Preoperative C-Reactive Protein Levels Predict Readmission Following Elective Vascular Surgery
CLI Journal Original Contribution – The Official Journal of CLI Global Society
Asrar Khan, MD1,2; Derrick L. Green, MD, MBA3; Steve Santilli, MD, PhD, MBA3; Debra K. Johnson, RN1,2;
Selma Carlson, MD1,2; Mackenzi Mbai, MD1,2; Rosemary F. Kelly, MD4;
Amy A. Gravely, MS5; Brad Bart, MD1,2; Selcuk Adabag, MD1,2; Santiago Garcia, MD6;
Qun Chen, PhD7,8; Ion S. Jovin, MD7,8; Edward Lesnefsky, MD7,8; Edward O. McFalls, MD, PhD1,2
C-reactive protein (CRP) levels may be reduced with long-term administration of ubiquinone (CoQ10) in patients with chronic ischemic heart disease, but the impact of a short-term period of administration in patients undergoing elective vascular surgery is uncertain.
A double-blind, randomized, controlled trial was implemented to determine whether preoperative administration of CoQ10 could reduce cardiac biomarker elevations. Patients were randomly assigned to CoQ10 (400 mg per day) versus placebo for 3 days prior to surgery. B-type natriuretic peptide (BNP), troponin, and CRP levels were obtained before and after surgery. The primary endpoint was peak biomarker elevations and secondary endpoints were length of stay and readmission.
A total of 123 patients were randomly assigned to CoQ10 (n = 62) or placebo (n = 61) for 3 days before surgery. At 24 hours post-surgery, the group receiving CoQ10 had lower BNP levels, with no intergroup differences in CRP. Within 1 year post discharge, 36 patients (29%) were readmitted and preoperative risk for readmission included diabetes mellitus (hazard ratio [HR], 3.60; 95% confidence interval [CI], 1.46-8.91), active smoking (HR, 3.55; 95% CI, 1.43-8.78), and CRP (HR, 1.35; 95% CI, 1.04-1.76). C-index for all 3 variables predicting readmission was 0.727.
Short-term administration of CoQ10 reduced perioperative BNP, but not CRP levels. CRP, along with diabetes and active smoking, were independent predictors of readmission and might be suitable variables to modify as a means of reducing subsequent rehospitalizations following elective vascular procedures.
CLI Journal Original Contribution – The Official Journal of CLI Global Society: Read Full Article
Among Medicare beneficiaries undergoing vascular surgery, nearly 1 in 4 patients are readmitted within 30 days of hospital discharge and as a diagnosis-related group (DRG), cause of readmission is second only to congestive heart failure.1 Although readmissions following vascular surgery are often unplanned,2,3 identifiable clinical risk factors can be recognized at the time of discharge and include age, socioeconomic factors, and select comorbidities.4-9 There is emerging interest in exploring the utility of perioperative biomarkers as a means of predicting those patients who have the highest risk of adverse postoperative outcomes, including unplanned readmissions.10 Preoperative N-terminal prohormone B-type natriuretic peptide (NT-proBNP) has been recommended as an optimal means of risk stratifying patients undergoing noncardiac operations11 and has value in patients undergoing vascular surgery.12 In support of those studies, we have shown that preoperative NT-proBNP levels predict postoperative risk of myocardial injury.13 C-reactive protein (CRP), a readily available biomarker, can also predict poor outcomes in patients with ischemic heart disease14,15 and together with BNP, may have value in predicting adverse events in patients with vascular disease.16,17
Ubiquinone (CoQ10) is an endogenous antioxidant that improves outcomes in patients with heart failure and ischemic heart disease.18 Reducing oxidant stress in the mitochondria within the myocyte may play a key role in attenuating inflammation within cardiac tissue. In fact, in a meta-analysis, CoQ10 administration significantly decreased plasma CRP levels.19 Interleukin-6 (IL-6) is a secondary messenger cytokine that induces hepatic CRP production20 and is also lowered by administration of CoQ10.21 To no surprise, the greatest effect on CRP reduction with CoQ10 administration is among those patients with elevated IL-6 levels.22 A plausible mechanism for CoQ10’s antioxidant effect on reduced inflammation is the inhibition of IL-6, which is upstream from the production of proinflammatory cytokines.23
In the present study, we assessed the utility of CRP levels in predicting risk of readmission to the hospital following hospital discharge. Because long-term administration of CoQ10 has been shown to reduce CRP levels in selected patients,24,25 testing the effects of a short-term period of administration on postoperative CRP levels is relevant.
The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
1Division of Cardiology, Minneapolis VA Medical Center, Minneapolis, Minnesota;
2Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, Minnesota;
3Division of Vascular Surgery, Minneapolis VA Medical Center, Minneapolis, Minnesota;
4Division of Cardiothoracic Surgery, University of Minnesota, Minneapolis, Minnesota;
5Department of Research Statistical Center, Minneapolis VA Medical Center, Minneapolis, Minnesota;
6Minneapolis Heart Institute, Minneapolis, Minnesota;
7Department of Medicine, Virginia Commonwealth University, Richmond, Virginia; and the
8Division of Cardiology, McGuire VA Medical Center, Richmond, Virginia.
Manuscript accepted May 4, 2022.
Address for correspondence: Edward McFalls, MD, Richmond VAMC, Hunter Holmes McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA 23249. Email: firstname.lastname@example.org
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