High sensitivity troponin T concentrations in patients undergoing noncardiac surgery: A prospective cohort study

Kavsak, Peter A.; Walsh, Mike; Srinathan, Sadeesh; Thorlacius, Laurel; Buse, Giovanna Lurati; Botto, Fernando; Pettit, Shirley; McQueen, Matthew; Hill, Stephen A.; Thomas, Sabu; Mrkobrada, Marko; Alonso‐Coello, Pablo; Berwanger, Otávio; Biccard, Bruce; Cembrowski, George S.; Chan, Matthew T. V.; Chow, Clara K; Miguel, Angeles de; García, Mercedes Muñoz; Graham, Michelle M.; Jacka, Michael J.; Kueh, J.H.; Li, Stephen C.H.; Lit, Lydia C.W.; Martínez-Brú, Cecilia; Naidoo, Prebashini; Nägele, Peter; Pearse, Rupert M; Rodseth, Reitze; Sessler, Daniel I.; Sigamani, Alben; Szczeklik, Wojciech; Tiboni, Maria; Villar, Juan Carlos; Wang, C.Y.; Xavier, Denis; Devereaux, P. J.

doi:10.1016/j.clinbiochem.2011.05.017

Cited by 85 publications

(70 citation statements)

References 9 publications

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“…1,[3][4][5]9 The incidence of PMI observed in our study was comparable to that observed, eg, in VISION if using a comparable absolute hs-cTnT-delta criterion. 1,[3][4][5]9 Differences in observed incidence rates found in several previous studies seem to relate to differences in the study populations, definitions of PMI, and the cTn assays used. 1,[3][4][5]9 The VISION study included patients >45 years (mean age, 63 years) irrespective of preexisting coronary artery disease or peripheral artery disease, and therefore at lower cardiovascular risk than in this study (median age, 74 years).…”

supporting

confidence: 71%

Perioperative Myocardial Injury After Noncardiac Surgery

et al. 2018

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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...

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confidence: 71%

Perioperative Myocardial Injury After Noncardiac Surgery

et al. 2018

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“…However, in a substudy of the Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION), we found that 21% of patients had an elevated high-sensitivity cTnT before surgery, regardless of kidney function or urgency of the surgery, suggesting that measurable quantities of cTnT are also present in many patients without severely impaired kidney function. 18 Whether this means that substantial numbers of patients have myocardial injury before undergoing surgery is unclear.…”

Section: Discussionmentioning

confidence: 99%

Kidney Function Alters the Relationship between Postoperative Troponin T Level and Death

Walsh

Wang²,

Ong³

et al. 2015

Journal of the American Society of Nephrology

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Cardiac troponin T (cTnT), even at low concentrations, is a risk factor for 30-day mortality in patients undergoing noncardiac surgery, but it is uncertain whether that risk is generalizable to patients with poor kidney function. We, therefore, evaluated the relationship between cTnT concentration and kidney function on the outcome of 30-day mortality in a post hoc analysis of a prospective cohort study of patients undergoing noncardiac surgery. cTnT was measured for 3 days after surgery and considered abnormal if the peak was $0.02 ng/ml. Of the included 14,037 patients, 267 (1.9%) patients died within 30 days of surgery. The adjusted hazard ratios for death with an abnormal cTnT concentration were 4.37 (95% confidence intervals [95% CI], 3.21 to 6.22), 6.15 (95% CI, 2.95 to 140.9), 6.30 (95% CI, 3.12 to 21.23), 1.33 (95% CI, 0.56 to 4.85), and 1.46 (95% CI, 0.46 to 9.21) for eGFR$60, 45 to ,60, 30 to ,45, 15 to ,30, and ,15 ml/min per 1.73 m 2 or on dialysis, respectively. Compared with patients with eGFR$60 ml/min per 1.73 m 2 , the adjusted hazard ratio was significantly lower for patients with eGFR=15 to ,30 ml/min per 1.73 m 2 (interaction P value=0.02). Redefining abnormal cTnT concentration as $0.03 ng/ml or a change of $0.02 ng/ml did not alter results. Because the risk associated with postoperative cTnT levels may be different for patients with eGFR,30 ml/min per 1.73 m 2 , additional research is required to determine how to interpret perioperative cTnT values for patients with low kidney function.

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“…17 In a sub-study of the VISION cohort, a higher incidence of cTnT elevations (>99th centile) was also reported in patients post-surgery and was detected more frequently using the hscTnT assay than its less-sensitive predecessor. 3 In our intervention study, we have extended work involving non-cardiac surgery patients, through a three-way comparison of hs-cTnT, cTnI and hs-cTnI assays and correlation of data to post-operative complications and mortality. Consistent with the findings by Kavsak et al, 3 we also report higher troponin concentrations post-operatively, irrespective of troponin measurement or treatment group.…”

Section: Peri-operative Troponin Monitoringmentioning

confidence: 99%

“…3 In our intervention study, we have extended work involving non-cardiac surgery patients, through a three-way comparison of hs-cTnT, cTnI and hs-cTnI assays and correlation of data to post-operative complications and mortality. Consistent with the findings by Kavsak et al, 3 we also report higher troponin concentrations post-operatively, irrespective of troponin measurement or treatment group. Temporally significant troponin increases were observed for all assays but occurred earliest for the hs-cTnI assay.…”

Section: Peri-operative Troponin Monitoringmentioning

confidence: 99%

“…1 Prognostic value can also be obtained from peri-operative troponin measurements, as shown for asymptomatic patients in the VISION study (Vascular Events in Non-cardiac Surgery Patients), where the peak post-operative cTnT concentration was reported to be significantly associated with 30-day mortality. 2 In this patient cohort, where major vascular complications and a higher incidence of cTnT elevations (>99th centile) are reported post-operatively, 3 such elevations were detected more readily using the high-sensitivity (hs) cTnT assay. The possibility of evolving myocardial injury may also be determined for those patients with post-operative troponin elevations showing a temporal increase of more than a defined relative change (%).…”

Section: Introductionmentioning

confidence: 99%

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Peri-operative troponin monitoring using a prototype high-sensitivity cardiac troponin I (hs-cTnI) assay: comparisons with hs-cTnT and contemporary cTnI assays

et al. 2013

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Background: Non-cardiac surgery is associated with major vascular complications and higher incidences of elevated plasma troponin (cTn) concentration. Goal-directed therapy (GDT) is a stroke volume (SV)-guided approach to intravenous (IV) fluid therapy that improves tissue perfusion, oxygenation and reduces post-operative complications. In patients undergoing major gastro-intestinal surgery, we compared high sensitive and contemporary troponin assays and correlated results with patient outcome. Methods: Patients (n ¼ 135) were randomized to receive IV fluid, guided by either the central venous pressure (CVP group, n ¼ 45) or SV (AE dopexamine inotrope, n ¼ 45 per group). Serum was obtained pre-and post-operatively (0, 8 and 24 h) for troponin analysis by a prototype hs-cTnI assay (Abbott Laboratories), hs-cTnT (Roche Diagnostics) and contemporary cTnI (Beckman Coulter) assays. Results: All troponin measurements were increased (P 4 0.05) post-operatively but there was no difference (P > 0.05) amongst treatments. Post-operative increases were reported more frequently (P 4 0.05) and earlier with hs-cTnI. Temporal increases (P 4 0.05) were reported in patients with and without complications for hs-cTnI/T assays but only in the complications group for cTnI measurements. Elevations 599th centile occurred most often (P 4 0.05) for hs-cTnT measurements but with similar frequency for both outcome groups (all assays). Only the hs-cTnI assay showed an increased relative risk of mortality (P 4 0.05) for elevations 599th centile Conclusions: Our study may suggest a possible preference for the hs-cTnI assay in the peri-operative setting; however, our findings should be verified for larger cohort studies where emerging reference range data is incorporated for improving risk prediction with hs-cTn assays.

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High sensitivity troponin T concentrations in patients undergoing noncardiac surgery: A prospective cohort study

Cited by 85 publications

References 9 publications

Perioperative Myocardial Injury After Noncardiac Surgery

Perioperative Myocardial Injury After Noncardiac Surgery

Kidney Function Alters the Relationship between Postoperative Troponin T Level and Death

Peri-operative troponin monitoring using a prototype high-sensitivity cardiac troponin I (hs-cTnI) assay: comparisons with hs-cTnT and contemporary cTnI assays

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