High-Sensitivity Troponin I after Cardiac Surgery and 30-Day Mortality

Devereaux PJ 1 , Lamy A 1 , Chan MTV 1 , Allard RV 1 , Lomivorotov VV 1 , Landoni G 1 Show all authors , Zheng H 1 , Paparella D 1 , McGillion MH 1 , Belley-Côté EP 1 , Parlow JL 1 , Underwood MJ 1 , Wang CY 1 , Dvirnik N 1 , Abubakirov M 1 , Fominskiy E 1 , Choi S 1 , Fremes S 1 , Monaco F 1 , Urrútia G 1 , Maestre M 1 , Hajjar LA 1 , Hillis GS 1 , Mills NL 1 , Margari V 1 , Mills JD 1 , Billing JS 1 , Methangkool E 1 , Polanczyk CA 1 , Sant'Anna R 1 , Shukevich D 1 , Conen D 1 , Kavsak PA 1 , McQueen MJ 1 , Brady K 1 , Spence J 1 , Le Manach Y 1 , Mian R 1 , Lee SF 1 , Bangdiwala SI 1 , Hussain S 1 , Borges FK 1 , Pettit S 1 , Vincent J 1 , Guyatt GH 1 , Yusuf S 1 , Alpert JS 1 , White HD 1 , Whitlock RP 1 , VISION Cardiac Surgery Investigators

Affiliations 

  • 1 From McMaster University (P.J.D., A.L., M.H.M., E.P.B.-C., N.D., D.C., P.A.K., M.J.M., J.S., Y.L.M., R.M., S.F.L., S.I.B., S.H., F.K.B., G.H.G., S.Y., R.P.W.), Hamilton Health Sciences (P.J.D., A.L., E.P.B.-C., N.D., D.C., P.A.K., Y.L.M., F.K.B., G.H.G., S.Y., R.P.W.), and the Population Health Research Institute (P.J.D., A.L., M.H.M., E.P.B.-C., D.C., M.J.M., K.B., J.S., Y.L.M., R.M., S.F.L., S.I.B., F.K.B., S.P., J.V., S.Y., R.P.W.), Hamilton, Queen's University, Kingston (R.V.A., J.L.P.), and Sunnybrook Health Sciences Centre and the University of Toronto, Toronto (S.C., S.F.) - all in Ontario, Canada; the Chinese University of Hong Kong, Hong Kong (M.T.V.C., M.J.U.), and the First Affiliated Hospital of Xinjiang Medical University, Urumqi (H.Z.) - both in China; E. Meshalkin National Medical Research Center (V.V.L., M.A.) and Novosibirsk State University (V.V.L.), Novosibirsk, and the Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo (D.S.) - all in Russia; IRCCS San Raffaele Scientific Institute (G.L., E.F., F.M.) and Vita-Salute San Raffaele University (G.L., F.M.), Milan, the University of Foggia, Foggia (D.P.), and Santa Maria Hospital GVM Care and Research, Bari (D.P., V.M.) - all in Italy; the University of Malaya, Kuala Lumpur, Malaysia (C.Y.W.); Hospital de la Santa Creu i Sant Pau (G.U., M.M.) and Institut d'Investigació Biomèdica Sant Pau-CIBERESP (G.U.) - both in Barcelona; Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo (L.A.H.), and Hospital Moinhos de Vento (C.A.P.), Hospital de Clínicas de Porto Alegre (C.A.P.), and Instituto de Cardiologia do Rio Grande do Sul (R.S.), Porto Alegre - all in Brazil; Royal Perth Hospital and the University of Western Australia - both in Perth (G.S.H.); the University of Edinburgh, Edinburgh (N.L.M.), the Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool (J.D.M.), and the Royal Wolverhampton NHS Trust, Wolverhampton (J.S.B.) - all in the United Kingdom; the University of California, Los Angeles, Los Angeles (E.M.); the University of Arizona College of Medicine, Tucson (J.S.A.); and Auckland City Hospital and the University of Auckland - both in Auckland, New Zealand (H.D.W.)
N Engl J Med, 2022 Mar 03;386(9):827-836.
PMID: 35235725 DOI: 10.1056/NEJMoa2000803

Abstract

BACKGROUND: Consensus recommendations regarding the threshold levels of cardiac troponin elevations for the definition of perioperative myocardial infarction and clinically important periprocedural myocardial injury in patients undergoing cardiac surgery range widely (from >10 times to ≥70 times the upper reference limit for the assay). Limited evidence is available to support these recommendations.

METHODS: We undertook an international prospective cohort study involving patients 18 years of age or older who underwent cardiac surgery. High-sensitivity cardiac troponin I measurements (upper reference limit, 26 ng per liter) were obtained 3 to 12 hours after surgery and on days 1, 2, and 3 after surgery. We performed Cox analyses using a regression spline that explored the relationship between peak troponin measurements and 30-day mortality, adjusting for scores on the European System for Cardiac Operative Risk Evaluation II (which estimates the risk of death after cardiac surgery on the basis of 18 variables, including age and sex).

RESULTS: Of 13,862 patients included in the study, 296 (2.1%) died within 30 days after surgery. Among patients who underwent isolated coronary-artery bypass grafting or aortic-valve replacement or repair, the threshold troponin level, measured within 1 day after surgery, that was associated with an adjusted hazard ratio of more than 1.00 for death within 30 days was 5670 ng per liter (95% confidence interval [CI], 1045 to 8260), a level 218 times the upper reference limit. Among patients who underwent other cardiac surgery, the corresponding threshold troponin level was 12,981 ng per liter (95% CI, 2673 to 16,591), a level 499 times the upper reference limit.

CONCLUSIONS: The levels of high-sensitivity troponin I after cardiac surgery that were associated with an increased risk of death within 30 days were substantially higher than levels currently recommended to define clinically important periprocedural myocardial injury. (Funded by the Canadian Institutes of Health Research and others; VISION Cardiac Surgery ClinicalTrials.gov number, NCT01842568.).

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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