Perioperative Myocardial Injury After Noncardiac Surgery

Abstract

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...

Intraoperative Troponin Elevation in Liver Transplantation Is Independently Associated With Mortality: A Prospective Observational Study

“…A troponin value of 61 ng/L was the most appropriate cutoff to predict 30‐day mortality with a sensitivity of 57.2% (95% CI, 27.6%‐86.6%), specificity of 90% (95% CI, 85.4%‐94.5%), negative predictive value of 96.6% (95% CI, 93.6%‐99.6%), and positive predictive value of 29.6% (95% CI, 10.6%‐48.7%). Remarkably, different troponin thresholds proposed for the diagnosis of perioperative myocardial injury published elsewhere (except hsTnT >65 ng/L) failed to show any discriminant capacity (Supporting Table 1).…”

“…Recent studies have suggested that patients with cirrhosis with enhanced systolic function show a paradoxical response under hemodynamically stressful situations, suffering an important decrease in contractility indicative of a marked decrease in contractile reserve . On the other hand, several studies have indicated that even subtle elevations of troponin levels are clinically relevant and have prognostic implications in different surgical contexts …”

“…Furthermore, the latest evidence establishes that the newer hsTn assays have better sensitivity and negative predictive value for the identification of myocardial injury, thus improving diagnosis and risk prediction . Therefore, the use of hsTn assays are preferred in the intraoperative setting.…”

“…Although controversial, this event is defined by the appearance of a troponin value exceeding the 99th percentile upper reference limit without evidence of myocardial ischemia . Myocardial injury has been suggested to have a prognostic impact similar to that reported for myocardial infarction (MI), and the occurrence of perioperative myocardial injury has been associated with 30‐day mortality in various surgical contexts …”

Sequential Surgical Procedures in Vascular Surgery Patients Are Associated With Perioperative Adverse Cardiac Events

“…Patients at elevated risk for cardiovascular complications are prone to perioperative adverse cardiac events, such as myocardial injury after non-cardiac surgery (MINS) (1) and face higher perioperative mortality (1)(2)(3)(4). Atherosclerosis and its complications are driven by systemic inflammation (5), however the mechanisms underlying perioperative cardiovascular complications are not fully understood (6,7).…”