Association Between Myocardial Injury and Cardiovascular Outcomes of Orthopaedic Surgery

Abstract

Background: Myocardial injury after noncardiac surgery (MINS) is common and of prognostic importance. Little is known about MINS in orthopaedic surgery. The diagnostic criterion for MINS was a level of ≥0.03 ng/mL on a non-high-sensitivity troponin T (TnT) assay due to myocardial ischemia. Methods: We undertook an international, prospective study of 15,103 patients ≥45 years of age who had inpatient noncardiac surgery; 3,092 underwent orthopaedic surgery. Non-high-sensitivity TnT assays were performed on postoperative days 0, 1, 2, and 3. Among orthopaedic patients, we determined (1) the prognostic relevance of the MINS diagnostic criteria, (2) the 30-day mortality rate for those with and without MINS, and (3) the probable proportion of MINS cases that would go undetected without troponin monitoring because of a lack of an ischemic symptom. Results: Three hundred and sixty-seven orthopaedic patients (11.9%) had MINS. MINS was associated independently with 30-day mortality including among those who had had orthopaedic surgery. Orthopaedic patients without and with MINS had a 30-day mortality rate of 1.0% and 9.8%, respectively (odds ratio [OR], 11.28; 95% confidence interval [CI], 6.72 to 18.92). The 30-day mortality rate was increased for patients with MINS who had an ischemic feature (i.e., symptoms, or evidence of ischemia on electrocardiography or imaging) (OR, 18.25; 95% CI, 10.06 to 33.10) and for those who did not have an ischemic feature (OR, 7.35; 95% CI, 3.37 to 16.01). The proportion of orthopaedic patients with MINS who were asymptomatic and in whom the myocardial injury would have probably gone undetected without TnT monitoring was 81.3% (95% CI, 76.3% to 85.4%). Conclusions: One in 8 orthopaedic patients in our study had MINS, and MINS was associated with a higher mortality rate regardless of symptoms. Troponin levels should be measured after surgery in at-risk patients because most MINS cases (>80%) are asymptomatic and would go undetected without routine measurements. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The effect of anesthesia on the risk of postoperative myocardial injury in elderly patients with hip fracture: randomized controlled trial

“…Postoperative elevation of cardiac troponins often accompanies hip fracture surgery and is associated with cardiac complications in the early postoperative period, as well as with higher 30-day and annual mortality rates in patients older than 65 years. The risks of MINS are incomparably higher in orthopaedic operations, in particular, in osteosynthesis of the proximal femur, compared with other non-cardiac surgeries [8]. Therefore, ensuring adequate analgesia, prevention of cardiac, thromboembolic, infectious, pulmonary complications is the main task of the operating team.…”

Prognostic value of perioperative high sensitivity troponin in patients undergoing hip and knee arthroplasty

“…In the largest prospective studies, myocardial injury has been reported in 7.5 % to 16 % of the orthopedic procedures. 3 , 7 , 8 , 13 , 22 , 23 In patients evaluated by non hs-TnT (from the VISION study, which considered only the postoperative peak of troponin), myocardial injury occurred in 40 % of patients after amputation, 14 % after major hip or pelvic surgery, and 5 % after TKA. 13 The authors discussed that although the risk of myocardial injury varied across subcategories of orthopedic surgery, one in 20 patients had perioperative troponin elevations even in lowest-risk surgery (TKA), which was reported as quite relevant for predicting risk.…”

“… 3 , 7 , 8 , 13 , 22 , 23 In patients evaluated by non hs-TnT (from the VISION study, which considered only the postoperative peak of troponin), myocardial injury occurred in 40 % of patients after amputation, 14 % after major hip or pelvic surgery, and 5 % after TKA. 13 The authors discussed that although the risk of myocardial injury varied across subcategories of orthopedic surgery, one in 20 patients had perioperative troponin elevations even in lowest-risk surgery (TKA), which was reported as quite relevant for predicting risk. It is important to highlight that in the VISION study[7,13] myocardial injury reported as Myocardial Injury after Noncardiac Surgery (MINS) is a more restrictive term than PMI and refers to ischemic causes (in which mismatch is much more common than thrombosis) and does not include other possible causes of troponin elevation, such as pulmonary embolism or acute heart failure.…”

“… 11 , 12 It has also been addressed prospectively since between 15 % and 20 % of patients included in the large observational studies underwent orthopedic procedures. 8 , 13 Elective major orthopedic surgeries, including THA and TKA, are classically considered intermediate-risk procedures with a low risk of cardiac events. 14 , 15 Certainly, the risk is low in some patients, but it may be underestimated by traditional risk scores in others, which deserves clinical attention.…”

Current Strategies in Medical Management of the Geriatric Hip Fracture Patient

“…In one recent study, 40% of patients undergoing surgery for hip fracture met criteria for MINS, with an in-hospital mortality of 11% in those with MINS versus 2.8% in those without. 45 There are no proven methods of prevention or management. The AHA has recommended routine troponin monitoring in patients at high risk of MINS, which includes many geriatric hip fracture patients.…”