Relation of Perioperative Elevation of Troponin to Long-Term Mortality After Orthopedic Surgery

Oberweis, Brandon S.; Smilowitz, Nathaniel R.; Nukala, Swetha; Rosenberg, Andrew D.; Xu, Jinfeng; Stuchin, Steven A.; Iorio, Richard; Errico, Thomas J.; Radford, Martha J.; Berger, Jeffrey S.

doi:10.1016/j.amjcard.2015.03.003

Cited by 24 publications

(41 citation statements)

References 25 publications

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“…Myocardial injury after non-cardiac surgery, a well-described independent risk factor for short and long-term mortality, could not be ascertained and was not included in the composite outcome. 4,23,24 …”

Section: Discussionmentioning

confidence: 99%

Perioperative Major Adverse Cardiovascular and Cerebrovascular Events Associated With Noncardiac Surgery

et al. 2017

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Importance Major adverse cardiovascular and cerebrovascular events (MACCE) are a significant source of perioperative morbidity and mortality following non-cardiac surgery. Objective To evaluate national trends in perioperative cardiovascular outcomes and mortality after major non-cardiac surgery and identify surgical subtypes associated with cardiovascular events using a large administrative database of United States hospital admissions. Design, Setting, Participants Patients who underwent major non-cardiac surgery from 2004 to 2013 were identified using the National Inpatient Sample. Main Outcomes Perioperative MACCE (primary outcome), defined as in-hospital, all-cause death, acute myocardial infarction (AMI), or acute ischemic stroke, were evaluated over time. Results Among 10,581,621 hospitalizations for major non-cardiac surgery, perioperative MACCE occurred in 317,479 (3.0%), corresponding to an annual incidence of ≈150,000 after applying sample weights. Major adverse cardiovascular and cerebrovascular events occurred most frequently in patients undergoing vascular (7.7%), thoracic (6.5%), and transplant surgery (6.3%). Between 2004 and 2013, the frequency of MACCE declined from 3.1% to 2.6% (p for trend <0.0001; adjusted OR 0.95, 95% CI 0.94–0.97) driven by a decline in frequency of perioperative death (adjusted OR 0.79, 95% CI 0.77–0.81) and AMI (adjusted OR 0.87, 95% CI 0.84–0.89) but with an increase in perioperative ischemic stroke from 0.52% in 2004 to 0.77% in 2013 (p for trend <0.0001; adjusted OR 1.79; CI 1.73–1.86). Conclusions & Relevance Perioperative MACCE occurs in 1 of every 33 hospitalizations for non-cardiac surgery. Despite reductions in the rate of death and AMI among patients undergoing major non-cardiac surgery in the United States, perioperative ischemic stroke increased over time. Additional efforts are necessary to improve cardiovascular care in the perioperative period of patients undergoing non-cardiac surgery.

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Section: Discussionmentioning

confidence: 99%

Perioperative Major Adverse Cardiovascular and Cerebrovascular Events Associated With Noncardiac Surgery

et al. 2017

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“…This is similar to our incidence of 0.7% for a PMI while in the hospital (<5 days) after a THA or TKA. Oberweis et al [ 19 ] reported that for all patients undergoing hip, knee, or spine surgery, the incidence of “myocardial necrosis” (elevated troponins) was 5.9%, and 17% of those patients entered into a ROMI protocol. This is similar to our finding of 19% for at-risk TKA, THA, or spine fusion with elevated postoperative troponins.…”

Section: Discussionmentioning

confidence: 99%

The Incidence of Perioperative Cardiac Events after Orthopedic Surgery: A Single Institutional Experience of Cases Performed over One Year

Urban

Wolfe

Sanghavi

et al. 2017

HSS Journal®: The Musculoskeletal Journal of Hospital for Speci

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BackgroundOrthopedic patients with ischemic heart disease are at risk for postoperative cardiac complications.Questions/PurposesUsing information from two medical information retrieval systems which insured the capture of all events for the period of study, our goals were to determine the incidence of myocardial injury in at-risk patients after orthopedic surgery and to delineate the type and incidence of cardiac complications in this population.MethodsFor one year, at an orthopedic hospital, we identified all postoperative patients with a measured cTnI level using an electronic ordering system. Preoperative cardiac risk factors and postoperative cardiac complications were identified in patients undergoing a total hip arthroplasty (THA), total knee arthroplasty (TKA), and posterior spinal fusion (PSF). A postoperative myocardial infarction was defined by a cTnI > 0.1 ng/mL, ECG changes, new echocardiographic regional wall motion abnormalities, and evaluation by a cardiologist. Categorical variables were compared among groups with a Fisher’s exact or Chi-square test. Continuous variables were compared among groups with ANOVA or the Kruskal-Wallis test. The associations of cardiac risk factors with myocardial injury are expressed as odds ratios from logistic regression models.ResultsDuring a one-year period, from 10,627 inpatient orthopedic procedures, 805 patients were identified as at risk for postoperative myocardial ischemia. A total of 20.6% (166/805) of these patients had elevated serum cTnI levels (cTnI > 0.02 ng/mL), and there were ten documented postoperative MIs (10/805; 1.2%). For the at-risk TKA, THA, or PSF patients, 19% (102/532) had elevated cTnI levels and 31% (32/102) had postoperative cardiac complications, including arrhythmias (56%), congestive heart failure (2%), and MI (1%). Adjusting for sex, age, BMI, cardiac risk factors, and medications (statins and β-blockers), PSF patients had 3.9 times the risk of myocardial injury (p = 0.003) compared to TKA patients and 4.2 times that of THA patients.ConclusionsThe incidence of postoperative myocardial ischemia after major orthopedic surgery in patients with cardiac risk factors is high (8.7%), but the incidence of documented myocardial infarctions and serious cardiac complications remains low (1.2–2%). Patients with higher postoperative cTnI releases were more likely to have cardiac complications, and some procedures (spinal fusions) placed the patients at a higher risk.Electronic supplementary materialThe online version of this article (doi:10.1007/s11420-017-9561-9) contains supplementary material, which is available to authorized users.

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“…Although orthopedic procedures have historically been classified as intermediate-risk surgery, data on postoperative cardiovascular outcomes are limited [20]. Myocardial injury has been reported to occur in 5.8% to 17% of patients in single-center studies and correlates with long-term mortality [14,30]. In a small series of patients undergoing hip surgery, postoperative positive troponins were associated with a 10-fold increase in the incidence of major cardiac events at 1 year [21].…”

Section: Discussionmentioning

confidence: 99%

Perioperative antiplatelet therapy and cardiovascular outcomes in patients undergoing joint and spine surgery

Smilowitz

Oberweis

Nukala

et al. 2016

Journal of Clinical Anesthesia

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Study objective Perioperative thrombotic complications after orthopedic surgery are associated with significant morbidity and mortality. The use of aspirin to reduce perioperative cardiovascular complications in certain high-risk cohorts remains controversial. Few studies have addressed aspirin use, bleeding, and cardiovascular outcomes among high-risk patients undergoing joint and spine surgery. Design/setting/patients We performed a retrospective comparison of adults undergoing knee, hip, or spine surgery at a tertiary care center during 2 periods between November 2008 and December 2009 (reference period) and between April 2013 and December 2013 (contemporary period). Measurements Patient demographics, comorbidities, management, and outcomes were ascertained using hospital datasets. Main results A total of 5690 participants underwent 3075 joint and spine surgeries in the reference period and 2791 surgeries in the contemporary period. Mean age was 61 ± 13 years, and 59% were female. In the overall population, incidence of myocardial injury (3.1% vs 5.8%, P < .0001), hemorrhage (0.2% vs 0.8%, P = .0009), and red blood cell transfusion (17.2% vs 24.8%, P < .001) were lower in the contemporary period. Among 614 participants with a preoperative diagnosis of coronary artery disease (CAD), in-hospital aspirin use was significantly higher in the contemporary period (66% vs 30.7%, P < .0001); numerically, fewer participants developed myocardial injury (13.5% vs 19.3%, P = .05), had hemorrhage (0.3% vs 2.1%, P = .0009), and had red blood cell transfusion (37.2% vs 44.2%, P < .001) in the contemporary vs reference period. Conclusions In a large tertiary care center, the incidence of perioperative bleeding and cardiovascular events decreased over time. In participants with CAD, perioperative aspirin use increased and appears to be safe.

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Relation of Perioperative Elevation of Troponin to Long-Term Mortality After Orthopedic Surgery

Cited by 24 publications

References 25 publications

Perioperative Major Adverse Cardiovascular and Cerebrovascular Events Associated With Noncardiac Surgery

Perioperative Major Adverse Cardiovascular and Cerebrovascular Events Associated With Noncardiac Surgery

The Incidence of Perioperative Cardiac Events after Orthopedic Surgery: A Single Institutional Experience of Cases Performed over One Year

Perioperative antiplatelet therapy and cardiovascular outcomes in patients undergoing joint and spine surgery

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