Incremental value of high-sensitive troponin T in addition to the revised cardiac index for peri-operative risk stratification in non-cardiac surgery

Weber, Michael A.; Luchner, Andreas; Seeberger, Manfred D.; Müeller, Christian; Liebetrau, Christoph; Schlitt, Axel; Apostolović, Svetlana; Janković, Radmilo; Banković, Dragić; Jovic, Marina; Mitrović, Veselin; Nef, Holger; Möllmann, Helge; Hamm, Christian W.

doi:10.1093/eurheartj/ehs445

Cited by 164 publications

(143 citation statements)

References 21 publications

Supporting

Mentioning

128

Contrasting

Unclassified

Order By: Relevance

“…Chronic hs-cTn elevations are expected in a relevant amount of (surgical) patients, 10 and were previously shown to be independently associated with increased risk of death and major adverse cardiac events. 11 We chose an absolute rather than a relative delta hs-cTnT level for the diagnosis of PMI, because absolute changes have shown higher diagnostic accuracy than relative changes in the detection of acute myocardial infarction (AMI) in the nonoperative setting. …”

mentioning

confidence: 99%

Perioperative Myocardial Injury After Noncardiac Surgery

et al. 2018

Self Cite

View full text Add to dashboard Cite

1 ORIGINAL RESEARCH ARTICLE ORIGINAL RESEARCH ARTICLEEditorial, see p XXX BACKGROUND: Perioperative myocardial injury (PMI) seems to be a contributor to mortality after noncardiac surgery. Because the vast majority of PMIs are asymptomatic, PMI usually is missed in the absence of systematic screening. METHODS:We performed a prospective diagnostic study enrolling consecutive patients undergoing noncardiac surgery who had a planned postoperative stay of ≥24 hours and were considered at increased cardiovascular risk. All patients received a systematic screening using serial measurements of high-sensitivity cardiac troponin T in clinical routine. PMI was defined as an absolute high-sensitivity cardiac troponin T increase of ≥14 ng/L from preoperative to postoperative measurements. Furthermore, mortality was compared among patients with PMI not fulfilling additional criteria (ischemic symptoms, new ECG changes, or imaging evidence of loss of viable myocardium) required for the diagnosis of spontaneous acute myocardial infarction versus those that did. RESULTS:From 2014 to 2015 we included 2018 consecutive patients undergoing 2546 surgeries. Patients had a median age of 74 years and 42% were women. PMI occurred after 397 of 2546 surgeries (16%; 95% confidence interval, 14%-17%) and was accompanied by typical chest pain in 24 of 397 patients (6%) and any ischemic symptoms in 72 of 397 (18%). Crude 30-day mortality was 8.9% (95% confidence interval [CI], 5.7-12.0) in patients with PMI versus 1.5% (95% CI, 0.9-2.0) in patients without PMI (P<0.001). Multivariable regression analysis showed an adjusted hazard ratio of 2.7 (95% CI, 1.5-4.8) for 30-day mortality. The difference was retained at 1 year with mortality rates of 22.5% (95% CI, 17.6-27.4) versus 9.3% (95% CI, 7.9-10.7). Thirty-day mortality was comparable among patients with PMI not fulfilling any other of the additional criteria required for spontaneous acute myocardial infarction (280/397, 71%) versus those with at least 1 additional criterion (10.4%; 95% CI, versus 8.7%; 95% CI, P=0.684). CONCLUSIONS:PMI is a common complication after noncardiac surgery and, despite early detection during routine clinical screening, is associated with substantial short-and long-term mortality. Mortality seems comparable in patients with PMI not fulfilling any other of the additional criteria required for spontaneous acute myocardial infarction versus those patients who do. CLINICAL TRIAL REGISTRATION: Perioperative myocardial injury (PMI) has recently been identified as an important, yet often undetected complication after noncardiac surgery, strongly associated with 30-day mortality. [1][2][3][4][5] In contrast with spontaneous myocardial infarction (MI), PMI most commonly does not exhibit typical symptoms of myocardial ischemia, such as chest pain, angina pectoris, or dyspnea, and is therefore missed in routine clinical practice in most institutions in the United States and worldwide. [1][2][3][4][5] Considering that >300 million surgeries are performed annually and that de...

show abstract

mentioning

confidence: 99%

Perioperative Myocardial Injury After Noncardiac Surgery

et al. 2018

Self Cite

View full text Add to dashboard Cite

show abstract

“…Preoperative measurement of cardiac troponin has been shown to add prognostic information to clinical scoring. In fact, the area under the receiver operator characteristic curve was higher for cTnT measured with a hs-assay than for the clinical Lee Index for predicting in-hospital major cardiac events, 0.78 vs 0.68; and in patients with cTnT above the upper reference limit of 14 ng/L, the OR for in-hospital major cardiac events was 3.7 (95% CI 1.9 -7.3) (48 ). As many as 24% of the patients had a cTnT Ͼ14 ng/L in that study.…”

Section: Preoperative Increase In Cardiac Troponinmentioning

confidence: 91%

Application of Cardiac Troponin in Cardiovascular Diseases Other Than Acute Coronary Syndrome

Eggers¹,

Lindahl

2017

Clinical Chemistry

View full text Add to dashboard Cite

BACKGROUND Increased cardiac troponin concentrations in acute coronary syndrome (ACS) identify patients with ongoing cardiomyocyte necrosis who are at increased risk. However, with the use of more precise assays, cardiac troponin increases are commonly noted in other cardiovascular conditions as well. This has generated interest in the use of cardiac troponin for prognostic assessment and clinical management of these patients. In this review, we have summarized the data from studies investigating the implications of cardiac troponin concentrations in various acute and chronic conditions beyond ACS, i.e., heart failure, myocarditis, Takotsubo cardiomyopathy, aortic dissection, supraventricular arrhythmias, valve disease, pulmonary arterial hypertension, stroke, and in the perioperative setting. CONTENT Cardiac troponin concentrations are often detectable and frankly increased in non-ACS conditions, in particular when measured with high-sensitivity (hs) assays. With the exception of myocarditis and Takotsubo cardiomyopathy, cardiac troponin concentrations carry strong prognostic information, mainly with respect to mortality, or incipient and/or worsening heart failure. Studies investigating the prognostic benefit associated with cardiac troponin–guided treatments however, are almost lacking and the potential role of cardiac troponin in the management of non-ACS conditions is not defined. SUMMARY Increased cardiac troponin indicates increased risk for adverse outcome in patients with various cardiovascular conditions beyond ACS. Routine measurement of cardiac troponin concentrations can however, not be generally recommended unless there is a suspicion of ACS. Nonetheless, any finding of an increased cardiac troponin concentration in a patient without ACS should at least prompt the search for possible underlying conditions and these should be managed meticulously according to current guidelines to improve outcome.

show abstract

“…11,15) Recently, the study by Weber, et al suggested that high-sensitive troponin assay provides strong prognostic information in patients undergoing noncardiac surgery incremental to the widely accepted revised cardiac index. 27) Many trials have sought prognosticating factors in noncardiac surgery. 4,5,6,10,21,22,[27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42] In these studies, poor functional capacity, recent MI and unstable angina, decompensated heart failure, significant arrhythmia, diabetes mellitus, renal insufficiency, cerebrovascular disease, advanced age, tachycardia, anemia, surgical kind, and elevated troponin-I level were determined to be independent prognostic factors after noncardiac surgery, most of which were in agreement with our study.…”

Section: )mentioning

confidence: 99%

Troponin-I Level After Major Noncardiac Surgery and Its Association With Long-Term Mortality

et al. 2016

View full text Add to dashboard Cite

SummaryIndividuals with intermediate to high cardiac risk for major noncardiac surgery suffer from perioperative myocardial ischemic injury. The purpose of this study was to evaluate the long-term impact of postoperative cardiac troponin elevation on clinical outcome after major noncardiac surgery.Patients (n = 750) aged ≥ 50 years who underwent major noncardiac surgery were eligible for the study. Postoperative cardiac troponin-I data were collected retrospectively and consecutively. The primary outcome measure was allcause mortality. The median follow-up period was 1727 days in all patients.Among 750 patients, 92 (12.2%) showed elevated postoperative troponin-I above 0.10 ng/mL. Operative mortality was 4.1% (31 subjects), and patients with troponin-I elevation showed a higher operative mortality rate (RR: 4.23, 95% CI: 2.67-11.31, P < 0.001). In multivariate Cox regression analysis, a troponin-I concentration above 0.10 ng/mL was associated with all-cause mortality (RR: 1.73, 95% CI: 1.27-2.36, P < 0.001). It should be noted that there was a significant difference between patients with elevated and non-elevated troponin-I in the rate of mortality until 6 months. However, these differences disappeared after 6 months. An elevated troponin-I level conferred an increase in mortality during the 7 year follow-up period after major noncardiac surgery. This difference in mortality was mainly derived from the result within the first 6 months. (Int Heart J 2016; 57: 278-284) Key words: Myocardial ischemia, Death, Surgical procedures A ll surgical procedures elicit a stress response, although the extent of the response depends on the extent of the surgery and the use of anesthetics and analgesics that are used to reduce the response. The stress response can lead to increases in heart rate and blood pressure, which can precipitate episodes of myocardial ischemia. 1)Individuals with intermediate to high cardiac risk for noncardiac surgery suffer from perioperative myocardial ischemic injury.2) Cardiac troponins are a useful tool that help clinicians in making the diagnosis of perioperative myocardial infarction.3-5) Many previous studies have investigated the role of cardiac troponins in the diagnosis of perioperative myocardial ischemic events and demonstrated the prognostic value of postoperative cardiac troponin elevation.6-9) A recent metaanalysis of studies in predominantly high-risk surgery patients also showed that cardiac troponin elevation was a strong independent predictor of mortality within the first year after surgery. 10) Editorial p.265The development of perioperative cardiovascular complications not only affects the short-term period prognosis but may also influence the long-term consequences. However, few studies have explored the long-term, defined as beyond the first year after major noncardiac surgery, prognostic value of cardiac troponin elevation in the prediction of postoperative outcome. We undertook this study to evaluate the clinical outcome of cardiac troponin elevation after major noncardiac sur...

show abstract

Incremental value of high-sensitive troponin T in addition to the revised cardiac index for peri-operative risk stratification in non-cardiac surgery

Abstract: High-sensitive troponin T provides strong prognostic information in patients undergoing non-cardiac surgery incremental to the widely accepted revised cardiac index.

Cited by 164 publications

References 21 publications

Perioperative Myocardial Injury After Noncardiac Surgery

Perioperative Myocardial Injury After Noncardiac Surgery

Application of Cardiac Troponin in Cardiovascular Diseases Other Than Acute Coronary Syndrome

Troponin-I Level After Major Noncardiac Surgery and Its Association With Long-Term Mortality

Contact Info

Product

Resources

About