Association of Postoperative High-Sensitivity Troponin Levels With Myocardial Injury and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery

Writing Committee for the VISION Study Investigators , Devereaux PJ 1 , Biccard BM 2 , Sigamani A 3 , Xavier D 4 , Chan MTV 5 Show all authors , Srinathan SK 6 , Walsh M 1 , Abraham V 7 , Pearse R 8 , Wang CY 9 , Sessler DI 10 , Kurz A 10 , Szczeklik W 11 , Berwanger O 12 , Villar JC 13 , Malaga G 14 , Garg AX 15 , Chow CK 16 , Ackland G 17 , Patel A 1 , Borges FK 18 , Belley-Cote EP 1 , Duceppe E 1 , Spence J 1 , Tandon V 1 , Williams C 19 , Sapsford RJ 20 , Polanczyk CA 21 , Tiboni M 1 , Alonso-Coello P 22 , Faruqui A 4 , Heels-Ansdell D 1 , Lamy A 1 , Whitlock R 1 , LeManach Y 1 , Roshanov PS 1 , McGillion M 1 , Kavsak P 1 , McQueen MJ 1 , Thabane L 1 , Rodseth RN 23 , Buse GAL 24 , Bhandari M 1 , Garutti I 25 , Jacka MJ 26 , Schünemann HJ 1 , Cortes OL 27 , Coriat P 28 , Dvirnik N 1 , Botto F 29 , Pettit S 1 , Jaffe AS 30 , Guyatt GH 1

Affiliations 

  • 1 McMaster University, Hamilton, Ontario, Canada
  • 2 University of Cape Town, Cape Town, South Africa
  • 3 Narayana Hrudayalaya Limited, Bangalore, Karnataka, India
  • 4 St John's Medical College and Research Institute, Bangalore, India
  • 5 Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
  • 6 Winnipeg Health Sciences Centre, University of Manitoba, Winnipeg, Manitoba, Canada
  • 7 Christian Medical College, Ludhiana, Punjab, India
  • 8 Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, England
  • 9 University of Malaya, Kuala Lumpur, Malaysia
  • 10 Cleveland Clinic, Cleveland, Ohio
  • 11 Jagiellonian University Medical College, Krakow, Poland
  • 12 Research Institute Hcor (Hospital do Coracao), Sao Paulo, Brazil
  • 13 Universidad Autónoma de Bucaramanga and Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
  • 14 Universidad Peruana Cayetano Heredia, Lima, Peru
  • 15 Western University, London, Ontario, Canada
  • 16 The George Institute for Global Health, Westmead Hospital, University of Sydney, Sydney, Australia
  • 17 University College Hospital NHS Trust and William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
  • 18 Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
  • 19 Royal Liverpool and Broadgreen University Hospitals, Liverpool, England
  • 20 Leeds Teaching Hospitals NHS Trust, Leeds, England
  • 21 Federal University of Rio Grande do Sul and Hospital Moinhos de Vento, Porto Alegre, Brazil
  • 22 Iberoamerican Cochrane Center (IIB Sant Pau-CIBERESP), Hospital Sant Pau, Barcelona, Spain
  • 23 University of KwaZulu-Natal, Pietermaritzburg, South Africa
  • 24 University Hospital Düsseldorf, Düsseldorf, Germany
  • 25 Hospital Universitario Gregorio Marañón, Madrid, Spain
  • 26 University of Alberta, Edmonton, Alberta, Canada
  • 27 Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
  • 28 Universite Pierre et Marie Curie, Paris, France
  • 29 Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
  • 30 Mayo Clinic, Rochester, Minnesota
JAMA, 2017 Apr 25;317(16):1642-1651.
PMID: 28444280 DOI: 10.1001/jama.2017.4360

Abstract

Importance: Little is known about the relationship between perioperative high-sensitivity troponin T (hsTnT) measurements and 30-day mortality and myocardial injury after noncardiac surgery (MINS).

Objective: To determine the association between perioperative hsTnT measurements and 30-day mortality and potential diagnostic criteria for MINS (ie, myocardial injury due to ischemia associated with 30-day mortality).

Design, Setting, and Participants: Prospective cohort study of patients aged 45 years or older who underwent inpatient noncardiac surgery and had a postoperative hsTnT measurement. Starting in October 2008, participants were recruited at 23 centers in 13 countries; follow-up finished in December 2013.

Exposures: Patients had hsTnT measurements 6 to 12 hours after surgery and daily for 3 days; 40.4% had a preoperative hsTnT measurement.

Main Outcomes and Measures: A modified Mazumdar approach (an iterative process) was used to determine if there were hsTnT thresholds associated with risk of death and had an adjusted hazard ratio (HR) of 3.0 or higher and a risk of 30-day mortality of 3% or higher. To determine potential diagnostic criteria for MINS, regression analyses ascertained if postoperative hsTnT elevations required an ischemic feature (eg, ischemic symptom or electrocardiography finding) to be associated with 30-day mortality.

Results: Among 21 842 participants, the mean age was 63.1 (SD, 10.7) years and 49.1% were female. Death within 30 days after surgery occurred in 266 patients (1.2%; 95% CI, 1.1%-1.4%). Multivariable analysis demonstrated that compared with the reference group (peak hsTnT <5 ng/L), peak postoperative hsTnT levels of 20 to less than 65 ng/L, 65 to less than 1000 ng/L, and 1000 ng/L or higher had 30-day mortality rates of 3.0% (123/4049; 95% CI, 2.6%-3.6%), 9.1% (102/1118; 95% CI, 7.6%-11.0%), and 29.6% (16/54; 95% CI, 19.1%-42.8%), with corresponding adjusted HRs of 23.63 (95% CI, 10.32-54.09), 70.34 (95% CI, 30.60-161.71), and 227.01 (95% CI, 87.35-589.92), respectively. An absolute hsTnT change of 5 ng/L or higher was associated with an increased risk of 30-day mortality (adjusted HR, 4.69; 95% CI, 3.52-6.25). An elevated postoperative hsTnT (ie, 20 to <65 ng/L with an absolute change ≥5 ng/L or hsTnT ≥65 ng/L) without an ischemic feature was associated with 30-day mortality (adjusted HR, 3.20; 95% CI, 2.37-4.32). Among the 3904 patients (17.9%; 95% CI, 17.4%-18.4%) with MINS, 3633 (93.1%; 95% CI, 92.2%-93.8%) did not experience an ischemic symptom.

Conclusions and Relevance: Among patients undergoing noncardiac surgery, peak postoperative hsTnT during the first 3 days after surgery was significantly associated with 30-day mortality. Elevated postoperative hsTnT without an ischemic feature was also associated with 30-day mortality.

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

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