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High-sensitivity troponin T levels identify myocardial injury after noncardiac surgery
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WASHINGTON — Elevated measurements of a high-sensitivity troponin T assay help identify patients with myocardial injury who have an increased risk for death after noncardiac surgery, according to data presented at the American College of Cardiology Scientific Sessions.
“We found that approximately 18% of patients will sustain a heart injury after noncardiac surgery, but without monitoring troponins, 93% of these will be missed,” P.J. Devereaux, MD, PhD, director of cardiology at McMaster University in Hamilton, Canada, said in a press release. “Our data show that unrecognized heart injuries may account for one in four of the deaths that happen in the first 30 days after surgery.”
In the VISION study, Devereaux and colleagues sought to determine the association between troponin T levels measured by a high-sensitivity troponin T assay and 30-day mortality risk after noncardiac surgery as well as identify diagnostic criteria for myocardial injury after noncardiac surgery.
Devereaux and colleagues evaluated 21,842 participants (mean age, 63 years; 49% women) from 23 centers in 13 countries who underwent noncardiac surgery. Patients had troponin T measurements taken 6 to 12 hours after surgery and daily for 3 days. About 40% had preoperative troponin T measurements.
Sixteen percent underwent orthopedic surgery, 20% underwent major general surgery and 35% underwent low-risk surgery. The researchers recorded all major complications, including stroke, pulmonary embolism, sepsis and bleeding. They also adjusted the data based on preoperative and surgical variables associated with 30-day mortality, including active cancer, general surgery, urgent or emergent surgery, history of peripheral vascular disease, history of chronic obstructive pulmonary disease, age, recent high-risk CAD, history of stroke and neurosurgery.
Of all participants, 21,050 completed 30-day follow-up, with 266 (1.2%; 95% CI, 1.1-1.4) dying within 30 days after surgery.
Risk for death increased with higher postoperative levels of peak troponin T, according to the data. The adjusted HRs were as follows:
- 3.73 (95% CI, 1.58-8.82) for levels between 5 ng/L < 14 ng/L;
- 9.11 (95% CI, 3.76-22.09) for levels between 14 ng/L < 20 ng/L;
- 23.63 (95% CI, 10.32-54.09) for levels between 20 ng/L < 65 ng/L;
- 70.34 (95% CI, 30.6-161.7) for levels between 65 ng/L < 1,000 ng/L; and
- 227.01 (95% CI, 87.35-589.92) for levels of 1,000 ng/L or higher.
Results also showed that for every change in absolute troponin T level of 5 ng/L or greater, risk for 30-day mortality increased nearly five-fold (adjusted HR = 4.69; 95% CI, 3.52-6.25).
Additionally, among the 4,385 patients with elevated postoperative troponin T measurements, levels were not related to ischemic myocardial injury in 11%. Moreover, 13.8% with elevated perioperative levels had their peak value before surgery, suggesting the importance of obtaining baseline measurements.
There was no interaction in the relationship between postoperative level of troponin T threshold of at least 20 ng/L and 30-day mortality and estimated glomerular filtration rate or sex (P for interaction = .83 and .2, respectively).
Elevated postoperative troponin T levels without ischemic feature (eg, ischemic symptoms, ischemic ECG findings) predicted 30-day mortality (adjusted HR = 3.2; 95% CI, 2.37-4.32), Devereaux noted, suggesting elevated postoperative troponin T measurements judged as resulting from myocardial ischemia without requirement of ischemic feature could be diagnostic criteria for myocardial injury after noncardiac surgery.
Myocardial injury after noncardiac surgery accounted for 24.2% (95% CI, 10.6-44.1) of deaths within 30 days after surgery, with 94.1% occurring by day 2 after surgery. Of those with myocardial injury, 93.1% experienced no ischemic symptoms, indicating that many would probably have gone undetected without monitoring of troponin T levels, Devereaux said.
Further, of the 3,904 patients with myocardial injury, 21.7% (95% CI, 20.4-23) fulfilled universal definition of MI, including elevated troponin levels and at least one ischemic feature. CV complications were also more prevalent among those with myocardial injury compared to those who did not have myocardial injury after noncardiac surgery (MINS). The OR for experiencing a composite of nonfatal cardiac arrest, congestive HF, coronary revascularization and death in patients with myocardial injury after surgery was 8.47 (95% CI, 6.94-10.34).
The association between increased 30-day mortality and postoperative troponin T levels as well as the fact that many patients with myocardial ischemia exhibited no symptoms suggest the potential benefit of measuring troponin T with high-sensitivity assays to help prevent perioperative death, Devereaux said. – Melissa Foster
Reference:
Devereaux PJ. Joint American College of Cardiology/New England Journal of Medicine Late-Breaking Clinical Trials. Presented at: American College of Cardiology Scientific Session; March 17-19, 2017; Washington, D.C.
Disclosure: Devereaux reports receiving research grants from Abbott Diagnostics, Boehringer Ingelheim and Roche Diagnostics.
Editor’s note: On March 31, 2017, this article was updated with additional data from the researchers.