Natriuretic peptide [NP; B-type NP (BNP), N-terminal proBNP (NT-proBNP), and midregional proANP (MR-proANP)] concentrations are quantitative plasma biomarkers for the presence and severity of haemodynamic cardiac stress and heart failure (HF). End-diastolic wall stress, intracardiac filling pressures, and intracardiac volumes seem to be the dominant triggers. This paper details the most important indications for NPs and highlights 11 key principles underlying their clinical use shown below. NPs should always be used in conjunction with all other clinical information. NPs are reasonable surrogates for intracardiac volumes and filling pressures. NPs should be measured in all patients presenting with symptoms suggestive of HF such as dyspnoea and/or fatigue, as their use facilitates the early diagnosis and risk stratification of HF. NPs have very high diagnostic accuracy in discriminating HF from other causes of dyspnoea: the higher the NP, the higher the likelihood that dyspnoea is caused by HF. Optimal NP cut-off concentrations for the diagnosis of acute HF (very high filling pressures) in patients presenting to the emergency department with acute dyspnoea are higher compared with those used in the diagnosis of chronic HF in patients with dyspnoea on exertion (mild increase in filling pressures at rest). Obese patients have lower NP concentrations, mandating the use of lower cut-off concentrations (about 50% lower). In stable HF patients, but also in patients with other cardiac disorders such as myocardial infarction, valvular heart disease, atrial fibrillation or pulmonary embolism, NP concentrations have high prognostic accuracy for death and HF hospitalization. Screening with NPs for the early detection of relevant cardiac disease including left ventricular systolic dysfunction in patients with cardiovascular risk factors may help to identify patients at increased risk, therefore allowing targeted preventive measures to prevent HF. BNP, NT-proBNP and MR-proANP have comparable diagnostic and prognostic accuracy. In patients with shock, NPs cannot be used to identify cause (e.g. cardiogenic vs. septic shock), but remain prognostic. NPs cannot identify the underlying cause of HF and, therefore, if elevated, must always be used in conjunction with cardiac imaging.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/ejhf.1494

Heart Failure Association of the European Society of Cardiology practical guidance on the use of natriuretic peptide concentrations

Background— Elderly patients with ischemic heart disease are increasingly referred for coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). However, reports of poor outcomes in the elderly have led to questions about the benefit of these strategies. We studied survival by prescribed treatment (CABG, PCI, or medical therapy) for patients in 3 age categories: 6000 elderly patients with ischemic heart disease were compared with younger patients. In 15 392 patients >70 years of age, 4-year adjusted actuarial survival rates for CABG, PCI, and medical therapy were 95.0%, 93.8%, a...

Survival After Coronary Revascularization in the Elderly

Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(18)30832-8.pdf

Dabigatran in patients with myocardial injury after non-cardiac surgery (MANAGE): an international, randomised, placebo-controlled trial

Key Clinical PointsAcute Hip Fracture Hip fractures (categorized according to anatomical location as a femoral-neck fracture or an intertrochanteric or subtrochanteric fracture) can have a devastating effect on quality of life and function, with a high risk of death at 1 year. Femoral-neck fractures, if nondisplaced or in a young patient, are typically treated with internal fixation. For fractures at the base of the femoral neck (sometimes called basicervical fractures), displaced fractures, and those with a more vertically oriented fracture line, reoperation rates are lower when a sliding hip screw is used than when multiple cancellous screws are used. Approaches to displaced femoral-neck fractures remain controversial, but evidence currently favors arthroplasty over internal fixation, especially in persons 65 years of age or older. Unstable intertrochanteric and subtrochanteric fractures of the femur are treated with the use of intramedullary nails, whereas stable fractures of these types are typically ...

https://www.nejm.org/doi/pdf/10.1056/NEJMcp1611090

Management of Acute Hip Fracture

Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery.

A recent editorial[1][1] on coronary artery bypass graft (CABG) surgery in patients 65 years of age and over stated that "the beneficial effect on mortality in older patients with 3-vessel or left main coronary artery disease is not seriously questioned...." Given the risk of morbidity and mortality

/pdf/coronary-artery-bypass-surgery-for-elderly-patients-is-our-2qee3nxfoa.pdf

Coronary artery bypass surgery for elderly patients: is our practice based on evidence or faith?

We studied four cardiology grand rounds transmitted by videoconference from a tertiary care centre to four other hospitals in eastern Canada. We collected data with evaluation questionnaires and by video recording participants at the receiving-site and the presentation they received from the presenting site. Receiving-site participants (n=20) rated their satisfaction with all domains significantly lower than did presenting-site participants (n=49). The greatest difference in ratings was in the ability to see slides (receiving sites 2.6/5, presenting site 4.6/5). Review of video recordings revealed that slides showing material copied from print sources was difficult to read at receiving sites. While 56% of discussion time was devoted to questions from receiving sites, participants there rated their ability to participate in discussion lower than those at the presenting site (3.9/5 vs 4.4/5). This may be because some parts of the discussion from the presenting site were not transmitted. Receiving-site participants rated the educational value of the rounds lower than their presenting-site colleagues (3.9/5 vs 4.4/5) but answered a similar percentage of knowledge questions correctly (85 vs 89%).

Paul MacDonald

Papers

Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery.

Coronary artery bypass surgery for elderly patients: is our practice based on evidence or faith?

Cardiology grand rounds: effect of videoconferencing on educational value.