Évaluation de la pertinence de l’application de l’algorithme d’estimation du risque cardiaque périopératoire de la Société canadienne de cardiologie publié en 2016 chez les patients subissant une chirurgie élective non cardiaque avec insuffisance rénale chronique de stade 3b et plus

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Marc-Alexandre Lavoie
Matthieu Touchette

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Abstract

Résumé
En 2016, la Société canadienne de cardiologie (SCC) a publié de nouvelles lignes directrices périopératoires s’appliquant aux patients qui doivent subir une intervention chirurgicale non cardiaque. Elle propose, entre autres, un algorithme décisionnel d’estimation du risque cardiaque périopératoire et de surveillance post-opératoire chez les patients subissant une chirurgie élective non cardiaque. Or, cet algorithme pourrait être moins pertinent à appliquer chez les patients avec une insuffisance rénale chronique (IRC) de stade 3b et plus (débit de filtration glomérulaire estimé (DGFe) < 45 mL/min/1,73m2) subissant une chirurgie élective non cardiaque. De fait, dans la présente étude, 145 sur 249 patients avec une IRC de stade 3b et plus, soit 58,2% (IC 95% : 51%–64%, p = 0,011) ont présenté un dosage préopératoire de NT-proBNP ≥ 300 mg/L. Parmi ces patients, 71,0% ont eu un dosage de troponines postopératoire complété. Bien que 24,3% d’entre eux aient subi un Myocardial Injury after Noncardiac Surgery (MINS), seulement 7,8% de ces patients ont bénéficié d’une intensification de leur thérapie antiplaquettaire ou hypolipidémiante afin de réduire leur mortalité à 30 jours postopératoire. La pertinence de l’application de cet algorithme décisionnel pourrait donc être remise en question chez les patients avec une IRC de stade 3b et plus, notamment quant au rapport coût-avantage.


Abstract
In 2016, the Canadian Cardiovascular Society (CCS) released new perioperative guidelines for patients undergoing noncardiac surgery. The guidelines push on, among other things, a tree algorithm allowing estimation of perioperative cardiac risk and postoperative monitoring in patients undergoing elective noncardiac surgery. However, little is known about applying this algorithm to patients with stages 3b-5 chronic kidney disease (CKD) undergoing elective noncardiac surgery. In fact, the present study shows that 145 out of 249 patients with stages 3b-5 CKD (58.2% [95% CI: 51%-64%, p = 0.011]) presented preoperative NT-proBNP levels ≥ 300 mg/L. Of these 145 patients, 103 participants (71.0%) had a postoperative troponin measurement. Although 25 patients (24.3%) of the latter underwent myocardial injury after noncardiac surgery (MINS), only 8 patients (7.8%) benefited from a treatment intensification of their antiplatelet or lipid-lowering therapy to reduce mortality within 30 days following surgery. The CCS’ algorithm’s relevance can therefore be called into question in patients with stages 3b-5 CKD, particularly in regard to the benefit-cost ratio.

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