Perioperative myocardial necrosis in patients at high cardiovascular risk undergoing elective non-cardiac surgery

Alcock, R.; Kouzios, Dorothy; Naoum, Christopher; Hillis, Graham S.; Brieger, David

doi:10.1136/heartjnl-2011-301577

Cited by 59 publications

(53 citation statements)

References 36 publications

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“…A postoperative myocardial necrosis by hsTnT was identified in 22% of patients (a proportion ∼4-fold higher with respect to conventional cTn T assay), even if only 2% of patients experienced clinically apparent AMI. Interestingly, a preoperative hsTnT elevation, detected in 31% of patients, did not predict peri-operative MI [68]. A larger study has reported that hsTnT measured 7 days prior to surgery outperforms conventional risk algorithms, including clinical variables as well as use of natriuretic peptides, in predicting major adverse events (death, AMI, acute heart failure, and cardiac arrest/resuscitation) [69].…”

Section: This Is Not the End: Other Pieces To The Puzzlementioning

confidence: 99%

“…With the introduction of hsTn, the prognostic value of the marker in these patients has potentially increased according to the capability to detect very minor myocardiocyte damage. A recent study has evaluated if the hsTnT increasing 24 h after surgery could detect peri-operative myocardial damage in patients at high cardiovascular risk undergoing elective non-cardiac surgery [68]. A postoperative myocardial necrosis by hsTnT was identified in 22% of patients (a proportion ∼4-fold higher with respect to conventional cTn T assay), even if only 2% of patients experienced clinically apparent AMI.…”

Section: This Is Not the End: Other Pieces To The Puzzlementioning

confidence: 99%

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Laboratory medicine as the science that underpins medicine: the “high-sensitivity” troponin paradigm

Ferraro¹,

Panteghini

2015

Clinical Chemistry and Laboratory Medicine (CCLM)

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Abstract:The availability of so-called high-sensitivity troponin assays (hsTn) has scored a compelling goal for laboratory medicine, allowing the safe clinical application of international recommendations for the definition of acute myocardial infarction (AMI). However, the introduction of hsTn has not been welcomed by clinicians, claiming an increase in false-positive results. Here we critically trace back the steps following the introduction of hsTn by referring to the 5-year practical experience in our academic hospital and to suitable information available in the literature. In agreement with published data, we found that hsTn introduction was associated with an increased number of AMI diagnoses, whereas the test volume, the revascularization rate, and the proportion of cases with negative angiography findings remained virtually unchanged. Fast-track protocols for ruling out AMI have been further optimized to recommend sampling at presentation and after 3 h only. We focus on a cost-effective use of hsTn that can account for all clinical variables increasing the pre-test probability in order to ensure that tests are ordered only for patients at medium to high risk for acute coronary syndrome (ACS). To guide interpretation of results, hsTn typical release patterns suggestive for AMI should be identified by evaluating the significance of concentration changes. hsTn have markedly shortened the time to rule out or rule in AMI and has the potential to improve the prognostic assessment of critical patients in clinical contexts different from ACS.

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Section: This Is Not the End: Other Pieces To The Puzzlementioning

confidence: 99%

Section: This Is Not the End: Other Pieces To The Puzzlementioning

confidence: 99%

Laboratory medicine as the science that underpins medicine: the “high-sensitivity” troponin paradigm

Ferraro¹,

Panteghini

2015

Clinical Chemistry and Laboratory Medicine (CCLM)

View full text Add to dashboard Cite

show abstract

“…As many as 24% of the patients had a cTnT Ͼ14 ng/L in that study. However, there is mixed evidence regarding whether a preoperatively increased cardiac troponin concentration predicts perioperative myocardial injury (49,50 ). Nonetheless, a preoperatively increased cardiac troponin should prompt a careful search for underlying structural heart disease that may be subclinical.…”

Section: Preoperative Increase In Cardiac Troponinmentioning

confidence: 99%

“…The majority of patients with perioperative myocardial injury do not have classical type 1 MI and go clinically undetected. Imbalance in myocardial oxygen supply/demand causing ischemic injury, e.g., in case of perioperative hypotension tachycardia or fever, is probably the most common cause of perioperative myocardial injury with increase in cardiac troponin (type 2 MI) (49,52,53 ). Patients with preexisting coronary artery disease are at a particular ischemic risk.…”

Section: Myocardial Injury After Noncardiac Surgery (Mins)-perioperatmentioning

confidence: 99%

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

Eggers¹,

Lindahl

2017

Clinical Chemistry

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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.

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“…In effect, the peripheral presence of troponin amounts to a cry for help in a population where many cardiac events are silent and thus remain clinically unnoticed. 9,10 Routine postoperative monitoring for this biomarker can thus help identify a population that would ordinarily escape detection until the precipitation of a major clinical event. Second, as the pathophysiology of cardiac events centers around rupture of vulnerable plaque (type-1 MI), supply:demand mismatch (type-2 MI), or both of these phenomena, escalation or institution of important medical risk-reducing treatments (such as aspirin, beta-blockers, or statins), can be established to improve outcomes.…”

Section: Model To Improve Postoperative Cardiac Outcomesmentioning

confidence: 99%

Rethinking cardiac risk reduction after noncardiac surgery: The postoperative Carpe diem

Chopra

Eagle

2012

Journal of Hospital Medicine

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Patients undergoing noncardiac surgery frequently experience major adverse cardiac events. As a significant proportion of these patients develop cardiac complications despite optimal use of preoperative clinical risk‐prediction algorithms, physicians have long searched for better methods of forecasting and ameliorating cardiac risk in this population. Recently, postoperative troponin levels have been found to be powerful and independent predictors of cardiovascular mortality in patients undergoing noncardiac surgery. Importantly, the predictive properties of these markers outperform preoperative clinical risk‐prediction algorithms. We thus posit that the assessment of postoperative troponin represents an as yet untapped “golden opportunity” for cardiac risk reduction. As cardiac troponin isolates an unusually high‐risk subgroup, we outline a strategy that utilizes this marker to improve cardiac outcomes. Where pertinent, strengths and limitations of this approach are discussed and areas of uncertainty identified. As with all hypotheses, this proposition fuels many questions and calls for a research agenda dedicated to quantifying risk or benefit, and defining best practices. Journal of Hospital Medicine 2012. © 2012 Society of Hospital Medicine

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Perioperative myocardial necrosis in patients at high cardiovascular risk undergoing elective non-cardiac surgery

Cited by 59 publications

References 36 publications

Laboratory medicine as the science that underpins medicine: the “high-sensitivity” troponin paradigm

Laboratory medicine as the science that underpins medicine: the “high-sensitivity” troponin paradigm

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

Rethinking cardiac risk reduction after noncardiac surgery: The postoperative Carpe diem

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