Implementation of a Clinical Screening and Response System for Cardiac Complications After Noncardiac Surgery

Study Overview
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Brief Summary
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The investigators aim to show the feasibility and medicoeconomic impact of implementing a clinical screening and response system for the early detection of perioperative cardiac complications in high-risk patients. Specifically, the investigators aim to: 1) evaluate the feasibility of implementation of a PMI-screening; 2) evaluate the medicoeconomic impact of implementing a PMI-screening; 3) identify barriers to implementation; 4) generate data for a future randomized controlled trial on outcomes by exploring opportunities to improve care following PMI, the occurrence and timing of major adverse cardiac events (MACE), and the treatment effect associated with PMI-screening.

Detailed Description
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Background: Perioperative myocardial infarction/injury (PMI) is increasingly recognised as frequent, but often undiagnosed and untreated contributor to mortality following noncardiac surgery. Due to differences in pathophysiology and perioperative anaesthesia and analgesia, most PMI do not cause typical ischemic symptoms and are therefore missed in routine clinical practice. Active surveillance using cardiac troponin (cTn) is now guideline-recommended for the early detection of PMI to possibly improve outcome1. Given substantial concerns regarding the feasibility and health economic impact of implementing such a strategy, it is not yet widely applied. Aim: to show feasibility of implementation as well as health economic impact of an active surveillance for the early detection of PMI in high-risk patients. Methodology: in this observational before-after study the investigators will enrol patients at high cardiovascular risk undergoing noncardiac surgery before and after implementation of a PMI screening. Patients in the pre-implementation phase will receive standard of care, while in the post-implementation phase patients receive a PMI-screening, consisting of a preoperative and two postoperative measurements of high-sensitivity cTn (hs-cTn) and a cardiology consultation will be done in case of detection of a PMI. Patient data, resource utilisation, and PMI-aetiology will be collected. Interviews with key stakeholders will identify barriers to implementation. One-year follow-up will be conducted to evaluate occurrence of death, MACE, and safety endpoints. Potential significance: This study will generate important insights regarding the feasibility, safety and the health economic impact of implementing an active surveillance for the early detection of PMI.

Official Title
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Implementation of a Clinical Screening and Response System for the Early Detection of Cardiac Complications After Noncardiac Surgery: Feasibility and Medicoeconomic Impact

Conditions
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Myocardial Injury, Myocardial Infarction, Perioperative Complication

Intervention / Treatment
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* Other: Patient assessment and follow-up


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Consecutive patients fulfilling the institutional criteria for inclusion into the routine PMI-screening aged 40-85 years at increased cardiovascular risk undergoing inpatient, noncardiac, elective or emergent surgery postoperative stay of ≥2 nights at the participating institution orthopaedic, traumatology, vascular, spinal, thoracic, neurosurgical, and visceral surgery. Exclusion Criteria: patients with cardiac surgery or interventions in the last 14 days chronic renal failure under dialysis, renal transplant surgery moderate-to-severe dementia previous inclusion within 5 days documented refusal to use of their data for research purposes or refusal of further use during follow-up Patients declining consent for follow-up will be excluded from follow-up analyses.

Ages Eligible for Study
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Minimum Age: 40 Years
Maximum Age: 85 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Before implementation<br>Patients included before implementation of the PMI-screening | Other: Patient assessment and follow-up<br>* There is no study-specific intervention. The investigators will record data generated by clinical activity before, during and after implementation of the PMI-screening. Follow-up data and the final PMI event adjudication will be the only data generated specifically for this study.<br>|
| After implementation<br>Patients included after implementation of the PMI-screening | Other: Patient assessment and follow-up<br>* There is no study-specific intervention. The investigators will record data generated by clinical activity before, during and after implementation of the PMI-screening. Follow-up data and the final PMI event adjudication will be the only data generated specifically for this study.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Perioperative Myocardial Infarction/Injury (PMI)-Screening (Reach) | Percentage of patients eligible for PMI-screening according to inclusion criteria, but not screened during the implementation phase (defined as no or only one measurement of hs-cTn done during screening days) | during the hospital stay (up to postoperative day 2) | 
| Incidence of PMI | Percentage of patients experiencing PMI following noncardiac surgery | after the surgery until postoperative day 2 | 
| Cardiology consultation (Fidelity) | Percentage of patients with detected PMI by PMI-screening on screening days, seen vs. not seen by a cardiologist | during hospital stay (up to postoperative day 5) | 
| Diagnostic challenge | Number of cases with mismatch of initial classification of PMI aetiology (and management pathway) at time of consultation versus final adjudication. In case of two differential diagnoses stated on the cardiology consultation, mismatch is seen when none of the diagnoses correspond to the final adjudication. If three or more differential diagnoses are stated, mismatch is seen in any case even if the final adjudication diagnosis is stated | during hospital stay (up to postoperative day 5) | 
| Barriers to implementation | Barriers to implementation will be assessed by a semi-quantitive questionnaire complemented by qualitative focus group including the local investigators and representatives of cardiology and anaesthesiology | following the post-implementation period (6 months after implementation) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Medicoeconomic impact | Cost of postoperative blood draws on day 1 and 2, length of hospital stay, days on intensive care unit, consultations within day 1-3, ECG within day 1-3, cardiac stress testing within 30 days, and cardiac catheterisation within 30 days, denoted in Swiss Francs | Within 3 - 30 days following surgery | 
| Resource Usage | Number of postoperative blood draws on day 1 and 2, length of hospital stay, days on intensive care unit, consultations within day 1-3, ECG within day 1-3, cardiac stress testing within 30 days, and cardiac catheterisation within 30 days | Within 3 - 30 days following surgery | 
| Major adverse cardiac events (MACE) | Occurrence and timing of a composite of major adverse cardiac events (MACE) within twelve months, consisting of: All-cause death, acute myocardial infarction Type 1, survived sudden cardiac death, and Acute heart failure | 1 year | 
| Complications of cardiology diagnostics | Number of inappropriate interventions or complications of cardiology diagnostics and interventions, consisting of: Overtreatment (Coronary angiographies showing normal coronaries), complications of cardiac interventions (myocardial infarction, stroke, death) | 30 days | 
| Major bleeding | Bleeding Academic Research Consortium Typ 3-5 | Postoperative day 1 - 1 year (blinding of first 24h following surgery) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Myocardial injury, Myocardial infarction, Perioperative care, Noncardiac surgery, Screening