Preoperative levels of heart proteins may help predict death or cardiac complications in patients undergoing noncardiac surgery

December 24, 2019

1. Preoperative levels of heart proteins may help predict death or cardiac complications in patients undergoing noncardiac surgery
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Assessing preoperative levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP), a biomarker of heart stress and structural changes, may improve risk prediction beyond the clinical risk score in patients having noncardiac surgery. Findings from a cohort study are published in Annals of Internal Medicine.

Globally, more than 200 million adults have major noncardiac surgery annually and more than 10 percent have major cardiac complications within the first 30 days, resulting in death, disability, prolonged hospitalization, or increased health care expenditure. Several guidelines recommend using the Revised Cardiac Risk Index (RCRI) to predict perioperative cardiac risk. Although the RCRI is easy to use, its accuracy in predicting major perioperative cardiovascular complications is limited. Preliminary evidence suggests that NT-proBNP measurement may improve perioperative cardiovascular risk prediction.

Researchers from McMaster University, Hamilton General Hospital planned a substudy of the VISION (Vascular Events in Noncardiac Surgery Patients Cohort Evaluation) study to determine whether preoperative NT-proBNP had additional predictive value beyond the RCRI for the composite of vascular death and myocardial injury within 30 days after noncardiac surgery. The substudy included 10,402 patents at 16 hospitals in 9 countries and all patients had NT-pro-BNP levels measured before surgery and troponin T levels measured daily for up to 3 days after surgery. The researchers found that preoperative NT-proBNP concentrations were independently associated with the occurrence of vascular death or myocardial injury at 30 days after surgery. Preoperative NT-proBNP thresholds in addition to the RCRI substantially improved discrimination of patients and perioperative risk stratification and also predicted the risk for secondary outcomes.

Media contacts: For embargoed PDFs please contact Lauren Evans at To speak with the lead author, P.J. Devereaux, MD, PhD, please email

2. Majority of internal medicine residency program directors misinterpret ABIM leave policies
Misunderstandings about leave may lead to unnecessary extensions of resident training

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A recent nationwide survey of 279 internal medicine residency program directors showed that the vast majority did not correctly interpret the American Board of Internal Medicine (ABIM) leave policies. While 51 percent of those surveyed said they understood ABIM's Leave of Absence and Vacation policy, most could not answer specific questions about the rules. These misunderstandings could lead to unnecessary extensions in residents' training programs. Findings from a brief research study are published in Annals of Internal Medicine.

When managing parental leave, program directors must balance resident needs with adherence to ABIM policies (as they understand them), and must minimize extensions of training that are required when residents take more leave than is permitted. As such, the Association of Program Directors and the Internal Medicine (APDIM) Survey Committee of the ABIM collaborated in an effort to assess internal medicine program directors' understanding of ABIM leave policies and their application to common scenarios, including parental leave. The survey showed that about half of the program directors thought that they understood the policies, but their answers showed that they misinterpreted leave times as being shorter than they actually are. When presented with various scenarios for leave, the program directors rarely answered questions about them correctly. For example, when asked about a scenario where a resident asks for 8 weeks of maternity leave, only 6.5 percent of program directors correctly chose not to extend training; 82.7 percent said they would extend training to follow ABIM policy.

According to the authors, misunderstandings are of concern because many residents requesting leave worry about program extensions. Given the lack of clarity surrounding ABIM policies, the authors suggest that parental leave policies should be clarified.

Media contacts: For an embargoed PDF, please contact Lauren Evans at To reach the lead author, Kathleen Finn, MD, M.Phil, please contact Michael Morrison at

Also new in this issue:

It's Time to Revise the Uniform Determination of Death Act
Ariane Lewis, MD; Richard J. Bonnie, LLB; and Thaddeus Pope, JD, PhD
Ideas & Opinions

American College of Physicians

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