Association Between Myocardial Injury and Cardiovascular Outcomes of Orthopaedic Surgery: A Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) Substudy

Thomas S 1 , Borges F 2 , Bhandari M 2 , De Beer J 2 , Urrútia Cuchí G 3 , Adili A 2 Show all authors , Winemaker M 2 , Avram V 2 , Chan MTV 4 , Lamas C 5 , Cruz P 5 , Aguilera X 3 , Garutti I 5 , Alonso-Coello P 3 , Villar JC 6 , Jacka M 7 , Wang CY 8 , Berwanger O 2 , Chow C 9 , Srinathan S 10 , Pettit S 2 , Heels-Ansdell D 2 , Rubery P 1 , Devereaux PJ 2 , VISION Investigators

Affiliations 

  • 1 University of Rochester, Rochester, New York
  • 2 McMaster University, Hamilton, Ontario, Canada
  • 3 Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
  • 4 The Chinese University of Hong Kong, Hong Kong
  • 5 Hospital General Universitario Gregorio Marañón, Madrid, Spain
  • 6 Universidad Autónoma de Bucaramanga, Bucaramanga, Colombia
  • 7 University of Alberta, Edmonton, Alberta, Canada
  • 8 University of Malaya, Kuala Lumpur, Malaysia
  • 9 University of Sydney, Sydney, New South Wales, Australia
  • 10 University of Manitoba, Winnipeg, Manitoba, Canada
J Bone Joint Surg Am, 2020 May 20;102(10):880-888.
PMID: 32118652 DOI: 10.2106/JBJS.18.01305

Abstract

BACKGROUND: Myocardial injury after noncardiac surgery (MINS) is common and of prognostic importance. Little is known about MINS in orthopaedic surgery. The diagnostic criterion for MINS was a level of ≥0.03 ng/mL on a non-high-sensitivity troponin T (TnT) assay due to myocardial ischemia.

METHODS: We undertook an international, prospective study of 15,103 patients ≥45 years of age who had inpatient noncardiac surgery; 3,092 underwent orthopaedic surgery. Non-high-sensitivity TnT assays were performed on postoperative days 0, 1, 2, and 3. Among orthopaedic patients, we determined (1) the prognostic relevance of the MINS diagnostic criteria, (2) the 30-day mortality rate for those with and without MINS, and (3) the probable proportion of MINS cases that would go undetected without troponin monitoring because of a lack of an ischemic symptom.

RESULTS: Three hundred and sixty-seven orthopaedic patients (11.9%) had MINS. MINS was associated independently with 30-day mortality including among those who had had orthopaedic surgery. Orthopaedic patients without and with MINS had a 30-day mortality rate of 1.0% and 9.8%, respectively (odds ratio [OR], 11.28; 95% confidence interval [CI], 6.72 to 18.92). The 30-day mortality rate was increased for patients with MINS who had an ischemic feature (i.e., symptoms, or evidence of ischemia on electrocardiography or imaging) (OR, 18.25; 95% CI, 10.06 to 33.10) and for those who did not have an ischemic feature (OR, 7.35; 95% CI, 3.37 to 16.01). The proportion of orthopaedic patients with MINS who were asymptomatic and in whom the myocardial injury would have probably gone undetected without TnT monitoring was 81.3% (95% CI, 76.3% to 85.4%).

CONCLUSIONS: One in 8 orthopaedic patients in our study had MINS, and MINS was associated with a higher mortality rate regardless of symptoms. Troponin levels should be measured after surgery in at-risk patients because most MINS cases (>80%) are asymptomatic and would go undetected without routine measurements.

LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

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

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