so thank you very much for the
opportunity to talk to today i'll be
talking about the vision cardiac surgery
study which we recently published the results
on for the high censor trip on
an eye as a journal or medicine
so in this trial we were evaluating
patients undergoing cardiac surgery
ends or kitchens have cardiac surgery
ah
patients can have important injuries to their
hearts
that have prognostic relevance and sometimes i
can relate to a patient having perioperative
i'm heart attack or another form of
current injury
there are challenges and making that diagnosis
arm ends guidelines have recommended to either
use ten times the upper limit of
normal or thirty five to seventy times
the agreement normal i'm across different guidelines
say what is an abnormal tripled in
value in this setting that would represent
important myocardial injury
and in some of the definition of
they also it's high that seeing he
you changes or on symptoms
because these guidelines were initially using data
that was based upon using see can
be as the heart marker to done
if i heard injury but the reality
as many hospitals no longer have cmp
available and the world is move towards
using high sensitive to opponent acids and
and this is what most hospice are
now available there is uncertainty of whether
or not the actual threshold values from
the guidelines are the right values to
be using and if they are not
the right values than this has the
potential there will be missed classifying patients
is having important events when it that
perhaps they didn't and or perhaps class
by some patients that they didn't have
an important about when in fact they
did so in this study we undertook
a large international perspective cohort study at
twenty four centers in twelve countries we
included in these analyses were everyone had
i censorship on and i measured before
surgery in the first three days after
surgery we included a total of
thirteen thousand eight hundred and sixty two
patients i'm in this cohort to just
over two percent these patients died and
then if we also look at major
bass your complications during the first thirty
days on the risk of that complication
was up to three percent i'm what
we demonstrated in our study is that
it
if we look at whether or not
what values of highs such on him
as these are prognostic important after non
cardiac surgery be identified
i'm three important points the first is
is that isolated bypass surgery coronary artery
bypass surgery cabbage or islay the arctic
valve replacement repair really follows a very
similar pattern of chicago elevation after the
surgery snatch be lumped into one category
and then there's all the other cutter
cardiac surgery which can include cabbage plaza
valve or different types of valves being
done
and those follow a much higher pattern
of hard injury just due to the
reality of how much heart muscle trauma
happens around the times have surgery we
also demonstrated that the peace and proponents
are occurring in the first twenty four
hours after surgery and others separate level
of peaks on day two and three
whereas the guidelines up till now really
need a recommendation to use a single
threshold of your own in the first
forty eight hours after surgery is not
made a distinction between the various types
of heart surgery so showing that you
can put isolated cabbage surgery and i
salute you already valve replacement together and
all other heart surgeries and others specific
today one and today two and three
after surgery he demonstrated that on day
one and the peak thresholds with the
high censor to pollen
am i as day or two hundred
to five hundred times the upper limit
of normal armed in striking contrast with
the guidelines for suggesting of ten seventy
times overland park
i'm in this
is important so that people will know
what right threshold use and also because
many of randomized controlled trials that are
evaluating surgical interventions often do include whether
not patients suffer a perry up with
heart attack if in fact we're using
the wrong threshold we're going to put
a lot of noise into the signal
and lunar believe
understand where the novels interventions really work
i'm so this is what our study
has shown is that we need very
different thresholds for the high sensitive on
an eye as a impatience having cardiac
surgery to demonstrate who was in fact
having prognostic we important myocardial injury
so i think the most common i'm
inquiry would be is that am
can you use these thresholds towards the
diagnosis of myocardial infarction and i would
put forty that the answer is yes
we will have further analyses that will
look at these data coming out these
patients but i'm for the biomarkers to
have relevance they have to have prognostic
importance and that's why the first step
up from
establishing at what level the japonica values
or prognostic be relevant i'm is important
and we're seeing what i think a
lot of decisions have appreciated clinically is
that the values that have been recommend
the guidelines habits or that almost all
patients are having for nostra are hurting
rep for surgery and that is not
clinically
people's experience i'm so these threshold the
worst out wishing i think can be
used to diagnose of myocardial infarction
and i can be very helpful to
people on a manager patients clinically in
this setting
i'm
and another question
that patients me or that has come
up is whether or not our results
in form other forms of pollen i'm
our results are specific to the highsmith
on an avid as say that being
said we've also done very similar work
in non cardiac surgery
arm and in that setting in general
we showed that the highs and strip
on an asset is ten to have
per gnostic relevance and similar ah values
times government normal so i think it
is highly probable that the results were
seen will end up of me being
replicated in using a
other to on an isis from eye
as it is nice it's your opponent
yeah says a bit further work is
needed to firmly established that point
i think that all the fat clinicians
today in the sense that if
clinicians or mound you're patient the heart
surgery and they're concerned the patients not
doing well they measured proponents and are
using the high on proponent i added
as a this will definitely help them
to know whether or not in fact
there is important heart injury happening or
there is not for target tree happening
with the prior guidelines they will be
diagnosed a lot more people in many
people rome easily as having important hard
injury but this will allow them to
happy to know whether or not the
are the patient is having and as
had important heart injury i think will
also help people and doing randomized controlled
trials to help make a more ah
credible definition of what should be used
for proponent values on to help make
the diagnosis of myocardial infarction after heart
surgery in the setting
so next steps will be of were
just finishing the analysis we've read about
ninety thousand easy geez will be looking
at easy to use an inquiry that
data into the results along to put
in on the see how easy to
get it will help up better inform
ends validate
the work towards important
mile cardinal injury and myocardial infarction after
heart surgery
i think what's important cardiologists arm know
but the state is bad
with the current guidelines so as an
example using the universal definition of my
would recommend using on about your ten
times or below are all and ninety
seven point five percent of patients after
heart surgery using the high sense which
point i asked surpass that threshold so
tells you that that threshold cannot be
the right threshold because
essentially that nothing to the diagnostic criteria
because century everyone's your past and the
reality is you need much higher to
on a values in order for them
to represent prognostic important injuries and i
think this will help reassure physicians said
they don't over call important hard injury
and er patients after heart surgery