Vascular surgery patients: perioperative and long-term risk according to the ACC/AHA guidelines, the additive role of post-operative troponin elevation

Abstract

After pre-operative stratification, patients undergoing elective major vascular surgery remain at high risk of MI and death. Events occur mainly early after surgery. cTnI elevations are frequent and independently associated with increased risk. These findings suggest the need for a major re-evaluation of our approach to these patients.

Sleep Apnea in Total Joint Arthroplasty Patients and the Role for Cardiac Biomarkers for Risk Stratification: an Exploration of Feasibility

“…Most of the studies that have investigated the role of perioperative measurement of cTns evaluated patients undergoing noncardiac surgery, rather than solely on TJA, and were assessing for myocardial injury [23,26,28] and infarction [21][22][23][24][25][26][27] (see Table 1). These studies have a great deal of heterogeneity in the specific assays and timing of troponin measurement, as well as specific populations within the larger grouping of noncardiac surgery.…”

“…Thus, this review focuses on several of the larger and more applicable studies. However, overall, several studies have shown that elevated cTn levels predicted or were associated with 30-day mortality [23,27,[29][30][31] and long-term (up to 5 years) morbidity [32] or mortality [21,24,[33][34]. These studies share similarities in their limitations, strengths and weaknesses, and the majority of such findings are grouped under the 'Limitations and challenges' section unless as discussed below.…”

“…Other studies have found increased levels of cTnI or cTnT (including hs-cTnT), drawn preoperation and or for any of the first three mornings postoperation [21,[23][24]26,28,32], or for at least two consecutive days postoperation [22,25,34] were helpful in identifying risk for postoperative cardiac complications for up to 1 month [23,[25][26][28][29]], 1 year [32] and up to 5 years [21,24,34] following surgery. In addition to increased postoperative morbidity, both cTnI and cTnT or hs-cTnT have been associated with identifying increased risk of mortality.…”

“…A systematic review and meta-analyses found that increased cTn levels following surgery were an independent predictor of mortality within 1 year [33]. Furthermore, increased postoperative cTnI [23][24][28][29] and cTnT or hs-cTnT [21,27,[30][31],34] levels predicted or are associated with decreased 5-year [34], 1-3 year [21,[23][24] and 30-day survival [27,[29][30][31]]. …”

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

“…Several potential mechanisms have been recognized to contribute to the pathophysiology of peri-operative AMI, resulting in type 1 or type 2 AMI, or due to stent thrombosis, which is particularly associated with oral anti-platelet therapy interruption [66]. Notably, the pre-operative risk assessment is of great clinical relevance, and over the past decade, cTn elevation has been recognized as a relevant prognostic factor for adverse short-and longer-term outcomes [67]. 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.…”