Non-Cardiac Thoracic Surgical and Endovascular Perioperative MACE: Quick, Easy Prediction and Mitigation Strategy

This article is the second of the two part series focusing on predicting and reducing perioperative major adverse cardiac events (MACE) resulting from the procedures cardiothoracic surgeons perform. The first addressed cardiac surgery (1). This article addresses non-cardiac procedural complications


Introduction
This article is the second of the two part series focusing on predicting and reducing perioperative major adverse cardiac events (MACE) resulting from the procedures cardiothoracic surgeons perform. The first addressed cardiac surgery (1). This article addresses non-cardiac procedural complications At least 4% of the world's population, 300 million people, undergo noncardiac surgery yearly (2). Up to 9.6% suffer major adverse cardiac events(MACE) within 3 mo. of major elective surgery(3), the most common major, deadly complications (4). Although perioperative MACE can be quickly, easily, and reasonably accurately estimated (5)(6)(7), seemingly there's little we can do proactively to mitigate it. This review covers: (1) estimation of perioperative MACE; (2) current options available to reduce MACE (8,9); and (3) suggests new, proactive, simple, safe, promising pharmacologic approaches that might further reduce MACE (10)(11)(12).

Estimating Mace (1) Lee's Revised Cardiac Risk Index (Lrcri, 1999)
This is probably the most frequently used tool (3). A score of 0(absent) or 1(present) is given for: LRCRI's advantage is that it's easily and quickly scored. Disadvantages include: use of CK mb, not troponin, to diagnose AMI; exclusion of emergency surgery, endovascular or infrainguinal procedures; no accounting for frailty or inactivity; and of the operations Lee categorized high (up to 5%) risk in 1999, today some are, at most, of moderate risk. Reguardless, adhere to Lee's list for scoring and use current risk data relating to newer procedures employed since 1999 to decide if their risk should be scored high This is likely the 2 nd most often used among several risk scores. The physician needs a calculator into which the following 5 variables are entered to obtain operative risk: In comparison to LRCRI, it's more accurate for vascular surgery MACE and predicting death.

Mitigating Mace
Sadly, under the present Guidelines, options are limited .Using the 3

Reducing Perioperative Ami Risk
We added RAN to CAD therapy in 51 anginal patients and MACE (unstable angina, AMI [ STEMI, non-STEMI],elective coronary revascularization, cardiac death) was compared to a well-matched cohort of 59 asymptomatic CAD patients. Mean follow-up was 6.1 yrs. Symptomatic CAD patients are well known to have a worse prognosis than asymptomatic patients. However, RAN reduced MACE 37% (p=0.0274): non-STEMI, unstable angina, and death by 31%, even though only 35% had an ischemic (+) MPI stress test.

Reducing Perioperative Ventricular Arrthytmias
Premature ventricular contractions (PVCs) are caused by (1) disorders of impulse conduction (reentrant, fixed-coupled) or (2) impulse initiation: (a)triggered (common),non-fixed coupled, caused by early or delayed afterdepolarizations(EADS,DADs),or (b) enhanced automaticity (less common). Another unique mechanism of action of RAN is that it reduces EADs and DADs. We treated 59 patients with triggered PVCs, typically refractory to other drugs with RAN. Ninety-five% of patients responded, including a 91% reduction in runs of VT. No proarrhythmia occurred (nor has any ever been reported; in fact, RAN protected against proarrhythmias in animal experiments).

Would Preoperative (R)Alpha Lipoic Acid( (R)Ala) Be Helpfull Preventing Perioperative Sudden Cardiac Death In Type 2 Diabetics (Dm Ii)?
We just completed a prospective, open-label cohort 133 DM II patient study (83 took the natural antioxidant, over the counter, (r)ALA; 50 controls, mean follow-up 6.31 yrs.). (r)ALA (mean dose 300mg b.i.d.) reduced sudden cardiac death (SCD) by 43%(p=0.0076) via preventing the decrease in cardio-protective parasympathetic activity caused by Diabetic Autonomic Neuropathy and Cardiovascular Autonomic Neuropathy (CAN), present (often asymptomatically) in at least 65% of DM II patients. The reduction in SCD began within 3 months. So I have all my DAN and CAN DM II patients on (r)ALA unless autonomic function testing (which typically has not been done) by me is normal.