preoperative testing does lead to these interventions, as is now often the case, are there data to justify these approaches? (Fig.III).
Although syncope is most often caused by a benign condition, the substrate can be a serious heart disease, which is able to lead to serious complications and even sudden cardiac death. In addition, the decline in quality of life due to frequent injuries during falls, particularly in the elderly, is a major health problem. For these reasons, it is important to identify patients who should be immediately admitted to the hospital because of the risk of complications and fatal outcome of those where there is no such danger. This is precisely the role of riskstratification of syncope. It is believed that the use of standardized guidelines for riskstratification, can reduce hospital admissions by 52% without significant risk of cardiovascular incidents. The main goals of treatment of syncope are prolonging life, prevent recurrences of syncope, limit physical injuries and thus improve the quality of life. Since syncope is symptom caused by a wide spectrum of disorders, the therapy is diverse also.
the associated surgical subtypes. Data from over 10 million cases analysed found a 3% incidence which translated into 150 000 events annually with higher rates in vascular, thoracic and transplant surgery. The incidence has shown a declining trend over the past decade due to improvements in perioperative riskstratification, surgical and anaesthetic techniques. However, with the increasing number of high-risk patients presenting for major non-cardiac surgery, the concern is that the improvements that have been made will be attenuated. 1
With these guiding principles, our experience at Memo- rial Sloan-Kettering Cancer Center is that MPI (along with other stress imaging modalities) can be invaluable to the perioperative care of select cancer patients whose surgical procedures are often extensive and prolonged (respective median and maximum operating room times: genitourinary, 278 and 873 min; thoracic, 128 and 780 min; hepatobiliary, 220 and 608 min; orthopedic, 178 and 1,330 min; head or neck, 163 and 1,346 min; neurosurgery, 231 and 840 min; and gynecology, 198 and 974 min). Because of these patients’ underlying cancer, active or recent chemotherapy and radiation treatment, and intercurrent illness, their exer- cise capacity is often either poor or uncertain, making them potential candidates for stress testing by ACC/AHA guide- lines. We reserve stress testing for those with suggestive symptoms, multiple risk factors, and an abnormal baseline EKG that requires interrogation as part of the comprehen- sive cardiac evaluation. The value of exercise treadmill EKG testing without imaging has been highly limited in this setting. The prognostic information from MPI has pro- vided a critical element in the preoperative evaluation that often influenced the choice of cancer therapy, extent of surgery, and intensity and venue of postoperative care even when coronary interventions were not pursued.
Tree-structured analysis by CART Pro 6.0 (Salford Systems, San Diego, CA) was used to perform recursive parti- tioning analysis. All variables with a P value of ⬍ .2 on univariate analysis and with a ⱖ 90% completion rate were en- tered as candidate predictors. We de- cided a priori to limit the use of subjec- tive clinical determinants in the model (eg, reports of vomiting at home was considered objective, but lethargy at home was considered subjective and not a candidate). With CART analysis, splitting rules are developed in a step- wise fashion by analyzing each poten- tial predictor and all possible cut points (if continuous). Splits are made to minimize false-negative or false- positive assignments for the outcome variable. A parameter that represents “cost” can be modiﬁed such that the model maximizes sensitivity or speci- ﬁcity. Our objective was to make the most sensitive decision tree and thereby conﬁdently identify low-risk patients; we iteratively assigned a high cost to misclassiﬁcation of a case of intussusception into a low-risk node.
Chronic pain is now commonly regarded as a “sociopsychobio- medical” issue and not surprisingly; this is also true for CPSP. 4 Psychosocial risk factors for its development have therefore been identified early, and these are both cognitive behavioural and emotional. In an early systematic review, depression, psycholog- ical vulnerability, stress, and late return to work were identified as the primary psychosocial risk factors. 10 Recent work has focused on psychological factors, such as preoperative anxiety, including trait anxiety as well as fears specific to pending surgery, but even more so the concept of catastrophizing. 24 Pain catastrophizing has been broadly defined as a tendency to magnify or exaggerate the threat value or seriousness of painful sensations. 20
Under these conditions, for enterprises and economic systems of different levels, the problem of aggregation of large volumes of information – the results of monitoring of a variety of aspects of the activity of the environment – is being updated. The latter significantly alter the input parameters of management models, may have a destabilizing effect, and, therefore, cause an increase in the uncertainty of the situation and the resulting risk and, as a consequence, the instability of the economic system. Enterprises that are interested in increasing the stability of their own business and the predictability of development trajectories, evaluate the level of awareness of the tendencies and regularities of processes in the external environment as a measure of conceptual advantage. It is precisely this – the targeted security- protection meaning becomes an economic risk in the information (digital) economy, and the corresponding change in the managerial and model paradigm is grounded historically and methodologically [2, 7-10].
This is an important topic; syncope is a common presentation to EDs and there are problems with current management. These include the lack of high quality evidence based strategies to detect patients at high risk of short-term adverse events and those of long- term adverse outcome, the high admission rate and the low inci- dence of short-term adverse events. Challenges that can contribute to unsatisfactory practice include the lack of specialist syncope experts and specialist syncope clinics in many hospitals, the lack of a clear speciality leading the field (cardiology, internal medicine and geriatric medicine specialties are among the commonest to lead care in most hospitals), differences in the speciality leading care in the ED (emergency medicine is the commonest to lead care in most EDs however in some countries where it is less developed, internal or geriatric medicine maybe the first to see syncope patients in the ED), differences in the time that patients are allowed to spend in the ED before they must be admitted to a hospital bed (ranging from 4 hours in the United Kingdom to over 24 hours in others), differences in diagnostic pathways within and between hospitals, and finally difficulties disseminating and teaching best practice due to many of the above issues.