Use of clinically based troponin underestimates the cardiac injury in non-cardiac surgery: a single-centre cohort study in 51,701 consecutive patients

Beattie, W. Scott; Karkouti, Keyvan; Tait, Gordon; Steel, Andrew; Yip, Paul; McCluskey, Stuart A.; Farkouh, Michael E.; Wijeysundera, Duminda N.

doi:10.1007/s12630-012-9782-9

Cited by 67 publications

(57 citation statements)

References 34 publications

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“…The prevalence of myocardial infarction within the CAIS data was almost twice that seen in the original derivation. We suspect this is related to the use of high-sensitivity serum troponin measurements that are now the gold standard for the diagnosis of perioperative myocardial infarction 24,25 and superior for the diagnosis of acute myocardial infarction. 12 The absolute number of pulmonary edema events is the same, but this represents an increased prevalence in our more recent data, since the number of patients with preexisting congestive heart failure is one-quarter that of the original study.…”

Section: Discussionmentioning

confidence: 99%

The Revised Cardiac Risk Index in the new millennium: a single-centre prospective cohort re-evaluation of the original variables in 9,519 consecutive elective surgical patients

Davis

Tait

Carroll

et al. 2013

Can J Anesth/J Can Anesth

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The Revised Cardiac Risk Index in the new millennium: a single-centre prospective cohort re-evaluation of the original variables in 9,519 consecutive elective surgical patients L'indice de risque cardiaque modifié dans le nouveau millénaire: une réévaluation prospective et unicentrique de cohorte des variables originales chez 9519 patients consécutifs devant subir une chirurgie non urgente Abstract Purpose Cardiac complications following non-cardiac surgery are major causes of morbidity and mortality. The Revised Cardiac Risk Index (RCRI) has become a standard for predicting post-surgical cardiac complications. This study re-examined the original six risk factors to confirm their validity in a large modern prospective database.Methods Using the definitions in the original risk index, this study included 9,519 patients aged C 50 undergoing elective non-cardiac surgery with an expected length of stay C two days at two major tertiary-care teaching hospitals. The validity of the original predictors was tested in this population using binomial logistic regression modelling, area under the receiver operator curve (ROC) analysis, and the net reclassification index. Results Rates of major cardiac complications with 0, 1, 2, C 3 of the predictors were 0.5%, 2.6%, 7.2%, and 14.4%, respectively, in our patient cohort compared with 0.4%, 1.1%, 4.6%, and 9.7%, respectively, in the original cohort. Similar to the original report, binary logistic regression analysis showed that both preoperative treatment with insulin (odds ratio [OR] 1.4; 95% confidence interval [CI] 0.7 to 2.6) and preoperative creatinine [ 176.8 mmolÁL -1 (OR 1.7; 95% CI 0.8 to 3.6) did not improve the predictive ability of the index. Analysis of the remaining four factors resulted in an area under the curve (AUC) identical to that seen for the reconstructed six-factor RCRI (AUC = 0.79). We found that a Author contributions Christopher Davis organized and performed the analysis, wrote the first draft of the manuscript, and was responsible for major revisions to both the analysis and manuscript. Gordon Tait was responsible for creation of the database and the data integrity. He performed and or supervised quality checks on the data and helped perform the data analysis. Gordon Tait, Jo Carroll, and Duminda N. Wijeysundera made key revisions to the manuscript. Jo Carroll assisted in the creation of the database and quality control of the data. Duminda N. Wijeysundera and W. Scott Beattie were responsible in part for the concept of the study. Duminda N. Wijeysundera revised key aspects of the data analysis. W. Scott Beattie was responsible in part for supervision of the project. He obtained funding for the project, helped write all drafts of the manuscript, and made revisions to the data analysis. Dr. Beattie was Mr. Davis's summer elective supervisor. All authors have seen the data analysis and the revised manuscript and vouch for the authenticity of all aspects of this manuscript. glomerular filtration rate (GFR) \ 30 mLÁmin -1 was a better predictor of major...

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Section: Discussionmentioning

confidence: 99%

The Revised Cardiac Risk Index in the new millennium: a single-centre prospective cohort re-evaluation of the original variables in 9,519 consecutive elective surgical patients

Davis

Tait

Carroll

et al. 2013

Can J Anesth/J Can Anesth

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“…186,187,[207][208][209][210][211][212][213][214][215][216][217][218][219][220] The definition of an abnormal stress echocardiogram in some studies was restricted to the presence of new wall motion abnormalities with stress, indicative of myocardial ischemia, but in others also included the presence of akinetic segments at baseline, indicative of MI. These studies have predominantly evaluated the role of DSE in patients with an increased perioperative cardiovascular risk, particularly those undergoing abdominal aortic or peripheral vascular surgery.…”

Section: Dobutamine Stress Echocardiographymentioning

confidence: 99%

2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery

Fleisher¹,

Fleischmann²,

Auerbach³

et al. 2014

Circulation

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“…23 Levy et al further amalgamated the prognostic capability of an elevated troponin assay through the meta-analysis of 14 studies investigating perioperative mortality following 24 In a retrospective review of 51,701 patients undergoing noncardiac non-transplant surgery, Beattie et al identified that postoperative troponin I elevations incrementally predicted 30-day postoperative all-cause mortality. 25 Van Waes et al also confirmed that postoperative troponin elevations during the first three days after surgery predicted 30-day mortality in their study of 2,216 patients following major non-cardiac surgery. 26 The Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) Study examined major complications after non-cardiac surgery in a prospective international cohort of 15,133 patients and has since served as the basis of several publications of merit on the utility of measuring cardiac biomarkers postoperatively.…”

Section: 22mentioning

confidence: 72%

Chasing myocardial outcomes: perioperative myocardial infarction and cardiac troponin

Royo

Fleisher

2015

Can J Anesth/J Can Anesth

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Perioperative myocardial infarction represents the most common cardiovascular complication following non-cardiac surgery, but frequently presents without the usual clinical signs and symptoms consistent with acute coronary syndrome. Given the silent nature of this event, a clinician's reliance on risk stratification tools and cardiac specific biomarkers to assist in the identification of at-risk individuals is heightened in the perioperative setting. Although cardiac troponin elevations following non-cardiac surgery have been consistently linked to increased mortality, uncertainty remains over how to clinically intervene to prevent harm. This decision is further complicated by the increasing sensitivity of the newest generation of cardiac biomarker immunoassays. In this narrative review, the growing body of evidence surrounding cardiac troponin elevations in the perioperative setting, how the evidence has been integrated into recent clinical practice guidelines, and its implications for the detection of perioperative myocardial infarction are discussed.Résumé L'infarctus du myocarde périopératoire représente la complication cardiovasculaire la plus fréquente après chirurgie non cardiaque, mais il se présente fréquemment sans les signes et symptô mes cliniques usuels du syndrome coronarien aigu. Compte tenu de la nature silencieuse de cet événement, les cliniciens doivent pouvoir se fier d'autant plus à des outils de stratification du risque et à des biomarqueurs cardiaques spécifiques pour les aider à identifier les individus à risque dans le cadre périopératoire. Bien qu'une augmentation de la troponine cardiaque après une chirurgie non cardiaque ait été constamment liée à une augmentation de la mortalité, des incertitudes persistent sur la façon d'intervenir cliniquement afin d'éviter tout préjudice. Cette décision est encore compliquée par la sensibilité croissante de la nouvelle génération de dosages immunologiques des biomarqueurs cardiaques. Dans cette étude narrative, nous discuterons la masse croissante de données probantes concernant l'élévation de la troponine cardiaque dans un cadre périopératoire, la façon dont les données probantes ont été intégrées dans les lignes directrices de pratique clinique récentes et leurs conséquences sur la détection de l'infarctus du myocarde périopératoire.Despite 40 years of cumulative interest in the cardio vascular management of the patient undergoing noncardiac surgery, the subject matter remains as relevant as ever. Estimations of global surgical volume indicate that more than 200 million operations are performed worldwide each year.1 As the elderly have been shown

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Use of clinically based troponin underestimates the cardiac injury in non-cardiac surgery: a single-centre cohort study in 51,701 consecutive patients

Cited by 67 publications

References 34 publications

The Revised Cardiac Risk Index in the new millennium: a single-centre prospective cohort re-evaluation of the original variables in 9,519 consecutive elective surgical patients

The Revised Cardiac Risk Index in the new millennium: a single-centre prospective cohort re-evaluation of the original variables in 9,519 consecutive elective surgical patients

2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery

Chasing myocardial outcomes: perioperative myocardial infarction and cardiac troponin

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