Preoperative Myocardial Injury as a Predictor of Mortality in Emergency General Surgery: An Analysis Using the American College of Surgeons NSQIP Database

Zimmerman, Asha; Marwaha, Jayson S.; Nunez, Hector; Harrington, David; Heffernan, Daithi S.; Monaghan, Sean F.; Adams, Charles A.; Stephen, Andrew H.

doi:10.1016/j.jamcollsurg.2016.04.043

Cited by 14 publications

(19 citation statements)

References 15 publications

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“…However, several recent studies have suggested that preoperative elevation of cardiac troponin might be also related to increased postoperative mortality in non-cardiac surgery [11][12][13]. In the present analysis, 30-day mortality were 12% in all population.…”

Section: Plos Onecontrasting

confidence: 43%

“…A leading cause of postoperative mortality in non-cardiac surgery is myocardial injury [9], which was defined as the evidence of elevated cardiac troponin values with at least one value above the 99 th percentile upper reference limit [9,10]. As well as postoperative myocardial injury, preoperative cardiac troponin elevation has also been reported to be strongly associated with postoperative mortality in patients undergoing non-cardiac surgery [11][12][13]. Since volatile anesthetics can reduce not only myocardial infarct size but also cardiac biomarkers [1], the use of volatile anesthetics might be effective to improve clinical outcomes after non-cardiac surgery, especially in patients with preoperative elevation of cardiac troponin.…”

Section: Introductionmentioning

confidence: 99%

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Volatile versus total intravenous anesthesia for 30-day mortality following non-cardiac surgery in patients with preoperative myocardial injury

Park

Lee

et al. 2020

PLoS ONE

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We evaluated whether volatile anesthetics can improve the postoperative outcomes of noncardiac surgery in patients with preoperative myocardial injury defined by the cardiac troponin elevation. From January 2010 to June 2018, 1254 adult patients with preoperative myocardial injury underwent non-cardiac surgery under general anesthesia and were enrolled in this study. Patients were stratified into following two groups according to anesthetic agents; 115 (9.2%) patients whose anesthesia was induced and maintained with continuous infusion of propofol and remifentanil (TIVA group) and 1139 (90.8%) patients whose anesthesia was maintainted with volatile anesthetics (VOLATILE group). The primary outcome was 30day mortality. To diminish the remifentanil effect, a further analysis was conducted after excluding the patients who received only volatile anesthetics without remifentanil infusion. In a propensity-score matched analysis, 30-day mortality was higher in the TIVA group than the VOLATILE group (17.0% vs. 9.1%; hazard ratio [HR] 2.60; 95% confidence interval [CI], 1.14-5.93; p = 0.02). In addition, the TIVA group showed higher 30-day mortality than the VOLATILE group, even after eliminating the effect of remifentanil infusion (15.8% vs. 8.3%; HR 4.62; 95% CI, 1.82-11.74; p = 0.001). In our study, the use of volatile anesthetics showed the significant survival improvement after non-cardiac surgery in patients with preoperative myocardial injury, which appears to be irrelevant to the remifentanil use. Further studies are needed to confirm this beneficial effect of volatile anesthetics. Clinical trial number and registry URL: KCT0004349 (www.cris.nih.go.kr)

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Section: Plos Onecontrasting

confidence: 43%

Section: Introductionmentioning

confidence: 99%

Volatile versus total intravenous anesthesia for 30-day mortality following non-cardiac surgery in patients with preoperative myocardial injury

Park

Lee

et al. 2020

PLoS ONE

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“… 1) 2) After the development of a high-sensitivity assay, the new-generation cTn I test not only lowered the number of potentially missed coronary artery disease cases but also provided prognostic information in the context of noncoronary artery disease. 3) 4) In surgical patients, the postoperative elevation of cTn I has recently been accepted as a strong predictor of 30-day mortality. 5) 6) Mortality at 30 days in patients with postoperative cTn I elevation is at a concerning rate of 10%, which represents a five-fold increase from the background risk.…”

Section: Introductionmentioning

confidence: 99%

Mildly Elevated Cardiac Troponin below the 99th-Percentile Upper Reference Limit after Noncardiac Surgery

et al. 2020

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Background and Objectives In patients with perioperative cardiac troponin (cTn) I below the 99th-percentile upper range of limit (URL), mortality according to cTn I level has not been fully evaluated. This study evaluated the association between postoperative cTn I level above the lowest limit of detection but within the 99th-percentile URL and 30-day mortality after noncardiac surgery. Methods Patients with cTn I values below the 99th-percentile URL during the perioperative period were divided into a no-elevation group with cTn I at the lowest limit of detection (6 ng/L) and a minor elevation group with cTn I elevation below the 99th percentile URL (6 ng/L < cTn I < 40 ng/L). The primary outcome was 30-day mortality. Results Of the 5,312 study participants, 2,582 (48.6%) were included in the no-elevation group and 2,730 (51.4%) were included in the minor elevation group. After propensity score-matching, the minor elevation group showed significantly increased 30-day mortality (0.5% vs. 2.3%; hazard ratio, 4.30; 95% confidence interval, 2.23–8.29; p<0.001). The estimated cutoff value of cTn I to predict 30-day mortality was 6 ng/L with the area under the receiver operating characteristic curve 0.657. Conclusions A mild elevation of cTn I within the 99th-percentile URL after noncardiac surgery was significantly associated with increased 30-day mortality as compared with the lowest limit of detection. Trial Registration Clinical Research Information Service Identifier: KCT0004244

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“…There have been relatively few studies for the effect of preoperative myocardial injury on the early postoperative mortalities, compared to that of postoperative myocardial injury [9][10][11]. Most of previous studies had been focused on postoperative cTn elevation and, in some studies, preoperative cTn elevation was excluded from the analysis since it was considered as chronic elevation [6,20,22].…”

Section: Discussionmentioning

confidence: 99%

“…Many previous studies have shown that pre-and postoperative cTn elevations, regardless of ischemic signs and/or symptoms, are strongly associated with postoperative mortality in patients undergoing non-cardiac surgery [1,[6][7][8][9][10][11][12][13]. In addition, myocardial injury was clearly differentiated from type 2 myocardial infarction based on the presence of signs and/or symptoms of clinical myocardial ischemia and specified into acute and chronic form according to the changes in hs-cTn level in the recently published 4th universal definition of myocardial infarction [14].…”

Section: Introductionmentioning

confidence: 99%

Comparison between the Effects of Pre- and Postoperative Myocardial Injuries on 30-Day Mortality After Non-Cardiac Surgery: A Retrospective Analysis Using an Inverse Probability Weighting Adjustment

Lee¹,

Park²,

Lee³

et al. 2019

Preprint

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Background: Although both pre- and postoperative myocardial injuries are strongly associated with an increased postoperative mortality, no study has directly compared the effects of pre- and postoperative myocardial injuries on 30-day mortality after non-cardiac surgery. Therefore, we evaluated and compared the effects of pre- and postoperative myocardial injury on 30-day mortality after non-cardiac surgery.Methods: From January 2010 to December 2016, patients undergoing non-cardiac surgery were stratified into either the normal (n = 3,182), preoperative myocardial injury (n = 694), or postoperative myocardial injury (n = 756) groups. Myocardial injury was defined as a sole elevation of cardiac troponin value above the 99th percentile upper reference limit without ischemic symptom using the 4th universal definition of myocardial infarction. Patients in the preoperative myocardial injury group were further divided into the attenuated (n = 177) or persistent myocardial injury group (n = 517) according to the changes in postoperative cardiac troponin level. As the primary outcome, postoperative 30-day mortalities were compared among the groups using the weighted Cox proportional-hazards regression models with the inverse probability weighting.Results: Compared with the normal group, postoperative 30-day mortality was increased significantly both in the pre- and postoperative myocardial injury groups (1.4% vs. 10.7%; hazard ratio [HR] 3.12; 95% confidence interval [CI] 1.62-6.01; p = 0.001 and 1.4% vs. 7.4%; HR 4.49; 95% CI 2.34-8.60; p < 0.001, respectively), however, there was no difference between the pre- and postoperative myocardial injury groups (HR, 1.44; 95% CI 0.79–2.64; p = 0.45). In addition, the attenuated myocardial injury group showed a significantly lower postoperative 30-day mortality than the persistent myocardial injury group (5.6% vs. 12.4%; HR 2.23; 95% CI 1.17–4.44; p = 0.02).Conclusion: In patients undergoing non-cardiac surgery, preoperative myocardial injury also increased postoperative 30-day mortality to a similar degree of postoperative myocardial injury. In addition, attenuation of preoperative myocardial injury might decrease in 30-day mortality after non-cardiac surgery.

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Preoperative Myocardial Injury as a Predictor of Mortality in Emergency General Surgery: An Analysis Using the American College of Surgeons NSQIP Database

Cited by 14 publications

References 15 publications

Volatile versus total intravenous anesthesia for 30-day mortality following non-cardiac surgery in patients with preoperative myocardial injury

Volatile versus total intravenous anesthesia for 30-day mortality following non-cardiac surgery in patients with preoperative myocardial injury

Mildly Elevated Cardiac Troponin below the 99th-Percentile Upper Reference Limit after Noncardiac Surgery

Comparison between the Effects of Pre- and Postoperative Myocardial Injuries on 30-Day Mortality After Non-Cardiac Surgery: A Retrospective Analysis Using an Inverse Probability Weighting Adjustment

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